Debridement, Antibiotics, and Implant Retention in Unicompartmental Knee Arthroplasty Infection.

BACKGROUND: This multicenter study sought to further investigate the method and outcome of debridement, antibiotics, and implant retention (DAIR) for the management of unicompartmental knee periprosthetic joint infection (PJI). METHODS: This retrospective study was performed on 52 patients who underwent DAIR for PJI of a unicompartmental knee arthroplasty (UKA) across 4 academic medical centers, all performed by fellowship-trained arthroplasty surgeons. Patient demographics, American Society of Anesthesiologists score, infecting organism, operative data, antibiotic data, and success in infection control at 1 year were collected. RESULTS: The average time from index surgery to diagnosis of PJI was 11.1 weeks (range, 1.4 to 48). There was no correlation between time of diagnosis and success at 1 year (R = 0.09, P = .46). There was an association between surgical synovectomy and the eradication of infection (R = 0.28, P = .04). Overall, there was an 80.8% (42 of 52) infection-controlled success rate at 1 year from the DAIR procedure. All DAIR failures went on to require another procedure, either 1-stage (2 of 10) or 2-stage (8 of 10) revision to total knee arthroplasty (TKA). Of the DAIR successes, 6 (14.3%) went on to require conversion to TKA for progression of arthritis within 5 years. CONCLUSIONS: This study demonstrates that DAIR is a safe and moderately effective procedure in the setting of acute PJI of UKA across institutions, with a success rate consistent with DAIR for TKA. The data suggest that a wide exposure and thorough synovectomy be incorporated during the DAIR UKA to improve the likelihood of successful eradication of PJI at the 1-year mark. LEVEL OF EVIDENCE: Level III.

Complications and Survivorship After Aseptic Revision Total Hip Arthroplasty: Is There a Difference by Surgical Approach?

BACKGROUND: Revision total hip arthroplasty (rTHA) has traditionally been performed through the posterolateral approach (PA). Anterior approaches (AA) for rTHA are increasingly being utilized. The purpose of this study was to compare complications and survivorship from re-revision and reoperation after aseptic rTHA performed using an AA versus a PA. METHODS: We retrospectively reviewed patients who underwent aseptic rTHA either through an AA (direct anterior approach [DAA], anterior-based muscle sparing [ABMS]) or PA from January 2017 to December 2021. There were 116 patients who underwent AA-rTHA (DAA 50, ABMS 66) or PA-rTHA (n = 105). Patient demographics, complications, and postoperative outcomes were collected. RESULTS: The most common indication in both groups was aseptic loosening (n = 26, 22.4% AA, n = 28, 26.7% PA). Acetabular revision alone was most common in the AA group (n = 33, 28.4%), while both components were most commonly revised in the PA groups (n = 47, 44.8%). In all the AA-rTHA group, the index total hip arthroplasty was performed through a PA in 51% of patients, while the PA-rTHA group had the index procedure performed via AA in 4.8%. There was no statistically significant difference in re-revision rate between the DAA, ABMS, or PA groups (9.55 versus 5.3% versus 11.4%, respectively, P = .11). The most common overall reason for re-revision was persistent instability, with no difference in incidence of postoperative hip dislocation (n = 4, 6.8% DAA, n = 3, 5.3%, n = 10, 9.5% PA; P = .31). CONCLUSIONS: This study demonstrates no difference in complication or re-revision survivorship after aseptic rTHA performed through a DAA, ABMS approach, or PA, nor between anterior or posterior-based approaches. LEVEL OF EVIDENCE: Level III.

A national analysis on complications and readmissions for adult cerebral palsy patients undergoing primary spinal fusion surgery.

STUDY DESIGN: Retrospective National Database Study. OBJECTIVE: Surgical intervention with spinal fusion is often indicated in cerebral palsy (CP) patients with progressive scoliosis. The purpose of this study was to utilize the National Readmission Database to determine the national estimates of complication rates, 90-day readmission rates, and costs associated with spinal fusion in adult patients with CP. METHODS: The 2012-2015 NRD databases were queried for all adult (age ≥ 19 years) patients diagnosed with CP (ICD-9: 333.71, 343.0-4, and 343.8-9) undergoing spinal fusion (ICD-9: 81.00-08). RESULTS: 1166 adult patients with CP (42.7% female) underwent spinal fusion surgery between 2012 and 2015. 153 (13.1%) were readmitted within 90 days following the primary surgery, with a mean 33.8 ± 26.5 days. Mean hospital charge of the primary admission was $141,416 ± $157,359 and $167,081 ± $145,416 for the non-readmitted and readmitted patients, respectively (p = 0.06). The mean 90-day readmission charge was $72,479 ± $104,100. Most common complications with the primary admission included UTIs (no readmission vs. readmission: 7.6% vs. 4.8%; p = 0.18), respiratory (6.9% vs. 5.6%; p = 0.62), implant (3.8% vs. 6.0%; p = 0.21), and paralytic ileus (3.6% vs. 3.2%; p = 0.858). Multivariate analyses demonstrated the following as independent predictors for 90-day readmission: comorbid anemia (OR: 2.8; 95% CI: 1.6-4.9; p < 0.001), coagulopathy (2.9, 1.1-8.0, 0.037), perioperative blood transfusion (2.0, 1.1-3.8, 0.026), wound complication (6.4, 1.3-31.6, 0.023), and transfer to short-term hospital versus routine disposition (4.9, 1.0-23.3, 0.045). CONCLUSION: Quality improvement efforts should be aimed at reducing rates of infection related complications as this was the most common reason for short-term complications and unplanned readmission following surgery.

Statistical fragility of randomized clinical trials in shoulder arthroplasty.

BACKGROUND: The P value is a statistical tool used to assess the statistical significance of clinical trial outcomes in orthopedic surgery. However, the P value does not evaluate research quality or clinical significance. The Fragility Index (FI) is an alternative statistical method that can be used to assess the quality and significance of clinical research and is defined as the number of patients in a study intervention group necessary to convert an outcome from statistically significant to statistically insignificant or vice versa. The primary purpose of this study was to evaluate the statistical robustness of clinical trials regarding shoulder arthroplasty using the FI. The secondary goal was to identify trial characteristics associated greater statistical fragility. METHODS: A systematic review of randomized clinical trials in shoulder arthroplasty was performed. The FI was calculated for all dichotomous, categorical study outcomes discussed in the identified studies. Descriptive statistics and the Pearson correlation coefficient were used to evaluate all studies and characterize associations between study variables. RESULTS: A total of 13 randomized controlled trials were identified and evaluated; these trials had a median sample size of 47 patients (mean, 54 patients; range, 26-102 patients) and a median of 7 patients (mean, 5.8 patients; range, 0-14 patients) lost to follow-up. The median FI was 6 (mean, 5; range, 1-11), a higher FI than what has been observed in other orthopedic subspecialties. However, the majority of outcomes (74.4%) had an FI that was less than the number of patients lost to follow-up, and most outcomes (89.7%) were statistically insignificant. CONCLUSION: Randomized controlled trials in shoulder arthroplasty have comparable statistical robustness to the literature in other orthopedic surgical subspecialties. We believe that the inclusion of the FI in future comparative studies in the shoulder arthroplasty literature will allow surgeons to better assess the statistical robustness of future research.

Using prescription dispensing data infographics to facilitate collaborative pharmacist-prescriber discussions on mutual patients.

OBJECTIVE: To develop prescriber-specific infographics containing community pharmacy prescription dispensing data and share them with targeted prescribers to determine their utility in facilitating initial collaborative conversations regarding the care of mutual patients. METHODS: Prescription dispensing data from an independent community pharmacy in western Pennsylvania was collected to generate highly visual infographics for the most frequent prescribers to the pharmacy. Infographics were individualized for prescribers, and they included information on mutual patients between the pharmacy and the prescriber. Infographics were then shared with prescribers during semistructured, audio-recorded interviews. Interview questions elicited feedback on prescriber medication-related needs, quality and performance measures, infographic format and utility, and prescriber-pharmacist collaboration. Interviews were transcribed and coded by 2 independent investigators using qualitative analysis software. Coding discrepancies were resolved. A thematic analysis of the interview data was conducted. RESULTS: Eight interviews were conducted with prescribers. The following themes emerged: (1) the infographic prompted prescribers to recognize potential collaborative opportunities with community pharmacists; (2) the infographic stimulated discussion on prescribing patterns and mutual patient populations; (3) prescribers value discussing the infographic data in a face-to-face meeting; (4) prescribers want to hear from pharmacists when mutual patients have medication-related problems; and (5) the infographic helped prescribers identify quality measures that they were not currently meeting. CONCLUSION: Infographics containing prescription dispensing data for mutual patients may be a useful tool when shared by community pharmacists to facilitate collaborative discussions with prescribers.

Arithmetic of focused vortex beams in three-dimensional optical lattice arrays.

In this work, we present a method to generate a 3D lattice of vortex beams. We apply phase look-up tables (LUTs) designed to generate gratings having an arbitrary content of diffraction orders. This phase LUT can be applied to a variety of diffraction optical elements, such as linear phase gratings, blazed diffractive lenses, and spiral phase patterns. We concentrate on combinations of all of these to create 3D structures of vortex beams. In particular, we generate all of these elements in the first output quadrant and eliminate the zero-order diffraction that often unavoidably accompanies these patterns. We discuss different ways of producing these 3D vortex gratings, and how the various output beams are related to the arithmetic of the 3D distribution of topological charges. Experimental results are provided by means of a liquid crystal spatial light modulator.

Improving Quality of Life and Psychosocial Health for Penile Cancer Survivors: A Narrative Review.

Treatment of penile cancer (PC) focuses on organ preservation, employing various surgical and non-surgical approaches. These interventions may lead to disfigurement, impacting patients' functional outcomes and psychosocial well-being. We reviewed studies related to penile health and PC up to February 2024, limited to studies published in English. Studies employing health-related quality of life (HRQoL) assessments have identified a detrimental association between aggressive treatment and overall health status, physical functioning, and relationships. In contrast, organ-sparing demonstrates improved measures related to HRQoL and sexual function. Assessment through validated questionnaires reveals diverse voiding outcomes, and varying impacts on QoL and sexual activity, emphasizing the necessity for multidisciplinary personalized care. Studies highlight substantial variations in sexual function, with patients reporting adaptations, reduced satisfaction, and concerns about body image and sexual well-being. Furthermore, unmet needs include challenges in patient-clinician communication, obtaining information, and accessing psychosocial support. Patient experiences underscore the importance of timely diagnosis, treatment access, and addressing psychological consequences. Organ-sparing approaches have higher QoL preservation and sexual function. Individualized support, including sexual therapy, support groups, and family counseling, is essential for post-treatment rehabilitation. Timely diagnosis and comprehensive care are paramount in addressing the multifaceted impact of PC on patients and families.

Global Burden of Penile Cancer: A Review of Health Disparities for a Rare Disease.

We performed a narrative review evaluating the influence of race and socioeconomic status for penile cancer patients based on region. We found higher incidence in underdeveloped nations. Globally, HPV-associated tumors are more prevalent, particularly in areas with high HPV and HIV infection. Socioeconomic determinants exacerbated these disparities. Similarly, in the United States, disparities were notable among racial and ethnic groups, with black men having worse survival. Understanding sociodemographic differences may help mitigate disparities by improving access to care with targeted interventions including education on risk factors and HPV vaccination to reduce penile cancer burden in vulnerable parts of the world.

Optimizing Total Hip and Knee Arthroplasty Among an Underserved Population: Lessons Learned From a Quality-Improvement Initiative.

Background: Under-represented minorities and those with noncommercial insurance have higher medical comorbidities and complications following elective total joint arthroplasty (TJA). In an effort to bridge this gap, our center implemented a preoperative optimization protocol for TJA in a Medicaid Clinic (Clinic). The purpose of this study is to assess the effectiveness of that protocol and highlight challenges associated with caring for this patient population. Methods: This retrospective analysis included 117 patients undergoing TJA between January 2015 and January 2020. In 2015, the protocol was implemented as a mandatory practice prior to TJA. A contemporary control cohort from the private office was also analyzed. Patient demographics, American Society of Anesthesiologists score, and postoperative complications were collected. Results: Within the clinic group, 52.5% (62) patients identified as Hispanic with 46.6% (55) Spanish-speaking as primary language, compared to 9.3% (11) and 8.5% (10) in the office group (P = .0001), respectively. Clinic group patients were significantly more likely to experience a complication compared to office patients (20 vs 7, respectively). There was no difference in complication or reoperation rate between clinic patients who underwent the optimization protocol and those who did not. Conclusions: The findings from this study highlight the demographic and comorbidities profile of an underserved population, and report on results of a quality improvement initiative among that population, which failed to improve postoperative outcomes. These results underscore the need for further study in this population to improve outcomes and health equity.

Reliability and Time Course of Postexercise Hypotension during Exercise Training among Adults with Hypertension.

Postexercise hypotension (PEH), or the immediate decrease in blood pressure (BP) lasting for 24 h following an exercise bout, is well-established; however, the influence of exercise training on PEH dynamics is unknown. This study investigated the reliability and time course of change of PEH during exercise training among adults with hypertension. PEH responders (n = 10) underwent 12 weeks of aerobic exercise training, 40 min/session at moderate-to-vigorous intensity for 3 d/weeks. Self-measured BP was used to calculate PEH before and for 10 min after each session. The intraclass correlation coefficient (ICC) and Akaike Information Criterion (AIC) determined PEH reliability and goodness-of-fit for each week, respectively. Participants were obese (30.6 ± 4.3 kg∙m-2), middle-aged (57.2 ± 10.5 years), and mostly men (60%) with stage I hypertension (136.5 ± 12.1/83.4 ± 6.7 mmHg). Exercise training adherence was 90.6 ± 11.8% with 32.6 ± 4.2 sessions completed. PEH occurred in 89.7 ± 8.3% of these sessions with BP reductions of 9.3 ± 13.1/3.2 ± 6.8 mmHg. PEH reliability was moderate (ICC ~0.6). AIC analysis revealed a stabilization of maximal systolic and diastolic BP reductions at 3 weeks and 10 weeks, respectively. PEH persisted throughout exercise training at clinically meaningful levels, suggesting that the antihypertensive effects of exercise training may be largely due to PEH. Further studies in larger samples and under ambulatory conditions are needed to confirm these novel findings.

Generalized diffractive optical elements with asymmetric harmonic response and phase control.

We report a method to generate phase-only diffractive beam splitters allowing asymmetry of the target diffracted orders, as well as providing a tailored phase difference between the diffracted orders. We apply a well-established design method that requires the determination of a set of numerical parameters, and avoids the use of image iterative algorithms. As a result, a phase lookup table is determined that can be used for any situation where a first-order (blazed) diffractive element is modified to produce higher orders with desired intensity and/or phase relation. As examples, we demonstrate the phase difference control on triplicators, as well as on other generalized diffractive elements like bifocal Fresnel lenses and phase masks for the generation of vortex beams. Results are experimentally demonstrated by encoding the calculated phase pattern onto parallel-aligned liquid crystal spatial light modulators.

Interpreting perimortem blast trauma from skeletal remains: Complications and considerations.

Blast trauma results from highly variable events that can lead to similar effects in the skeleton. Clinical literature, which largely focuses on soft tissue, provides limited efficacy for interpreting fully skeletonized cases. Interpretation of skeletal blast trauma is hampered by the low number of fully skeletonized case studies and experimental replication studies, which mainly use nonhuman proxies. The purpose of this study is to discuss fracture patterns on two individuals from WWII as a means to better understand and identify fracture patterns associated with blast trauma. Existing clinical and anthropological criteria are reviewed and applied to two World War II cases, both presumed to exhibit blast trauma based on historical contexts. These case studies exhibit combinations of complicated and extensive signs of blunt-force and projectile trauma, reflecting the diversity of skeletal trauma resulting from blast-related events. This analysis emphasizes the arguably impossible task of establishing a diagnosis based on the available literature and lack of prior knowledge about specific losses. Ultimately, analysts must consider the totality of skeletal trauma, combining biomechanical theory and relevant clinical and anthropological literature to arrive at useful yet defensible assessments of trauma. However, refined criteria and additional studies are needed to assess complicated trauma from blast-related events in anthropological contexts.

Fighting and Penalty Minutes Associated With Long-term Mortality Among National Hockey League Players, 1967 to 2022.

Importance: National Hockey League (NHL) players are exposed to frequent head trauma. The long-term consequences of repetitive brain injury, especially for players who frequently engage in fighting, remains unknown. Objective: To investigate the mortality rates and causes of death among NHL enforcers with more career fights and penalty minutes as compared with matched controls. Design, Setting, and Participants: This matched cohort study examined 6039 NHL players who participated in at least 1 game in the seasons between October 11, 1967, and April 29, 2022, using official NHL data. Cohorts designated as enforcer-fighter (E-F) and enforcer-penalties (E-P) were selected. The E-F cohort consisted of players who participated in 50 or more career fights (n = 331). The E-P cohort included players with 3 or more penalty minutes per game (n = 183). Control-matched NHL players were identified for each E-F player (control-fighter [C-F]) (n = 331) and each E-P player (control-penalties [C-P]) (n = 183). Exposures: Fighting and penalty minutes were both used as proxies for head trauma exposure. Players with significantly increased exposure to fighting and penalties (E-F and E-P cohorts) were compared with NHL players with less frequent exposure to head trauma (C-F and C-P cohorts). Main Outcomes and Measures: Mortality rates and age at death of the enforcer and control cohorts, and their causes of death using data obtained from publicly available sources such as online and national news sources, including NHL.com. Results: Among the 6039 NHL players identified (mean [SD] age, 47.1 [15.2] years), the mean (SD) number of fights was 9.7 (24.5). The mortality rates of E-F and C-F players (13 [3.9%] vs 14 [4.2%], respectively; P = .84) or E-P and C-P players (13 [7.1.%] vs 10 [5.5%]; P = .34) were not significantly different. The mean (SD) age at death was 10 years younger for E-F players (47.5 [13.8] years) and E-P players (45.2 [10.5] years) compared with C-F players (57.5 [7.1] years) and C-P players (55.2 [8.4] years). There was a difference in causes of death between the control and enforcer players (2 neurodegenerative disorders, 2 drug overdoses, 3 suicides, and 4 vehicular crashes among enforcers vs 1 motor vehicle crash among controls; P = .03), with enforcers dying at higher rates of overdose (2 of 21 [9.5%] vs 0 of 24) and suicide (3 of 21 [14.3%] vs 0 of 24) (P = .02). Conclusions and Relevance: The findings of this matched cohort study indicate that there is no difference in overall mortality rates between NHL enforcers and controls. However, being an enforcer was associated with dying approximately 10 years earlier and more frequently of suicide and drug overdose.

Clinical Characteristics, Outcomes, and Pathology Analysis in Patients With Dorsal Arachnoid Web.

BACKGROUND: Dorsal arachnoid webs (DAWs) are rare pathological abnormalities of the arachnoid layer of the spinal cord that can result in pain and myelopathy. OBJECTIVE: To present clinical, imaging, and pathological characteristics of patients diagnosed with DAW, case illustrations, and a review of the literature. METHODS: Seventeen cases of DAW between 2015 and 2019 at a tertiary medical center were retrospectively identified through a case log search. Patient characteristics, preoperative imaging, operative notes, and pathology reports were collected. Our main outcome assessed was postoperative resolution of symptoms. Odds ratios were used to determine associations between preoperative signs and symptoms with postoperative symptom resolution. RESULTS: The mean age of the cohort was 50.5 years (IQR = 16) and presented primarily with back pain (64.7%). On imaging, all patients were found to have the "scalpel sign," and nearly half had a syrinx present (41.2%). All DAWs were located in the thoracic spine, with the most common location being the midthoracic (70.6%). The mean follow-up length for all patients was 4.3 months. There were no preoperative symptoms significantly associated with postoperative symptom resolution; however, a trend was noted with the presence of a preoperative syrinx. Pathology samples consistently demonstrated fibroconnective or collagenous tissue with no evidence of inflammation or neoplasm. CONCLUSION: DAW is a rare pathology that can result in myelopathy or inappropriate interventions if misdiagnosed. Surgical intervention using laminectomy with intradural exploration should be considered in symptomatic patients with DAW because it is curative with a strong chance of preoperative symptom resolution with relatively low complication rates.

Patient Controlled Analgesia and an Alternative Protocol: A Comparison of Outcomes After Thoracic and Lumbar Surgery.

Introduction: Patient controlled analgesia (PCA) is a common form of pain management after spine surgeries, in which patients get custom control of their opioid dose. PCA has been demonstrated as a safe form of analgesia; however, use of PCA comes with risks that can be mitigated by opting for alternative pain management. This study aimed to compare the outcomes of patients using PCA to those with an alternative analgesia protocol that does not involve PCA. Methods: A retrospective chart review from January 2017 to July 2018 was conducted. Patients included in this study were those 18 or older who were admitted to a large midwestern tertiary medical center in Wichita, Kansas, and underwent thoracic or lumbar spinal surgery from a single spine surgeon. Data from patient demographics, comorbidities, and type of procedure were collected and compared to control for possible confounding variables. Patients were divided into two groups: patients receiving a PCA pain protocol post-operatively and those receiving a non-PCA protocol. Statistical analyses were performed and all tests with p < 0.05 were considered significant. Results: This study found patients in the PCA protocol had similar outcomes to those in the alternative analgesia protocol. This was true for both primary and secondary outcomes. The primary outcome was patient length of stay after the operation. Secondary outcomes included readmission rates, frequency of naloxone rescue, transfers to higher levels of care, and total opioid consumption. Conclusions: This study supported that a non-PCA protocol for post-operative pain management yields similar outcomes to a PCA protocol in the setting of thoracic and lumbar surgery.

Return to Play Criteria Following Surgical Management of Osteochondral Defects of the Knee: A Systematic Review.

OBJECTIVE: The objective of this study was to identify and describe the existing literature on criteria used for return to play (RTP) following surgical management of osteochondral defects of the knee. DESIGN: A systematic review was performed to evaluate the surgical management of osteochondral defects of the knee in skeletally mature patients with a minimum of 2-year follow-up using Level I to IV studies in PubMed EMBASE from January 1998 to January 2016. RESULTS: Twelve studies with at least one explicitly stated criterion for RTP were identified from a review of 253 published articles. The majority of included studies were Levels II and IV (33%, respectively). Autologous chondrocyte implantation (ACI) was exclusively evaluated in 33.3% of papers and 16.7% evaluated osteochondral allograft transplantation (OCA). Eight different RTP criteria were used alone or in combination across the reviewed studies and time was the most often utilized criterion (83.3%). Minimum time to RTP ranged from 3 to 18 months. CONCLUSIONS: This systematic review identifies current criteria used in the available literature to dictate RTP. Time from surgery was the most commonly employed criterion across the reviewed studies. Given the complex biological processes inherent to the healing of cartilaginous defects, further research is needed to design more comprehensive guidelines for RTP that are patient-centered and utilize multiple functional and psychological domains relevant to the process of returning to sport.

Microsurgical Resection of an Intramedullary Spinal Cord Hemangioblastoma Through an Anterior Cervical Approach: 2-Dimensional Operative Video.

This video demonstrates the microsurgical removal of an intramedullary spinal cord hemangioblastoma through an anterior cervical approach. While most spinal hemangioblastomas arise from the dorsal or dorsolateral pial surface and can be safely resected through a posterior approach,1,2 ventral tumors can present a significant challenge to safe surgical removal.3-5 This patient presented with a progressively symptomatic ventral pial based hemangioblastoma at the C5-6 level with large polar cysts extending from C3 to T1. The tumor was approached through a standard anterior cervical exposure with a C5 and C6 corpectomy. Following midline durotomy, the tumor was identified and complete microsurgical resection was achieved. The principles and techniques of tumor resection are illustrated and described in the video. Following tumor resection and dural closure, a fibular allograft was inserted into the corpectomy defect and a C4-C7 fixation plate was placed. The patient was maintained in a supine position for 36 h. He was discharged home on postoperative day 3 in a cervical collar. The patient did well with near-complete recovery of neurological function. Postoperative magnetic resonance imaging at 6 wk showed a substantial resolution of the polar cysts and no evidence of residual tumor. The patient featured in this video consented to the procedure.

Microsurgical Resection of a Lumbar Synovial Cyst: 2-Dimensional Operative Video.

Lumbar spine synovial cysts develop from degenerated zygapophyseal joints. Symptomatic patients present with radicular pain and weakness or neurogenic claudication.1 In the absence of significant concomitant degenerative spondylolisthesis, symptomatic patients can be managed with a laminectomy and microsurgical resection of the cyst, without the need for instrumented fusion.2,3 In this video, we present the microsurgical resection of a left-sided L4-5 synovial cyst in a 68-yr-old man with radicular pain refractory to conservative management. The radiographical features, relevant surgical anatomy, and salient operative steps are reviewed, and strategies for preventing cyst recurrence are emphasized. There were no complications, the postoperative course was unremarkable, and the patient was discharged on postoperative day 1 with significant improvement in his presenting symptoms. No identifying information is present, and patient consent was obtained for the procedure and for publishing the material included in this video.

Statistical Fragility of Surgical Clinical Trials in Orthopaedic Trauma.

INTRODUCTION: The Fragility Index (FI) and the Fragility Quotient (FQ) are powerful statistical tools that can aid clinicians in assessing clinical trial results. The purpose of this study was to use the FI and FQ to evaluate the statistical robustness of widely cited surgical clinical trials in orthopaedic trauma. METHODS: We performed a PubMed search for orthopaedic trauma clinical trials in high-impact orthopaedics-focused journals and calculated the FI and FQ for all identified dichotomous, categorical outcomes. RESULTS: We identified 128 studies with 545 outcomes. The median FI was 5, and the median FQ was 0.0482. For statistically significant and not statistically significant outcomes, the median FIs were 3 and 5, and the mean FQs were 0.0323 and 0.0526, respectively. The FI was greater than the number of patients lost to follow-up in most outcomes. CONCLUSIONS: The orthopaedic trauma literature is of equal or higher quality than research in other orthopaedic subspecialties, suggesting that other orthopaedic subspecialties may benefit from modeling their clinical trials after those in orthopaedic trauma.

Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review.

BACKGROUND: The Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA). METHODS: We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables. RESULTS: We included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012). CONCLUSIONS: This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made. LEVEL OF EVIDENCE: Level I; Systematic Review.