Open Ankle Fractures in Older Individuals: A Multi-center Study.

The purpose of this study is to identify demographics, etiology, comorbidities, treatment, complications, and outcomes for older patients with open ankle fractures. Patients ≥60 years old who sustained an open ankle fracture between January 1, 2004 - March 31, 2014 at 6 Level 1 trauma centers were retrospectively reviewed. Univariate analysis using Chi-squared or Student's T-test was performed to identify associations between preoperative variables and two postoperative outcomes of interest: amputation and 1-year mortality. Multivariate analysis was performed using stepwise logistical regression to identify independent predictors of postoperative amputation and 1-year mortality. Of the 162 total patients, the most common mechanism of injury was a ground-level fall (51.9%). The most common fracture types were bimalleolar fractures (52.5%) followed by trimalleolar fractures (26.5%), with 41.5% of the fractures classified as Gustilo Anderson Classification Type 2 and 38.6% classified as Type 3A. The average number of surgeries required per patient was 2.1. Complications included: 15.4% superficial infection rate, 9.9% deep infection rate, and 9.3% amputation rate. The 1-year mortality rate was 13.6% and the overall mortality rate was 25.9%. Male gender and fracture type were found to be independent predictors for amputation after surgery (P = 0.009, 0.005, respectively). Older age and having diabetes were independent predictors for 1-year mortality after surgery (P = 0.021, 0.005 respectively). Overall, open ankle fractures in older individuals were associated with high rates of amputation and mortality.

Interpreting the Current Literature on Outcomes of Robotic-Assisted Versus Conventional Total Knee Arthroplasty Using Fragility Analysis: A Systematic Review and Cross-Sectional Study of Randomized Controlled Trials.

BACKGROUND: Fragility analysis is a method of further characterizing outcomes in terms of the stability of statistical findings. This study assesses the statistical fragility of recent randomized controlled trials (RCTs) evaluating robotic-assisted versus conventional total knee arthroplasty (RA-TKA versus C-TKA). METHODS: We queried PubMed for RCTs comparing alignment, function, and outcomes between RA-TKA and C-TKA. Fragility index (FI) and reverse fragility index (RFI) (collectively, "FI") were calculated for dichotomous outcomes as the number of outcome reversals needed to change statistical significance. Fragility quotient (FQ) was calculated by dividing the FI by the sample size for that outcome event. Median FI and FQ were calculated for all outcomes collectively as well as for each individual outcome. Subanalyses were performed to assess FI and FQ based on outcome event type and statistical significance, as well as study loss to follow-up and year of publication. RESULTS: The overall median FI was 3.0 (interquartile range, [IQR] 1.0 to 6.3) and the median reverse fragility index was 3.0 (IQR 2.0 to 4.0). The overall median FQ was 0.027 (IQR 0.012 to 0.050). Loss to follow-up was greater than FI for 23 of the 38 outcomes assessed. CONCLUSIONS: A small number of alternative outcomes is often enough to reverse the statistical significance of findings in RCTs evaluating dichotomous outcomes in RA-TKA versus C-TKA. We recommend reporting FI and FQ alongside P values to improve the interpretability of RCT results.

Prevalence of Abnormal Ultrasonographic Findings in Asymptomatic Peroneal Tendons.

Background: The peroneus longus (PL) and peroneus brevis (PB) tendons comprise the lateral compartment of the leg and stabilize the foot during weightbearing. Peroneal tendinopathy can precipitate lateral ankle pain and induce functional disability. The progression of peroneal pathology to lateral ankle dysfunction is thought to stem from asymptomatic, subclinical peroneal tendinopathy. There may be clinical benefit to identifying asymptomatic patients with this condition before progression to disability. Various ultrasonographic characteristics have been observed in peroneal tendinopathy. The purpose of this study is to identify the frequency of subclinical tendinopathic characteristics in asymptomatic peroneal tendons. Methods: One hundred seventy participants underwent bilateral foot and ankle ultrasonographic examination. Images were assessed for abnormalities of the PL and PB tendons by a group of physicians who recorded frequencies of abnormalities. This team consisted of an orthopaedic surgeon specializing in foot and ankle surgery, a fifth-year orthopaedic surgery resident, and a family medicine physician with musculoskeletal sonographer certification. Results: A total of 340 PL and 340 PB tendons were assessed. Sixty-eight (20%) PL and 41 (12.1%) PB tendons had abnormal traits. Twenty-four PLs and 22 PBs had circumferential fluid, 16 PLs and 9 PBs had noncircumferential fluid, 27 PLs and 6 PBs had thickening, 36 PLs and 12 PBs had heterogenicity, 10 PLs and 2 PBs had hyperemia, and 1 PL had calcification. In Caucasian participants, male gender was associated with increased frequency of abnormal findings, but there were no other significant differences based on age, body mass index, or ethnicity. Conclusion: In our studied population of 170 patients who had no complaints of associated symptoms, we found that 20% of PLs and 12% of PBs displayed ultrasonographic abnormalities. When we included all unusual findings within and around the tendons, prevalence rates of ultrasonographic abnormalities were 34% for PLs and 22% for PBs. Level of Evidence: Level II, prospective cohort study.

Relationship Between Headache Characteristics and a Remote History of TBI in Veterans: A 10-Year Retrospective Chart Review.

BACKGROUND AND OBJECTIVES: The objective of this work was to examine the association between deployment-related traumatic brain injury (TBI) severity, frequency, and other injury characteristics with headache outcomes in veterans evaluated at a Veterans Administration (VA) polytrauma support clinic. METHODS: We conducted a retrospective chart review of 594 comprehensive TBI evaluations between 2011 and 2021. Diagnostic criteria were based on the Department of Defense/VA Consensus-Based Classification of Closed TBI. Adjusted odds ratios (AORs) and 95% CIs were estimated for headache prevalence (logistic), headache severity (ordinal), and prevalence of migraine-like features (logistic) with multiple regression analysis. Regression models were adjusted for age, sex, race/ethnicity, time since injury, and mental health diagnoses. RESULTS: TBI severity groups were classified as sub concussive exposure (n = 189) and mild (n = 377), moderate (n = 28), and severe TBI (n = 0). Increased headache severity was reported in veterans with mild TBI (AOR 1.72 [95% CI 1.15, 2.57]) and moderate TBI (AOR 3.89 [1.64, 9.15]) compared to those with subconcussive exposure. A history of multiple mild TBIs was associated with more severe headache (AOR 2.47 [1.34, 4.59]) and migraine-like features (AOR 5.95 [2.55, 13.77]). No differences were observed between blast and nonblast injuries; however, greater headache severity was reported in veterans with both primary and tertiary blast effects (AOR 2.56 [1.47, 4.49]). Alteration of consciousness (AOC) and posttraumatic amnesia (PTA) >30 minutes were associated with more severe headache (AOR 3.37 [1.26, 9.17] and 5.40 [2.21, 13.42], respectively). The length of time between the onset of last TBI and the TBI evaluation was associated with headache severity (AOR 1.09 [1.02, 1.17]) and prevalence of migraine-like features (AOR 1.27 [1.15, 1.40]). Last, helmet use was associated with less severe headache (AOR 0.42 [0.23, 0.75]) and lower odds of migraine-like features (AOR 0.45 [0.21, 0.98]). DISCUSSION: Our data support the notion of a dose-response relationship between TBI severity and headache outcomes. A history of multiple mild TBIs and longer duration of AOC and PTA are unique risk factors for poor headache outcomes in veterans. Furthermore, this study sheds light on the poor headache outcomes associated with subconcussive exposure. Past TBI characteristics should be considered when developing headache management plans for veterans.