Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 474 | Issue 6 | Jun, 2016

Do Orthopaedic Surgeons Acknowledge Uncertainty?

Teun Teunis MD, Stein Janssen MD, Thierry G. Guitton MD, PhD, David Ring MD, PhD, Robert Parisien MD

Much of the decision-making in orthopaedics rests on uncertain evidence. Uncertainty is therefore part of our normal daily practice, and yet physician uncertainty regarding treatment could diminish patients’ health. It is not known if physician uncertainty is a function of the evidence alone or if other factors are involved. With added experience, uncertainty could be expected to diminish, but perhaps more influential are things like physician confidence, belief in the veracity of what is published, and even one’s religious beliefs. In addition, it is plausible that the kind of practice a physician works in can affect the experience of uncertainty. Practicing physicians may not be immediately aware of these effects on how uncertainty is experienced in their clinical decision-making.

Will My Tibial Fracture Heal? Predicting Nonunion at the Time of Definitive Fixation Based on Commonly Available Variables

Kevin O’Halloran MD, Max Coale BA, Timothy Costales BS, Timothy Zerhusen BS, Renan C. Castillo PhD, Jason W. Nascone MD, Robert V. O’Toole MD

Accurate prediction of tibial nonunions has eluded researchers. Reliably predicting tibial nonunions at the time of fixation could change management strategies and stimulate further research.

The Radiographic Union Score for Hip (RUSH) Identifies Radiographic Nonunion of Femoral Neck Fractures

Tym Frank MD, Georg Osterhoff MD, Sheila Sprague PhD, Alisha Garibaldi MSc, Mohit Bhandari MD, PhD, Gerard P. Slobogean MD, MPH

The Radiographic Union Score for Hip (RUSH) is a previously validated outcome instrument designed to improve intra- and interobserver reliability when describing the radiographic healing of femoral neck fractures. The ability to identify fractures that have not healed is important for defining nonunion in clinical trials and predicting patients who will likely require additional surgery to promote fracture healing. We sought to investigate the utility of the RUSH score to define femoral neck fracture nonunion.

Allogeneic and Autogenous Bone Grafts Are Affected by Historical Donor Environmental Exposure

Caleb Behrend MD, Jonathon Carmouche MD, Paul W. Millhouse MD, Lauren Ritter MPH, Joseph Moskal MD, Paul Rubery MD, Edward Puzas PhD

Bone graft materials are routinely evaluated for infectious agents; however, data regarding contamination of bone graft from environmental exposure of the donors to osteotoxic substances such as lead are not routinely available. In animal models, stored lead in bone has been shown to impair fracture healing and osteocyte function. In clinical studies, lead is linked to skeletal disease at relatively low concentrations. Presumably the levels of lead in allografts mirror the level of lead in bone in the population; however, the degree to which processing might decrease this and the frequency with which potentially osteotoxic levels appear in bone grafts have not been studied.

Large-magnitude Pelvic and Retroperitoneal Tissue Damage Predicts Organ Failure

Greg Gaski MD, Travis Frantz BS, Scott Steenburg MD, Teresa Bell PhD, Todd McKinley MD

Pelvic and retroperitoneal trauma is a major cause of morbidity and mortality in multiply injured patients. The Injury Severity Score (ISS) has been criticized for underrepresenting and inaccurately defining mechanical injury. The influence of pelvic injury volume on organ dysfunction and multiple organ failure (MOF) has not been described. Through the use of CT, this investigation sought to precisely define volumes of mechanical tissue damage by anatomic region and examine its impact on organ failure.

Do Transsacral-transiliac Screws Across Uninjured Sacroiliac Joints Affect Pain and Functional Outcomes in Trauma Patients?

John Heydemann MD, Braden Hartline MD, Mary Elizabeth Gibson MD, Catherine G. Ambrose PhD, John W. Munz MD, Matthew Galpin RC, Timothy S. Achor MD, Joshua L. Gary MD

Patients with pelvic ring displacement and instability can benefit from surgical reduction and instrumentation to stabilize the pelvis and improve functional outcomes. Current treatments include iliosacral screw or transsacral-transiliac screw, which provides greater biomechanical stability. However, controversy exists regarding the effects of placement of a screw across an uninjured sacroiliac joint for pelvis stabilization after trauma.

Does Surgical Stabilization of Lateral Compression-type Pelvic Ring Fractures Decrease Patients’ Pain, Reduce Narcotic Use, and Improve Mobilization?

Jennifer Hagen MD, Renan Castillo PhD, Andrew Dubina MD, Greg Gaski MD, Theodore T. Manson MD, Robert V. O’Toole MD

Debate remains over the role of surgical treatment in minimally displaced lateral compression (Young-Burgess, LC, OTA 61-B1/B2) pelvic ring injuries. Lateral compression type 1 (LC1) injuries are defined by an impaction fracture at the sacrum; type 2 (LC2) are defined by a fracture that extends through the posterior iliac wing at the level of the sacroiliac joint. Some believe that operative stabilization of these fractures limits pain and eases mobilization, but to our knowledge there are few controlled studies on the topic.

Does Postoperative Radiation Decrease Heterotopic Ossification After the Kocher-Langenbeck Approach for Acetabular Fracture?

Jason A. Davis MD, Brennan Roper BS, John W. Munz MD, Timothy S. Achor MD, Matthew Galpin RC, Andrew M. Choo MD, Joshua L. Gary MD

Controversy regarding heterotopic ossification (HO) prophylaxis exists after Kocher-Langenbeck for treatment of acetabular fracture. Prophylaxis options include antiinflammatory oral medications, single-dose radiation therapy, and débridement of gluteus minimus muscle. Prior literature has suggested single-dose radiation therapy as the best prophylaxis to prevent HO formation. However, recent reports have emerged of radiation-induced sarcoma after radiotherapy for HO prophylaxis, which has led many surgeons to reconsider the risks and benefits of single-dose radiation therapy. We set out to determine if radiotherapy, in addition to standard débridement of gluteus minimus muscle, affected postoperative HO formation after a Kocher-Langenbeck approach for acetabular fracture.

Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures?

Justin M. Haller MD, David Holt MD, David L. Rothberg MD, Erik N. Kubiak MD, Thomas F. Higgins MD

High-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined.

Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis

Nicholas Smith MD, MSc, Craig Stone MD, MSc, FRCSC, Andrew Furey MD, MSc, FRCSC

Although Lisfranc injuries are uncommon, representing approximately 0.2% of all fractures, they are complex and can result in persistent pain, degenerative arthritis, and loss of function. Both open reduction and internal fixation (ORIF) and primary fusion have been proposed as treatment options for these injuries, but debate remains as to which approach is better.

Can Vascular Injury be Appropriately Assessed With Physical Examination After Knee Dislocation?

Douglas S. Weinberg MD, Nicholas R. Scarcella BS, Joshua K. Napora MD, Heather A. Vallier MD

Knee dislocations are rare injuries with potentially devastating vascular complications. An expeditious and accurate diagnosis is necessary, as failing to diagnose vascular injury can result in amputation; however, the best diagnostic approach remains controversial.

Validation of the KOOS, JR: A Short-form Knee Arthroplasty Outcomes Survey

Stephen Lyman PhD, Yuo-Yu Lee MS, Patricia D. Franklin MD, MBA, MPH, Wenjun Li PhD, Michael B. Cross MD, Douglas E. Padgett MD

Medicare is rapidly moving toward using patient-reported outcome measures (PROMs) for outcomes assessment and justification of orthopaedic and other procedures. Numerous measures have been developed to study knee osteoarthritis (OA); however, many of these surveys are long, disruptive to clinic flow, and result in incomplete data capture and/or low followup rates. The Knee injury and Osteoarthritis Outcome (KOOS) physical function short-form (KOOS-PS), while shorter, ignores pain, which is a primary concern of patients with advanced knee OA.

Validation of the HOOS, JR: A Short-form Hip Replacement Survey

Stephen Lyman PhD, Yuo-Yu Lee MS, Patricia D. Franklin MD, MBA, MPH, Wenjun Li PhD, David J. Mayman MD, Douglas E. Padgett MD

Patient-reported outcome measures (PROMs) are increasingly in demand for outcomes evaluation by hospitals, administrators, and policymakers. However, assessing total hip arthroplasty (THA) through such instruments is challenging because most existing measures of hip health are lengthy and/or proprietary.

Variation in Resource Utilization for Patients With Hip and Pelvic Fractures Despite Equal Medicare Reimbursement

Andre M. Samuel BBA, Matthew L. Webb AB, Adam M. Lukasiewicz MSc, Bryce A. Basques MD, MHS, Daniel D. Bohl MD, MPH, Arya G. Varthi MD, Joseph M. Lane MD, Jonathan N. Grauer MD

Medicare currently reimburses hospitals for inpatient admissions with “bundled” payments based on patient Diagnosis-related Groups (DRGs) regardless of true hospital costs. At present, DRG 536 (fractures of the hip and pelvis) includes a broad spectrum of patients with orthopaedic trauma, likely with varying inpatient resource utilization. With the growing incidence of fractures in the elderly, inadequate reimbursements from Medicare for certain patients with DRG 536 may lead to growing financial strain on healthcare institutions caring for these patients with higher costs.

Addition of a Medial Locking Plate to an In Situ Lateral Locking Plate Results in Healing of Distal Femoral Nonunions

Michael A. Holzman MD, Bryan D. Hanus MD, John W. Munz MD, Daniel P. O’Connor PhD, Mark R. Brinker MD

Nonunion of the distal femur after lateral plating is associated with axial malalignment, chronic pain, loss of ambulatory function, and decreased knee ROM. The addition of a medial locking plate with autogenous bone grafting can provide greater stability to allow bone healing and may be used to achieve union in these challenging cases.

Do Patients After Chondrosarcoma Treatment Have Age-appropriate Bone Mineral Density in the Long Term?

Gerhard M. Hobusch MD, Thomas M. Tiefenboeck MD, Janina Patsch MD, Christoph Krall MD, Gerold Holzer MD

In long-term survivors of osteosarcoma and Ewing sarcoma treated with the addition of radio- and chemotherapy, low bone mineral density (BMD) and fractures have been observed, presumably resulting from these adjuvants. Because patients with chondrosarcoma usually are not treated with conventional adjuvant treatment, observation of low BMD in patients with chondrosarcoma presumably would be the result of other mechanisms. However, BMD in patients with a history of chondrosarcoma has not been well characterized.

Creating an Intraoperative MRI Suite for the Musculoskeletal Tumor Center

Nathan W. Mesko MD, David M. Joyce MD, Hakan Ilaslan MD, Michael J. Joyce MD

Altered anatomy in a previously irradiated surgical bed can make accurate localization of anatomic landmarks and local recurrence nearly impossible. The use of intraoperative MRI (iMRI) has been described in neurosurgical settings, but to our knowledge, no such description has been made regarding its utility for local recurrence localization in sarcoma surgery.

Erratum to: Do Orthopaedic Surgeons Acknowledge Uncertainty?

Teun Teunis MD, Stein Janssen MD, Thierry G. Guitton MD, PhD, David Ring MD, PhD, Robert Parisien MD
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