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  • Musculoskeletal Educational Resources for the Aspiring Orthopaedic Surgeon. JB & JS open access Wadhwa, H., Van Rysselberghe, N. L., Campbell, S. T., Bishop, J. A. 2022; 7 (1)

    Abstract

    Musculoskeletal (MSK) education is underemphasized in medical school curricula, which can lead to decreased confidence in treating MSK conditions and suboptimal performance on orthopaedic surgery elective rotations or subinternships. Given the low amount of formalized education in MSK medicine, students aiming to learn about orthopaedic surgery must gain much of their foundational knowledge from other resources. However, there are currently no centralized introductory educational resources to fill this need. We provide a framework for navigating the different types of resources available for trainees and highlight the unaddressed needs in this area.

    View details for DOI 10.2106/JBJS.OA.21.00113

    View details for PubMedID 35651664

  • Countersinking the Lag Screw or Blade During Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures: Less Collapse and Implant Prominence Without Increased Cutout Rates. The Journal of the American Academy of Orthopaedic Surgeons Henry Goodnough, L., Wadhwa, H., Tigchelaar, S. S., Pfaff, K., Heffner, M., van Rysselberghe, N., DeBaun, M. R., Gardner, M. J., Bishop, J. A. 1800; 30 (1): e83-e90

    Abstract

    INTRODUCTION: The lag screw or helical blade of a cephalomedullary nail facilitates controlled collapse of intertrochanteric proximal femur fractures. However, excessive collapse results in decreased hip offset and symptomatic lateral implants. Countersinking the screw or helical blade past the lateral cortex may minimize subsequent prominence, but some surgeons are concerned that this will prevent collapse and result in failure through cutout. We hypothesized that patients with countersunk lag screws or helical blades do not experience higher rates of screw or blade cutout and have less implant prominence after fracture healing.METHODS: A retrospective review of 175 consecutive patients treated with cephalomedullary nails for AO/OTA 31A1-3 proximal femur fractures and a minimum 3-month follow-up and 254 patients with a 6-week follow-up at a single US level I trauma center. Patients were stratified based on countersunk versus noncountersunk lag screw or helical blade in a cephalomedullary nail. The primary outcome was the cutout rate at minimum 3 months, and the secondary outcome was radiographic collapse at minimum 6 weeks.RESULTS: Cutout rates were no different in patients with countersunk and noncountersunk screws and blades, and countersinking was associated with less collapse and less implant prominence at 6 weeks.DISCUSSION: Surgeons can countersink the lag screw or blade when treating intertrochanteric proximal femur fractures with a cephalomedullary nail without increasing failure rates and with the potential benefits of less prominent lateral implants and decreased collapse.

    View details for DOI 10.5435/JAAOS-D-20-01029

    View details for PubMedID 34932507

  • To Fix or Revise: Differences in Periprosthetic Distal Femur Fracture Management Between Trauma and Arthroplasty Surgeons. The Journal of the American Academy of Orthopaedic Surgeons Van Rysselberghe, N. L., Campbell, S. T., Goodnough, L. H., Amanatullah, D. F., Gardner, M. J., Bishop, J. A. 2021

    Abstract

    INTRODUCTION: This study sought to determine the effect of trauma fellowship training on the surgical decision to fix or revise to distal femoral replacement in periprosthetic distal femur fractures.METHODS: An anonymous online survey including nine cases of geriatric periprosthetic distal femur fractures was distributed through the Orthopaedic Trauma Association website. Respondents were asked whether they would recommend fixation or revision to distal femoral replacement. Fractures were classified by the location relative to the anterior flange (proximal or distal) and the presence or absence of comminution. Recommendations were compared between type of fellowship completed (trauma, arthroplasty, or both), practice setting, and number of periprosthetic distal femur fractures treated monthly.RESULTS: One hundred fifty-one surgeon survey responses were included. Completion of a trauma fellowship was associated with a higher likelihood of recommending fixation for any periprosthetic distal femur fracture compared with arthroplasty training (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.97 to 3.29; P < 0.0001). Disagreement was significant for comminuted proximal (OR 6.90, 95% CI 3.24 to 14.68; P < 0.0001), simple distal (OR 20.90, 95% CI 6.41 to 67.71; P < 0.001), and comminuted distal fractures (OR 2.47, 95% CI 1.66 to 3.68; P < 0.0001). Dual fellowship-trained surgeons were less likely to recommend fixation than surgeons who completed a trauma fellowship alone (OR 0.60, 95% CI 0.39 to 0.93; P = 0.027) and more likely to recommend fixation than surgeons who completed an arthroplasty fellowship alone (OR 1.70, 95% CI 1.13 to 2.63; P = 0.012). Surgeons who treat three or more periprosthetic distal femur fractures monthly showed a significant preference for fracture fixation compared with lower volume surgeons (OR 2.45, 95% CI 1.62 to 3.68; P < 0.0001).DISCUSSION: Fellowship-trained trauma surgeons show a notable preference for fracture fixation over distal femoral replacement for periprosthetic distal femur fractures, as compared with arthroplasty-trained surgeons. Additional research is needed to clarify surgical indications that maximize outcomes for these injuries.

    View details for DOI 10.5435/JAAOS-D-20-00968

    View details for PubMedID 34288890

  • Medial Column Support in Pilon Fractures Using Percutaneous Intramedullary Large Fragment Fixation. Journal of orthopaedic trauma Goodnough, L. H., Tigchelaar, S. S., Van Rysselberghe, N. L., DeBaun, M. R., Gardner, M. J., Hecht, G. G., Lucas, J. F. 2021

    View details for DOI 10.1097/BOT.0000000000002073

    View details for PubMedID 33675625

  • Cephalomedullary helical blade is independently associated with less collapse in intertrochanteric femur fractures than lag screws. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Goodnough, L. H., Wadhwa, H., Tigchelaar, S. S., Pfaff, K., Heffner, M., Van Rysselberghe, N., DeBaun, M. R., Bishop, J. A., Gardner, M. J. 2021

    Abstract

    OBJECTIVES: Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws.DESIGN: Retrospective cohort study.SETTING: Single U.S. Level I Trauma Center.PATIENTS: 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up.INTERVENTION: Lag screw or helical blade in a cephalomedullary nail.OUTCOME MEASURES: The primary outcome was fracture site collapse at 3months.RESULTS: There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7mm, inter-quartile range 2.5-7.8mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7-11.2mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5mm less collapse (95%CI -4.2, -0.72mm, p 0.006) and lower likelihood of excessive collapse (>10mm at 3months, OR 0.3, 95% CI 0.13-0.74, p 0.007), regardless of fracture pattern.CONCLUSIONS: Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.

    View details for DOI 10.1007/s00590-021-02875-8

    View details for PubMedID 33587180

  • Management of the posterior wall fracture in associated both column fractures of the acetabulum. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie Chen, M. J., Hollyer, I. n., Wadhwa, H. n., Tigchelaar, S. S., Van Rysselberghe, N. L., Bishop, J. A., Bellino, M. J., Gardner, M. J. 2021

    Abstract

    The primary aim of this study was to compare clinical outcomes in patients with associated both column (ABC) acetabular fractures with fracture of the posterior wall (PW), in which the PW underwent reduction and fragment-specific fixation versus those that were treated with column fixation alone. Secondary aims were to assess PW fracture incidence and morphology, as well as to compare radiographic outcomes including fracture healing and interval displacement of the PW in those that did and did not undergo fragment-specific fixation of the PW.This was a retrospective series of ABC acetabular fractures treated at a single Level I trauma center. Separate fractures of the PW were identified, and associated features were assessed. Associated both column fractures that underwent reduction and fragment-specific fixation of the PW where then compared to ABC fractures with PW involvement that underwent column reconstruction alone. Radiographic and clinical outcomes were compared.Fractures of the PW occurred in 55.7% of ABC fractures and were associated with central displacement of the femoral head. The majority of PW fractures were large and involved the acetabular roof. All PW fractures healed without displacement by 3 months, regardless of whether or not reduction and stabilization was performed. Mid-term outcomes at 1-year were similar regardless of whether or not the PW was reduced and stabilized, with regards to Tönnis grade, Merle d'Aubigné-Postel score, and conversion to total hip arthroplasty.Reduction and fragment-specific fixation of the PW component of ABC acetabular fractures did not improve outcomes in this small comparative study. Posterior wall fractures associated with ABC patterns are frequently large-sized fragments that involve the acetabular roof and are rendered stable after reconstruction of the columns.

    View details for DOI 10.1007/s00590-020-02850-9

    View details for PubMedID 33386470

  • Distal Femur Replacement versus Open Reduction and Internal Fixation for Treatment of Periprosthetic Distal Femur Fractures: Systematic Review and Meta-Analysis. Journal of orthopaedic trauma Wadhwa, H. n., Salazar, B. P., Goodnough, L. H., Van Rysselberghe, N. L., DeBaun, M. R., Wong, H. N., Gardner, M. J., Bishop, J. A. 2021

    Abstract

    To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF).PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies.Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age <55, nontraumatic indications for DFR, ORIF with non-locking plates, native distal femoral fractures, or revision surgeries were excluded. Selection adhered to PRISMA criteria.Study quality was assessed using previously reported criteria. There were 40 Level IV studies, 17 Level III studies, and 1 Level II study.Fifty-eight studies with 1,484 patients were included in the meta-analysis. Complications assessed (Incidence Rate Ratio (IRR) (95%CI): 0.78 (0.59-1.03)) and reoperation or revision (IRR (95%CI): 0.71 (0.49-1.04)) were similar between the DFR and ORIF cohorts. Mean knee range of motion (ROM) was greater in the ORIF cohort (DFR: 90.47 vs. ORIF: 100.36, p < 0.05). Mean Knee Society Score (KSS) (DFR: 79.41 vs. ORIF: 82.07, p = 0.35) and return to preoperative ambulatory status were similar (IRR (95%CI): 0.82 (0.48-1.41)).In comparing complications among patients treated for periprosthetic distal femur fracture with DFR or ORIF, there was no difference between the groups. There were also no differences in functional outcomes, although knee ROM was greater in the ORIF group. This systematic review and meta-analysis highlights the need for future prospective trials evaluating the outcomes of these divergent treatment strategies.Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1097/BOT.0000000000002141

    View details for PubMedID 34001801

  • ICD-10 codes do not accurately reflect ankle fracture injury patterns. Injury Seltzer, R. A., Van Rysselberghe, N. L., Fithian, A. T., LaPrade, C. M., Sharma, J., Oquendo, Y. A., Michaud, J. B., DeBaun, M. R., Gardner, M. J., Bishop, J. A. 2021

    Abstract

    To determine the accuracy of International Classification of Disease Version 10 (ICD-10) coding for ankle fracture injury patterns.Retrospective cohort study PATIENTS: 97 adult patients with fractures about the ankle (rotational ankle fracture or distal tibia fracture) from 2016 to 2020, selected by stratified random sampling.Assignment of an ICD-10 code representative of a rotational ankle fracture, pilon fracture, or unspecified fracture of the lower leg.Injury radiographs were reviewed by three authors to determine the correct code. Agreement between the correct code and the electronic medical record (EMR) assigned code was determined using kappa's statistic in the aggregate as well as percent agreement, sensitivity, specificity, and positive predictive value (PPV) between individual codes.59 of 97 cases (60.8%) demonstrated discordance between the existing EMR and surgeon-assigned codes. Aggregate agreement between all codes was fair (K = 0.26). Lateral malleolus fracture codes demonstrated the highest PPV (0.91, 95% CI 0.72-0.99), while the lowest PPV was found for "other fractures of the lower leg" (0.05, 95% CI 0.0-0.24) and "other fracture of the fibula" (0.0, 95% CI 0.0-0.15). Generalized "other fracture" codes comprised 45% of EMR codes compared to only 6% of assigned codes (p < 0.001). EMR codes were specific but not sensitive.There is substantial discordance between existing EMR and surgeon-assigned ICD-10 codes for ankle fractures. Database research that relies on ICD-10 coding as a surrogate for primary clinical data should be interpreted with caution and institutions should make efforts to increase the accuracy of their coding.

    View details for DOI 10.1016/j.injury.2021.10.005

    View details for PubMedID 34654551

  • Artificial Neural Networks Predict 30-Day Mortality After Hip Fracture: Insights From Machine Learning. The Journal of the American Academy of Orthopaedic Surgeons DeBaun, M. R., Chavez, G., Fithian, A., Oladeji, K., Van Rysselberghe, N., Goodnough, L. H., Bishop, J. A., Gardner, M. J. 2020

    Abstract

    OBJECTIVES: Accurately stratifying patients in the preoperative period according to mortality risk informs treatment considerations and guides adjustments to bundled reimbursements. We developed and compared three machine learning models to determine which best predicts 30-day mortality after hip fracture.METHODS: The 2016 to 2017 National Surgical Quality Improvement Program for hip fracture (AO/OTA 31-A-B-C) procedure-targeted data were analyzed. Three models-artificial neural network, naive Bayes, and logistic regression-were trained and tested using independent variables selected via backward variable selection. The data were split into 80% training and 20% test sets. Predictive accuracy between models was evaluated using area under the curve receiver operating characteristics. Odds ratios were determined using multivariate logistic regression with P < 0.05 for significance.RESULTS: The study cohort included 19,835 patients (69.3% women). The 30-day mortality rate was 5.3%. In total, 47 independent patient variables were identified to train the testing models. Area under the curve receiver operating characteristics for 30-day mortality was highest for artificial neural network (0.92), followed by the logistic regression (0.87) and naive Bayes models (0.83).DISCUSSION: Machine learning is an emerging approach to develop accurate risk calculators that account for the weighted interactions between variables. In this study, we developed and tested a neural network model that was highly accurate for predicting 30-day mortality after hip fracture. This was superior to the naive Bayes and logistic regression models. The role of machine learning models to predict orthopaedic outcomes merits further development and prospective validation but shows strong promise for positively impacting patient care.

    View details for DOI 10.5435/JAAOS-D-20-00429

    View details for PubMedID 33315645

  • Can upstream patient education improve fracture care in a digital world? Use of a decision aid for the treatment of displaced diaphyseal clavicle fractures. Journal of orthopaedic trauma Lai, C. H., DeBaun, M. R., Van Rysselberghe, N., Abrams, G. D., Kamal, R. N., Bishop, J. A., Gardner, M. J. 2020

    Abstract

    BACKGROUND: The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCF) are ideal for a targeted intervention as there is no superior treatment, and decisions are often dependent on patient preference. A decision aid provided prior to consultation may educate a patient and minimize decisional conflict similarly to in-person consultation with an orthopaedic traumatologist.METHODS: Patients with DDCF were enrolled into two groups. The usual care group participated in a discussion with a trauma fellowship trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with International Patient Decision Aid Standards. Primary comparisons were made based on decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance.RESULTS: A total of 41 patients enrolled. Decisional conflict scores were similar and low between the two groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid.DISCUSSION: Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid prior to consultation may help incorporate patient values and preferences into the decision-making process between surgery and non-operative management.LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.1097/BOT.0000000000001916

    View details for PubMedID 33105455

  • Metaphyseal callus formation in pilon fractures is associated with loss of alignment: Is stiffer better? Injury Van Rysselberghe, N. L., Campbell, S. T., Goodnough, L. H., Salazar, B. P., Bishop, J. A., Bellino, M. J., Lucas, J. F., Gardner, M. J. 2020

    Abstract

    To assess the relationship between metaphyseal callus formation and preservation of distal tibial alignment in pilon fractures treated with internal plate fixation.Retrospective Review SETTING: Academic Level I Trauma Center PATIENTS: Forty-two patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation.Internal fixation with anterolateral plating, medial plating, or both. Modified Radiographic Union Score in Tibial fracture (mRUST) scores were determined from six-month radiographs.Change in lateral and anterior distal tibial angles (LDTA and ADTA) at six months post-operatively.High callus formation (mRUST ≥ 11 at six months) was associated with a greater loss of coronal reduction as measured by LDTA compared to low callus formation (mRUST < 11): 3.8 vs 2.1° (p = .019), with no difference in ADTA change between groups. In a multivariable logistic regression controlling for age, smoking, obesity, and open fracture, higher mRUST scores were a predictor of coronal reduction loss of five or more degrees (OR 1.71, p=.039). Dual column plating did not independently predict maintenance of alignment.Recent literature has popularized dual column fixation for pilon fractures, but it remains unknown whether increased metaphyseal stiffness enhances or impairs healing. In this series, decreased metaphyseal callus formation was associated with maintained coronal alignment, suggesting that a stiffer mechanical environment may be preferable to prevent short term reduction loss in these complex injuries.III.

    View details for DOI 10.1016/j.injury.2020.10.080

    View details for PubMedID 33097204