Douglas R. Dirschl

Barriers to full-text publication following presentation of abstracts at annual orthopaedic meetings.

Background: Oral presentations at national and international meetings offer an excellent forum for the dissemination of current research findings. However, publication rates of full-text articles after presentation of abstracts at international meetings have ranged from 11% to 78%, which suggests that at least 32% of the abstracts presented are never published as complete articles in peer-reviewed journals. In an effort to identify the reasons that surgeons had not had a paper published following presentation of their work at an international orthopaedic meeting, we conducted a survey of a cross section of authors of orthopaedic papers presented at a national meeting.Methods: We retrieved all abstracts from the 1996 scientific program of the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons. A computerized Medline and PubMed search established whether the abstract had been subsequently published as a full-text article. The authors of the abstracts that had not been subsequently published were surveyed to identify the reasons for the failure to publish.Results: A total of 465 abstracts were presented at the sixty-third Annual Meeting of the American Academy of Orthopaedic Surgeons in 1996. We surveyed the authors of 306 abstracts for which we were unable to locate a subsequent full-text publication on Medline. One hundred and ninety-nine investigators (65%) responded to the questionnaire. At the time of the survey, seventy-two manuscripts had been published, thirty-two had been submitted and rejected, fourteen were under consideration by journals, seven had been accepted for publication or were in press, and three were not recalled by the investigator. In addition, seventy-one abstracts (35.7%) of the 199 had not been submitted for publication. The authors of those abstracts were asked to indicate one or more reasons why they had not submitted a manuscript for publication. Thirty-three investigators (46.5%) indicated that they lacked sufficient time for research activities, twenty-two (31.0%) reported that the study presented at the meeting in 1996 was still in progress, fourteen (19.7%) believed that the responsibility for writing the manuscript belonged to someone else, and twelve (16.9%) reported that difficulties with co-authors who would not participate had impeded the completion of the manuscript. Nine investigators (12.7%) responded that the pursuit of publication was a low priority.Conclusions: In a survey of investigators who had not had a full-text article published after presenting the abstract at a national meeting, we found that the failure to publish was due to one of three main reasons: (1) they did not have enough time to prepare a manuscript for publication (the reason most frequently given); (2) almost one-third of the studies that had not been submitted for publication were ongoing; and (3) relationships with co-authors sometimes presented a barrier to final publication. Thorough preparation before the study and the establishment of stricter guidelines to limit the presentation of preliminary data at national and international meetings may improve publication rates.

Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures.

Objectives To document the incidence of late pain and hardware removal after open reduction and internal fixation (ORIF) of ankle fractures. To test the hypothesis that late pain overlying the distal tibial and fibular hardware is associated with poorer functional outcomes. Design Retrospective review. Setting Level II trauma center. Patients One hundred twenty-six skeletally mature patients undergoing ORIF of unstable malleolar fractures who were followed up for at least six months from injury were included. Main Outcome Measurements Analog pain score, Short Form-36 Health Survey (SF-36), and Short Form Musculoskeletal Functional Assessment (SMFA). Results Thirty-nine (31 percent) of the 126 patients had lateral pain overlying their fracture hardware. Twenty-nine patients (23 percent) had had their hardware removed or desired to have it removed. Of the twenty-two patients with hardware-related pain who had undergone hardware removal, only eleven had improvement in their lateral ankle pain; the mean analog pain score decreased from 6 ± 3.16 (mean ± standard deviation) before hardware removal to 3 ± 2.9 after hardware removal (p = 0.008). In general, SF-36 and SMFA scores at final follow-up were significantly lower for patients who had pain overlying their lateral hardware than for those who had no pain. For the group of patients who had lateral ankle pain, no significant difference was noted in SMFA or SF-36 scores for patients who had and who had not had their lateral hardware removed (p > 0.5). Conclusion The incidence of late pain overlying the distal tibial and fibular plate or screws is not insignificant. Although pain is generally decreased after hardware removal, nearly half of patients continue to have pain even after hardware removal. Functional outcome scores are poorer for patients with pain overlying lateral ankle hardware than in those with no pain at this location; this poorer outcome seems to be independent of whether the hardware was removed. Although the results of this study do not support or condemn the routine removal of fracture hardware after healing of unstable ankle fractures, they give orthopaedic surgeons some information that may assist them in counseling patients as to the expected functional outcome after ORIF of ankle fractures and the likelihood of relief of pain after removal of fracture hardware from the distal tibia and fibula.

Tibial plafond fractures: How do these ankles function over time?

Background: The intermediate outcome of fractures of the tibial plafond treated with current techniques has not been reported, to our knowledge. The purpose of this study, performed at a minimum of five years after injury, was to determine the effect of these fractures on ankle function, pain, and general health status and to determine which factors predict favorable and unfavorable outcomes.Methods: Fifty-six ankles (fifty-two patients) with a tibial plafond fracture were treated with a uniform technique consisting of application of a monolateral hinged transarticular external fixator coupled with screw fixation of the articular surface. Thirty-one patients with thirty-five involved ankles returned between five and twelve years after the injury for a physical examination, assessment of ankle pain and function with the Iowa Ankle Score and Ankle Osteoarthritis Scale, assessment of general health status with the Short Form-36 (SF-36), and radiographic examination of the ankle.Results: Arthrodesis had been performed on five of the forty ankles for which the outcome was known at a minimum of five years after the injury. Other than removal of prominent screws (two patients), no other surgical procedure had been performed on any patient. The average Iowa Ankle Score was 78 points (range, 28 to 96 points). The scores on the SF-36 and Ankle Osteoarthritis Scale demonstrated a long-term negative effect of the injury on general health and on ankle pain and function when compared with those parameters in age-matched controls. The degree of osteoarthrosis was grade 0 in three ankles, grade 1 in six, grade 2 in twenty, and grade 3 in six. The majority of patients had some limitation with regard to recreational activities, with an inability to run being the most common complaint (twenty-seven of the thirty-one patients). Fourteen patients changed jobs because of the ankle injury. Fifteen ankles were rated by the patient as excellent; ten, as good; seven, as fair; and one, as poor. Nine patients with previously recorded ankle scores had better scores after the longer follow-up interval. The patients perceived that their condition had improved for an average of 2.4 years after the injury.Conclusions: Although tibial plafond fractures have an intermediate-term negative effect on ankle function and pain and on general health, few patients require secondary reconstructive procedures and symptoms tend to decrease for a long time after healing.Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Correlating selection criteria with subsequent performance as residents.

The objective of this study was to determine which criteria in the residency application had the highest correlation with subsequent performance of orthopaedic residents. Data collected from the application files of 58 residents included scores on standardized tests, number of honors grades in the basic and clinical years of medical school, election to Alpha Omega Alpha, numbers of research projects and publications, and numbers of extracurricular activities. Measures of performance included scores on the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery Part I Examination, and faculty evaluations of overall, cognitive, affective, and psychomotor performance. The number of honors grades on clinical rotations was the strongest predictor of performance, whereas election to Alpha Omega Alpha was second. The only other significant correlation was between the number of fine motor activities and psychomotor performance. None of the predictor variables had a significant correlation with Orthopaedic In-Training Examination or American Board of Orthopaedic Surgery Examination scores. Consistency between faculty rankings in each of the four categories was supported by regression analysis. From the results of this study, it appears that academic performance in clinical clerkships in medical school is the most predictive of resident performance. Range restriction in the data available for orthopaedic residency applicants, however, likely precludes the development of a reliable model to assist in the selection of orthopaedic residents.

High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on Fracture Healing

OBJECTIVES To evaluate the effects of pulsatile lavage and bulb syringe irrigation on fracture healing in vivo. DESIGN Randomized prospective trial in an animal model. SETTING Medical school orthopaedic department. SUBJECTS Thirty New Zealand white rabbits. INTERVENTION The control group (C) underwent osteotomy of the medial femoral condyle, stabilization, and closure. The bulb syringe and pulsatile lavage groups underwent the same procedure as group C, with the addition of irrigation with one liter of normal saline via a bulb syringe (B) or a pulsatile lavage system (P). Animals were administered two fluorescent bone stains: xylenol orange at the time of operation, and calcein green one week postoperatively. Animals were euthanized two weeks postoperatively and femurs were retrieved for histological analysis. MAIN OUTCOME MEASURES Union was determined by examination of microradiographs under light microscopy. The viability of bone along the fracture site was determined by evaluation of xylenol orange and calcein green staining under fluorescent microscopy. The density of new bone formed in the osteotomy site was assessed by computerized digitization of standardized regions of the proximal and distal osteotomy. RESULTS Xylenol orange bands were present a mean of 66 +/- 8 percent (mean +/- standard error of the mean), 65 +/- 6 percent, and 44 +/- 5 percent of the distance along the osteotomy in groups C, B, and P, respectively (p < 0.001). Calcein green bands were present throughout the osteotomy site in all specimens. Calcified new bone was present in 62 +/- 4 percent, 58 +/- 7 percent, and 41 +/- 9 percent of the area measured in groups C, B, and P, respectively (p = 0.07). Twenty percent of the osteotomies in groups C and B did not unite, compared with 30 percent in group P (p > 0.5). CONCLUSIONS Pulsatile lavage irrigation of fresh intraarticular fractures in rabbits has a detrimental effect on early new bone formation; this effect, however, is no longer apparent two weeks following irrigation. While this study evaluated the effects of pulsatile lavage irrigation in noncontaminated fractures without extensive soft tissue injury, the detrimental effects observed on early new bone formation may translate to an increased risk of nonunion in the setting of a contaminated open fracture with extensive soft tissue injury. Based on the results of this investigation, the selective use of pulsatile lavage irrigation appears warranted. In the absence of gross wound contamination, irrigation with a bulb syringe appears less likely to impair fracture healing than does pulsatile lavage irrigation. Expansion of the model used in this study to include bacterial contamination and soft tissue crushing may further elucidate the effects of pulsatile lavage irrigation on fracture healing.

Designing, conducting, and evaluating journal clubs in orthopaedic surgery.

The first record of a journal club was that founded in 1875 by Sir William Osler at McGill University for the purchase and distribution of periodicals to which he could not afford to subscribe as an individual. Evidence-based medicine is becoming an accepted educational paradigm in medical education at various levels. An analysis of the literature related to journal clubs in residency programs in specialties other than orthopaedic surgery reveals that the three most common goals were to teach critical appraisal skills (67%), to have an impact on clinical practice (59%), and to keep up with the current literature (56%). The implementation of the structured article review checklist has been found to increase resident satisfaction and improves the perceived educational value of the journal club without increasing resident workload or decreasing attendance at the conference. Periodic evaluation of the conference and the institution of appropriate changes ensures that the journal club remains a valuable and successful part of the training program.

Osteomyelitis : common causes and treatment recommendations

Infections involving bone continue to be a common problem. In children this is usually an acute haematogenous osteomyelitis. Early diagnosis with culture of an aspiration specimen is of paramount importance. Treatment with antibacterial agents is often successful unless pus is obtained in aspiration. In cases with an established abscess, surgical drainage is often needed in addition to antibiotic treatment. Staphylococcus aureus is the most common causative organism, although other microbes are often found in special circumstances such as in neonates, patients with sickle cell disease and those with nail puncture wounds. In adults, a pyogenic osteomyelitis is often due to direct trauma and generally is chronic in nature. Surgical debridement is the mainstay of treatment in these cases. Antibiotic treatment is often helpful but not curative by itself. Fungal and mycobacterial osteomyelitis is especially common in immunocompromised hosts. Amphotericin B remains the preferred treatment for fungal infections. Long term antituberculous multiple drug therapy is often sufficient to treat mycobacterial osteomyelitis.

Resident selection and predictors of performance: can we be evidence based?

Selection of orthopaedic residents can be a difficult process; we have endeavored to make it more objective by developing a scoring methodology for screening applications. The purpose of this investigation is to determine if an academic score, using objective elements only, will discriminate among applicants and will correlate with outcomes. Applications to our orthopaedic residency program for 2004 and 2005 were assigned an academic score as a screening tool in the residency selection process. Data was analyzed for the entire group both by gender and whether the applicant had interviewed for the program. Additionally, the applications of program graduates over the past 5 years were retrospectively assigned academic scores, which were compared with outcomes of the training program. Academic scores for applicants formed a generally normal distribution, and residents training in the program generally had higher scores. The distribution of scores for female applicants was similar to male applicants; however, a greater percentage of female applicants interviewed for the program. Scores on the OITE and ABOS examinations tended to parallel academic scores, but faculty ratings of performance in the program showed no difference between those with high and low academic scores. Calculating academic scores makes the application screening process more objective but does not appear to correlate with outcomes of the training program.

Rank Order Analysis of Tibial Plafond Fractures: Does Injury or Reduction Predict Outcome?

We investigated the effects of severity of initial injury pattern and the quality of the articular reduction on outcome of displaced intra-articular distal tibial fractures, using a series of 25 patients who were treated with articulated external fixation and limited internal fixation, which provided a spectrum of reduction quality. Outcome was assessed by clinical ankle scores and radio-graphic arthrosis. The results demonstrate the rank order method to be a reliable means of stratifying severity of injury and quality of reduction. Neither injury nor reduction correlated with clinical ankle score. Reduction had a significant correlation with radiographic arthrosis. We conclude that the rank order method is useful in stratification of fracture patients, and that factors other than injury pattern and quality of articular reduction are important in determining outcome of patients with this severe articular injury.

Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009.

BACKGROUND Clinical practice recommendations state that patients with fragility fractures should be evaluated for osteoporosis and treated for the disease if it is present. The purpose of this study was to assess osteoporosis evaluation and treatment patterns for patients with fragility fractures and assess whether anti-osteoporosis pharmacotherapy initiated immediately following a fragility fracture is associated with improved adherence to the treatment protocol. METHODS This retrospective cohort study involved data from a large commercially insured population seen in the period from 2001 through 2009. Patients were community-dwelling individuals aged fifty years or older who had a new low-energy fracture at the hip, vertebra, wrist, or humerus with no evidence of a fragility fracture, osteoporosis treatment, malignant disease, or Paget disease for twelve months preceding the fracture. Rates of diagnostic testing and pharmacotherapy for osteoporosis within twelve months post-fracture were evaluated. Patients treated with oral bisphosphonates were evaluated to determine whether twelve-month adherence to the treatment protocol differed between those who had initiated therapy sooner (at zero to ninety days) and those who initiated it later (at ninety-one to 365 days) following the fracture. RESULTS The 88,571 women and 41,984 men had an average age of 72.3 years and 70.5 years, respectively. Nineteen percent (16,464) of the women and 10% (4014) of the men initiated osteoporosis pharmacotherapy, and 30% (26,481) of the women and 15% (6427) of the men underwent diagnostic testing and/or pharmacotherapy following fracture. Treatment rates were highest following vertebral fracture and lowest following wrist or humeral fracture. Treatment rates significantly decreased over time (from 2001 through 2009). The average twelve-month adherence (medication possession ratio) was 56% and 61% among women and men, respectively. Adherence was similar between patients who had initiated treatment sooner after the fracture and those who had initiated it later after the fracture. CONCLUSIONS Clinical guidelines for evaluation and treatment following fragility fracture were met for less than one-third of women and less than one-sixth of men. While primary fracture prevention remains the ideal, secondary prevention is critical and there is a need to reverse the downward trend in adherence to post-fracture guidelines.