The Iowa orthopaedic journal最新文献

Background: Limited research exits surrounding Maisonneuve fractures due to rarity. Additionally, even less data has been published evaluating the patient reported outcomes of surgically treated Maisonneuve fractures using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF) and Pain Intensity (PI) score. The aim of this study was to put forth a cohort of patient reported outcomes using PROMIS PF and PROMIS PI.

Methods: Maisonneuve fracture patients with minimum 12-month follow-up treated at a level-1 trauma center from 2006 to 2020 completed PROMIS PF and PROMIS PI tests. Medical records were reviewed to gather patient characteristics, mechanism of energy, operative variables, and complications.

Results: The final cohort consisted of 28 patients with a mean follow up of 59.6 months with a mean time between injury and primary operation of 7.9 days. The mean PROMIS PF and PROMIS PI scores of the cohort were 56.3 (SD 10.8 [95% CI 15.9, 171.0] and 40.9 (SD 7.5 [95% CI 36,44]) respectively. The mean Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) and FAAM Sports were 90.4 (15.4 [95% CI 84, 109] and 75.2 (SD 28.9 [95% CI 62, 91] respectively. Thirteen patients received syndesmotic screws only, nine received plate + syndesmotic screw, three received suture-button devices only, and three patients received syndesmotic screws + suture-button device. When the methods of syndesmotic fixation were divided into three groups, (1- syndesmotic screws only, 2-plate + syndesmotic screw, 3- suture-button device only and syndesmotic screw + suture-button device), the PROMIS PF scores for each treatment group was 60.2 (SD 8.5 [95% CI 54, 66]], 46.5 (SD 9.7 [95% CI 41, 53]), 62.8 (SD 9.7 [95% CI 54, 77]), respectively. The treatment group of plate + syndesmotic screw has significantly worse PROMIS PF compared to the syndesmotic screw only group.

Conclusion: This study is the largest cohort utilizing PROMIS PF and PI to evaluate surgically treated Maisonneuve fractures. The resultant PROMIS PF an PI scores further demonstrate the favorable outcomes for surgical treatment of Maisonneuve fractures. Level of Evidence: III.

Background: As surgeons enter practice or senior surgeons embark on new procedures, we must weigh the potential risks to our patients. Despite the concept of a "learning curve" gaining traction, there is limited guidance on the specific learning curves within orthopaedic sports medicine. The purpose of this article is to explore the ways in which learning curves are defined within orthopaedic sports medicine and report the number of cases required to overcome them.

Methods: Pubmed-MEDLINE, Scopus, and Embase databases were queried for "Learning Curves" pertaining to orthopaedic sports medicine procedures according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Abstracts were reviewed by two independent reviewers for inclusion and subdivided into categories including: Shoulder Arthroscopy and Reconstruction, Shoulder Arthroplasty, Hip Arthroscopy, Knee Arthroscopy and Reconstruction, and Knee Osteotomy.

Results: 4,558 articles were reviewed. 14 articles for shoulder arthroscopy and reconstructive procedures, 10 articles for shoulder arthroplasty, 17 articles for hip arthroscopy, 7 articles for knee arthroscopy and reconstructive procedures, and 2 articles for knee osteotomy were ultimately included. The net defined learning curve for each respective surgical sub-category was 22 for shoulder arthroscopy and reconstruction, 28 for shoulder arthroplasty, 71 for hip arthroscopy, 28 for knee arthroscopy and reconstruction, and 32 for knee osteotomy.

Conclusion: Surgeons should consider the synthesis of the described learning curves for shoulder, hip, and knee surgery when incorporating these procedures into their practice. Level of Evidence: II.

Background: This study aimed to determine the level of exposure to sliding hip screws amongst orthopedic surgery residents compared to intramedullary nail fixation for intertrochanteric femur fractures.

Methods: Data was collected from five orthopedic surgery residency programs through the case log system of the accreditation council for graduate medical education (ACGME) based on current procedural terminology codes (CPT). The rates of IMN for treatment of IT fracture (27245) were compared to SHS fixation (27244) for the period of 2017-2021. The location of the procedure was also logged as either a level one trauma center, non-trauma hospitals, and a veteran's affairs hospital (VA). Rates of SHS usage were compared by year and location type using multivariate logistic binary regression.

Results: 5,910 IT femur fractures were treated by orthopedic residents during the time period. IMN was utilized for 88.8% of cases. The highest usage of SHS was 15.6% in 2017 with a statistically significant decrease to 9.2% in 2021 (p < 0.001). SHS utilization was lowest at non-trauma centers (5.4%) and highest at level one trauma centers (11.7%).

Conclusion: Residents get limited experience with SHS compared to IMN in their training programs, and there is a significant trend toward fewer SHS implants being used by residents over the past 5 years. Residents' limited experience with SHS during residency may contribute for the trend toward IMN use. Surgeons at academic institutions ought to recognize this trend and strongly consider their implant choice when treating intertrochanteric femur fractures for fear of sliding hip screws becoming a lost art. Level of Evidence: IV.

Background: Formation of bone cysts in the acetabulum or femoral head is common in symptomatic acetabular dysplasia, but the prevalence and significance of cysts in hips undergoing PAO is poorly understood. The purposes of this study were (1) to determine the prevalence of cysts in hips undergoing PAO, (2) to identify predictors of the presence of cysts, (3) to determine if the presence or location of cysts was associated with intra-articular damage and (4) to determine if the presence or location of cysts impacted early clinical outcomes after PAO.

Methods: We performed a retrospective review of 270 consecutive hips (249 patients) who were diagnosed with symptomatic acetabular dysplasia and underwent PAO without previous ipsilateral hip surgery. Preoperative low-dose CTs were utilized to identify the presence of cysts, and patient-reported outcome measures (PROs) were recorded at baseline and 1-year minimum follow-up (223 hips, 83%). The prevalence of cysts was reported, and associated factors were determined by univariate analysis (Student's T-test/Mann-Whitney U test for continuous measures, Chi-squared test/ Fischer's exact test for dichotomous measures). PROs and clinical "composite failure", defined as reoperation or failure to reach both the MCID and PASS, were similarly compared.

Results: CT analysis of 270 dysplastic hips undergoing PAO demonstrated 17.0% (n=46) with acetabular (13.7%) or femoral cysts (4.4%). Hips with cysts were older (31.0±9.2 years) than those without cysts (24.1±7.9 years, p<0.001), reported higher Tonnis OA grade (p<0.001), showed higher rates of femoral chondromalacia (p=0.008), and had greater acetabular inclination (16.9° ±6.1) compared to hips without cysts (14.8° ±5.9, p=0.046). At 1-year minimum follow-up (223 hips, 83%), neither the presence nor location of cysts significantly impacted PROs. Cystic hips showed an increased but statistically insignificant difference in reoperations, conversion to THA, or composite failure outcomes.

Conclusion: Seventeen percent of dysplastic hips undergoing PAO had acetabular (13.7%) or femoral (4.4%) cysts on CT. Cysts in dysplastic hips were associated with increased Tonnis grade and acetabular inclination but did not significantly impact early PROs. Greater composite failure rates failed to show statistical significance, suggesting that patients with cystic dysplasia should continue counseling for hip-preserving treatments. Level of Evidence: III.

Background: Displaced calcaneal fractures present significant challenges in achieving optimal reduction and fixation while minimizing complications. The traditional extensive lateral approach provides excellent exposure but is associated with high rates of wound complications, including infection and dehiscence. The sinus tarsi approach has gained popularity as a less invasive alternative, offering direct access to the posterior facet. However, it is limited in its ability to directly access and mobilize the calcaneal tuberosity, which is critical for restoring the height, length, and alignment of the calcaneus. This study describes a surgical technique with short term outcomes in which the sinus tarsi approach is combined with a laterally based femoral distractor which aids in manipulation and alignment of the calcaneal tuberosity.

Methods: This retrospective study included 28 patients with displaced intra-articular calcaneal fractures (OTA/AO 82 C1-C3; Sanders type II-IV) treated at a level I academic center between 2020 and 2022. All fractures were managed using a combination of the sinus tarsi approach and a laterally based femoral distractor. Complications were recorded as well as comparison radiographic parameters both pre-and post-operatively..

Results: Complications included one case of superficial skin necrosis and two cases of implant removal due to pain. There were no instances of deep infection requiring unplanned return to the operating room. No loss of tuberosity reduction or subfibular impingement was observed at the final follow-up (mean follow-up 14 months).

Conclusion: The combination of the sinus tarsi approach with femoral distractor use offers a method for reduction of displaced calcaneal fractures. This technique demonstrated appropriate restoration of hindfoot anatomy with reconstruction of height, length, width, and alignment in our patient cohort. This technique may potentially minimize the risk of complications compared to traditional methods, though further studies are needed to confirm these benefits and compare this technique with established approaches. Level of Evidence: IV.

Background: 3D printing is a fast-growing technology in orthopaedic surgery. The utility of 3D-printed orthopaedic implants has yet to be fully defined. This biomechanical study examines the capabilities of one such implant in an ankle fracture model.

Methods: One-third tubular plates were 3D-printed using CFR-PLA (carbon fiber-reinforced polylactic acid) and PC (polycarbonate). Samples and stainless-steel controls were used to fix Weber B Sawbones fibula fracture models and analyzed with lateral bending, torsional, and torsional failure mechanical testing.

Results: Stainless-steel one-third tubular plates were shown to have superior mechanical properties than the 3D-printed plates overall in valgus bending and with torsional failure. However, CFR-PLA 3D-printed plates demonstrated greater strength in torsion testing..

Conclusion: The differences in mechanical properties between stainless-steel one-third tubular plates and 3D-printed plates, while statistically significant, are likely not clinically significant. 3D-printed implants could be used as a viable alternative in ankle fracture fixation in the future.

Clinical relevance: To the authors' knowledge, this is the first biomechanical study performed on 3D-printed plates in an ankle fracture model. Given the increasing use of 3D printing, the findings described here could establish a basis for future areas of research.

Background: As online medical resources become more accessible, patients increasingly consult AI platforms like ChatGPT for health-related information. Our study assessed the accuracy and appropriateness of ChatGPT's responses to common questions about lateral epicondylitis, comparing them against OrthoInfo as a gold standard.

Methods: Eight frequently asked questions about lateral epicondylitis from OrthoInfo were selected and presented to ChatGPT at both standard and sixth-grade reading levels. Responses were evaluated for accuracy and appropriateness using a five-point Likert scale, with scores of four or above deemed satisfactory. Evaluations were conducted by two fellowship-trained Shoulder and Elbow surgeons, two Hand surgeons, and one Orthopaedic Sports fellow. We utilized the Flesch-Kincaid test to assess readability, and responses were statistically analyzed using paired t-tests.

Results: ChatGPT's responses at the sixth-grade level scored lower in accuracy (mean = 3.9 ± 0.87, p = 0.046) and appropriateness (mean = 3.7 ± 0.92, p = 0.045) compared to the standard level (accuracy = 4.7 ± 0.43, appropriateness = 4.7 ± 0.45). When compared with OrthoInfo, standard responses from ChatGPT showed significantly lower accuracy (mean difference = -0.275, p = 0.004) and appropriateness (mean difference = -0.475, p = 0.016). The Flesch-Kincaid grade level was significantly higher in the standard response group (mean = 14.06, p < 0.001) compared to both OrthoInfo (mean = 8.98) and the sixth-grade responses (mean = 8.48). No significance was noted between the Flesch-Kincaid grades of OrthoInfo and the sixth-grade responses.

Conclusion: At a sixth-grade reading level, Chat-GPT provides oversimplified and less accurate information regarding lateral epicondylitis. Although standard level responses are more accurate, they still do not meet the reliability of OrthoInfo and exceed the recommended readability for patient education materials. While ChatGPT cannot be recommended as a sole information source, it may serve as a supplementary resource alongside professional medical consultation. Level of Evidence: IV.

Background: Fluoroscopy is a critical tool in operative fracture reduction and fixation that residents begin using early in their careers. Judiciously managing fluoroscopy use in a procedure should be a focus in training. Total radiation dose is routinely recorded, but the distribution of fluoroscopy use throughout a procedure has not been well researched. This study aimed to determine how much fluoroscopy residents use in cephalomedullary nail (CMN) fixation of hip fractures. The study further sought to identify distinct tasks in the procedure that require more or less fluoroscopy.

Methods: Eighty-five CMN cases for which complete sets of fluoroscopic images were available were studied. Nine distinct tasks were analyzed in each case: set up, reduction, entry point navigation, reaming, nail placement, femoral head navigation, proximal screw placement, distal screw(s) placement, and final checks. Image use and time elapsed during tasks was recorded and attributed to the most-junior resident, who would typically be most hands-on at our institution for this procedure.

Results: Residents completed CMN placement in an average of 66.2 minutes (± 31.7) using an average of 185 images (± 113). Entry point navigation required the most time, 14 ± 10.8 minutes, and images, 49 ± 42. This was a significantly greater use of time (t(121) = 4.96, p < 0.001) and images (t(133) = 3.45, p < 0.001) than other tasks.

Conclusion: These data highlight the sheer volume of fluoroscopy used by residents in a common procedure. The sub-task analysis indicates that the freehand entry point navigation requires the greatest use of fluoroscopy and time, suggesting residents may benefit from additional laboratory-based training on this portion of the procedure.

Clinical relevance: Orthopedic surgeons utilize fluoroscopy in a wide array of procedures. These findings emphasize the need to be intentional in the use of intra-operative fluoroscopy over a decades long career to prevent its potentially harmful effects. These results can also be used to improve education by creating objective metrics to evaluate resident fluoroscopy use and provide feedback.

Background: While authors have subclassified long head of biceps tendon (LHBT) lesions in numerous ways, there is no classification system based solely on the arthroscopic appearance of the LHBT. We present a scoping review of the existing classification systems for LHBT tendinopathy and propose a novel classification based on its intraoperative, arthroscopic appearance.

Methods: We conducted a comprehensive search of classification systems for LHBT pathology using EMBASE and Ovid-Medline platforms. Our proposed classification system consists of four types based on intraoperative arthroscopic appearance of the LHBT: normal (A), erythema without fraying (B), fraying (C), and labral anchor instability (D). Fourteen arthroscopic videos and thirteen photos were reviewed by three orthopaedic sports medicine surgeons and two orthopaedic sports medicine fellows. Intra-and inter-observer reliability were assessed using Krippendorff's Alpha (α).

Results: Seventeen full length articles were included in our review, including classification systems based on visual characteristics, advanced imaging, and histology. For our proposed classification, there was excellent inter- and intra-observer reliability between all reviewers (α=0.92). Interobserver reliability when reviewing arthroscopic photos was also excellent (α=0.81). There was excellent agreement for all reviewers between video and photo cases (α=0.81).

Conclusion: The current literature lacks a concise classification system for LHBT tendinopathy based on its intraoperative, arthroscopic appearance. Our proposed classification system is intended to offer a simple and reproducible way to describe LHBT tendinopathy based on intraoperative arthroscopic appearance of the tendon. This classification has excellent inter- and intra-observer reliability when reviewing arthroscopic video cases as well as excellent inter-observer reliability when reviewing arthroscopic photos. This serves as a validation of classification for a future planned randomized control trial comparing LHBT tenodesis to benign neglect in the setting of rotator cuff repair. Level of Evidence: III.

Background: Distal femur fractures are a rising cause of morbidity among the US aging population. Due to the urgent nature of orthopaedic trauma management, preoperative optimization is often limited. Metabolic syndrome (MetS), defined by abdominal obesity, hypertriglyceridemia, dyslipidemia, hyperglycemia, and hypertension, has been associated with increased risk of postoperative complications among many surgical subspecialties. The purpose of the study was to investigate the impact of MetS on postoperative outcomes of patients with distal femur fractures.

Methods: The ACS-NSQIP database was queried for patients with distal femur fracture between 2015-2021. Patients were matched for demographics, comorbidities, and pre- and intraoperative variables using Pearson-Chi square tests. Postoperative complications were compared between groups using univariate and multivariable logistic regression analyses..

Results: 516 (14.2%) of distal femur fracture patients had a diagnosis of MetS. MetS was significantly associated with higher odds of acute renal failure (OR 2.72 [95% CI 1.02-6.90]; p = 0.038), cardiac arrest (OR 3.13 [95% CI 1.28 - 7.27]; p = 0.009), and non-home discharge (OR 1.36 [95% CI 1.06 -1.76]; p=0.018) (Table 1). There was no statistically significant difference in length of stay, surgical site infection, myocardial infarction, stroke, deep venous thrombosis, pulmonary embolism, 30-day mortality, or reoperation rate between MetS and non-MetS group.

Conclusion: When compared to distal femur fracture patients without MetS, MetS patients were likely to be age > 70, on dialysis, with a history of congestive heart failure, and have bleeding disorders. Further, MetS patients had higher odds of adverse 30-day outcomes and non-home discharge. Level of Evidence: III.