Publications by authors named "Stein J Janssen"

100 Publications

Greater tuberosity fractures are not a continuation of Hill-Sachs lesions, but do they have a similar etiology?

JSES Int 2022 May 12;6(3):396-400. Epub 2022 Jan 12.

Shoulder and Elbow Unit, Joint Research, OLVG, Amsterdam, the Netherlands.

Background: It is unclear whether greater tuberosity fractures (GTF) in the setting of a shoulder dislocation are due to an avulsion of the rotator cuff or a result of an extensive Hill-Sachs lesion (HSL). To explore whether these lesions have similar etiology, the primary aim of this study is to compare the postinjury morphology of the proximal humerus after GTF and HSL.

Methods: Computed tomography scans of 19 patients with HSL and 18 patients with GTF after first-time shoulder dislocations were analyzed. We assessed the location by measuring height in relation to the highest point of the humerus and angles for the origin (most medial point of lesion), center, and endpoint (most lateral point of lesion) between GTF and HSL and the bicipital groove. For both GTF and HSL, we assessed whether infraspinatus and supraspinatus insertions were involved and whether they were off-track or on-track.

Results: Measured from the bicipital groove, HSLs and GTFs have different origins (153˚ vs. 110˚;  < .0001, respectively), centers (125˚ vs. 60˚;  < .0001, respectively), and endpoints (92˚ vs. 37˚;  < .0001, respectively). HSLs had a higher position (0.76 cm vs. 1.71 cm;  < .0001), involved the supraspinatus footprint less often (16% vs. 72%;  = .0008), and were less likely to be off-track (31% vs. 94%;  = .0002). Half of the GTF were on the lateral side of the glenoid track and thus extra-capsular, versus 0% of HSL.

Conclusion: HSLs and GTFs have different anatomical characteristics and thus GTFs are likely to be distinct from extensive HSLs.
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http://dx.doi.org/10.1016/j.jseint.2021.11.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9091784PMC
May 2022

Body Composition Predictors of Adverse Postoperative Events in Patients Undergoing Surgery for Long Bone Metastases.

J Am Acad Orthop Surg Glob Res Rev 2022 03 9;6(3). Epub 2022 Mar 9.

From the Department of Orthopaedic Surgery-Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA (Mr. Twining, Dr. Groot, Dr. Kapoor, Dr. Bongers, Dr. Schwab); the Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA (Dr. Buckless, Dr. Torriani, Ms. Bredella); and the Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Center-University of Amsterdam, Amsterdam, the Netherlands (Janssen).

Introduction: Body composition assessed using opportunistic CT has been recently identified as a predictor of outcome in patients with cancer. The purpose of this study was to determine whether the cross-sectional area (CSA) and the attenuation of abdominal subcutaneous adipose tissue, visceral adipose tissue (VAT), and paraspinous and abdominal muscles are the predictors of length of hospital stay, 30-day postoperative complications, and revision surgery in patients treated for long bone metastases.

Methods: A retrospective database of patients who underwent surgery for long bone metastases from 1999 to 2017 was used to identify 212 patients who underwent preoperative abdominal CT. CSA and attenuation measurements for subcutaneous adipose tissue, VAT, and muscles were taken at the level of L4 with the aid of an in-house segmentation algorithm. Bivariate and multivariate linear and logistic regression models were created to determine associations between body composition measurements and outcomes while controlling for confounders, including primary tumor, metastasis location, and preoperative albumin.

Results: On multivariate analysis, increased VAT CSA {regression coefficient (r) (95% confidence interval [CI]); 0.01 (0.01 to 0.02); P < 0.01} and decreased muscle attenuation (r [95% CI] -0.07 [-0.14 to -0.01]; P = 0.04) were associated with an increased length of hospital stay. In bivariate analysis, increased muscle CSA was associated with increased chance of revision surgery (odds ratio [95% CI]; 1.02 [1.01 to 1.03]; P = 0.04). No body composition measurements were associated with postoperative complications within 30 days.

Discussion: Body composition measurements assessed using opportunistic CT predict adverse postoperative outcomes in patients operated for long bone metastases.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-22-00001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8913089PMC
March 2022

Body composition predictors of mortality in patients undergoing surgery for long bone metastases.

J Surg Oncol 2022 Apr 13;125(5):916-923. Epub 2022 Jan 13.

Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Background And Objectives: Body composition measurements using computed tomography (CT) may serve as imaging biomarkers of survival in patients with and without cancer. This study assesses whether body composition measurements obtained on abdominal CTs are independently associated with 90-day and 1-year mortality in patients with long-bone metastases undergoing surgery.

Methods: This single institutional retrospective study included 212 patients who had undergone surgery for long-bone metastases and had a CT of the abdomen within 90 days before surgery. Quantification of cross-sectional areas (CSA) and CT attenuation of abdominal subcutaneous adipose tissue, visceral adipose tissue, and paraspinous and abdominal muscles were performed at L4. Multivariate Cox proportional-hazards analyses were performed.

Results: Sarcopenia was independently associated with 90-day mortality (hazard ratio [HR] = 1.87; 95% confidence interval [CI] = 1.11-3.16; p = 0.019) and 1-year mortality (HR = 1.50; 95% CI = 1.02-2.19; p = 0.038) in multivariate analysis while controlling for clinical variables such as primary tumors, comorbidities, and chemotherapy. Abdominal fat CSAs and muscle attenuation were not associated with mortality.

Conclusions: The presence of sarcopenia assessed by CT is predictive of 90-day and 1-year mortality in patients undergoing surgery for long-bone metastases. This body composition measurement can be used as novel imaging biomarker supplementing existing prognostic tools to optimize patient selection for surgery and improve shared decision making.
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http://dx.doi.org/10.1002/jso.26793DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8917991PMC
April 2022

Clinical Outcome Differences in the Treatment of Impending Versus Completed Pathological Long-Bone Fractures.

J Bone Joint Surg Am 2022 02;104(4):307-315

Orthopaedic Oncology Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Background: The outcome differences following surgery for an impending versus a completed pathological fracture have not been clearly defined. The purpose of the present study was to assess differences in outcomes following the surgical treatment of impending versus completed pathological fractures in patients with long-bone metastases in terms of (1) 90-day and 1-year survival and (2) intraoperative blood loss, perioperative blood transfusion, anesthesia time, duration of hospitalization, 30-day postoperative systemic complications, and reoperations.

Methods: We retrospectively performed a matched cohort study utilizing a database of 1,064 patients who had undergone operative treatment for 462 impending and 602 completed metastatic long-bone fractures. After matching on 22 variables, including primary tumor, visceral metastases, and surgical treatment, 270 impending pathological fractures were matched to 270 completed pathological fractures. The primary outcome was assessed with the Cox proportional hazard model. The secondary outcomes were assessed with the McNemar test and the Wilcoxon signed-rank test.

Results: The 90-day survival rate did not differ between the groups (HR, 1.13 [95% CI, 0.81 to 1.56]; p = 0.48), but the 1-year survival rate was worse for completed pathological fractures (46% versus 38%) (HR, 1.28 [95% CI, 1.02 to 1.61]; p = 0.03). With regard to secondary outcomes, completed pathological fractures were associated with higher intraoperative estimated blood loss (p = 0.03), a higher rate of perioperative blood transfusions (p = 0.01), longer anesthesia time (p = 0.04), and more reoperations (OR, 2.50 [95% CI, 1.92 to 7.86]; p = 0.03); no differences were found in terms of the rate of 30-day postoperative complications or the duration of hospitalization.

Conclusions: Patients undergoing surgery for impending pathological fractures had lower 1-year mortality rates and better secondary outcomes as compared with patients undergoing surgery for completed pathological fractures when accounting for 22 covariates through propensity matching. Patients with an impending pathological fracture appear to benefit from prophylactic stabilization as stabilizing a completed pathological fracture seems to be associated with increased mortality, blood loss, rate of blood transfusions, duration of surgery, and reoperation risk.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.21.00711DOI Listing
February 2022

What are the best diagnostic tests for diagnosing bacterial arthritis of a native joint? : a systematic review of 27 studies.

Bone Joint J 2021 Dec;103-B(12):1745-1753

Department of Orthopedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.

Aims: This study aimed to answer two questions: what are the best diagnostic methods for diagnosing bacterial arthritis of a native joint?; and what are the most commonly used definitions for bacterial arthritis of a native joint?

Methods: We performed a search of PubMed, Embase, and Cochrane libraries for relevant studies published between January 1980 and April 2020. Of 3,209 identified studies, we included 27 after full screening. Sensitivity, specificity, area under the curve, and Youden index of diagnostic tests were extracted from included studies. We grouped test characteristics per diagnostic modality. We extracted the definitions used to establish a definitive diagnosis of bacterial arthritis of a native joint per study.

Results: Overall, 28 unique diagnostic tests for diagnosing bacterial arthritis of a native joint were identified. The following five tests were deemed most useful: serum ESR (sensitivity: 34% to 100%, specificity: 23% to 93%), serum CRP (sensitivity: 58% to 100%, specificity: 0% to 96%), serum procalcitonin (sensitivity: 0% to 100%, specificity: 68% to 100%), the proportion of synovial polymorphonuclear cells (sensitivity: 42% to 100%, specificity: 54% to 94%), and the gram stain of synovial fluid (sensitivity: 27% to 81%, specificity: 99% to 100%).

Conclusion: Diagnostic methods with relatively high sensitivities, such as serum CRP, ESR, and synovial polymorphonuclear cells, are useful for screening. Diagnostic methods with a relatively high specificity, such as serum procalcitonin and synovial fluid gram stain, are useful for establishing a diagnosis of bacterial arthritis. This review helps to interpret the value of various diagnostic tests for diagnosing bacterial arthritis of a native joint in clinical practice. Cite this article:  2021;103-B(12):1745-1753.
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http://dx.doi.org/10.1302/0301-620X.103B12.BJJ-2021-0114.R1DOI Listing
December 2021

A structured evaluation of the symptomatic medial Oxford unicompartmental knee arthroplasty (UKA).

EFORT Open Rev 2021 Oct 19;6(10):850-860. Epub 2021 Oct 19.

Department of Orthopaedic Surgery, FORCE (Foundation for Orthopaedic Research Care Education), Amphia Hospital, Breda, The Netherlands.

Unicompartmental knee arthroplasty (UKA) has several advantages over total knee arthroplasty; however, in many reports, the risk of revision remains higher after UKA.Many reasons for failure of UKA exist.Successful treatment starts with accurate assessment of the symptomatic UKA as a specific mode of failure requires a specific solution.A structured and comprehensive evaluation aids assessment of the symptomatic UKA.This review provides an overview of the causes for a symptomatic medial UKA, its risk factors, diagnostic modalities that can be used, and briefly discusses treatment options. Cite this article: 2021;6:850-860. DOI: 10.1302/2058-5241.6.200105.
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http://dx.doi.org/10.1302/2058-5241.6.200105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8559574PMC
October 2021

Antihypertensive drugs demonstrate varying levels of hip fracture risk: A systematic review and meta-analysis.

Injury 2022 Mar 28;53(3):1098-1107. Epub 2021 Sep 28.

Department of Orthopaedic Surgery & Trauma Surgery, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Centre, Meibergdreef 9, Amsterdam 1105AZ, the Netherlands. Electronic address:

Objective: By aggregating the literature, we evaluated the association between use of specific antihypertensive drugs and the risk of hip fractures compared with nonuse.

Study Design And Setting: We systematically searched the Pubmed, Embase, and Cochrane databases from inception of each database until July 30, 2020 to identify articles including patients 18 years of age or older reporting on the association between antihypertensive drugs and the risk of hip fracture. Antihypertensive drugs were restricted to thiazides; beta-blockers; calcium-channel blockers; angiotensin-converting enzyme (ACE) inhibitors; and angiotensin receptor blockers. Nonusers encompass all patients that are not using the specific antihypertensive drug that has been reported. Unadjusted odds ratios with 95% confidence intervals (CIs) of the association between antihypertensive drug use and hip fractures were reported. Meta-analysis was performed when a minimum of five studies were identified for each antihypertensive drug class. Quality assessment was done using ROBINS-I tool. The GRADE approach was used to evaluate the certainty of the evidence.

Results: Of 962 citations, 22 observational studies were included; 9 studies had a cohort design and 13 studies were case-control studies. No randomized controlled trials were identified. We found very low certainty of evidence that both thiazides (pooled odds ratio: 0.85, 95% CI 0.73 to 0.99, p = 0.04) as well as beta-blockers (pooled odds ratio: 0.88, 95% CI 0.79 to 0.98, p = 0.02) were associated with a reduced hip fracture risk as compared to specific nonuse. One study, reporting on angiotensin receptor blockers, also suggested a protective effect for hip fractures, whereas we found conflicting findings in four studies for calcium-channel blockers and in two studies for ACE inhibitors.

Conclusion: Among 22 observational studies, we found very low certainty of evidence that, compared to specific nonuse of antihypertensive drugs, use of thiazides, beta-blockers, and angiotensin receptor blockers were associated with a reduced protective hip fracture risk, while conflicting findings for calcium-channel blockers and ACE inhibitors were found. Given the low quality of included studies, further research -randomized controlled trials- are needed to definitively assess the causal relationship between specific antihypertensive drug classes and (relatively infrequent) hip fractures.
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http://dx.doi.org/10.1016/j.injury.2021.09.036DOI Listing
March 2022

The Impact of the Soong Index on Hardware Removal and Overall Reoperation Rates After Volar Locking Plate Fixation of Distal Radius Fractures.

J Hand Surg Am 2022 06 4;47(6):584.e1-584.e9. Epub 2021 Sep 4.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address:

Purpose: This study sought to determine the impact of volar plate prominence on reoperation rates after open reduction and internal fixation of distal radius fractures with volar locking plates and to identify other factors associated with removal of hardware (ROH) or a reoperation.

Methods: A retrospective study of patients who underwent distal radius open reduction and internal fixation between 2012 and 2016 at 2 level I trauma centers was conducted. Plate prominence was evaluated using the Soong index at the first postoperative visit. The details of patient demographics, fracture and plate characteristics, complications, and reoperations were recorded. Bivariate and multivariable regression analyses were used to identify factors associated with increased rates of ROH and overall reoperation.

Results: A total of 732 (70.2%) of 1,042 patients completed follow-up at an average of 38.2 months, including 34 patients with bilateral operations, yielding 766 distal radius fractures. One hundred sixteen (15.1%) patients underwent reoperation at an average of 12.1 ± 13.6 months after the index surgery. Removal of hardware was the most commonly performed reoperation (77 patients, 10%). The multivariable regression analysis revealed significantly higher rates of ROH in Soong grade 1 or 2 patients (odds ratio 16, 95% CI 5.8-47; odds ratio 44, 95% CI 14-140, respectively) than in Soong grade 0 patients. Plate type, younger age, bilateral injuries, and concomitant procedures at the time of the index operation were all associated with increased risk of ROH. There were significant differences between individual surgeons the in rates of ROH (range 2.1%-22%) and overall reoperation (range 5.2%-36%). Compared with other hand surgeons, fellowship-trained hand surgeons had lower rates of ROH (8% vs 14%, respectively) and overall reoperation (12% vs 22%, respectively).

Conclusions: The rates of ROH and overall reoperation increase with increasing Soong grade. Plate type is independently predictive of future ROH. Older patients and those undergoing open reduction and internal fixation experience lower rates of subsequent reoperation.

Type Of Study/level Of Evidence: Prognostic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.06.021DOI Listing
June 2022

Greater radial tuberosity size is associated with distal biceps tendon rupture: a quantitative 3-D CT case-control study.

Knee Surg Sports Traumatol Arthrosc 2021 Dec 4;29(12):4075-4081. Epub 2021 Sep 4.

Department of Orthopaedic Surgery, Amsterdam University Medical Centres, Location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Purpose: During pronation, the distal biceps tendon and radial tuberosity internally rotate into the radioulnar space, reducing the linear distance between the radius and ulna by approximately 50%. This leaves a small space for the distal biceps tendon to move in and could possibly cause mechanical impingement or rubbing of the distal biceps tendon. Hypertrophy of the radial tuberosity potentially increases the risk of mechanical impingement of the distal biceps tendon. The purpose of our study was to determine if radial tuberosity size is associated with rupturing of the distal biceps tendon.

Methods: Nine patients with a distal biceps tendon rupture who underwent CT were matched 1:2 to controls without distal biceps pathology. A quantitative 3-dimensional CT technique was used to calculate the following radial tuberosity characteristics: 1) volume in mm, 2) surface area in mm, 3) maximum height in mm and 4) location (distance in mm from the articular surface of the radial head).

Results: Analysis of the 3-dimensional radial tuberosity CT-models showed larger radial tuberosity volume and maximum height in the distal biceps tendon rupture group compared to the control group. Mean radial tuberosity volume in the rupture-group was 705 mm (SD: 222 mm) compared to 541 mm (SD: 184 mm) in the control group (p = 0.033). Mean radial tuberosity maximum height in the rupture-group was 4.6 mm (SD: 0.9 mm) compared to 3.7 mm (SD: 1.1 mm) in the control group, respectively (p = 0.011). There was no statistically significant difference in radial tuberosity surface area (ns) and radial tuberosity location (ns).

Conclusion: Radial tuberosity volume and maximum height were significantly greater in patients with distal biceps tendon ruptures compared to matched controls without distal biceps tendon pathology. This supports the theory that hypertrophy of the radial tuberosity plays a role in developing distal biceps tendon pathology.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1007/s00167-021-06722-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8595228PMC
December 2021

Bacterial arthritis of native joints can be successfully managed with needle arthroscopy.

J Exp Orthop 2021 Aug 24;8(1):67. Epub 2021 Aug 24.

Department of Orthopedic Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Purpose: To assess the feasibility of needle arthroscopy for management of suspected bacterial arthritis in native joints.

Methods: During a pilot period, patients presenting with symptoms suggestive of native joint bacterial arthritis were eligible for initial management with needle arthroscopy. Procedures were performed in the operating theatre or at the patient bedside in the emergency department or inpatient ward. As our primary outcome measure, it was assessed whether needle arthroscopic lavage resulted in a clear joint. In addition, the need for conversion to standard arthroscopy or arthrotomy, the need for conversion from local to general anaesthesia, complications and the need for additional surgical intervention at follow-up during admission were recorded.

Results: Eleven joints in 10 patients (four males, age range 35 - 77) were managed with needle arthroscopy. Needle arthroscopic lavage resulted in a clear joint in all cases. Conversion to standard arthroscopy or arthrotomy was not needed. Seven procedures were performed at the patient bedside using local anaesthesia. These procedures were well tolerated and conversion to general or spinal anaesthesia was not required. There were no procedure complications. One patient received multiple needle arthroscopic lavages. No further surgical interventions beside the initial needle arthroscopic lavage were required for successful management in other cases.

Conclusions: Needle arthroscopy can be a feasible tool in the initial management of complaints suggestive for native joint bacterial arthritis, providing an effective, quick and well-tolerable intervention in the operating theatre or at the patient bedside, with the potential to relief health systems from need for scarce operating theatre time.
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http://dx.doi.org/10.1186/s40634-021-00384-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382939PMC
August 2021

Factors Associated with a Recommendation for Operative Treatment for Fracture of the Distal Radius.

J Wrist Surg 2021 Aug 11;10(4):316-321. Epub 2021 Mar 11.

Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia.

 Evidence suggests that there is substantial and unexplained surgeon-to-surgeon variation in recommendation of operative treatment for fractures of the distal radius. We studied (1) what factors are associated with recommendation for operative treatment of a fracture of the distal radius and (2) which factors are rated as the most influential on recommendation of operative treatment.  One-hundred thirty-one upper extremity and fracture surgeons evaluated 20 fictitious patient scenarios with randomly assigned factors (e.g., personal, clinical, and radiologic factors) for patients with a fracture of the distal radius. They addressed the following questions: (1) Do you recommend operative treatment for this patient (yes/no)? We determined the influence of each factor on this recommendation using random forest algorithms. Also, participants rated the influence of each factor-excluding age and sex- on a scale from 0 (not at all important) to 10 (extremely important).  Random forest algorithms determined that age and angulation were having the most influence on recommendation for operative treatment of a fracture of the distal radius. Angulation on the lateral radiograph and presence or absence of lunate subluxation were rated as having the greatest influence and smoking status and stress levels the lowest influence on advice to patients.  The observation that-other than age-personal factors have limited influence on surgeon recommendations for surgery may reflect how surgeon cognitive biases, personal preferences, different perspectives, and incentives may contribute to variations in care. Future research can determine whether decision aids-those that use patient-specific probabilities based on predictive analytics in particular-might help match patient treatment choices to what matters most to them, in part by helping to neutralize the influence of common misconceptions as well as surgeon bias and incentives.  There is no level of evidence for the study.
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http://dx.doi.org/10.1055/s-0041-1725962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328550PMC
August 2021

Supercutaneous locking compression plate in the treatment of infected non-union and open fracture of the leg.

Arch Orthop Trauma Surg 2021 Aug 4. Epub 2021 Aug 4.

Department of Orthopaedic Surgery, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Centre, Amsterdam, The Netherlands.

Introduction: Salvage of infected tibia and fibula non-union and severe open fractures is challenging and often requires staged treatment. We describe all cases that underwent supercutaneous plating of the leg as external fixation technique and assessed union rate, time to union, rate of infection clearance, and patient-reported outcome measures.

Methods: This is a retrospective cohort study from a single level 1 trauma center. We included 19 patients that underwent supercutaneous plating-locking compression plate applied as external fixator-of the leg. Indications were: infected non-union of a pilon, cruris, or ankle fracture (n = 13); post-traumatic fistula draining osteomyelitis of the tibia (n = 3); infected mal-reduced subacute cruris fracture (n = 1); acute open pilon fracture (n = 1); and acute open cruris fracture (n = 1). Outcome measures were: union, time to union, infection clearance, the 36-item Short Form (SF-36) physical component summary scale (PCS) and mental component summary scale (MCS), and NRS pain scores.

Results: Union was achieved in 88% of the patients after a median of 279 days [interquartile range (IQR) 154-440]. Infection clearance was achieved in 94% of the patients. The PCS (median 51, IQR 46-56, p = 0.903) and MCS (median 57, IQR 50-60, p = 0.241) do not differ from normative population values. NRS Pain score at rest was 0 on average (IQR 0-1), 2 on average when walking (IQR 0-4), and 1 on average when climbing stairs (IQR 0-2).

Conclusion: Supercutaneous plating is a simple and reliable technical trick to bridge and stabilize a nonunion or fracture site while clearing an infection and have soft-tissues heal before subsequent definitive (internal)fixation and/or cancellous bone grafting. Reasonable union and infection clearance rates are achieved, and good functional outcome can generally be expected.

Level Of Evidence: Therapeutic level III.
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http://dx.doi.org/10.1007/s00402-021-04104-7DOI Listing
August 2021

Factors associated with surgeon recommendation for additional cast immobilization of a CT-verified nondisplaced scaphoid waist fracture.

Arch Orthop Trauma Surg 2021 Nov 24;141(11):2011-2018. Epub 2021 Jul 24.

Department of Orthopedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Flinders Drive, Bedford Park, Adelaide, South Australia, 5042, Australia.

Introduction: Data from clinical trials suggest that CT-confirmed nondisplaced scaphoid waist fractures heal with less than the conventional 8-12 weeks of immobilization. Barriers to adopting shorter immobilization times in clinical practice may include a strong influence of fracture tenderness and radiographic appearance on decision-making. This study aimed to investigate (1) the degree to which surgeons use fracture tenderness and radiographic appearance of union, among other factors, to decide whether or not to recommend additional cast immobilization after 8 or 12 weeks of immobilization; (2) identify surgeon factors associated with the decision to continue cast immobilization after 8 or 12 weeks.

Materials And Methods: In a survey-based study, 218 surgeons reviewed 16 patient scenarios of CT-confirmed nondisplaced waist fractures treated with cast immobilization for 8 or 12 weeks and recommended for or against additional cast immobilization. Clinical variables included patient sex, age, a description of radiographic fracture consolidation, fracture tenderness and duration of cast immobilization completed (8 versus 12 weeks). To assess the impact of clinical factors on recommendation to continue immobilization we calculated posterior probabilities and determined variable importance using a random forest algorithm. Multilevel logistic mixed regression analysis was used to identify surgeon characteristics associated with recommendation for additional cast immobilization.

Results: Unclear fracture healing on radiographs, fracture tenderness and 8 (versus 12) weeks of completed cast immobilization were the most important factors influencing surgeons' decision to recommend continued cast immobilization. Women surgeons (OR 2.96; 95% CI 1.28-6.81, p  =  0.011), surgeons not specialized in orthopedic trauma, hand and wrist or shoulder and elbow surgery (categorized as 'other') (OR 2.64; 95% CI 1.31-5.33, p  =  0.007) and surgeons practicing in the United States (OR 6.53, 95% CI 2.18-19.52, p  =  0.01 versus Europe) were more likely to recommend continued immobilization.

Conclusion: Adoption of shorter immobilization times for CT-confirmed nondisplaced scaphoid waist fractures may be hindered by surgeon attention to fracture tenderness and radiographic appearance.
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http://dx.doi.org/10.1007/s00402-021-04062-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8497306PMC
November 2021

Limited Fasciectomy Versus Collagenase Clostridium histolyticum for Dupuytren Contracture: A Propensity Score Matched Study of Single Digit Treatment With Minimum 5 Years of Telephone Follow-Up.

J Hand Surg Am 2021 10 16;46(10):888-895. Epub 2021 Jul 16.

Harvard Medical School, Boston, MA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA. Electronic address:

Purpose: The purpose of this study was to compare reintervention and perceived recurrence, with minimum 5 years of telephone follow-up, after limited fasciectomy or collagenase Clostridium histolyticum (CCH) in the treatment of Dupuytren contracture affecting a single digit.

Methods: We performed a retrospective cohort study of 48 patients with single digit treatment who underwent limited surgical fasciectomy at one hospital and 111 patients who underwent CCH treatment at a second hospital from 2010 to 2013. Patients were contacted by telephone about reintervention and perceived recurrence. Average length of telephone follow-up was 7.3 years in the CCH group and 7.4 years in the surgery group. The 2 groups were compared using 2 methods to control for potential confounding bias: (1) propensity score matching and (2) multivariable analysis accounting for potential confounders.

Results: After propensity score matching, there were 44 patients in each group with similar disease and demographic characteristics. Rates of reintervention and perceived recurrence were significantly higher in the CCH group than the surgery group at a minimum of 5 years following treatment.

Conclusions: Long-term overall reintervention and perceived recurrence following treatment of Dupuytren contracture affecting a single digit were higher with CCH treatment than surgical fasciectomy when comparing groups with similar baseline characteristics. Our findings may be used to counsel patients on the durability of the outcomes of treatment when considering treatment options for Dupuytren contractures.

Type Of Study/level Of Evidence: Therapeutic IV.
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http://dx.doi.org/10.1016/j.jhsa.2021.05.022DOI Listing
October 2021

Patient Perception and Preferences for Virtual Telemedicine Visits for Hand and Upper Extremity Surgery.

Telemed J E Health 2022 04 12;28(4):509-516. Epub 2021 Jul 12.

Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Telemedicine in upper extremity surgery is an evolving modality that provides a viable alternative to the traditional in-person visit for achieving convenient, safe, and cost-effective health care. Our study aimed to identify patient preferences for virtual visits for hand and upper extremity surgery. An institutional review board approved survey was prospectively administered to all patients >18 years of age, presenting for any complaint to an orthopedic hand and upper extremity clinic at a Level I academic trauma center from September to December 2019. This survey included questions about access and literacy of technology as well as patient preferences regarding virtual visits. The medical record was reviewed to collect demographics, insurance type, and reasons for their visit. Bivariate and multivariate analyses were performed according to survey responses. Two hundred consecutive patients () completed surveys. Surveys revealed that >88% of patients own a computer or smartphone, have WiFi access at home, and own a device capable of video chat. In total, 75% of patients reported that they would be moderately or highly comfortable in their ability to use a device for a virtual visit. In bivariate and multivariate analyses, technological literacy and access to a private space to conduct a visit were associated with high interest in virtual visits. Telemedicine is a viable alternative to in-person patient visits. Our study demonstrates that most patients are willing and able to participate in a virtual visit for a hand or upper extremity issue.
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http://dx.doi.org/10.1089/tmj.2021.0146DOI Listing
April 2022

Cognitive Biases in Orthopaedic Surgery.

J Am Acad Orthop Surg 2021 Jul;29(14):624-633

From the Department of Orthopaedic Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam (Janssen), The Netherlands, the Department of Plastic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands (Teunis), the Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX (Ring), and the Elliot Orthopaedic Surgical Specialists (Parisien), Elliot Hospital, Manchester, NH.

Introduction: Cognitive biases are known to affect all aspects of human decision-making and reasoning. Examples include misjudgment of probability, preferential attention to evidence that confirms one's beliefs, and preference for certainty. It is not known whether cognitive biases influence orthopaedic surgeon decision-making. This study measured the influence of a few cognitive biases on orthopaedic decision-making in hypothetical vignettes. The questions we addressed were as follows: Do orthopaedic surgeons display the cognitive biases of base rate neglect and confirmation bias in hypothetical vignettes? Can anchoring and framing biases be demonstrated?

Methods: One hundred ninety-six orthopaedic surgeons completed a survey consisting of three vignettes evaluating base rate neglect, five evaluating confirmation bias, and two separate vignettes each randomly exposing half of the group to different anchors and frames.

Results: For the three vignettes evaluating base rate neglect, 43% (84 of 196) chose answers consistent with base rate neglect in vignette 1, 88% (173 of 196) in vignette 2, and 35% (69 of 196) in vignette 3. Regarding confirmation bias, 51% (100 of 196) chose an answer consistent with confirmation bias for vignette 1, 11% (22 of 196) for vignette 2, 22% (43 of 196) for vignette 3, 22% (44 of 196) for vignette 4, and 29% (56 of 196) for vignette 5. There was a measurable anchoring heuristic (56% versus 34%; a difference of 22%) and framing effect (77% versus 61%; a difference of 16%).

Conclusion: The influence of cognitive biases can be documented in patient vignettes presented to orthopaedic surgeons. Strategies can anticipate cognitive bias and develop practice debiasing strategies to limit potential error.
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http://dx.doi.org/10.5435/JAAOS-D-20-00620DOI Listing
July 2021

Pronator Quadratus Repair Does Not Affect Reoperation Rates Following Volar Locking Plate Fixation of Distal Radius Fractures.

Hand (N Y) 2021 Jun 9:15589447211017239. Epub 2021 Jun 9.

Brigham and Women's Hospital, Boston, MA, USA.

Background: The purpose of this study was to evaluate the impact of pronator quadratus (PQ) repair on reoperation rates after distal radius open reduction internal fixation (ORIF) using a volar locking plate.

Methods: A retrospective study of all patients undergoing distal radius ORIF with a volar locking plate between January 2012 and December 2016 at 2 urban, academic level I trauma centers was performed. Patient demographics, fracture and procedure characteristics, surgeon subspecialty, PQ repair, and reoperations were recorded. Descriptive statistics were used to determine whether patient-related or injury-related characteristics were associated with PQ repair. Bivariate and multivariable regression analyses were used to assess the effect of PQ repair on subsequent reoperations.

Results: In total, 509 patients were included, including 31 patients with bilateral injuries. The average follow-up time was 3.7 ± 2.8 years. Patients undergoing PQ repair were younger (57 ± 17 years vs 61 ± 17 years) and were more likely to have a lower Soong grade (53% vs 44% with Soong grade 0) than patients without PQ repair. Pronator quadratus repair was not found to have a significant impact on hardware removal, reoperations for flexor tendon pathology, or overall reoperations.

Conclusions: Pronator quadratus repair was more commonly performed in younger patients and in patients with a lower Soong grade. Hand-subspecialized surgeons are more likely to pursue PQ repair than trauma-subspecialized surgeons. This study did not detect statistically significant differences in hardware removal, flexor tendon pathology, or overall reoperations between groups.
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http://dx.doi.org/10.1177/15589447211017239DOI Listing
June 2021

Distal biceps tendon injection.

Clin Shoulder Elb 2021 06 27;24(2):93-97. Epub 2021 May 27.

Department of Orthopedic Surgery, OLVG, Amsterdam, The Netherlands.

Background: Injection therapy around the distal biceps tendon insertion is challenging. This therapy may be indicated in patients with a partial distal biceps tendon tear, bicipitoradial bursitis and tendinopathy. The primary goal of this study was to determine the accuracy of manually performed injections without ultrasound guidance around the biceps tendon.

Methods: Seven upper limb specialists, two general orthopedic specialists, and three orthopedic surgical residents manually injected a cadaver elbow with acrylic dye using an anterior and a lateral infiltration approach. After infiltration the cadaveric elbows were dissected to determine the location of the acrylic dye.

Results: In total, 79% of the injections were localized near the biceps tendon. Of these injections, 20% were localized on the radius near the bicipitoradial bursa. In total, 53% of the performed infiltrations were injected by anterior and 47% by lateral approaches. Of the injections near the distal biceps (79%), 47% were injected by an anterior and 53% by a lateral approach. Of the injections on the radius (20%), 33% were injected by anterior and 67% by lateral approach. Of the inaccurate injections (21%), 75% were injected anterior and 25% lateral.

Conclusion: Manual infiltration without ultrasound guidance for distal biceps pathology lacks accuracy. We therefore recommend ultrasound guidance for more accurate infiltration.
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http://dx.doi.org/10.5397/cise.2021.00010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8181841PMC
June 2021

Payments by Industry to Residency Program Directors in the United States: A Cross-Sectional Study.

Acad Med 2022 02;97(2):278-285

D. Ring is professor of orthopaedic surgery and psychiatry, Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, Texas.

Purpose: To assess the proportion, nature, and extent of financial payments from industry to residency program directors in the United States.

Method: This cross-sectional study used open-source data from Doximity and the Centers for Medicare and Medicaid (CMS) open payments database. Profiles of 4,686 residency program directors from 28 different specialties were identified using Doximity and matched to records in the CMS database. All payments received per residency program director over the years 2014 to 2018 were extracted, including amount in U.S. dollars, payment year, and nature of payment (research versus general payments). Total payments (research plus general payments) received over the 5 years were added up per residency program director. Only personal payments were included.

Results: Overall, 74% (3,465/4,686) of all residency program directors received 1 or more personal payments, totaling $77,058,139, with a median of $216 (interquartile range, $0-$2,150) and a mean of $16,444 (standard deviation, $183,061) per residency program director over the 5 years. Ninety-five percent of total payment value were general payments, and 5% were personal research payments. About 11% (536/4,686) of residency program directors received more than $10,000, while 3% (133/4,686) received more than $100,000 in the study years. There was a substantial difference in the proportion (P < .001), nature (P < .001), and amount (P < .001) of payments of residency program directors between specialties. Almost all residency program directors of interventional radiology (96% [74/77]), vascular surgery (96% [53/55]), and orthopedic surgery (92% [184/201]) received payments, while only one-third to one-half of those in preventive medicine (29% [18/62]), pediatrics (43% [90/211]), and pathology (51% [73/143]) received payments.

Conclusions: Industry payments to residency program directors are common, although large variation exists between specialties. The majority of direct payments to residency program directors are for non-research-related activities.
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http://dx.doi.org/10.1097/ACM.0000000000004166DOI Listing
February 2022

CORR Insights®: What Is the Value of Undergoing Surgery for Spinal Metastases at Dedicated Cancer Centers?

Authors:
Stein J Janssen

Clin Orthop Relat Res 2021 06;479(6):1320-1322

S. J. Janssen, Resident in Orthopaedic Surgery, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.

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http://dx.doi.org/10.1097/CORR.0000000000001695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133256PMC
June 2021

Emotional tones in scientific writing: comparison of commercially funded studies and non-commercially funded orthopedic studies.

Acta Orthop 2021 04 2;92(2):240-243. Epub 2020 Dec 2.

Department of Orthopaedic Surgery, Amsterdam, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Centre, The Netherlands.

Background and purpose - There is ongoing debate as to whether commercial funding influences reporting of medical studies. We asked: Is there a difference in reported tones between abstracts, introductions, and discussions of orthopedic journal studies that were commercially funded and those that were not commercially funded?Methods - We conducted a systematic PubMed search to identify commercially funded studies published in 20 orthopedic journals between January 1, 2000 and December 1, 2019. We identified commercial funding of studies by including in our search the names of 10 medical device companies with the largest revenue in 2019. Commercial funding was designated when either the study or 1 or more of the authors received funding from a medical device company directly related to the content of the study. We matched 138 commercially funded articles 1 to 1 with 138 non-commercially funded articles with the same study design, published in the same journal, within a time range of 5 years. The IBM Watson Tone Analyzer was used to determine emotional tones (anger, fear, joy, and sadness) and language style (analytical, confident, and tentative).Results - For abstract and introduction sections, we found no differences in reported tones between commercially funded and non-commercially funded studies. Fear tones (non-commercially funded studies 5.1%, commercially funded studies 0.7%, p = 0.04), and analytical tones (non-commercially funded studies 95%, commercially funded studies 88%, p = 0.03) were more common in discussions of studies that were not commercially funded.Interpretation - Commercially funded studies have comparable tones to non-commercially funded studies in the abstract and introduction. In contrast, the discussion of non-commercially funded studies demonstrated more fear and analytical tones, suggesting them to be more tentative, accepting of uncertainty, and dispassionate. As text analysis tools become more sophisticated and mainstream, it might help to discern commercial bias in scientific reports.
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http://dx.doi.org/10.1080/17453674.2020.1853341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158288PMC
April 2021

Analysis of Online Reviews of Orthopaedic Surgeons and Orthopaedic Practices Using Natural Language Processing.

J Am Acad Orthop Surg 2021 Apr;29(8):337-344

From the Department of Orthopaedic Surgery, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Centre, Amsterdam, The Netherlands (Dr. Langerhuizen, Dr. Kerkhoffs, and Dr. Janssen), the Center for Health Communication, Moody College of Communication, Dell Medical School, The University of Texas at Austin, Austin, TX (Dr. Brown), the Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia (Dr. Doornberg), and the Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX (Dr. Ring).

Background: There is growing interest in measuring and improving patient experience. Machine learning-based natural language processing techniques may help identify instructive themes in online comments written by patients about their healthcare provider. Separating individual surgeon and orthopaedic office reviews, we analyzed themes that are discussed based on the rating category, the association with review length, the number of people posting more than one review for a surgeon or office, the mean number of reviews per rating category, and the difference in review tones.

Methods: On Yelp.com, we collected 11,614 free-text reviews-together with a one- to five-star rating-of orthopaedic surgeons. Using natural language processing, we identified the most frequently occurring word combinations among rating categories. Themes were derived by categorizing word combinations. Dominant tones (emotional and language styles) were assessed by the IBM Watson Tone Analyzer. We calculated chi-square tests for linear trend and Spearman's rank correlation coefficients to assess differences among rating category.

Results: For individual surgeons and orthopaedic offices, themes such as logistics, care and compassion, trust, recommendation, and customer service varied among rating categories. More positive reviews are shorter for individual surgeons and orthopaedic offices, while rating category was comparable among people posting more than one review for both groups. Tones of joy and confidence were associated with higher ratings. Sadness and tentative tones were associated with lower ratings.

Discussion: For individual orthopaedic surgeons and orthopaedic offices, patient experience may be influenced mostly by the patient-clinician relationship. Training in more effective communication strategies may help improve self-reported patient experience.
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http://dx.doi.org/10.5435/JAAOS-D-20-00288DOI Listing
April 2021

CORR Insights®: What Are the Minimum Clinically Important Differences in SF-36 Scores in Patients with Orthopaedic Oncologic Conditions?

Authors:
Stein J Janssen

Clin Orthop Relat Res 2020 09;478(9):2159-2160

S. J. Janssen, Resident in Orthopaedic Surgery, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.

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http://dx.doi.org/10.1097/CORR.0000000000001429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431244PMC
September 2020

Do 3-D Printed Handheld Models Improve Surgeon Reliability for Recognition of Intraarticular Distal Radius Fracture Characteristics?

Clin Orthop Relat Res 2020 12;478(12):2901-2908

D. W. G. Langerhuizen, G. M. M. J. Kerkhoffs, S. J. Janssen, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centre, Amsterdam, the Netherlands.

Background: For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined.

Questions/purposes: (1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model?

Methods: We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test.

Results: We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09).

Conclusions: Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius.

Level Of Evidence: Level II, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7899383PMC
December 2020

Is Deep Learning On Par with Human Observers for Detection of Radiographically Visible and Occult Fractures of the Scaphoid?

Clin Orthop Relat Res 2020 11;478(11):2653-2659

A. E. J. Bulstra, R. L. Jaarsma, J. N. Doornberg, Flinders University, Department of Orthopaedic & Trauma Surgery, Flinders Medical Centre, Adelaide, Australia.

Background: Preliminary experience suggests that deep learning algorithms are nearly as good as humans in detecting common, displaced, and relatively obvious fractures (such as, distal radius or hip fractures). However, it is not known whether this also is true for subtle or relatively nondisplaced fractures that are often difficult to see on radiographs, such as scaphoid fractures.

Questions/purposes: (1) What is the diagnostic accuracy, sensitivity, and specificity of a deep learning algorithm in detecting radiographically visible and occult scaphoid fractures using four radiographic imaging views? (2) Does adding patient demographic (age and sex) information improve the diagnostic performance of the deep learning algorithm? (3) Are orthopaedic surgeons better at diagnostic accuracy, sensitivity, and specificity compared with deep learning? (4) What is the interobserver reliability among five human observers and between human consensus and deep learning algorithm?

Methods: We retrospectively searched the picture archiving and communication system (PACS) to identify 300 patients with a radiographic scaphoid series, until we had 150 fractures (127 visible on radiographs and 23 only visible on MRI) and 150 non-fractures with a corresponding CT or MRI as the reference standard for fracture diagnosis. At our institution, MRIs are usually ordered for patients with scaphoid tenderness and normal radiographs, and a CT with radiographically visible scaphoid fracture. We used a deep learning algorithm (a convolutional neural network [CNN]) for automated fracture detection on radiographs. Deep learning, an advanced subset of artificial intelligence, combines artificial neuronal layers to resemble a neuron cell. CNNs-essentially deep learning algorithms resembling interconnected neurons in the human brain-are most commonly used for image analysis. Area under the receiver operating characteristic curve (AUC) was used to evaluate the algorithm's diagnostic performance. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate that a prediction is no better than a flip of a coin. The probability of a scaphoid fracture generated by the CNN, sex, and age were included in a multivariable logistic regression to determine whether this would improve the algorithm's diagnostic performance. Diagnostic performance characteristics (accuracy, sensitivity, and specificity) and reliability (kappa statistic) were calculated for the CNN and for the five orthopaedic surgeon observers in our study.

Results: The algorithm had an AUC of 0.77 (95% CI 0.66 to 0.85), 72% accuracy (95% CI 60% to 84%), 84% sensitivity (95% CI 0.74 to 0.94), and 60% specificity (95% CI 0.46 to 0.74). Adding age and sex did not improve diagnostic performance (AUC 0.81 [95% CI 0.73 to 0.89]). Orthopaedic surgeons had better specificity (0.93 [95% CI 0.93 to 0.99]; p < 0.01), while accuracy (84% [95% CI 81% to 88%]) and sensitivity (0.76 [95% CI 0.70 to 0.82]; p = 0.29) did not differ between the algorithm and human observers. Although the CNN was less specific in diagnosing relatively obvious fractures, it detected five of six occult scaphoid fractures that were missed by all human observers. The interobserver reliability among the five surgeons was substantial (Fleiss' kappa = 0.74 [95% CI 0.66 to 0.83]), but the reliability between the algorithm and human observers was only fair (Cohen's kappa = 0.34 [95% CI 0.17 to 0.50]).

Conclusions: Initial experience with our deep learning algorithm suggests that it has trouble identifying scaphoid fractures that are obvious to human observers. Thirteen false positive suggestions were made by the CNN, which were correctly detected by the five surgeons. Research with larger datasets-preferably also including information from physical examination-or further algorithm refinement is merited.

Level Of Evidence: Level III, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7571968PMC
November 2020

Factors associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome.

Eur J Orthop Surg Traumatol 2020 Aug 30;30(6):1089-1095. Epub 2020 Apr 30.

Department of Orthopaedic Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.

Introduction: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome.

Methods: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy.

Results: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001).

Conclusions: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.
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http://dx.doi.org/10.1007/s00590-020-02662-xDOI Listing
August 2020

Risk Factors for Hardware-Related Complications After Olecranon Fracture Fixation.

Orthopedics 2020 May 20;43(3):141-146. Epub 2020 Mar 20.

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P<.003; TB, P<.004). Age and body mass index (BMI) were associated with ROH plus symptomatic hardware after P&S. Age (but not BMI) was associated with ROH/symptomatic hardware after TB. Measured hardware prominence was not associated with ROH or ROH plus symptomatic hardware for either the P&S or the TB cohort. Risk factors including patient age and BMI were found to be significantly associated with hardware-related complications. [Orthopedics. 2020;43(3):141-146.].
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http://dx.doi.org/10.3928/01477447-20200314-03DOI Listing
May 2020

The Prevalence of Calcifications at the Origin of the Extensor Carpi Radialis Brevis Increases with Age.

Arch Bone Jt Surg 2020 Jan;8(1):21-26

Hand Service, Department of Orthopedic Surgery, Massachusetts General Hospital, Massachusetts, Boston, USA.

Background: Enthesopathy of the extensor carpi radialis brevis origin [eECRB] is a common idiopathic, non-inflammatory disease of middle age that is characterized by excess glycosaminoglycan production and frequently associated with radiographic calcification of its origin. The purpose of our study was to assess the relationship of calcification of the ECRB and advancing age.

Methods: We included 28,563 patients who received an elbow radiograph and assessed the relationship of calcifications of the ECRB identified on radiograph reports with patient age, sex, race, affected side, and ordering indication using multivariable logistic regression.

Results: Calcifications of the ECRB were independently associated with age (OR:1.04; ); radiographs ordered for atraumatic pain (OR2.6; ) or lateral epicondylitis (OR5.5; ); and Hispanic ethnicity (OR1.5; ) and less likely to be found at the left side (OR0.68; ). Similarly, incidental calcifications of the ECRB, those on radiographs not ordered for atraumatic pain or lateral epicondylitis, were independently associated with age (OR1.03; ) and Hispanic ethnicity (OR1.5; ) and less likely to be found on the left side (OR0.71; ).

Conclusion: We observed that about nine percent of people have ECRB calcification by the time they are in their sixth decade of life and calcifications persist in the absence of symptoms which supports the idea that eECRB is a common, self-limited diagnosis of middle age.
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http://dx.doi.org/10.22038/abjs.2019.31558.1823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007720PMC
January 2020

Influence of training on dorsal tangential radiographic view to detect screw protrusion after anterior plating of the distal radius: a cadaveric study.

J Hand Surg Eur Vol 2020 Oct 10;45(8):864-870. Epub 2020 Feb 10.

Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia.

In this cadaveric study of anterior plating of the distal radius, we aimed to determine the interobserver agreement and diagnostic performance for detecting dorsally protruding screws using the dorsal tangential radiographic view before and after specific training. Without prior instruction, 13 observers interpreted the dorsal tangential view of cadaveric specimens, in which anterior radial plates were placed. After seeing a training video on the dorsal tangential view, they repeated the task. Though we found that accuracy and interobserver agreement was lower than described in some other clinical series, training led to statistically significant improvements of (1) the interobserver agreement on the decision to exchange screws, (2) the self-confidence of the surgeon in obtaining adequate views, and (3) the number of fluoroscopic images required to obtain these views. After training, the number of protruding screws missed was reduced by 36%, but 7% of dorsally protruding screws was still missed.
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http://dx.doi.org/10.1177/1753193419898060DOI Listing
October 2020

Variation in Offer of Operative Treatment to Patients With Trapeziometacarpal Osteoarthritis.

J Hand Surg Am 2020 Feb 16;45(2):123-130.e1. Epub 2019 Dec 16.

Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX. Electronic address:

Purpose: Operative treatment of trapeziometacarpal osteoarthritis (TMC OA) is discretionary. There is substantial surgeon-to-surgeon variation in offers of surgery. This study assessed factors associated with variation in recommendation of operative treatment to patients with TMC OA. Secondarily, we studied factors associated with preferred operative technique and surgeon demographic factors variability in recommendation for operative treatment.

Methods: We invited all hand surgeon members of the Science of Variation Group to review 16 scenarios of patients with TMC OA and asked the surgeons whether they would recommend surgical treatment for each patient and, if yes, which surgical technique they would offer (trapeziectomy, trapeziectomy with ligament reconstruction and/or tendon interposition, joint replacement, or arthrodesis). Scenarios varied in pain intensity, relief after injection, radiographic severity, and psychosocial symptoms.

Results: Patient characteristics associated with greater likelihood to recommend surgical treatment were substantial pain, a previous injection that did not relieve pain, radiograph with severe TMC OA, and few symptoms of depression. Practice region was the only factor associated with preferred surgical technique and trapeziectomy with ligament reconstruction and/or tendon interposition the most commonly recommended treatment. There was low agreement among surgeons regarding treatment recommendations.

Conclusions: The notable variation in offers of operative treatment for TMC OA is largely associated with variable attention to subjective factors. Future studies might address the relative influence of surgeon incentives and beliefs, objective pathophysiology, and subjective patient factors on variation in surgeon recommendations.

Clinical Relevance: Surgeons' awareness of the potential influence of subjective factors on their recommendations might contribute to efforts to ensure that patient choices reflect what matters most to them and are not based on misconceptions.
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http://dx.doi.org/10.1016/j.jhsa.2019.10.017DOI Listing
February 2020
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