Kelly A. Lefaivre

100 most cited articles in orthopaedic surgery.

BackgroundCitation analysis reflects the recognition a work has received in the scientific community by its peers, and is a common method to determine ‘classic’ works in medical specialties.Questions/purposesWe determined which published articles in orthopaedic journals have been most cited by other authors by ranking the 100 top-cited works. By analyzing characteristics of these articles, we intended to determine what qualities make an orthopaedic article important to the specialty. Finally, we determined if there was a change in level of evidence of studies on this list with time.MethodsScience Citation Index Expanded was searched for citations to articles published in any of the 49 journals in the subject category “ORTHOPEDICS.” Each of the 49 journals was searched separately using the “cited reference search” to determine the 100 most often cited articles. Each article was reviewed for basic information including year of publication, country of origin, source journal of the article, article type, and level of evidence. We categorized the journal article by field of research where possible.ResultsThe number of citations ranged from 1748 to 353. The 100 most often cited articles in orthopaedic surgery were published in 11 of the 49 journals, spanning from general to more specific subspecialty journals. The majority of the papers (76) were clinical, with the remaining representing some type of basic science research. The most common level of evidence was IV (42 of the 76 studies). Of the 76 clinical articles, 27 introduced or tested classification systems or outcome measurement tools.ConclusionsAuthors aiming to write a highly cited article in an orthopaedic surgery journal will be favored by language of publication, source journal, country of origin, and introduction of a classification scheme or outcome tool.

Simple Decompression Versus Anterior Subcutaneous and Submuscular Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Meta-Analysis

PURPOSE Optimal surgical management of cubital tunnel syndrome remains uncertain despite the publication of numerous case series, observational studies, systematic reviews, and, in recent years, randomized controlled studies. The purpose of this meta-analysis was to compare simple decompression to anterior transposition of the ulnar nerve for the treatment of this condition, using comparative trials and randomized controlled trials. METHODS Computerized database searches of MEDLINE, EMBASE, Cochrane Central, and all relevant surgical archives were performed. Studies involving adults with cubital tunnel syndrome in whom surgical intervention was simple decompression or anterior transposition (subcutaneous or submuscular) were included. Analysis was limited to randomized controlled trials and comparative observational studies. Included studies were assessed for quality, heterogeneity, and publication bias. Odds ratios of clinical improvement comparing simple decompression to anterior transposition (submuscular or subcutaneous) were calculated for each study. RESULTS Ten studies involving a total of 449 simple decompressions, 342 subcutaneous transpositions, and 115 submuscular transpositions were included. There was little evidence of publication bias or statistical study heterogeneity. Odds of improvement with simple decompression versus anterior transposition were 0.751, 95% confidence interval (0.542, 1.040). Subanalyses on the basis of transposition technique (subcutaneous or submuscular) and study quality did not render a statistically significant result. CONCLUSIONS This report represents the best cumulative evidence to date examining the surgical management of cubital tunnel syndrome. In this study, we found no statistically significant difference, but rather a trend toward an improved clinical outcome with transposition of the ulnar nerve as opposed to simple decompression. Additional prospective, randomized studies that use reproducible preoperative and postoperative objective measures might add statistical power to this finding.

Geographic trends in incidence of hip fractures: a comprehensive literature review

SummaryA comprehensive review of literature was conducted to investigate variation in hip fracture incident rates around the world. The original crude incidence rates were standardized for age and sex for comparability. After standardization, the highest rates of hip fracture were found in Scandinavia and the lowest rates in Africa.IntroductionThis study was conducted to investigate the geographic trends of the incidence of osteoporotic hip fractures through a comprehensive review of literature.MethodsStudies were identified for inclusion in the review by searching the MEDLINE database via PubMed and applying strict inclusion and exclusion criteria. Age-specific incidence rates were extracted from the articles, and in order to provide a common platform for analysis, we used directly age-standardized and age–sex-standardized rates (using the 2005 United Nations estimates of the world population as standard) to complete the analysis.ResultsForty-six full text articles spanning 33 countries/regions were included in the review. For ease of comparison, the results were analyzed by geographic regions: North America, Latin America, Scandinavia, Europe (excluding Scandinavia), Africa, Asia, and Australia. The highest hip fracture rates were found in Scandinavia and the lowest in Africa. We found comparable rates from countries in North America, Australia, and Europe outside of Scandinavia. The diverse makeup of the Asian continent also resulted in quite variable hip fracture rates: ranging from relatively high rates in Iran to low rates, comparable to those from Africa, in mainland China.ConclusionsGiven the aging of populations globally, and in the industrialized countries specifically, hip fractures will become a progressively larger public health burden. The geographic trends observed in hip fracture incidence rates can provide important clues to etiology and prevention.

Outcomes Measures Used to Assess Results After Surgery for Cubital Tunnel Syndrome: A Systematic Review of the Literature

PURPOSE The primary objective of this systematic review was to identify and analyze the outcomes measures that have been used to evaluate postoperative results following surgery for cubital tunnel syndrome. The secondary objective was to compare the postoperative results among patients evaluated using patient-satisfaction instruments to those evaluated using surgeon-reported scales. METHODS Computerized database searches of MEDLINE, EMBASE, and MEDLINE In-Process were performed. Studies involving adults with cubital tunnel syndrome in whom the surgical intervention was simple decompression, anterior transposition (subcutaneous, submuscular or intramuscular), endoscopic decompression, or medial epicondylectomy were included. A systematic review was performed that included randomized controlled trials, comparative observational studies, noncomparative observational studies, and case series. RESULTS This systematic review of the literature identified 42 studies that satisfied the inclusion criteria. The authors identified 21 health outcomes measures used in cubital tunnel studies. These consisted of 2 generic instruments; 10 symptom-specific, author-reported instruments; 3 symptom-specific, patient-reported instruments; and 6 patient questionnaires. No measure demonstrated adequate development or validation for use in its target population. Available data revealed a consistently high level of patient satisfaction following simple decompression or submuscular transposition (65% to 92%). The results of the author-reported, symptom-specific scales varied widely and showed no obvious association with patient satisfaction. The variation in reporting of results prevented statistical comparisons between author-reported results and patient-reported results. CONCLUSIONS To the best of our knowledge, this is the first systematic review to delineate the outcomes measures used to evaluate the treatment of cubital tunnel syndrome. Our results show that reliable, reproducible, and valid outcomes measures are lacking from the surgical literature. A standardized assessment protocol for ulnar neuropathy is required for future comparison trials. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

A Systematic Review of Thromboprophylaxis for Pelvic and Acetabular Fractures

Objectives: Pelvic and acetabular fractures have been identified as risk factors for deep venous thrombosis (DVT) and thromboembolic complications. A systematic review was performed to evaluate the effectiveness of thromboprophylactic strategies to prevent DVT or pulmonary embolism (PE) after pelvic or acetabular fractures. Data Sources: Relevant articles were identified by searching MEDLINE, MEDLINE In Process & Other Non-indexed Citations, EMBASE, CENTRAL, and the Cochrane Database of Systematic Reviews. All languages and years indexed were searched. Study Selection: Manuscripts were included if (1) the study included an intervention or strategy aimed at preventing thromboembolic disease, (2) the subjects in the study had suffered a pelvic or acetabular fracture, and (3) the primary outcome of the study was DVT or PE. Data Extraction: The intervention, sample size, DVT, and/or PE incidence, and method of diagnosis were recorded for each study. Data Synthesis: Eleven studies with 1760 subjects were included. Included studies were grouped into 5 types of interventions: mechanical compression devices, inferior vena cava filters, low-molecular weight heparins, ultrasound screening, and magnetic resonance venography screening. Most studies were observational designs with minimal control data for comparison. Quantitative pooling was not possible based on significant study heterogeneity. Conclusions: Although several strategies have been used to prevent thromboembolism in pelvic and acetabular fracture patients, our results suggest that clinicians have limited data to guide their prophylactic decisions. Well-designed clinical trials to prevent and detect venous thromboembolism in pelvic and acetabular trauma are still needed.

Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly.

Our purpose was to examine survivorship of the native hip joint in patients ages 60 and over who underwent percutaneous reduction and fixation of acetabular fractures. A retrospective review at a University Level I Trauma Center was performed. Our institutional trauma database was reviewed. Patients aged 60 or older treated with percutaneous reduction and fixation of acetabular fractures between 1994 and 2007 were selected. 79 consecutive patients with 80 fractures were identified. Rate of conversion to total hip arthroplasty were used to construct a Kaplan-Meier curve showing survivorship of the native hip joint after treatment. 75 fractures had adequate clinical follow-up with a mean of 3.9 years (range 0.5-11.9 years). Average blood loss was 69 cc and there were no postoperative infections. 19/75 (25%) were converted to total hip arthroplasty at a mean time of 1.4 years after the index procedure. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years of follow-up. There were no conversions to arthroplasty beyond 4.7 years postoperatively. There were no statistically significant associations between conversion to arthroplasty and age, sex, closed vs. limited open reduction, and simple vs. complex fracture pattern. Percutaneous fixation is a viable treatment option for patients age 60 or greater with acetabular fractures. Rates of conversion to total hip arthroplasty are comparable to open treatment methods and if conversion is required, soft tissues are preserved for future surgery.

Prediction of pulmonary morbidity and mortality in patients with femur fracture

BACKGROUND We aimed to determine the effect of femur fractures on mortality, pulmonary complications, and adult respiratory distress syndrome (ARDS). In addition, we aimed to compare the effect of femur fractures with other major musculoskeletal injuries and to determine the effect of timing to surgery on these complications. METHODS All patients were identified from the trauma registries of two Level I trauma centers. Outcomes were defined at mortality in hospital, pulmonary complications, and ARDS in hospital. Regression analysis was used to determine the effect of femur fractures, while controlling for age, Abbreviated Injury Scales, Glasgow Coma Scale, and systolic blood pressure at presentation. We compared femur fractures with other major musculoskeletal injuries in similar models. Within the patients with femur fracture, time to surgery (< 8 hours, 8 hours to 24 hours, and > 24 hours) was evaluated using similar regression analysis. RESULTS Of the total 90,510 patients, 3,938 (4.35%) died in the hospital, 2,055 (2.27%) had a pulmonary complication, and 285 (0.31%) developed ARDS. Femur fracture is statistically predictive of mortality (odds ratio [OR], 1.606; 95% confidence interval [CI], 1.288-2.002) and pulmonary complications (OR, 1.659; 95% CI, 1.329-2.070), when controlling for other injury factors. This was comparable with the effect of pelvic fracture and other major musculoskeletal injuries. Femur fracture had a strong relationship with ARDS (OR, 2.129; 95% CI, 1.382-3.278). Patients treated in the 8 hours to 24 hours window had the lowest mortality risk (OR, 0.140; 95% CI, 0.052-0.375), and there was a trend to increased risk of ARDS in a delay to surgery of > 24 hours. CONCLUSIONS Femur fractures are a major musculoskeletal injury and increase the risk of mortality and pulmonary complications as much as any other musculoskeletal injuries. There is a unique relationship between ARDS and femur fractures, and this must be considered carefully in treatment planning for these patients.

Leading 20 at 20: top cited articles and authors in the Journal of Orthopaedic Trauma, 1987-2007.

Objective: To determine the 20 most cited articles and authors in the Journal of Orthopaedic Trauma during the first 20 years of publication, 1987 to 2007. Design: Review. Methods: We used Web of Science “cited reference search” to determine the most cited articles originating in the Journal of Orthopaedic Trauma from 1987 to 2007, the first 20 years of publication. The characteristics of each article were recorded. Next, we manually searched each authors citations for works in the same time period to determine the most cited authors. The number of first authorships for each author was then determined using Medline, and a relative citation impact ratio was calculated. Finally, citation reports for the journal overall were created to evaluate the citation impact of the journal over the last 10 years. Results: The top cited articles ranged from 64 to 566 citations with two articles over 100. Fifteen were clinical articles with the most common topic being tibia fractures (shaft, plateau, and pilon). The top cited authors ranged for 111 to 566 citations, whereas the citations per lead authorship ratio for the authors on that list ranged from 9.5 to 566 citations per lead authorship. The number of citations to the Journal of Orthopaedic Trauma overall over the last 20 years has increased from 181 in 1997 to 3050 in 2007. Conclusions: The influence of the Journal of Orthopaedic Trauma, its articles, and its authors is readily apparent in this review of the most cited articles and authors in the journal over its first 20 years of publication. This journal is a source of highly cited original articles and the work of many highly cited leaders in the field of orthopaedic trauma.

Complications after minimally invasive total knee arthroplasty as compared with traditional incision techniques: a meta-analysis

The primary objective of our meta-analysis was to compare the incidence of complications between minimally invasive surgery and standard total knee arthroplasty (TKA) approaches. We reviewed randomized controlled trials comparing minimally invasive TKA to standard TKA. After testing for publication bias and heterogeneity, the data were aggregated by random effects modeling. Our primary outcome was the number of complications. Our secondary outcomes were alignment outliers, Knee Society Function scores, and Knee Society Knee scores. The combined odds ratios for complications for the minimally invasive surgery group and alignment outliers were 1.58 (95% confidence interval, 1.01-2.47; P < .05) and 0.79 (95% confidence interval, 0.34-1.82; P = .58), respectively. The standard difference in means for Knee Society scores was no different between groups. Minimally invasive knee surgery should be approached with caution.

What constitutes a Young and Burgess lateral compression-I (OTA 61-B2) pelvic ring disruption? A description of computed tomography-based fracture anatomy and associated injuries.

Objective: The objectives of this study were to provide computed tomography (CT)-based description of the anatomic specifics of lateral compression (LC)-1 pelvic ring disruptions and to describe injury severity to other body systems and their correlation with fracture anatomy. Design: Retrospective radiographic assessment and review of records Setting: A level 1 trauma and tertiary referral center. Patients/Participants: We identified a consecutive series of 100 patients with Young and Burgess LC-1 pelvic ring disruptions from the trauma registry database at a level 1 trauma center and evaluated their radiographs, CT scans, and injury and admission information. Intervention: None. Main Outcome Measurements: Presentation films were used to confirm injury type. The CT scan of the bony pelvis was reviewed for each patient by independent reviewers, with disagreement being resolved by the senior author. Sixteen categories were reviewed for each patient (rami fractures, segmental/comminuted rami fractures, Nakatani classification of rami fractures, anterior and posterior sacral fractures, and Denis classification). Sacral fractures were graded based on severity (0, no fracture; 1, buckle fracture; 2, simple fracture line; 3, comminuted fracture line). The age, Injury Severity Score (ISS), and 6 categories of Abbreviated Injury Scale (AIS) were recorded for each patient. A statistical analysis was performed to test the associations between fracture characteristics and injury severity. Results: Our group had 54 women and 46 men. The mean age was 37.84 ± 1.95. All patients but 3 had 1 or more rami fractures, and all but 2 had a sacral fracture. Of the 116 superior rami fractures, Nakatani 3 was the most common type (60/116, 51.7%). Of the 217 rami fractures, 47 (21.7%) were segmental or comminuted. Of the 98 anterior sacral injuries, there were 9 (9.2%) buckle fractures, 39 (39.8%) simple fractures, and 50 (51.0%) comminuted fractures. Of these 98 anterior sacral injuries, 47 (48.0%) were complete, passing through the sacrum and exiting the posterior cortex. Increasing severity of anterior sacrum fracture was associated with the presence of a complete sacral fracture (P < 0.0001). Of the 98 sacral fractures, 50 (50.0%) were Denis type 1, 41 (41.8%) Denis type II, and 7 (7.1%) Denis type III. Higher Denis types had higher likelihood of complete fractures of the sacrum (P < 0.0001). There was a significant association between the presence of a comminuted rami fracture and a complete sacrum injury (P = 0.003) and a trend to higher rates in Nakatani 2 superior rami fractures (P = 0.169). There were 4 deaths due to trauma in this group, and the mean ISS score was 17.16 ± 1.3. The highest mean system AIS score in these patients was extremity (2.42 ± 0.06) followed by chest (1.28 ± 0.17) and abdomen (1.03 ± 1.30). There was a trend to higher mean ISS scores (P = 0.2287) and significantly higher abdominal AIS scores (P = 0.0014) in those with a complete sacral fracture. Those with comminuted and complete sacral fractures were more likely to be symptomatic and require posterior ring stabilization (P = 0.003 and 0.043, respectively) Conclusions: LC-1 fractures of the pelvic ring represent a spectrum of injuries, with a large proportion having complete disruption of the sacrum. This complete injury of the sacrum is predicted by Denis type, severity of anterior ring disruption, abdominal AIS, and potentially location of rami fracture and ISS. CT scanning best defines these injuries.