Alexander Joeris

Membrane Induced Osteogenesis in the Management of Posttraumatic Bone Defects.

Objective: To evaluate the union rate of posttraumatic bone defects treated with the induced membrane technique. Design: Single-center retrospective case series. Setting: Level I trauma center. Patients/Participants: Thirty-three patients who sustained 34 posttraumatic bone defects (19 tibia, 15 femur). Intervention: Staged management using the induced membrane technique described by Masquelet. After extensive debridement at the fracture site, a polymethylmethacrylate (PMMA) spacer was inserted into the resulting void. After soft tissue recovery, the spacer was removed, and the void, now enveloped by an induced membrane, was filled with an autologous iliac crest bone graft. Main Outcome Measures: Bone union rate, time to achieve bone union, length of hospital stay, number of surgeries, infection resolution, range of motion, musculoskeletal tumor society system functional score, and limb shortening. Results: The mean defect size was 6.7 cm, and infection was present in 23 (68%) of the bone defects. Bone union was evident in 91% of cases (31/34). The average time to union was 8.5 months. In 7 of 23 (30%) of infected cases, the infection recurred, and in 3 of them, the graft was resorbed, resulting in treatment failure. Conclusion: The induced membrane technique was effective for managing posttraumatic bone defects. A recurrence of infection was associated with treatment failure. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Parameters Pointing at an Increased Risk for Contralateral Hip Fractures Systematic Review

Background: Early identification of hip fracture (HF) patients bearing an increased risk for a contralateral occurrence would allow providing preventive measures timely. Objectives: To summarize the available evidence describing risk scores, prognostic instruments, or (groups of) parameters predicting contralateral HFs at the time point of the first fracture. Methods/Systematic Review: Articles were identified through searches in MEDLINE and Scopus from inception to April 2014, checking of reference lists of the included studies and reviews. One reviewer assessed all articles for inclusion and abstracted the data. Uncertain cases were discussed and decided with a second reviewer. Salient study and population characteristics were abstracted for each article. Studies reporting the association of a set of risk factors for second HFs were further examined and compared. The number of studies reporting on a risk parameter was assessed. Results: Searches identified 3560 records, and 47 studies were included in this review. There was a large spectrum of study designs, patient populations, and follow-up periods. Among 11 studies reporting on a set of parameters, female gender was assessed most commonly (7 times), followed by age (5) and parameters of general health, vision, and stroke (each 4 times). We were unable to depict stringent patterns of risk parameters to be used for decision making in clinical practice. Conclusions: The findings of this article call for a conjoint effort to achieve an expert consensus regarding a critical set of parameters for a risk instrument identifying patients bearing an increased risk for contralateral HFs early.

Improving site selection in clinical studies: a standardised, objective, multistep method and first experience results

Introduction A considerable number of clinical studies experience delays, which result in increased duration and costs. In multicentre studies, patient recruitment is among the leading causes of delays. Poor site selection can result in low recruitment and bad data quality. Site selection is therefore crucial for study quality and completion, but currently no specific guidelines are available. Material and methods Selection of sites adequate to participate in a prospective multicentre cohort study was performed through an open call using a newly developed objective multistep approach. The method is based on use of a network, definition of objective criteria and a systematic screening process. Illustrative example of the method at work Out of 266 interested sites, 24 were shortlisted and finally 12 sites were selected to participate in the study. The steps in the process included an open call through a network, use of selection questionnaires tailored to the study, evaluation of responses using objective criteria and scripted telephone interviews. At each step, the number of candidate sites was quickly reduced leaving only the most promising candidates. Recruitment and quality of data went according to expectations in spite of the contracting problems faced with some sites. Conclusion The results of our first experience with a standardised and objective method of site selection are encouraging. The site selection method described here can serve as a guideline for other researchers performing multicentre studies. Trial registration number ClinicalTrials.gov: NCT02297581.

The Great Unknown—A systematic literature review about risk associated with intraoperative imaging during orthopaedic surgeries

INTRODUCTION Modern techniques in orthopaedic surgery using minimally invasive procedures, and increased use of fluoroscopic imaging present a potential increased risk to surgeons due to ionizing radiation exposure. This article is a systematic review of recent literature on radiation exposure of orthopaedic surgeons. MATERIALS AND METHODS Pubmed and Cochrane searches were performed on intraoperative radiation exposure covering English and German articles published between 1.1.2000 and 11.8.2014. Inclusion criteria were clinical studies and systematic literature reviews focusing on radiation exposure of orthopaedic surgeons during surgical procedures of the musculoskeletal system reporting either effective dose (whole body) or equivalent dose at the organ level. All included articles were reviewed with focus on the surgical specialty, the procedure type, the imaging system used, the radiation measurement method, the fluoroscopy time, the radiation exposure, the use of radiation protection, and any references to specific safety guidelines. RESULTS Thirty-four eligible publications were identified. However, the lack of well-designed studies focusing on radiation exposure of surgeons prevents pooling of data. Highest exposure and subsequent equivalent doses were reported from spinal surgery (up to 4.8mSv of equivalent dose to the hand) and intramedullary nailing (up to 0.142mSV of equivalent dose to the thyroid). Radiation exposure was reduced by 96.9% and 94.2% when wearing a thyroid collar and a lead apron. CONCLUSIONS With the increasing use of intraoperative imaging, there is a growing need for radiation awareness by the operating surgeon. Strict adherence to radiation protection should be enforced to protect in-training surgeons. Strategies to reduce exposure include C-arm position, distance, protective wear, and new imaging technologies. Radiation exposure is harmful and action should be taken to minimize exposure.

Expert Consensus on Predictive Parameters for the Occurrence of a Fall and a Contralateral Hip Fracture 1 and 3 Years After Hip Fracture: A Delphi Survey:

Background: Early identification of people at risk for a contralateral hip fracture would be desirable to favorably influence patients’ prognosis. A recent systematic review failed to depict stringent patterns of risk parameters to be used for decision-making in clinical practice. Objective: To perform a consensus study using the Delphi method to reach an expert consensus on predictive parameters for the occurrence of a fall and a contralateral hip fracture 1 and 3 years after hip fracture. Methods: A list of potential members of the expert panel was identified based on the authors’ list of a recently conducted systematic review. Participating experts were asked to name parameters determining the probability for a fall and a contralateral hip fracture 1 and 3 years after an occurred hip fracture, separately. Additionally, we asked how those stated parameters should be measured. All mentioned parameters were compiled and sent back to the experts asking them to weight each single parameter by assigning a number between 1 (not important) and 10 (very important). The survey was conducted online using the REDCap software package. We defined expert agreement if the interquartile range of attributed weights for a parameter was ≤2. A relevant parameter had at least a median weight of 8. Results: Twelve experts from 7 countries completed the survey. Presence of fall history and mental and general health status were considered relevant irrespective of the outcome. For falling within 1 and 3 years, the number of medications and residential status were considered relevant, while for fractures within 1 and 3 years, osteoporosis management was considered important. Conclusion: Using the insights gained in this consensus study, empiric studies need to be set up assessing the prognostic value of the selected parameters.

Intraoperative Radiation Exposure of Orthopaedic Surgeons-Mismatch Between Concerns and Protection

Objective: Although orthopaedic surgeons frequently utilize intraoperative imaging, there is a lack of knowledge about their patterns of radiation protection. The goal of this study was thus to fill this gap by evaluating the use of protection against radiation in relation to concerns, safety guidelines and instructions. Methods: A survey addressing the issue was performed in 531 orthopaedic and trauma surgeons. The questionnaire comprised 26 questions concerning the use of intraoperative radiation in clinical practice, concerns about it and protection against. Results: Over 31% of the surgeons are very concerned about their radiation exposure in their job and about 48% are slightly to moderately concerned. Surgeons from Asia-Pacific, Latin America, and Middle East are significantly more concerned about radiation in their job compared to European surgeons (p<0.002). However, only one fifth of the surgeons wear a dosimeter and half of them never use it. Nearly 65% of the surgeons always wear a lead apron, but only 30.8% wear a thyroid protection. Lead gloves and lead glasses were always worn by only 2.5 % (13/531) and 3.1% (16/531) respectively. Half of the respondents are aware of the radiation protection officer in their clinic, but 38.8% stated the issue has never been the subject of training at their institution. Internal training significantly affects the usage of dosimeters (odds ratio=2.97, 95% confidence interval: 2.00 – 4.39; p<0.001). Conclusion: Although most operating surgeons worry about their exposure, the knowledge and the practical implementation of radiological protection measures in clinical practice is still insufficient. Education is key for better radiation protection in orthopaedic practice.

The influence of health economics on surgeon practice and hospital purchasing decisions: A survey of surgeons at the AO foundation davos courses

Objectives: The survey was conducted to gain a current understanding of how economic evaluations affect surgeon practice and determine their role in hospital purchasing decisions. Methods: A total of 589 surgeons completed a survey on their experience with health economics and hospital purchasing decisions. Demographics and survey results were analyzed both qualitatively and quantitatively. Statistical testing was performed through Chi-square analysis. Results: Of all respondents, 89% and 83% were affected by economic topics at the department level and personally, respectively, within the year before the survey. Fifty-eight percent had discussed device costs with their Finance Department and 32% stopped using their preferred implant for financial reasons. Forty percent indicated that their hospital included both the medical and Financial Departments in purchasing decisions, while 14% and 13% reported that these decisions involve the finance department only and the individual surgeon only, respectively. Fifty-five percent reported that a mixture of both financial/economic and medical/patient information is used when purchasing devices. Fifty-one percent stated that they “always” or “very often” consider the implant cost preoperatively, compared to 18% who responded with “rarely” or “never.” Conclusions: The rise of health economics has impacted surgeon practice; however, these individuals seldom receive training in the area. Interventions that improve knowledge of costs and economic evaluations among these decision-makers must be implemented in a manner that is accessible and well understood.

Patient-reported outcome measurements in clinical routine of trauma, spine and craniomaxillofacial surgeons: between expectations and reality: a survey among 1212 surgeons

Objective To gain information about the advantages/disadvantages of an implementation of patient-reported outcome measures (PROM) into the clinical routine of trauma/orthopaedic surgeons, and to identify the technical constraints confronting a successful implementation of PROMs. Design Online survey. Participants Surgeons who are members of the AO Foundation. Measures Participants answered questions regarding demographics, their familiarity with specific and generic PROMs and the use of PROMs in clinical routine. Furthermore, reasons for/against using PROMs, why not used more often, prerequisites to implement PROMs into clinical routine and whether PROMs would be implemented if adequate tools/technologies were available, were solicited. Χ2 tests and multivariable logistic regressions were conducted to evaluate the effect of the AO Region, surgeon specialisation, current position, clinical experience, and workplace on the familiarity with disease-specific PROMs, the familiarity with generic PROMs and the current use of PROMs. Exploratory factor analysis was used to identify issues underlying the extent of PROM usage. Results 1212 surgeons completed the survey (response rate: 6.8%; margin of error: ±2.72%): 54.2% were trauma/orthopaedic surgeons, 16.6% were spine surgeons, 27.9% were craniomaxillofacial surgeons and 16 had no defined specialty. Working in a certain AO Region, surgical specialisation and current workplace were associated with a higher familiarity of disease-specific PROMs and the use of PROMs in daily clinical routine (p≤0.05). Exploratory factor analysis identified four categories important for the use of PROMs and two categories preventing the use of PROMs. In case of the availability of an adequate tool, 66.2% of surgeons would implement PROMs in clinical routine. Conclusions Our survey results provide an understanding of the use of PROMs in clinical routine. There is consensus on the usefulness of PROMs. User-friendly and efficient tools/technologies would be a prerequisite for the daily use of PROMs. Additionally, educational efforts and/or policies might help.

Bone union with an in situ spacer after the first stage of the induced membrane technique

INTRODUCTION We report a case of an infected bone defect in the tibia in which the treatment was stopped in the first stage of the induced membrane technique. The polymethylmethacrylate (PMMA) spacer, retained in the bone defect, was encapsulated by the bone regeneration. CASE REPORT A 37-year-old male patient with a 7-cm infected bone defect in the tibia was submitted to the first stage of the induced membrane technique with debridement and implantation of a PMMA spacer with antibiotics. The patient refused the second stage of the procedure and achieved bone union with the spacer in situ. There was no recurrence of infection at the 6-year follow-up. CONCLUSION his is the first report of a case in which bone union was achieved with the spacer in situ after the first stage of the induced membrane technique. Keeping the spacer in the bone defect could be an option in some exceptional situations.

Evaluation of the geriatric co-management for patients with fragility fractures of the proximal femur (Geriatric Fracture Centre (GFC) concept): protocol for a prospective multicentre cohort study.

Introduction Treatment of fractures in the elderly population is a clinical challenge due partly to the presence of comorbidities. In a Geriatric Fracture Centre (GFC), patients are co-managed by a geriatrician in an attempt to improve clinical outcomes and reduce morbidity and mortality. Until now the beneficial effect of orthogeriatric co-management has not been definitively proven. The primary objective of this study is to determine the effect of GFC on predefined major adverse events related to a hip fracture compared to usual care centres (UCC). The secondary objectives include assessments in quality of life, patient-reported outcomes and cost-effectiveness. Methods and analysis Two hundred and sixty-six elderly patients diagnosedwith hip fracture and planned to be treated with osteosynthesis or endoprosthesis in either a GFC or UCC study site will be recruited, 133 per type of centre. All procedures and management will be done according to the sites standard of care. Study-related visits will be performed at the following time points: preoperative, intraoperative, discharge from the orthopaedic/trauma department, discharge to definite residential status, 12 weeks and 12 months postsurgery. Data collected include demographics, residential status, adverse events, patient-reported outcomes, fall history, costs and resources related to treatment. The risk of major adverse events at 12 months will be calculated for each centre type; patient-reported outcomes will be analysed by mixed effects regression models to estimate differences in mean scores between baseline and follow-ups whereas cost-effectiveness will be assessed using the incremental cost-effectiveness ratio. Ethics and dissemination Ethics approval for this study was granted from the local Ethics Committees or Institutional Review Board from each of the participating sites prior to patient enrolment. The results of this study will be published in peer-reviewed journals and presented at different conferences. Trial registration number ClinicalTrials.gov: NCT02297581; pre-results.