The Effect of Adverse Events on Orthopaedic Surgeons: A Review.

The purpose of this review was to evaluate the effect of adverse events (AEs) on orthopaedic surgeons, illustrate common ways orthopaedic surgeons deal with AEs, and describe solutions to reduce the negative effect of AEs and prevent them from recurring. AEs are common in orthopaedic surgery and increase the risk of depression, anxiety, and suicide. Orthopaedic surgeons may experience negative effects after AEs even when they are not at fault. AEs are linked to moral injury, second victim syndrome, burnout, and disruptive physician behaviors. Many surgeons deal with AEs in isolation out of fear of a negative effect on their professional reputation, potentially leading to increased psychological distress and unhealthy coping mechanisms. Healthy ways to address AEs and improve the well-being of surgeons include destigmatizing psychological stress after AEs and creating a culture of receptivity and peer support.

Increasing the Threshold to Perform Preperitoneal Pelvic Packing Decreases Morbidity Without Affecting Mortality.

OBJECTIVES: To determine the effectiveness of an updated protocol that increased the transfusion threshold to perform preperitoneal pelvic packing in patients with pelvic ring injuries and hemodynamic instability (HDI). DESIGN: Retrospective review. SETTING: Urban level 1 trauma center. PATIENTS SELECTION CRITERIA: Severely injured (injury severity score > 15) patients with pelvic ring injuries treated before and after increasing the threshold to perform preperitoneal pelvic packing from 2 to 4 units of red blood cells (RBCs). HDI was defined as a systolic blood pressure <90 mm Hg. OUTCOME MEASURES AND COMPARISONS: Mortality from hemorrhage, anterior pelvic space infections, and venous thromboembolisms before and after increasing preperitoneal pelvic packing threshold. RESULTS: One hundred sixty-six patients were included: 93 treated under the historical protocol and 73 treated under the updated protocol. HDI was present in 46.2% (n = 43) of the historical protocol group and 49.3% (n = 36) of the updated protocol group (P = 0.69). The median age of patients with HDI was 35.0 years (interquartile range 26.0-52.0), 74.7% (n = 59) were men, and the median injury severity score was 41.0 (interquartile range 29.0-50.0). Patients with HDI in the updated protocol group had a lower heart rate on presentation (105.0 vs. 120.0; P = 0.004), required less units of RBCs over the first 24 hours (6.0 vs. 8.0, P = 0.03), and did not differ in age, injury severity score, systolic blood pressure on arrival, base deficit or lactate on arrival, resuscitative endovascular balloon occlusion of the aorta, resuscitative thoracotomy, angioembolization, or anterior pelvis open reduction internal fixation (P > 0.05). The number of PPPs performed decreased under the new protocol (8.3% vs. 65.1%, P < 0.0001), and there were fewer anterior pelvic infections (0.0% vs. 13.9%, P = 0.02), fewer VTEs (8.3% vs. 30.2%; P = 0.02), and no difference in deaths from acute hemorrhagic shock (5.6% vs. 7.0%, P = 1.00). CONCLUSIONS: Increasing the transfusion threshold from 2 to 4 units of red blood cells to perform pelvic packing in severely injured patients with pelvic ring injuries decreased anterior pelvic space infections and venous thromboembolisms without affecting deaths from acute hemorrhage. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rise of the Machines: The Prevalence and Disclosure of Artificial Intelligence-Generated Text in High-Impact Orthopaedic Journals.

INTRODUCTION: While most orthopaedic journals permit the use of artificial intelligence (AI) in article development, they require that AI not be listed as an author, that authors take full responsibility for its accuracy, and that AI use be disclosed. This study aimed to assess the prevalence and disclosure of AI-generated text in abstracts published in high-impact orthopaedic journals. METHODS: Abstracts published from January 1, 2024, to February 19, 2024, in five orthopaedic journals were analyzed: the American Journal of Sports Medicine; the Journal of Arthroplasty; the Journal of Bone and Joint Surgery; the Knee Surgery, Sports, Traumatology, and Arthroscopy (KSSTA) journal; and the BMC Musculoskeletal Disorders (BMC MD) journal. Artificial intelligence detection software was used to evaluate each abstract for AI-generated text. Disclosure of AI use, country of origin, and article type (clinical, preclinical, review, or AI/machine learning) were documented. To evaluate the accuracy of AI detection software, 60 consecutive articles published in the Journal of Bone and Joint Surgery in 2014, before AI writing software was available, were also evaluated. These abstracts were evaluated again after being rewritten with AI writing software. The sensitivity and specificity of the software program for AI-generated text were calculated. RESULTS: A total of 577 abstracts were included in the analysis. AI-generated text was detected in 4.8% of abstracts, ranging from 0% to 12% by journal. Only one (3.6%) of the 28 abstracts with AI-generated text disclosed its use. Abstracts with AI-generated text were more likely to be from the Asian continent (57.1% vs. 28.0%, P = 0.001) and to involve topics of AI or machine learning (21.4% vs. 0.6%, P < 0.0001). The sensitivity and specificity of the AI detection software program were determined to be 91.7% (55/60) and 100% (60/60). DISCUSSION: A small percentage of abstracts published in high-impact orthopaedic journals contained AI-generated text, and most did not report the use of AI despite journal requirements. LEVEL OF EVIDENCE: Diagnostic Level III.

Associations with unplanned repeat irrigation and debridement of native septic arthritis.

PURPOSE: To identify associations with unplanned repeat irrigation and debridement (I&D) after arthrotomy for native septic arthritis. METHODS: A retrospective review identified patients with native septic arthritis treated with open arthrotomies. The primary outcome was unplanned repeat I&D within 90 days. Associations evaluated for included comorbidities, ability to bear weight, fever, immunosuppressed status, purulence, C-reactive protein, erythrocyte sedimentation rate, white blood cell count (synovial fluid and serum levels), and synovial fluid polymorphonuclear cell percentage (PMN%). RESULTS: There were 59 arthrotomies in 53 patients involving the knee (n = 32), shoulder (n = 10), elbow (n = 8), ankle (n = 6), and hip (n = 3). The median patient age was 52, and a 71.2% were male. An unplanned repeat I&D was required in 40.7% (n = 24). The median time to the second I&D was 4 days (interquartile range 3 to 9). On univariate analysis, unplanned repeat I&Ds were associated with fever (p = 0.03), purulence (p = 0.01), bacteria growth on cultures (p = 0.02), and the use of deep drains (p = 0.05). On multivariate analysis, the only variables that remained associated with unplanned repeat I&Ds were fever (odds ratio (OR) 5.5, 95% confidence interval (CI) 1.3, 23.6, p = 0.02) and purulence (OR 5.3, CI 1.1, 24.4, p = 0.03). CONCLUSIONS: An unplanned repeat I&D was required in 40.7% of patients and was associated with fever and purulence. These findings highlight the difficulty of controlling these infections and support the need for future research into better methods of management. LEVEL OF EVIDENCE: Diagnostic, Level III.

The Effect of Crystal Arthropathy on the Diagnostic Criteria of Native Septic Arthritis.

INTRODUCTION: Distinguishing between septic arthritis and crystal arthropathy flares can be challenging. The purpose of this study was to determine how the presence of synovial crystals affects the diagnostic criteria of septic arthritis. METHODS: A retrospective review identified patients undergoing joint aspirations to rule out native septic arthritis. Differences between septic arthritis presenting with and without synovial crystals were analyzed. A receiver-operating characteristic curve was plotted for laboratory markers to determine the area under the curve, or diagnostic accuracy, for septic arthritis and to evaluate thresholds that maximized sensitivity and specificity. RESULTS: There were 302 joint aspirations in 267 patients. Septic arthritis was diagnosed in 17.9% (54/302). Patients with synovial crystals were less likely to have septic arthritis (4.2% [5/119] vs. 26.8% [49/183], P < 0.0001). Septic arthritis in patients with no synovial crystals was associated with fever and a higher synovial white blood cell (WBC) count, synovial polymorphonuclear cell percentage (PMN%), serum WBC, and C-reactive protein (CRP) ( P < 0.05). Septic arthritis in patients with synovial crystals was only associated with inability to bear weight and a higher synovial WBC and CRP ( P < 0.05). Synovial PMN% was considered nondiagnostic of septic arthritis (area under the curve 0.56) in patients with crystals while synovial WBC and CRP had acceptable (0.76) and excellent (0.83) diagnostic utility, respectively. The WBC and CRP value thresholds that maximized sensitivity and specificity for septic arthritis were greater in patients with crystals (21,600 vs. 17,954 cells/µL and 125 vs. 69 mg/L, respectively). DISCUSSION: The presence of synovial crystals reduced the likelihood of septic arthritis and altered the laboratory diagnostic criteria. PMN% was nondiagnostic in the setting of synovial crystals.

Urinary bladder matrix versus dermal regeneration template for lower extremity wound coverage.

PURPOSE: To compare dermal regenerative template (DRT), with and without split-thickness skin-grafting (STSG), and urinary bladder matrix (UBM) for coverage of lower extremity wounds. METHODS: A retrospective review of 56 lower extremity wounds treated with either DRT and STSG (DRT-S) (n = 18), DRT only (n = 17), or UBM only (n = 21). Patient characteristics, comorbidities, American Society of Anesthesiology (ASA) classification, injury characteristics, wound characteristics, use of negative pressure wound therapy, surgical details, postoperative care, and failure of primary wound coverage procedure were documented. RESULTS: The DRT group, compared to the DRT-S group, was older [median difference (MD) 17.4 years, 95% confidence interval (CI) 9.1-25.7; p = 0.0008], more diabetic (proportional difference (PD) 54.2%, CI 21.2-76.1%; p = 0.002), had smaller wounds (MD - 91.0 cm2, CI - 125.0 to - 38.0; p = 0.0008), more infected wounds (PD 49.0%, CI 16.1-71.7%; p = 0.009), a shorter length of stay after coverage (MD - 5.0 days, CI - 29.0 to - 1.0; p = 0.005), and no difference in primary wound coverage failure (41.2% vs. 55.6%; p = 0.50). The UBM group, compared to the DRT group, was younger (MD - 6.8 years; CI - 13.5 to - 0.1; p = 0.04), had fewer patients with an ASA > 2 (PD - 35.0%, CI - 55.2% to - 7.0%; p = 0.02), diabetes (PD - 49.2%, CI - 72.4% to - 17.6%; p = 0.003), and had no difference in primary wound coverage failure (36.4% vs. 41.2%; p = 1.0). Failure of primary wound coverage was found to only be associated with larger wound surface areas (MD 22.0 cm2, CI 4.0-90.0; p = 0.01). CONCLUSIONS: DRT and UBM coverage had similar rates of primary wound coverage failure for lower extremity wounds. LEVEL OF EVIDENCE: Diagnostic, Level III.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur.

INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Lumbar decompression and fusion for symptomatic spinal stenosis in a patient with chronic thoracic sensory level from prior transverse myelitis: a case report.

BACKGROUND: Many patients with transverse myelitis suffer from sensory loss below the spinal level of the lesion. This is commonly associated with chronic neuropathic pain. However, the presence of somatic pain below a complete thoracic sensory level after transverse myelitis is exceptionally rare, and it is unclear if surgical decompression is an effective form of treatment for these patients. CASE PRESENTATION: In this report, we describe a 22-year-old Caucasian female who suffered from chronic lumbar back pain despite a complete thoracic sensory level secondary to prior transverse myelitis. Imaging demonstrated multilevel central stenosis below the sensory level, and her pain improved after surgical decompression. To our knowledge, this is the first reported case of symptomatic lumbar stenosis below a sensory level after transverse myelitis successfully treated with surgical decompression. CONCLUSION: This is the first reported case of a patient with symptomatic lumbar stenosis after transverse myelitis whose lower back pain and quality of life improved following surgical decompression and fusion. This case provides evidence that typical lumbago is possible in patients with sensory loss from transverse myelitis, and standard lumbar decompression may provide benefit for these patients.

The Effect of Vancomycin and Tobramycin Local Antibiotic Powder on Surgical Site Infections After Open Treatment of Fracture: A Retrospective Propensity-Matched Analysis.

OBJECTIVES: The aim of this study was to compare the effect of vancomycin/tobramycin local antibiotic powder (LAP) on surgical site infections (SSIs) after open treatment of fractures. DESIGN: This was a retrospective comparative study with propensity matching. SETTING: The study was set in an urban level 1 trauma center. PATIENTS SELECTION CRITERIA: Patients undergoing open procedures for fracture performed by a single surgeon before and after cessation of routine LAP use were included. OUTCOME MEASURES AND COMPARISONS: Deep and superficial SSIs were the measured outcomes. RESULTS: There were 652 open procedures for fracture performed by a single surgeon: LAP was used in 36.7% (114/310) of procedures before stopping its use, after which 342 procedures were performed without LAP. Comparison of all procedures performed with and without routine LAP use demonstrated no difference in infection rates, although there was a trend for the group without LAP to have fewer superficial SSIs (proportional difference [PD] -2.0%, 95% confidence interval [CI] -4.1% to 0.1%; P = 0.05) and more deep SSIs (PD 3.9%, 95% CI, -0.2% to 7.9%; P = 0.06). Prematch analysis demonstrated that LAP use was associated with external fixation (PD 8.5%, 95% CI, 1.6%-16.2%; P = 0.005), longer operative times (median difference 56.0 minutes, 95% CI, 39.0-74.0; P < 0.0001), greater estimated blood loss (median difference 70.0, 95% CI, 50.0-100.0; P < 0.0001), and no difference in superficial (PD 2.4%; 95% CI, -0.8% to 6.8%; P = 0.07) or deep SSIs (PD -1.6%, 95% CI, -6.2% to 4.1%; P = 0.54). After propensity matching (108 vs. 108) to control for the above differences, the LAP group, compared with the no LAP group, had no difference in superficial SSIs and was less likely to have deep SSIs (PD -8.3%, 95% CI, -16.2% to -0.2%; P = 0.04). CONCLUSIONS: The use of vancomycin and tobramycin LAP lowered the rate of deep SSIs after open treatment of fractures on propensity-matched analysis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multilevel Customized 3D-Printed Titanium Alloy Interbody Cages used to Treat Congenital Scoliosis: A Case Report.

Introduction: Customized, patient-specific interbody cages have been used in the treatment of spinal neoplasia, degenerative disease, infection, congenital anomalies, and trauma. However, to date, their use has been limited to a single spinal level, and the utility of customized spinal implants in multiple spinal levels remains unclear. In addition, limited studies exist that compare outcomes following fusion and decompression surgery using customized implants to traditional, standard implants. Case Report: We present two cases. Case 1 consists of a multilevel deformity surgery from L3-S1 ALIF and T10-Pelvis PSF in a patient with a congenital scoliosis (CS) using customized implants on multiple spinal levels. We compare Case 1 to Case 2, in which a patient underwent a lumbar decompression and fusion for CS using standard titanium implants. While the patient in Case 1 reported improved back pain and independent ambulation at 1-year post-operative and required no revision surgery, the patient in Case 2 required revision surgery 2 years post-operative due to pseudoarthrosis. Conclusion: CS with right wedge hemivertebrae may be treated with customized implants on multiple spinal levels, and customized implants may provide benefit standard implants.