Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

The Most-Cited Ankle Arthroplasty Implant Articles

Background: Citation analysis is a useful way of evaluating the impact, importance, and merit of articles within a medical specialty. Our study identified and analyzed the most-cited articles on ankle arthroplasty implants to evaluate their importance in the field of ankle arthroplasty research. Methods: Using the keywords “ankle arthroplasty” and “ankle replacement” and the search period 1970-2021, we found 3728 articles on ankle arthroplasty implants in the Scopus, Web of Science, and MEDLINE/PubMed databases. We included original articles, reviews, clinical trials, and case reports in the study. We retrieved the 50 most-cited articles published during the time frame and then screened them for studies of specific ankle arthroplasty implants and their postoperative outcomes. We also recorded and analyzed the articles’ subjects, authorship, journals, countries of origin, and years of publication. Results: The 50 most-cited articles were published between 1983 and 2014, with the majority (33) published between 2000 and 2010. They generated 9012 citations in the literature. The most-cited study accounted for 497 citations; the mean number of citations per article was 180.24 ± 76.24. Twenty-three (46%) of the articles addressed postoperative outcomes following a specific type of arthroplasty implant. Arthroplasty implant studies accounted for 4726 citations, or 52.4% of the citations of the 50 articles. The most frequently studied arthroplasty implant was STAR (15), followed by Agility (7), Buechel Pappas (5), and Salto (4). STAR accounted for 3311 citations, or 37% of the total citations of the 50 articles. Conclusion: Ankle arthroplasty research has made great progress in the past 2 decades, particularly in the area of postoperative outcomes of specific ankle implants, but continued research and publication on additional arthroplasty implants should become a priority. Level of Evidence: Level V, Review Article

Порівняльні результати ампутацій та органозберігальних операцій після військових травм нижніх кінцівок

Objective: to examine the hypothesis that functional outcomes following major lower-extremity trauma sustained in the military would be similar between patients treated with amputation and those who underwent limb salvage. Methods: this is a retrospective cohort study of 324 service members deployed to Afghanistan or Iraq who sustained a lower-limb injury requiring either amputation or limb salvage involving revascularization, bone graft/bone transport, local/free flap coverage, repair of a major nerve injury, a complete compartment injury/compartment syndrome. The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function. Standard instruments were used to measure depression (the Center for Epidemiologic Studies Depression Scale), posttraumatic stress disorder (PTSD Checklist-military version), chronic pain (Chronic Pain Grade Scale), and engagement in sports and leisure activities (Paffenbarger Physical Activity Questionnaire). The outcomes of treatment were compared by using regression analysis with adjustment for age, time until the interview, military rank, upper-limb and bilateral injuries, social support, and intensity of combat experiences. Results: overall response rates were modest (59.2 %) and significantly different between those who underwent amputation (64.5 %) and those treated with limb salvage (55.4 %) (p = 0.02). Also, 38.3 % screened positive for depressive symptoms and 17.9 %, for posttraumatic stress disorder (PTSD). One-third (34.0 %) were not working, on active duty, or in school. After adjustment for covariates, participants with an amputation had better scores in all SMFA domains compared with those whose limbs had been salvaged (p < 0.01). They also had a lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports. Conclusions: major lower-limb trauma sustained in the military results in significant disability. Service members who undergo amputation appear to have better functional outcomes than those who undergo limb salvage. Caution is needed in interpreting these results as there was a potential for selection bias.Цель: провести сравнительную оценку результатов лечения военнослужащих с травмами нижних конечностей, полученных в результате военных действий, после ампутаций и органосохраняющих конечность операций (ОКО). Методы: ретроспективное исследование включало 324 военнослужащих армии США, получивших травмы во время военных действий в Афганистане или Ираке, которым выполнены ампутации или ОКО с применением реваскуляризации, костной пластики, транспозиции кожно-мышечных лоскутов, пластики магистральных нервных стволов и лечения компартмент-синдрома. Функциональные результаты оценивали с помощью шкалы SMFA (Short Musculoskeletal Function Assessment). Анализировали также степень депрессии (Center for Epidemiologic Studies Depression Scale), посттравматические стрессовые расстройства (ПСР) по опроснику Checklist-military Version, хронические боли (Chronic Pain Grade Scale), спортивную и повседневную ак­тивность (Paffenbarger Physical Activity Questionnaire). Результаты анализировали с учетом возраста, времени после ранения, воинского звания, сочетания травм верхних и нижней конечностей, социальной поддержки и предшествующего опыта боевых действий.Результаты: общий процент ответивших был 59,2 % и значительно (р = 0,02) отличался в группе с ампутациями (64,5 %) и ОКО (55,4 %). У 38,3 % исследованных зафиксированы выраженные симптомы депрессии, у 17,9 % – ПСР. Не работали или не продолжали обучение 34,0 % пострадавших. У военнослужащих после ампутаций конечностей получены лучшие результаты по всем разделам шкалы SMFA по сравнению с теми, у кого конечности сохранены (р < 0,01). Они также имели более низкую вероятность развития ПСР и более высокие возможности заниматься спортом. Выводы: большинство травм нижних конечностей, полученных в результате боевых действий, приводят к инвалидности. Раненные после ампутации имеют лучшие отдаленные функциональные результаты, чем пострадавшие после ОКО. Результаты необходимо интерпретировать с осторожностью из-за возможных отклонений в чистоте отбора пациентов.Мета: провести порівняльне оцінювання результатів лікування військовослужбовців із травмами нижніх кінцівок, отриманих у результаті військових дій, після ампутацій і органозберігальних кінцівку операцій (ОКО).Методи: ретроспективне дослідження включало 324 військовослужбовці армії США, які отримали травми під час військових дій в Афганістані або Іраку та яким виконані ампутації або ОКО із застосуванням реваскуляризації, кісткової пластики, транспозиції шкірно-м’язових шматків, пластики магістральних нервових стовбурів та лікування компартмент-синдрому. Функціональні результати оцінювали за допомогою шкали SMFA (Short Musculoskeletal Function Assessment). Аналізували також ступінь депресії (Center for Epidemiologic Studies Depression Scale), посттравматичні стресові розлади (ПСР) за опитувальником Checklist-military Version, хронічні болі (Chronic Pain Grade Scale), спортивну і повсякденну активність (Paffenbarger Physical Activity Questionnaire). Результати аналізували з урахуванням віку, часу після поранення, військового звання, поєднаних травм верхніх і нижніх кінцівок, соціальної підтримки й попереднього досвіду бойових дій. Результати: загальний відсоток відповівших був 59,2 % і значно (р = 0,02) відрізнявся в групі з ампутацією (64,5 %) і ОКО (55,4 %). У 38,3 % досліджених зафіксовані виражені симптоми депресії, у 17,9 % — ПСР. Не працювали або не продовжували навчання 34,0 % постраждалих. У військовослужбовців після ампутацій кінцівок отримані кращі результати по всіх розділах шкали SMFA порівняно з тими, у кого кінцівки збережені (р < 0,01). Вони також мали нижчу ймовірність розвитку ПСР і вищі можливості займатися спортом. Висновки: більшість травм нижніх кінцівок, отриманих у результаті бойових дій, призводять до інвалідності. Поранені після ампутації мають кращі віддалені функціональні результати, ніж постраждалі після ОКО. Результати необхідно інтерпретувати з обережністю через можливі відхилення в чистоті відбору пацієнтів

Military and Civilian Collaboration: The Power of Numbers

The purpose of this study was to compare the number and types of extremity injuries treated at civilian trauma centers (CIV CENs) versus military treatment facilities (MTFs) participating in the Major Extremity Trauma Research Consortium (METRC) and to investigate the potential benefits of a clinical research network that includes both civilian trauma centers and MTFs. Two analyses were performed. First, registry data collected on all surgically treated fractures at four core MTFs and 21 CIV CENs over one year were compared. Second, actual numbers and distribution of patients by type of injury enrolled in three METRC studies were compared. While MTFs demonstrated higher percentages of severe injuries including open fractures, traumatic amputations, vascular injuries, contamination, and injuries with bone, muscle, and skin loss when compared to CIV CENS, the CIV CENs treated a substantially higher number and, more importantly, enrolled patients in almost all categories. Comparison of service members to civilians was challenged by several differences between the two patient populations including mechanism of injury, the medical care environment, and confounding factors such as age, social setting and co-morbidities. Despite these limitations, in times without active military conflict, clinical trials will likely rely on civilian trauma centers for patient enrollment; only when numbers are pooled across a large number of centers can requisite sample sizes be met. These data demonstrate the benefits of maintaining a military-civilian partnership to address the major gaps in research defined by the Military

Flexible Adult Acquired Flatfoot Deformity

Category: Other Introduction/Purpose: Adult acquired flatfoot deformity (AAFD) is a biomechanical derangement involving the three- dimensional (3D) midfoot and hindfoot osseous complex, which can be challenging to optimally characterize using conventional two-dimensional (2D) plain radiographs. Weightbearing (WB) Cone-Beam CT (CBCT) can better demonstrate the deformity of the 3D structures during WB. Therefore, we compared validated AAFD measurements between non-weightbearing (NWB) and WB CBCT images. Methods: In this prospective, IRB approved study, 20 patients were included, 12 males and 8 females, mean age of 54.21 (20-88) years, with clinical diagnosis of flexible AAFD. Subjects were scanned with standing (WB) and seated (NWB) CBCTs. WB and NWB CBCT images were assessed with traditional flatfoot measurements obtained at sagittal, coronal, and axial planes using predefined anatomical landmarks, by two independent observers. Interobserver reliability was calculated using Pearson correlation. Results: The measurements in patients with AAFD differed significantly between WB and NWB CBCT images. Specifically, WB images showed, when compared to NWB, decreased forefoot arch angle (mean difference: 9.91°, p < 0.0001), increased talus-first metatarsal angle (10.59°, p < 0.0001), increased navicular-medial cuneiform angle (13.89°, p < 0.0001), decreased navicular-floor (coronal 14.05mm/sagittal 14.91mm, p < 0.0001) and navicular-skin distances (coronal 5.87mm/sagittal 8.25mm, p < 0.0001), decreased medial cuneiform-floor (coronal 10.79mm/sagittal 11.07mm, p < 0.0001) and medial cuneiform-skin distances (coronal 4.45mm/sagittal 5.78mm, p < 0.0001), and decreased cuboid-floor (5.78mm, p < 0.0001) and cuboid-skin distances in the sagittal plane (4.60mm, p < 0.0001). Interobserver reliability was good to excellent (0.610-0.991). Conclusion: Traditional adult acquired flatfoot deformity radiographic measurements are obtainable using high resolution 3D WB CBCT imaging, and can help characterize the biomechanical derangements during weightbearing in subjects with flexible AAFD

Interobsever Variability of Measurements for Flatfoot Deformity Using High Resolution Weightbearing Cone-Beam CT Examination According to Reader Experience

Category: Other Introduction/Purpose: To evaluate interobserver reliability among readers of different clinical experience by applying measurements for adult acquired flatfoot deformity (AAFD) using high-resolution three-dimensional (3D) weightbearing (WB) cone-beam CT (CBCT) examination. Methods: In this IRB approved study, 20 patients with flexible AAFD [12 male, 8 female; mean age 54.2 (20-88) years] were scanned with standing (weightbearing) CTs. Two blinded observers, a medical student and a foot/ankle surgeon, applied validated AAFD measurements in sagittal, coronal, and axial planes using predefined anatomical landmarks. Interobserver reliability was calculated using Pearson correlation. Results: There was significant interobserver agreement with high correlation for the following measurements(p 0.05) was noted in mean talar-first metatarsal and subtalar horizontal angles. Conclusion: While literature describes large variability for AAFD measurements from plain radiographs among readers of varying medical experience, 3D WB CBCT can yield similar measurements using predefined planes with high reliability, independent of reader experience