Brian P. Cunningham

Have Levels of Evidence Improved the Quality of Orthopaedic Research

BackgroundSince 2003 many orthopaedic journals have adopted grading systems for levels of evidence (LOE). It is unclear if the quality of orthopaedic literature has changed since LOE was introduced.Questions/purposesWe asked three questions: (1) Have the overall number and proportion of Level I and II studies increased in the orthopaedic literature since the introduction of LOE? (2) Is a similar pattern seen in individual orthopaedic subspecialty journals? (3) What is the interobserver reliability of grading LOE?MethodsWe assigned LOE to therapeutic studies published in 2000, 2005, and 2010 in eight major orthopaedic subspecialty journals. Number and proportion of Level I and II publications were determined. Data were evaluated using log-linear models. Twenty-six reviewers (13 residents and 13 attendings) graded LOE of 20 blinded therapeutic articles from the Journal of Bone and Joint Surgery for 2009. Interobserver agreement relative to the Journal of Bone and Joint Surgery was assessed using a weighted kappa.ResultsThe total number of Level I and II publications in subspecialty journals increased from 150 in 2000 to 239 in 2010. The proportion of high-quality publications increased with time (pxa0<xa00.001). All subspecialty journals other than the Journal of Pediatric Orthopaedics and the Journal of Orthopaedic Trauma showed a similar behavior. Average weighted kappa was 0.791 for residents and 0.842 for faculty (pxa0=xa00.209).ConclusionsThe number and proportion of Level I and II publications have increased. LOE can be graded reliably with high interobserver agreement. The number and proportion of high-level studies should continue to increase.

Liposomal Formulation Increases Local Delivery of Amphotericin from Bone Cement: A Pilot Study

BackgroundAmphotericin is a highly toxic hydrophobic antifungal. Delivery of amphotericin from antifungal-loaded bone cement (ALBC) is much lower than would be expected for an equivalent load of water-soluble antibacterials. Lipid formulations have been developed to decrease amphotericin toxicity. It is unknown how lipid formulations affect amphotericin release and compressive strength of amphotericin ALBC.Questions/purposesWe asked if amphotericin release from liposomal amphotericin ALBC (1) changed with amphotericin load; (2) differed from release from amphotericin deoxycholate ALBC; (3) was an active drug; and (4) if liposomal amphotericin affected the bone cement strength.MethodsForty-five standardized test cylinders were fabricated from three formulations of ALBC: Simplex™ P bone cement with 200 mg liposomal amphotericin, 800 mg liposomal amphotericin, or 800 mg amphotericin deoxycholate per batch. For each ALBC formulation, cumulative released amphotericin was determined from five cylinders, and compressive strength was measured for 10 cylinders, five before elution and five after. Activity of released amphotericin was determined by growth inhibition assay.ResultsAmphotericin release was greater for increased load of liposomal amphotericin: 770 μg for 800 mg versus 118 μg for 200 mg. Amphotericin release was greater from liposomal ALBC than from deoxycholate ALBC: 770 μg versus 23 μg over 7 days for 800 mg amphotericin. Released amphotericin was active. Compressive strength of liposomal ALBC is decreased, 67 MPa and 34 MPa by Day 7 in elution for the 200-mg and 800-mg formulations, respectively.ConclusionsLiposomal amphotericin has greater amphotericin release from ALBC than amphotericin deoxycholate. Compressive strength of liposomal amphotericin ALBC decreases to less than recommended for implant fixation. Local toxicity data are needed before liposomal amphotericin ALBC can be used clinically.

Clavicular Length: The Assumption of Symmetry

Recent studies have shown subjectively worse outcomes associated with 15 to 20 mm of clavicle shortening. As a result, more than 15 mm of shortening has become a relative indication for operative management. Various methods to quantify shortening have been described in the literature. All measurement techniques described assume clavicular symmetry to assess clavicular shortening. The goal of this study was to assess the side-to-side variation in clavicle length in uninjured, skeletally mature adults.Clavicle length in 102 skeletally mature adults (age range, 22-91 years) was measured using computed tomography data. Clavicle length was defined as the distance between the lateral-most point of the clavicle in the acromioclavicular joint and the medial-most point of the clavicle in the sternoclavicular joint. The side-to-side difference in clavicular length was analyzed, and patients were organized into 2 groups: group 1 was symmetric (difference of less than 5 mm), and group 2 was asymmetric (difference of more than 5 mm). Mean difference in clavicle length for all patients was 4.25±3.8 mm (range, 0-23 mm). Clavicular symmetry was found in 73 (71.5%) of 102 patients. The remaining 29 patients had asymmetry greater than 5 mm. Asymmetry greater than 10 mm was found in 7 (7%) of 102 patients. Twenty-eight percent of clavicles were asymmetric, whereas 7% had clinically significant asymmetry that could affect treatment decisions.This finding calls into question previous methods developed to assess clavicular length in the setting of trauma because of the assumption of symmetry. Further studies are needed to evaluate the effect of hand dominance and pediatric trauma on this observation.

Population Characteristics and Clinical Outcomes From the SIGN Online Surgical Database

Summary: There are over 26,000 cases recorded in the SIGN Online Surgical Database (SOSD). Though follow-up is limited, there is an abundance of data describing the population being treated and the resultant outcomes. Furthermore, given the lack of evidence available, the clinical outcomes reported in the database are a first step toward understanding the safety and efficacy of Surgical Implant Generation Network (SIGN) nailing. Methods: All data from the SOSD from 2003 to August 2009 were included in the study. The primary outcome considered was the rate of deep infection. Results: The majority of patients were young men. Over 20% of patients had a delay of greater than 10 days from the time of the injury to surgery, and more than 5% were considered a nonunion preoperatively. Femoral shaft fractures were the most common indication for SIGN nailing. The infection rate was less than 2% for closed fractures and between 5% to 7% for open fractures. The number of patients with documented full painless weight bearing increased dramatically with more recent surgery. Discussion: Operative intervention has significant potential to reduce the burden of long-bone fractures at the familial and societal level. The infection rate was comparable to studies published in the Western literature. The weight bearing data are unlikely to be of clinical significance. Conclusion: There is a tremendous amount of data regarding patients treated with SIGN nails in the SOSD. With improvement in clinical follow-up, this will be invaluable in assessing the safety and efficacy of SIGN nailing and addressing important clinical questions.

Sciatic nerve entrapment in associated both-column acetabular fractures: a report of 2 cases and review of the literature.

Sciatic nerve injury associated with acetabular fractures has been reported in most series. Typically, sciatic neuropraxia occurs from traumatic impaction or compression due to posterior hip fracture-dislocation. We report 2 patients with sciatic nerve entrapment within the posterior column components of their associated both-column acetabular fractures. Following neuroplasty through a Kocher-Langenbeck surgical approach, both patients neurologic function improved. This unlikely cause of neurologic compromise should be considered in all patients with symptoms of sciatic nerve injury or irritation and particularly in the presence of a mechanical block during posterior column reduction through an ilioinguinal approach.

Professional Demands and Job Satisfaction in Orthopaedic Trauma: An OTA Member Survey.

Objectives: The goal of this study was to examine the factors that affect career satisfaction in orthopaedic traumatologists. We hypothesize that the level of stress and career satisfaction in orthopaedic traumatology would be affected by increased number of call nights and work hours. Data Sources: A 30-question survey was emailed to members of the OTA. The survey evaluated 5 critical areas: training/experience, practice characteristics, demands, stress management strategies, and satisfaction. Study Selection: After approval by the OTA research committee, all active and associate US members of the OTA were contacted. Data Extraction: The survey was open to the OTA members from July through November of 2012. Data Synthesis: Of 1031 members of the OTA, 263 members responded for an overall response rate of 25.5%. Most respondents were fellowship-trained (218, 82.9%) and predominantly young (<5 years in practice, 34.4%) or established surgeons (>15 years in practice, 28.5%). Most surgeons were married (229, 87.1%) and have not been divorced (226, 85.9%). Career satisfaction was statistically improved by belonging to larger practice (P = 0.016), decreased by work for more hours per week (P = 0.001), and improved by taking more call (P = 0.014). Conclusions: Career satisfaction among orthopaedic trauma surgeons was extremely high. Our results indicate that young surgeons may improve their job satisfaction and potentially prolong their career by limiting the numbers of hours worked, taking a consistent number of calls and joining a larger group. Level of Evidence: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Intraoperative CT in the Assessment of Posterior Wall Acetabular Fracture Stability

Posterior wall acetabular fractures that involve 10% to 40% of the posterior wall may or may not require an open reduction and internal fixation. Dynamic stress examination of the acetabular fracture under fluoroscopy has been used as an intraoperative method to assess joint stability. The aim of this study was to demonstrate the value of intraoperative ISO computed tomography (CT) examination using the Siemens ISO-C imaging system (Siemens Corp, Malvern, Pennsylvania) in the assessment of posterior wall acetabular fracture stability during stress examination under anesthesia. In 5 posterior wall acetabular fractures, standard fluoroscopic images (including anteroposterior pelvis and Judet radiographs) with dynamic stress examinations were compared with the ISO-C CT imaging system to assess posterior wall fracture stability during stress examination. After review of standard intraoperative fluoroscopic images under dynamic stress examination, all 5 cases appeared to demonstrate posterior wall stability; however, when the intraoperative images from the ISO-C CT imaging system demonstrated that 1 case showed fracture instability of the posterior wall segment during stress examination, open reduction and internal fixation was performed. The use of intraoperative ISO CT imaging has shown an initial improvement in the surgeons ability to assess the intraoperative stability of posterior wall acetabular fractures during stress examination when compared with standard fluoroscopic images.

Fracture healing: A review of clinical, imaging and laboratory diagnostic options

A fundamental issue in clinical orthopaedics is the determination of when a fracture is united. However, there are no established gold standards, nor standardized methods for assessing union, which has resulted in significant disagreement among orthopaedic surgeons in both clinical practice and research. A great deal of investigative work has been directed to addressing this problem, with a number of exciting new techniques described. This review provides a brief summary of the burden of nonunion fractures and addresses some of the challenges related to the assessment of fracture healing. The tools currently available to determine union are discussed, including various imaging modalities, biomechanical testing methods, and laboratory and clinical assessments. The evaluation of fracture healing in the setting of both patient care and clinical research is integral to the orthopaedic practice. Weighted integration of several available metrics must be considered to create a composite outcome measure of patient prognosis.

Femoral Shaft Nonunions

Femoral shaft nonunions are a clinical and surgical challenge for the orthopedic surgeon. Despite advances in surgical technique, fracture fixation alternatives, and adjuncts to healing, femoral shaft nonunions continue to be a significant clinical problem. A successful outcome is frequently time consuming, and requires utilization of a large number of resources creating a high cost to the patient. Femoral fractures may fail treatment secondary to the damage at the initial injury, soft tissues loss, poorly designed initial fixation, and host factors including cigarette use, advanced age, immune compromised state, and medical comorbidities. A critical component to a successful outcome is an accurate diagnosis, defining the etiology of the nonunion whether it may be a biological or mechanical matter or both including patient-specific risk factors. Orthopedic surgeons must understand the numerous treatment options and the role each plays in order to achieve union and ultimately rehabilitate the patient. With careful planning, a number of surgical options can result in excellent clinical outcomes including dynamization, exchange nailing, plate osteosynthesis, plate augmentation, external fixation, and judicious use of bone grafting and biologic agents.

Immediate weight-bearing as tolerated has improved outcomes compared to non–weight-bearing after surgical stabilisation of midshaft clavicle fractures in polytrauma patients

Immediate Weight Bearing as Tolerated Has Improved Outcomes Compared to Non-Weight Bearing After Surgical Stabilization of Midshaft Clavicle Fractures in Polytrauma Patients Brian P. Cunningham, MD1 ; Gilbert R. Ortega, MD2; Anthony S. Rhorer, MD1; Brian Miller, MD1; Hrayr Basmajian, MD3; Ryan McLemore, PhD1; Kelly A. Jackson, NP-C4 1Banner Good Samaritan, Phoenix, Arizona, USA; 2Sonoran Orthopedic Trauma Surgeons, Scottsdale, Arizona, USA; 3Loma Linda University Medical Center, Loma Linda, California, USA; 4Scottsdale Healthcare, Scottsdale, Arizona, USA