Orthopaedic residents' autonomy in hip fracture surgery: what is the effect on patient outcomes?

BACKGROUND: In the context of growing prevalence of hip fractures and hip fracture surgery in the elderly, it is unknown if surgical trainee autonomy in the operating room conflicts with optimal health care provision and safety of patients. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or joint reconstruction fellowship-trained orthopaedic surgeons. METHODS: A single-center cohort was retrospectively reviewed for all hip fracture cases, surgically treated with hemiarthroplasty or internal fixation during 2016. Data were analyzed and compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or joint replacement fellowship-trained surgeons. Demographics, time to surgery, and American Society of Anesthesiologists Physical Status Classification System (ASA), surgical parameters, preoperative and postoperative radiographs as well as primary (mortality, complications and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis and Kaplan-Meier survival analysis were performed to evaluate outcomes. RESULTS: Out of 478 cases, 404 (84.5%) were included in this study. Non-operative cases, techniques used solely by attending surgeons, such as total hip replacement, were excluded. The average follow-up time was 26.1 months (SD 10.9). Analysis of internal fixation and hemiarthroplasty groups demonstrated no significant difference between residents and attendings in complications (p = 0.353, 0.850, respectively), and mortality (p = 0.796, 0.734, respectively). In both groups, surgery time was significantly longer in the resident group (p < 0.001). CONCLUSION: The current study demonstrates that hip fracture surgery performed by adequately trained orthopaedic surgery residents can provide similar results to surgery performed by fellowship-trained attendings. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Managing the Complex Cavus Foot Deformity.

This article describes approaches to and the management of complex cavus foot deformities. Correction of rigid multiplanar deformities can be very challenging, given the presence of skeletal deformities in multiple planes and combined with a varying degree of muscle imbalance. The complexity of these cases always requires a case-by-case approach. Some of the cases presented here occur in patients who have previously undergone surgical management for their deformity, several of which are complicated by additional deformities. With a firm understanding and application of the principles of deformity correction, however, one may reliably offer satisfactory results.

Subtalar Arthrodesis with Use of Adipose-Derived Cellular Bone Matrix Compared with Autologous Bone Graft: A Multicenter, Randomized Controlled Trial.

UPDATE: This article was updated on November 7, 2019, because of a previous error. On page 1909, in the section entitled "Discussion," the sentence that had read "Radiographic nonunion rates of 69.2% and 45.6% were observed at 6 months for ACBM and autograft, respectively, as measured on CT scans; however, these nonunion rates do account for patients who were considered to have attained fusion according to traditional methods, including absence of pain and swelling and presence of arthrodesis on radiographs" now reads "Radiographic nonunion rates of 69.2% and 45.6% were observed at 6 months for ACBM and autograft, respectively, as measured on CT scans; however, these nonunion rates do not account for patients who were considered to have attained fusion according to traditional methods, including absence of pain and swelling and presence of arthrodesis on radiographs."An erratum has been published: J Bone Joint Surg Am. 2019 XXX. BACKGROUND: Subtalar arthrodesis effectively treats subtalar joint arthritis when other interventions have failed. Nonunion is a known complication of subtalar arthrodesis, with reported rates ranging from 5% to 45%. Historically, open arthrodesis has been performed with use of autologous bone graft; however, there are inherent disadvantages to autologous bone graft, including donor-site morbidity. Mesenchymal stem cells, when placed on a cellular scaffold, have shown promise as an alternative to autologous bone graft. The purpose of this multicenter, randomized controlled trial was to assess the safety and efficacy of an adipose-derived cellular bone matrix (ACBM) composite made with live cells compared with autograft in subtalar arthrodesis. METHODS: A total of 140 patients were enrolled in a prospective, randomized (1:1) controlled trial performed at 6 clinical sites in the U.S. End points, including radiographic, clinical, and functional outcomes, were assessed over 2 years of follow-up. RESULTS: A total of 109 patients underwent arthrodesis with ACBM (52 patients) and autograft (57 patients). At 6 months, fusion was achieved in 16 patients (30.8%) in the ACBM group and 31 patients (54.4%) in the autograft group as measured on computed tomography (p = 0.024), and in 41 patients (78.8%) in the ACBM group and 50 patients (87.7%) in the autograft group as assessed on clinical and radiographic evaluation (p = 0.213). Quality-of-life outcome measures demonstrated significant functional improvement from baseline for both groups. Fewer cases of serious adverse events occurred in the autograft group (10.5%) compared with the ACBM group (23.1%) (p = 0.078). CONCLUSIONS: In patients who require subtalar arthrodesis, the use of ACBM demonstrated lower rates of radiographic fusion compared with treatment with autograft. The nonunion rate in the autologous group, as measured on computed tomography, was high. Good clinical outcomes were achieved in spite of the high non-union rates. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Cavus Foot: Deciding Between Osteotomy and Arthrodesis.

Mild to moderate cavus deformity creates a dilemma in terms of surgical decision-making. The decision to pursue osteotomy or arthrodesis is not always clear. This article provides a framework for guiding management of these deformities, followed by a detailed surgical approach to correcting moderate cavus deformities, which emphasizes the use of a midfoot osteotomy-arthrodesis.

Suture Button Versus Syndesmotic Screw for Syndesmosis Injuries: A Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Operative treatment is indicated for unstable syndesmosis injuries, and approximately 20% of all ankle fractures require operative fixation for syndesmosis injuries. PURPOSE: To perform a meta-analysis of randomized controlled trials evaluating clinical outcomes between suture button (SB) and syndesmotic screw (SS) fixation techniques for syndesmosis injuries of the ankle. STUDY DESIGN: Meta-analysis. METHODS: A literature search was performed according to the PRISMA guidelines to identify randomized controlled trials comparing the SB and SS techniques for syndesmosis injuries. Level of evidence was assessed per the criteria of the Oxford Centre for Evidence-Based Medicine. Statistical analysis was performed with RevMan, and a P value ≤.05 was considered statistically significant. RESULTS: Five clinical studies were identified, allowing comparison of 143 patients in the SB group with 142 patients in the SS group. Patients treated with the SB technique had a higher postoperative American Orthopaedic Foot & Ankle Society score at a mean 20.8 months (95.3 vs 86.7, P < .001). The SB group resulted in a lower rate of broken implants (0.0% vs 25.4%, P < .001), implant removal (6.0% vs 22.4%, P = .01), and joint malreduction (0.8% vs 11.5%, P = .05) as compared with the SS group. CONCLUSION: The SB technique results in improved functional outcomes as well as lower rates of broken implant and joint malreduction. Based on the findings of this meta-analysis, the SB technique warrants a grade A recommendation by comparison with the SS technique for the treatment of syndesmosis injuries.

Safety and Effectiveness of Talus Subchondroplasty and Bone Marrow Aspirate Concentrate for the Treatment of Osteochondral Defects of the Talus.

Eleven patients with symptomatic talus osteochondral defects who underwent subchondroplasty with bone marrow aspirate concentrate injection were retrospectively reviewed. Foot and Ankle Outcome Score and visual analog scale pain score were recorded preoperatively and at the 1-year postoperative visit. The mean osteochondral defect size was 1.3×1.4 cm. The weight-bearing visual analog scale pain score improved from a mean of 7.8 to 1.8, and the Foot and Ankle Outcome Score improved from a mean of 67.1 to 89.6. At 1-year follow-up, 10 patients reported they would have the procedure again. Subchondroplasty and bone marrow aspirate concentrate injection offered good pain relief for talus osteochondral defects. The procedure allows immediate weight bearing postoperatively and does not compromise future treatments. [Orthopedics. 2018; 41(5):e734-e737.].