Internal Fixation Versus Hemiarthroplasty for Nondisplaced Femoral Neck Fractures: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare internal fixation (IF) versus hemiarthroplasty (HA) for elderly individuals (ie, older than 65 years) with nondisplaced (ie, Garden type I or II) femoral neck fracture (FNF). DATA SOURCE: We searched English literature of MEDLINE, PubMed, and Embase from inception to December 4, 2021. STUDY SELECTION: Eligibility criteria were randomized controlled trials (RCTs) compared IF versus HA for elderly individuals with nondisplaced FNF. Primary outcomes were Harris hip score (HHS), quality of life per European Quality of Life 5 Dimension (EQ-5D), and mortality. Secondary outcomes were complications, reoperation, intraoperative bleeding, operation duration, and length of hospital stay. DATA EXTRACTION: Two authors separately extracted data and assessed the risk of bias of the included studies using Cochrane risk-of-bias tool. DATA SYNTHESIS: Three RCTs yielding 400 patients were enrolled, of which 203 (50.7%) underwent IF. Internal fixation was inferior to HA with respect to 6-month HHS [mean difference (MD) = -8.28 (-14.46, -2.10), P = 0.009] and 1-year EQ-5D [MD = -0.07 (-0.14, -0.00), P = 0.04]. The 2 techniques were comparable regarding length of hospital stay (day), HHS at 1 and 2 years, EQ-5D at 2 years, and mortality. IF was inferior to HA in implant-related complication [20.1% vs. 6.0%, relative risk (RR) = 3.18 (1.72, 5.88), P = 0.0002] and reoperation rate [20.1% vs. 6.0%, RR = 3.30 (1.79, 6.08), P = 0.0001]. Hemiarthroplasty had a greater blood loss (mL) [MD = -138.88 (-209.58, -68.18), P = 0.001] and operation duration (min) [MD = -23.27 (-44.95, -1.60), P = 0.04] compared with IF. CONCLUSION: HA is the preferred technique for nondisplaced FNF if early recovery, higher mobility, and better quality of life are priorities. The choice of fixation should be weighed on an individual patient level. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures.

BACKGROUND: Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes. RESULTS: We obtained data for 21 211 patients, of whom 14 931 (70.39%) were not anemic, 3982 (18.77%) were mildly anemic, and 2298 (10.83%) were moderately to severely anemic. After adjustment, mild preoperative anemia was associated with higher odds of any adverse event (P < .001), deep surgical site infections (SSIs; P = .013), sepsis (P = .001), 30-day readmission (P < .001), and extended length of stay (LOS) (P < .001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (P < .001), deep SSIs (P = .003), sepsis (P = .001), readmission (P < .001), and extended LOS (P < .001). Both mild (P = .004) and moderate to severe (P < .001) anemia groups had higher odds of requiring a blood transfusion. CONCLUSION: Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. Future studies should evaluate whether optimization of hematocrit in these patients results in improved outcomes. LEVEL OF EVIDENCE: Level III, comparative study.

Preoperative Hypoalbuminemia Is Associated With Early Morbidity and Mortality After Revision Total Hip Arthroplasty.

Hypoalbuminemia is associated with early morbidity and mortality in revision total knee arthroplasty. We evaluated the effect of preoperative hypoalbuminemia on 30-day morbidity and mortality in revision total hip arthroplasty (THA). The National Surgical Quality Improvement Program (NSQIP) database was queried from 2015 to 2018 to identify patients who underwent revision THA. Patients were stratified based on the presence or absence of preoperative hypoalbuminemia and their odds of a major complication or death within 30 days of revision THA with multivariate logistic regression. After Bonferroni correction for these 2 primary outcomes, statistical significance was defined as P<.025. A total of 2492 revision THAs with complete data were identified, of which 486 (20%) had preoperative hypoalbuminemia. Preoperative hypoalbuminemia increased the absolute risk of a major complication by 15.3% compared with patients with revision THA without hypoalbuminemia (30% vs 14.7%, P<.001). Patients with preoperative hypoalbuminemia also had nearly a 7-fold higher incidence of death (3.3%) compared with those with revision THA without preoperative hypoalbuminemia (0.5%, P<.001). After logistic regression, the odds of having a major complication after revision THA with preoperative hypoalbuminemia within 30 days were increased by 80% (odds ratio, 1.8; 95% CI, 1.4-2.3; P<.001), and the odds of death within 30 days were increased by 210% (odds ratio, 3.1; 95% CI, 1.2-7.8; P=.020). Hypoalbuminemia is associated with early morbidity and mortality after revision THA. [Orthopedics. 2022;45(5):281-286.].

Development and Validation of SCFE Percutaneous Pinning Surgical Simulation.

BACKGROUND: In situ screw fixation with a single percutaneously placed femoral screw remains widely accepted for femoral head fixation in adolescent patients with slipped capital femoral epiphysis (SCFE). Given the potential risks involved with this procedure, a simulation whereby surgical skills could be refined before entering the operating room may be of benefit to orthopaedic trainees. METHODS: We developed a synthetic model for the simulated treatment of SCFE. Five orthopaedic attendings and twenty trainees were recorded performing an in situ percutaneous fixation on the SCFE model. Time, radiation exposure, and final anteroposterior and lateral radiographs of the SCFE model were recorded. After completion, the attendings and trainees answered a Likert-based questionnaire regarding the realism and utility of the simulation, respectively. Two blinded orthopaedic surgeons rated each participant's skill level based on previously described assessment tools, including a Global Rating Scale (GRS) of technical proficiency and radiographic grading index for screw placement. Performance metrics and survey responses were evaluated for construct validity, face validity, and interrater reliability. RESULTS: The attendings demonstrated superior technical proficiency compared with trainees in terms of higher GRS scores (27.9±1.9 vs. 14.7±5.0, P<0.001) and better radiographic grading of screw placement on lateral views (P=0.019). Similarly, compared with the trainees, the orthopaedic attendings demonstrated shorter operative times (11.0±4.1 vs. 14.7±6.2 min, P=0.035) and less radiation exposure (3.7±1.7 vs. 9.5±5.7 mGy, P=0.037). The interrater reliability was excellent for both the GRS scoring (intraclass correlation coefficient=0.973) and radiographic grading (weighted κ=1.000). The attendings and trainees rated the realism and teaching utility of the simulation as "very good," respectively. CONCLUSION: Our surgical simulation for in situ percutaneous fixation of SCFE represents a valid and reliable measure of technical competency and demonstrates much promise for potential use as a formative educational tool for orthopaedic residency programs. LEVEL OF EVIDENCE: Level II.

Predictors of USMLE Step 1 Outcomes: Charting Successful Study Habits.

BACKGROUND: The United States Medical Licensing Examination Step 1 is a test that affects many aspects of medical students' careers. The aim of this study was to assess the predictive value of various studying habits and academic traits. ACTIVITY: A survey concerning Step 1 study habits and scores was collected and analyzed. RESULTS AND DISCUSSION: Study results showed that preclinical curriculum grades, practice test scores, and the number of practice questions completed were positively correlated with Step 1 scores. The strongest predictor of Step 1 scores was preclinical curriculum grades: each unit increase in a letter grade was associated with a 12-point increase in Step 1 scores.

Accuracy of Signs and Symptoms for the Diagnosis of Acute Rhinosinusitis and Acute Bacterial Rhinosinusitis.

PURPOSE: To evaluate the accuracy of signs and symptoms for the diagnosis of acute rhinosinusitis (ARS). METHODS: We searched Medline to identify studies of outpatients with clinically suspected ARS and sufficient data reported to calculate the sensitivity and specificity. Of 1,649 studies initially identified, 17 met our inclusion criteria. Acute rhinosinusitis was diagnosed by any valid reference standard, whereas acute bacterial rhinosinusitis (ABRS) was diagnosed by purulence on antral puncture or positive bacterial culture. We used bivariate meta-analysis to calculate summary estimates of test accuracy. RESULTS: Among patients with clinically suspected ARS, the prevalence of imaging confirmed ARS is 51% and ABRS is 31%. Clinical findings that best rule in ARS are purulent secretions in the middle meatus (positive likelihood ratio [LR+] 3.2) and the overall clinical impression (LR+ 3.0). The findings that best rule out ARS are the overall clinical impression (negative likelihood ratio [LR-] 0.37), normal transillumination (LR- 0.55), the absence of preceding respiratory tract infection (LR- 0.48), any nasal discharge (LR- 0.49), and purulent nasal discharge (LR- 0.54). Based on limited data, the overall clinical impression (LR+ 3.8, LR- 0.34), cacosmia (fetid odor on the breath) (LR+ 4.3, LR- 0.86) and pain in the teeth (LR+ 2.0, LR- 0.77) are the best predictors of ABRS. While several clinical decision rules have been proposed, none have been prospectively validated. CONCLUSIONS: Among patients with clinically suspected ARS, only about one-third have ABRS. The overall clinical impression, cacosmia, and pain in the teeth are the best predictors of ABRS. Clinical decision rules, including those incorporating C-reactive protein, and use of urine dipsticks are promising, but require prospective validation.

Clinical medical education in rural and underserved areas and eventual practice outcomes: A systematic review and meta-analysis.

BACKGROUND: Undergraduate medical students are enrolled in clinical education programs in rural and underserved urban areas to increase the likelihood that they will eventually practice in those areas and train in a primary care specialty to best serve those patient populations. METHODS: MEDLINE and Cochrane Library online databases were searched to identify articles that provide a detailed description of the exposure and outcome of interest. A qualitative review of articles reporting outcome data without comparison or control groups was completed using the Medical Education Research Study Quality Instrument (MERSQI). A meta-analysis of articles reporting outcome data with comparison or control groups was completed with statistical and graphical summary estimates. RESULTS: Seven hundred and nine articles were retrieved from the initial search and reviewed based on inclusion and exclusion criteria. Of those, ten articles were identified for qualitative analysis and five articles included control groups and thus were included in the quantitative analysis. Results indicated that medical students with clinical training in underserved areas are almost three times as likely to practice in underserved areas than students who do not train in those areas (relative risk [RR] = 2.94; 95% confidence interval [CI]: 2.17, 4.00). Furthermore, medical students training in underserved areas are about four times as likely to practice primary care in underserved areas than students who do not train in those locations (RR = 4.35; 95% CI: 1.56, 12.10). DISCUSSION: These estimates may help guide medical school administrators and policymakers to expand underserved clinical training programs to help relieve some of the problems associated with access to medical care among underserved populations.

External Validation of Two Classification and Regression Tree Models to Predict the Outcome of Inpatient Cardiopulmonary Resuscitation.

OBJECTIVE: To prospectively validate a previously developed classification and regression tree (CART) model that predicts the likelihood of a good outcome among patients undergoing inpatient cardiopulmonary resuscitation. DESIGN: Prospective validation of a clinical decision rule. SETTING: Skåne University Hospital in Malmo, Sweden. PATIENTS: All adult patients (N = 287) experiencing in-hospital cardiopulmonary arrest and undergoing cardiopulmonary resuscitation between 2007 and 2010. INTERVENTIONS: Patients from Skåne University Hospital who underwent CPR (N = 287) were classified using the CART models to predict their likelihood of survival neurologically intact or with minimal deficits, based on a cerebral performance category score of 1. Discrimination and classification accuracy of the score in the Swedish population was compared to that in the original (derivation and internal validation) populations. MEASUREMENTS AND MAIN RESULTS: For model 1, the area under the receiver-operating characteristic curve (AUROCC) was 0.77, compared with 0.76 and 0.73 in the original derivation and validation populations, respectively. Model 1 classified 71 (2.8%) of 287 patients as being at a very low risk of a good neurologic outcome compared with 157 (26.1%) of 287 patients predicted to be at an above average risk of a good neurologic outcome. Model 2 had a similar AUROCC as the original validation population of 0.71 but lower than the original derivation population. Model 2 performed similarly to Model 1 with regards to its ability to correctly classify patients as very low or higher than average likelihood of a good neurologic outcome. CONCLUSION: Two CART models validated well in a different population, displaying similar discrimination and classification accuracy compared to the original population. Although additional validation in larger populations is desirable before widespread adoption, these results are very encouraging.

Diagnosis of acute rhinosinusitis in primary care: a systematic review of test accuracy.

BACKGROUND: Acute rhinosinusitis (ARS) is a common primary care infection, but there have been no recent, comprehensive diagnostic meta-analyses. AIM: To determine the accuracy of laboratory and imaging studies for the diagnosis of ARS. DESIGN AND SETTING: Systematic review of diagnostic tests in outpatient, primary care, and specialty settings. METHOD: The authors included studies of patients presenting with or referred for suspected ARS, and used bivariate meta-analysis to calculate summary estimates of test accuracy and the area under the receiver operating characteristic (ROC) curve. The authors also plotted summary ROC curves to explore heterogeneity, cutoffs, and the impact of different reference standards. RESULTS: Using antral puncture as the reference standard, A mode ultrasound (positive likelihood ratio [LR+] 1.71, negative likelihood ratio [LR-] 0.41), B mode ultrasound (LR+ 1.64, LR- 0.69), and radiography (LR+ 2.01, LR- 0.28) had only modest accuracy. Accuracy was higher using imaging as the reference standard for both ultrasound (LR+12.4, LR- 0.35) and radiography (LR+ 9.4, LR- 0.27), although this likely overestimates accuracy. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) both had clear threshold effects, and modest overall accuracy. The LR+ for ESR >30 and >40 were 4.08 and 7.40, respectively. A dipstick of nasal secretions for leucocyte esterase was highly accurate (LR+ 18.4, LR- 0.17) but has not been validated. CONCLUSION: In general, tests were of limited value in the diagnosis of ARS. Normal radiography helps rule out sinusitis when negative, whereas CRP and ESR help rule in sinusitis when positive, although, given their limited accuracy as individual tests, they cannot be routinely recommended. Prospective studies integrating signs and symptoms with point-of-care CRP, dipstick, and/ or handheld B-mode ultrasound are needed.