Derek J. Donegan

The 36-item short form.

Abstract The use of patient‐derived, objective outcome measures has expanded substantially within the orthopaedic literature. Qualityof‐life instruments are categorized as general health or as condition‐specific questionnaires. The Medical Outcomes Study 36‐Item Short Form (SF‐36) is a general health‐based survey of quality of life. It has been validated, is used widely across medical disciplines, and can be self‐administered by the patient with reliability. The SF‐36 has been implemented to define disease conditions, to determine the effect of treatment, to differentiate the effect of different treatments, and to compare orthopaedic conditions with other medical conditions. However, a bias of lower over upper extremity function has been demonstrated with the SF‐ 36, as have limitations in assessment of certain physical activities of daily living as well as upper and lower limits on the detection of certain changes in quality‐of‐life status. Nevertheless, with an adequate knowledge of its effectiveness and limitations, the SF‐36 can be a useful tool in many branches of orthopaedic surgery.

Use of Medical Comorbidities to Predict Complications After Hip Fracture Surgery in the Elderly

BACKGROUND Comorbidities before and complications following hip fracture surgery can impact the return of function. We hypothesized that the American Society of Anesthesiologists (ASA) classification of medical comorbidities is a useful surrogate variable for the patients general medical condition and would be a strong predictor of perioperative medical complications following hip fracture surgery. METHODS A retrospective review of the cases of 197 elderly patients who had undergone operative management of a hip fracture was performed. The ASA class, data regarding perioperative medical and surgical complications, and demographic data were obtained. Medical complications were defined as those requiring intervention by an internist or medical specialist. Differences in complication rates among the ASA classes were determined. RESULTS Medical complications were more common in patients in ASA class 3 (p < 0.001) and those in class 4 (p = 0.001) than in those in class 2. Patients in ASA class 3 had a 3.78 times greater chance of having a medical complication than did those in class 2 (p < 0.001). Patients in ASA class 4 had a 7.39 times greater chance of having medical complications than did those in class 2 (p = 0.001). No significant relationship was identified between the ASA class and surgical complications. CONCLUSIONS The ASA class is strongly associated with medical problems in the perioperative period following hip fracture surgery in the elderly. Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion.

Early Effects of Resident Work-Hour Restrictions on Patient Safety: A Systematic Review and Plea for Improved Studies

BACKGROUND since the inception of the eighty-hour work week, work hour restrictions have incited considerable debate. Work hour policies were designed to prevent medical errors and to reduce patient morbidity and mortality. It is unclear whether work hour restrictions have been helpful in medicine in general and in orthopaedic surgery specifically. This systematic review of the literature was designed to determine the success of these restrictions in terms of patient mortality, medical errors, and complications. METHODS a systematic review of the literature was performed to determine if work hour rules have improved patient and systems-based outcomes and reduced physician errors as measured by mortality, medical errors, and complications. A random effects model was utilized to determine whether patient mortality rates were improved under the new rules. RESULTS the odds of patient death before implementation of the work hour rules were 1.12 (95% confidence interval, 1.07 to 1.17) times those after implementation. These differences were consistent across disciplines. The data concerning medical or surgical complications before and after the institution of the work hour rules were mixed. There was little information in these studies concerning direct medical errors. The odds of death in nonteaching cohorts were not significantly different from that in teaching cohorts. CONCLUSIONS there appears to be a decrease in mortality following the institution of work hour rules. The difference seen in teaching cohorts is not significantly different from that in nonteaching cohorts. It is unclear whether this difference would have been observed even without work hour restrictions. No study has shown a reduction in mortality for orthopaedic patients in teaching cohorts that was greater than that observed in nonteaching cohorts. Because of methodological concerns and the lack of current literature linking physician fatigue and physician underperformance with patient mortality, it is unclear whether the goals of the work hour reductions have been achieved. Furthermore, because of a lack of a so-called dose-response relationship between work hour reduction and patient mortality, it is uncertain whether further reductions would be beneficial. LEVEL OF EVIDENCE therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Surgical resection of heterotopic bone about the elbow: an institutional experience with traumatic and neurologic etiologies.

PURPOSE We evaluated the outcomes of patients with elbow heterotopic ossification (HO) who underwent surgical intervention. Our goal was to elucidate differences in outcome of surgical treatment between those patients with traumatic brain injury, direct elbow trauma, or combined etiologies. In addition, we used regression analysis to adjust for confounding factors (such as age, gender, preoperative range of motion [ROM], location of HO, chronicity of HO [ie, time from HO formation to surgery], and whether motor control was spastic or normal) on the relationship between surgical outcome and etiology. METHODS We reviewed 60 patients (64 elbows) surgically treated for heterotopic ossification. A total of 42 patients had trauma as the primary etiology, 15 had traumatic brain injury, and 7 had combined etiologies. All had pain or functional limitations at presentation. All patients had surgical resection of their HO. Functional and ROM outcomes were recorded. RESULTS Mean preoperative arc of motion for the entire cohort was 57° (range, 0° to 150°). Mean postoperative arc for the entire cohort was 106° (range, 0° to 145°) at a mean follow-up of 44 months (range, 21-72 mo), demonstrating a significant gain. Average gain, in arc of motion was 49° (range, 10° to 140°). Gains in motion were not significantly different in any individual etiologic group. A total of 6% of cases were complicated by infection, 13% of cases had recurrence of HO, and 11% of cases required repeat surgery for infection or recurrence. Preoperative ROM was an important independent predictor of final range achieved and gain in ROM after surgical intervention. Recurrence rates were higher in patients with neurologic involvement. Postoperative stiffness was related to preoperative stiffness, delay of surgery longer than 12 months, and anterior location of the HO. CONCLUSIONS Surgical excision of heterotopic bone about the elbow results in significant gains in ROM regardless of etiology. The likelihood of recurrence is higher in patients with central nervous system injuries than in patients with purely localized trauma.

Intraobserver and Interobserver Agreement in the Measurement of Displaced Humeral Medial Epicondyle Fractures in Children

BACKGROUND Fractures of the humeral medial epicondyle occur frequently in children. The decision to pursue operative or nonoperative treatment often hinges on the amount of perceived fracture displacement. This study was performed to assess both intraobserver and interobserver agreement in the measurements of displacement of these fractures on radiographs by orthopaedic surgeons with various levels of training. METHODS We performed a retrospective review of the radiographs of thirty-eight patients with a fracture of the medial epicondyle of the humerus. Digital anteroposterior, lateral, and oblique radiographs of each involved elbow made at presentation were presented to five separate reviewers with different levels of orthopaedic training, including two junior residents (junior residents 1 and 2), one fellow, one junior attending surgeon, and one senior attending surgeon. Each reviewer recorded the amount of perceived displacement in millimeters. A difference of >2 mm between measurements represented clinical disagreement between reviewers. Intraobserver and interobserver agreement was assessed by calculating both the intraclass correlation coefficient and the percentage of clinical disagreement between ratings. RESULTS The intraclass correlation coefficients for intraobserver agreement regarding the measurements on the anteroposterior radiographs were 0.24 (95% confidence interval, 0.00 to 0.68) for junior resident 1, 0.82 (95% confidence interval, 0.41 to 0.95) for junior resident 2, 0.83 (95% confidence interval, 0.46 to 0.96) for the senior attending surgeon, 0.92 (95% confidence interval, 0.69 to 0.98) for the junior attending surgeon, and 0.98 (95% confidence interval, 0.92 to 1.00) for the fellow. The combined intraclass correlation coefficient for intraobserver agreement was 0.76. The reviewers as a group disagreed with their own measurements an average of 26% of the time. The intraclass correlation coefficient for interobserver reliability with regard to the measurements on the anteroposterior radiographs for the group was 0.80 (95% confidence interval, 0.64 to 0.89), and the reviewers disagreed with each other an average of 54% of the time. The intraclass correlation coefficient for interobserver agreement was 0.28 (95% confidence interval, 0.03 to 0.76) for the measurements on the lateral radiographs and 0.62 (95% confidence interval, 0.34 to 0.89) for the measurements on the oblique radiographs, with reviewers disagreeing an average of 87% of the time with regard to the measurements on the lateral radiographs and 64% of the time with regard to the measurements on the oblique radiographs. CONCLUSIONS Intraobserver agreement with regard to measurement of displacement of medial epicondyle fractures of the humerus varied among the reviewers but was low overall. Interobserver agreement was best for the measurements on the anteroposterior radiographs, but this was also low overall. These findings cast doubt on whether the amount of perceived displacement should be used as a criterion for choosing operative or nonoperative management of fractures of the humeral medial epicondyle. Agreement may be improved to acceptable levels by adopting a standard set of measurement guidelines, which include use of the anteroposterior radiograph when possible and consistently measuring at the point of maximal displacement.

Staged bone grafting following placement of an antibiotic spacer block for the management of segmental long bone defects.

Segmental long bone defects resulting from injury or surgical intervention are difficult problems to manage. Amputation, external fixators, vascularized fibular grafts, acute limb shortening, and various quantities of allograft and autograft have historically been the mainstays of treatment. Recently, the use of osteoinductive substances such as recombinant bone morphogenic proteins, and osteoconductive scaffolds such as calcium phosphate have found use in the treatment of these clinical situations. More recently, Masquelet described the use of a cement spacer placed within the osseous void followed by staged bone grafting within the induced biomembrane formed around the spacer as a potential treatment strategy to manage these large defects.This article describes a series of 11 patients for which we used this technique of staged bone grafting following placement of an antibiotic spacer to successfully manage osseous long bone defects ranging from 4 to 15 cm. The limbs were stabilized and aligned at the time of initial spacer placement with a plate and screw construct, intramedullary nail, or fine wire fixator. Osteoinductive substances including bone morphogenic protein-2 and platelet rich concentrate were used in addition to allograft to improve bony healing. In our series, osseous consolidation and full weight bearing was achieved in 10 of 11 patients. Two patients developed heterotopic ossification. There was 1 non-union and 1 infection, which occurred in the same patient. Staged bone grafting within an induced biomembrane created after the use of a cement spacer is a reasonable option in the management of both acute and delayed segmental long bone defects.

The Future of the Orthopaedic Clinician- Scientist Part II: Identification of Factors That May Influence Orthopaedic Residents' Intent to Perform Research

BACKGROUND The successful incorporation of research into the future careers of residents provides tremendous potential for increasing scientific orthopaedic inquiry and improving musculoskeletal care. Therefore, we sought to assess resident opinions regarding plans and incentives for future research and the opinions of academic chairs who must support them. METHODS Residents from sixteen departments were surveyed with a twenty-four-question online survey. Similar surveys were sent to chairs of all residency-sponsoring departments. RESULTS The response rate was 44% (183) for the residents and 60% (eighty-six) for the chairs. Forty-two percent of the residents felt certain or likely that they would perform research during their careers, and 28% were undecided. Ninety-nine percent thought that orthopaedic surgeons performing research is important to clinical orthopaedics. Ninety-three percent of the residents expressed the need for monetary incentives for research, but only 40% would help to provide it. Chairs similarly noted the importance of research subsidization (92%) and a willingness to support it (70%). Residents indicated that increased funding and protected time would provide the greatest incentives for research during residency; chairs agreed. After training, debt relief and salary support were most important for residents; chairs chose protected time and a chair who is supportive of research as most important. Primary authorship on a prior manuscript and past research experience were found to be associated with greater future research interest in univariate analyses; primary authorship maintained an independent association in multivariate analysis. Younger residents and women were more likely to be unsure of their research interest. CONCLUSIONS Many orthopaedic residents in training have interest in integrating research into their future practice and support the research mission of orthopaedic surgeons. Our results may aid in identifying residents with high research interest (and those unsure) and help to guide the provision of incentives to actuate those interests.

Geriatric Fractures About the Hip: Divergent Patterns in the Proximal Femur, Acetabulum, and Pelvis

Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management.

Level of evidence of presentations at american academy of orthopaedic surgeons annual meetings

BACKGROUND The American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting is a major international forum for scientific exchange and education. The purpose of this study was to evaluate the level of evidence of papers and posters presented at the 2001, 2004, 2007, and 2010 AAOS meetings to determine trends in the quality of study designs between the years 2001 and 2010. METHODS Abstracts for AAOS presentations from 2001 (288 papers and 468 posters), 2004 (290 papers and 466 posters), 2007 (525 papers and 541 posters), and 2010 (720 papers and 569 posters) were independently evaluated by three reviewers. The level of evidence of each presentation was determined based on the AAOS classification system. The results were subdivided according to orthopaedic subspecialty and type of presentation. RESULTS In subsequent years, there was a substantial increase in the percentage of Level I studies (2% in 2001, 3% in 2004, 5% in 2007, and 7% in 2010), Level II studies (15% in 2001, 18% in 2004, 23% in 2007, and 29% in 2010), and Level III studies (22% in 2001, 26% in 2004, 29% in 2007, and 33% in 2010), with a concomitant decrease in the percentage of Level IV studies (62% in 2001, 54% in 2004, 43% in 2007, and 31% in 2010). Overall, there was a significant nonrandom improvement in the level of evidence of presentations over the study period (p < 0.001). This trend was consistent across all orthopaedic subspecialties and in both the paper and the poster subgroups. CONCLUSIONS The level of evidence of studies presented at the AAOS Annual Meeting is steadily increasing, which signifies a mark of continual improvement in the quality of the scientific program.

Level of Evidence: Does It Change the Rate of Publication and Time to Publication of American Academy of Orthopaedic Surgeons Presentations?

BACKGROUND Presentations at the Annual Meetings of the American Academy of Orthopaedic Surgeons (AAOS) are often used to guide clinical practice, although many corresponding manuscripts are not published. The purpose of this study was to determine the relationship between level of evidence, rate of publication, and time to publication of presentations from an AAOS Annual Meeting. METHODS A comprehensive literature search for all 756 studies (288 papers and 468 posters) presented at the 2001 AAOS Annual Meeting was performed to determine which of these studies were ultimately published in the peer-reviewed literature. The corresponding AAOS abstracts were each assigned a level of evidence (LOE) with use of a consensus approach and The Journal of Bone and Joint Surgery (JBJS)/AAOS LOE classification system. The rate of publication and mean time to publication for each LOE was then calculated and compared. RESULTS The overall publication rate for the 2001 AAOS paper and poster presentations was 49% after five years, and 58% after ten years. At five and ten-year intervals, respectively, 77% and 85% of Level I presentations were published; 69% and 74% of Level II presentations were published; 58% and 66% of Level III presentations were published; and 39% and 51% of Level IV presentations were published. Overall, there was a significant nonrandom difference in publication rates at both five and ten years by LOE (p values of ≤0.001). Level I and II presentations were 2.9 times more likely than Level III and IV presentations to be published after five years (95% confidence interval 1.9 to 4.5), and 2.5 times more likely to be published after ten years (95% confidence interval 1.6 to 4.0). A similar association between LOE and five and ten-year publication rates was observed for both the paper and poster subgroups. The mean time to publication was 0.9 years for Level I studies, 1.4 years for Level II studies, 2.1 years for Level III studies, and 2.7 years for Level IV studies. CONCLUSIONS The LOE of AAOS presentations is positively related to rate of publication and inversely related to time to publication. Presentations with higher levels of evidence are published in the peer-reviewed literature at a greater and faster rate than those with lower levels of evidence.