Educating patients on osteoporosis and bone health: Can "ChatGPT" provide high-quality content?

PURPOSE: The rise of artificial intelligence (AI) models like ChatGPT offers potential for varied applications, including patient education in healthcare. With gaps in osteoporosis and bone health knowledge and adherence to prevention and treatment, this study aims to evaluate the accuracy of ChatGPT in delivering evidence-based information related to osteoporosis. METHODS: Twenty of the most common frequently asked questions (FAQs) related to osteoporosis were subcategorized into diagnosis, diagnostic method, risk factors, and treatment and prevention. These FAQs were sourced online and inputted into ChatGPT-3.5. Three orthopedic surgeons and one advanced practice provider who routinely treat patients with fragility fractures independently reviewed the ChatGPT-generated answers, grading them on a scale from 0 (harmful) to 4 (excellent). Mean response accuracy scores were calculated. To compare the variance of the means across the four categories, a one-way analysis of variance (ANOVA) was used. RESULTS: ChatGPT displayed an overall mean accuracy score of 91%. Its responses were graded as "accurate requiring minimal clarification" or "excellent," with a mean response score ranging from 3.25 to 4. No answers were deemed inaccurate or harmful. No significant difference was observed in the means of responses across the defined categories. CONCLUSION: ChatGPT-3.5 provided high-quality educational content. It showcased a high degree of accuracy in addressing osteoporosis-related questions, aligning closely with expert opinions and current literature, with structured and inclusive answers. However, while AI models can enhance patient information accessibility, they should be used as an adjunct rather than a substitute for human expertise and clinical judgment.

Readability of Trauma-related Patient Education Materials From the American Academy of Orthopaedic Surgeons and Orthopaedic Trauma Association Websites.

INTRODUCTION: Web-based resources serve as a fundamental educational platform for orthopaedic trauma patients; however, they are frequently written above the recommended sixth-grade reading level, and previous studies have demonstrated this for the American Academy of Orthopaedic Surgeons (AAOS) web-based articles. In this study, we perform an updated assessment of the readability of AAOS trauma-related educational articles as compared with injury-matched education materials developed by the Orthopaedic Trauma Association (OTA). METHODS: All 46 AAOS trauma-related web-based (https://www.orthoinfo.org/) patient education articles were analyzed for readability. Two independent reviewers used (1) the Flesch-Kincaid Grade Level (FKGL) and (2) the Flesch Reading Ease (FRE) algorithms to calculate the readability level. Mean readability scores were compared across body part categories. A one-sample t-test was done to compare mean FKGL with the recommended sixth-grade readability level and the average American adult reading level. A two-sample t-test was used to compare the readability scores of the AAOS trauma-related articles with those of the OTA. RESULTS: The average (SD) FKGL and FRE for the AAOS articles were 8.9 (0.74) and 57.2 (5.8), respectively. All articles were written above the sixth-grade reading level. The average readability of the AAOS articles was significantly greater than the recommended sixth-grade reading level (P < 0.001). The average FKGL and FRE for all AAOS articles were significantly higher compared with those of the OTA articles (8.9 ± 0.74 versus 8.1 ± 1.14, P < 0.001 and 57.2 ± 5.8 versus 65.6 ± 6.6, P < 0.001, respectively). Excellent agreement was observed between raters for the FKGL 0.956 (95% confidence interval, 0.922 to 0.975) and FRE 0.993 (95% confidence interval, 0.987 to 0.996). DISCUSSION: Our findings suggest that after almost a decade, the readability of the AAOS trauma-related articles remains unchanged. The AAOS and OTA trauma patient education materials have high readability levels and may be too difficult for patient comprehension. A need remains to improve the readability of these commonly used trauma education materials.

Implementing a Hospitalist Comanagement Service in Orthopaedic Surgery.

➤ Hospitalist comanagement of patients undergoing orthopaedic surgery is a growing trend across the United States, yet its implementation in an academic tertiary care hospital can be complex and even contentious.➤ Hospitalist comanagement services lead to better identification of at-risk patients, optimization of patient care to prevent adverse events, and streamlining of the admission process, thereby enhancing the overall service efficiency.➤ A successful hospitalist comanagement service includes the identification of service stakeholders and leaders; frequent consensus meetings; a well-defined standardized framework, with goals, program metrics, and unified commands; and an occasional satisfaction assessment to update and improve the program.➤ In this article, we establish a step-by-step protocol for the implementation of a comanagement structure between orthopaedic and hospitalist services at a tertiary care center, outlining specific protocols and workflows for patient care and transfer procedures among various departments, particularly in emergency and postoperative situations.

Failure after operative repair is higher for ballistic femoral neck fractures than for closed, blunt-injury fractures: a multicenter retrospective cohort study.

Introduction: The purpose of this study was to describe the outcomes after operative repair of ballistic femoral neck fractures. To better highlight the devastating nature of these injuries, we compared a cohort of ballistic femoral neck fractures to a cohort of young, closed, blunt-injury femoral neck fractures treated with open reduction and internal fixation (ORIF). Methods: Retrospective chart review identified all patients presenting with ballistic femoral neck fractures treated at three academic trauma centers between January 2016 and December 2021, as well as patients aged ≤50 with closed, blunt-injury femoral neck fractures who received ORIF. The primary outcome was failure of ORIF, which includes the diagnosis of non-union, avascular necrosis, conversion to total hip arthroplasty, and conversion to Girdlestone procedure. Additional outcomes included deep infection, postoperative osteoarthritis, and ambulatory status at last follow-up. Results: Fourteen ballistic femoral neck fractures and 29 closed blunt injury fractures were identified. Of the ballistic fractures, 7 (50%) patients had a minimum of 1-year follow-up or met the failure criteria. Of the closed fractures, 16 (55%) patients had a minimum of 1-year follow-up or met the failure criteria. Median follow-up was 21 months. 58% of patients with ballistic fractures were active tobacco users. Five of 7 (71%) ballistic fractures failed, all of which involved non-union, whereas 8 of 16 (50%) closed fractures failed (p=0.340). No outcomes were significantly different between cohorts. Conclusion: Our results demonstrate that ballistic femoral neck fractures are associated with high rates of non-union. Large-scale multicenter studies are necessary to better determine optimal treatment techniques for these fractures. Level of evidence: Level III. Retrospective cohort study.

Gluteal compartment syndrome: who is most at risk?

PURPOSE: Gluteal compartment syndrome (GCS) is a rare but devastating condition with a paucity of literature to help guide diagnosis and management. This study aims to identify and describe the risk factors and patient characteristics associated with GCS to facilitate early diagnosis. METHODS: This is a retrospective case series of patients undergoing gluteal compartment release between 2015 and 2022 at an academic Level I trauma center. Chart reviews were performed to extract data on patient demographics, presenting symptoms, risk factors, operative findings, and postoperative outcomes. RESULTS: 14 cases of GCS were identified. 12 (85.7%) were male, with a mean age of 39.4 ± 13 years and a mean BMI of 25.1 ± 4.1 kg/m2. 12 (85.7%) patients did not present as traumas and only 3 had ≥ 1 fracture. 9 patients reported drug use. Hemoglobin (Hgb) (11.7 ± 4 g/dL) was generally low (5 had Hgb < 10 g/dL). Creatine kinase (49,617 ± 60,068 units/L) was consistently elevated in all cases, and lactate (2.8 ± 1.6 mmol/L) was elevated in 9. 13 had non-viable muscle requiring debridement. Postoperatively, the mean ICU length of stay was 12 ± 23 days. 2 patients died during admission and all remaining patients required discharge to rehabilitation facilities. CONCLUSION: GCS is more likely to present in a young to middle-aged, otherwise healthy, male using drugs who is either found down or experienced an iatrogenic injury. Recognizing that GCS is different from that of the leg, in terms of etiology, may help avoid delays in diagnosis and treatment.

Atraumatic Polycompartment Syndrome Secondary to Cardiogenic Shock: A Case Report.

We report the case of a 53-year-old male who developed polycompartment syndrome (PCS) secondary to cardiogenic shock. After suffering a cardiac arrest, a self-perpetuating cycle of intra-abdominal hypertension (IAH) and vital organ damage led to abdominal compartment syndrome (AbCS), which then contributed to the precipitation of extremity compartment syndrome (CS) in bilateral thighs, legs, forearms, and hands. This report is followed by a review of the literature regarding the pathophysiology of this rare sequela of cardiogenic shock. While the progression from cardiogenic shock to AbCS and ultimately to PCS has been hypothesized, no prior case reports demonstrate this. Furthermore, this case suggests more generally that IAH may be a risk factor for extremity CS. Future studies should examine the potential interplay between IAH and extremity CS in patients at risk, such as polytrauma patients with tibial fractures.

What Factors Are Associated With Arterial Line-Related Limb Ischemia in Patients on Extracorporeal Membrane Oxygenation? A Single-Center Retrospective Cohort Study.

OBJECTIVES: The primary purpose of this study was to identify factors associated with the development of arterial line-related limb ischemia in patients on extracorporeal membrane oxygenation (ECMO). The authors also sought to characterize and report the outcomes of patients who developed arterial line-related limb ischemia. DESIGN: Retrospective cohort study. SETTING: A single academic tertiary referral ECMO center. PARTICIPANTS: Consecutive patients who were treated with ECMO over 6 years. INTERVENTIONS: Use of arterial line. MEASUREMENTS AND MAIN RESULTS: A total of 278 consecutive ECMO patients were included, with 19 (7%) patients developing arterial line-related limb ischemia during the ECMO run. Postcannulation Sequential Organ Failure Assessment (SOFA) (adjusted odds ratio [aOR] 1.20, 95% CI 1.08-1.32), Acute Physiology and Chronic Health Evaluation-II (aOR 0.84, 95% CI 0.74-0.95), and adjusted Vasopressor Dose Equivalence (aOR 1.03, 95% CI 1.01-1.05) scores were independently associated with the development of arterial line-associated limb ischemia. A SOFA score of ≥17 at the time of ECMO cannulation had an 80% sensitivity and 87% specificity for predicting arterial line-related limb ischemia. CONCLUSIONS: Arterial line-related limb ischemia is much more common in ECMO patients than in the typical intensive care unit setting. The SOFA score may be useful in identifying which patients may be at risk for arterial line-related limb ischemia. As this was a single-center retrospective study, these results are inherently exploratory, and prospective multicenter studies are necessary to validate these results.

Is Fasciotomy Associated With Increased Mortality in Extracorporeal Cardiopulmonary Resuscitation?

Our primary objective was to identify if fasciotomy was associated with increased mortality in patients who developed acute compartment syndrome (ACS) on extracorporeal cardiopulmonary resuscitation (ECPR). Additionally, we sought to identify any additional risk factors for mortality in these patients and report the amputation-free survival following fasciotomy. We retrospectively reviewed adult ECPR patients from the Extracorporeal Life Support Organization registry who were diagnosed with ACS between 2013 and 2021. Of 764 ECPR patients with limb complications, 127 patients (17%) with ACS were identified, of which 78 (63%) had fasciotomies, and 14 (11%) had amputations. Fasciotomy was associated with a 23% rate of amputation-free survival. There were no significant differences in demographics or baseline laboratory values between those with and without fasciotomy. Overall, 88 of 127 (69%) patients with ACS died. With or without fasciotomy, the mortality of ACS patients was similar, 68% vs. 71%. Multivariable logistic regression demonstrated that body mass index (BMI; adjusted odds ratio [aOR] = 1.22, 95% confidence interval [CI] = 1.01-1.48) and 24 hour mean blood pressure (BP; aOR = 0.93, 95% CI = 0.88-0.99) were independently associated with mortality. Fasciotomy was not an independent risk factor for mortality (aOR = 0.24, 95% CI = 0.03-1.88). The results of this study may help guide surgical decision-making for patients who develop ACS after ECPR. However, the retrospective nature of this study does not preclude selection bias in patients who have received fasciotomy. Thus, prospective studies are necessary to confirm these findings.

Reducing Complications in Pilon Fracture Surgery: Surgical Time Matters.

OBJECTIVE: To correlate patient-specific and surgeon-specific factors with outcomes after operative management of distal intra-articular tibia fractures. DESIGN: Retrospective cohort study. SETTING: 3 Level 1 tertiary academic trauma centers. PATIENTS/PARTICIPANTS: The study included a consecutive series of 175 patients with OTA/AO 43-C pilon fractures. MAIN OUTCOME MEASUREMENTS: Primary outcomes included superficial and deep infection. Secondary outcomes included nonunion, loss of articular reduction, and implant removal. RESULTS: The following patient-specific factors correlated with poor surgical outcomes: increased age with superficial infection rate ( P < 0.05), smoking with rate of nonunion ( P < 0.05), and Charlson Comorbidity Index with loss of articular reduction ( P < 0.05). Each additional 10 minutes of operative time over 120 minutes was associated with increased odds of requiring I&D and any treatment for infection. The same linear effect was seen with the addition of each fibular plate. The number of approaches, type of approach, use of bone graft, and staging were not associated with infection outcomes. Each additional 10 minutes of operative time over 120 minutes was associated with an increased rate of implant removal, as did fibular plating. CONCLUSIONS: While many of the patient-specific factors that negatively affect surgical outcomes for pilon fractures may not be modifiable, surgeon-specific factors need to be carefully examined because these may be addressed. Pilon fracture fixation has evolved to increasingly use fragment-specific approaches applied with a staged approach. Although the number and type of approaches did not affect outcomes, longer operative time was associated with increased odds of infection, while additional fibular plate fixation was associated with higher odds of both infection and implant removal. Potential benefits of additional fixation should be weighed against operative time and associated risk of complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Readability of the Orthopaedic Trauma Association Patient Education Tool.

INTRODUCTION: Online educational materials have become a fundamental resource for orthopaedic surgery patients; however, they are frequently written at a high level of reading ability and are too complicated for some patients to understand. The aim of this study was to appraise the readability of the Orthopaedic Trauma Association (OTA) patient education materials. METHODS: All 41 articles on the OTA patient education website ( https://ota.org/for-patients) were analyzed for readability. Readability scores were calculated by 2 independent reviewers using the (1) FleschKincaid Grade Level (FKGL) and the (2) Flesch Reading Ease algorithms. Mean readability scores were compared across anatomic categories. One-sample t test was performed to compare mean FKGL with the recommended sixth-grade readability level and the average American adult reading level. RESULTS: The average (SD) FKGL of the 41 OTA articles was 8.15 (1.14). The average (SD) Flesch Reading Ease for the OTA patient education materials was 65.5 (6.60). Four (11%) of the articles were at or below a sixth-grade reading level. The average readability of the OTA articles was significantly higher than the recommended sixth-grade level ( P < 0.001; 95% confidence interval, 7.79-8.51). The average readability of the OTA articles was not significantly different from the average eighth-grade reading skill level of US adults ( P = 0.41; 95% confidence interval, 7.79-8.51). CONCLUSION: Our findings suggest that despite most OTA patient education materials having readability levels suitable for the average US adult, these reading materials are still above the recommended sixth-grade level and may be too difficult for patient comprehension.

Distal Radius Fracture Management: Surgeon Factors Markedly Influence Decision Making.

INTRODUCTION: It is our hypothesis that physician-specific variables affect the management of distal radius (DR) fractures in addition to patient-specific factors. METHODS: A prospective cohort study was conducted evaluating treatment differences between Certificate of Additional Qualification hand surgeons (CAQh) and board-certified orthopaedic surgeons who treat patients at level 1 or level 2 trauma centers (non-CAQh). After institutional review board approval, 30 DR fractures were selected and classified (15 AO/OTA type A and B and 15 AO/OTA type C) to create a standardized patient data set. The patient-specific demographics and surgeon's information regarding the volume of DR fractures treated per year, practice setting, and years posttraining were obtained. Statistical analysis was done using chi-square analysis with a postanalysis regression model. RESULTS: A notable difference was observed between CAQh and non-CAQh surgeons. Surgeons in practice longer than 10 years or who treat >100 DR fractures/year were more likely to choose surgical intervention and obtain a preoperative CT scan. The two most influential factors in decision making were the patients' age and medical comorbidities, with physician-specific factors being the third most influential in medical decision making. DISCUSSION: Physician-specific variables have a notable effect on decision making and are critical for the development of consistent treatment algorithms for DR fractures.

What Factors Are Associated With Delayed Wound Closure in Open Reduction and Internal Fixation of Adult Both-bone Forearm Fractures?

BACKGROUND: Delayed wound closure is often used after open reduction and internal fixation (ORIF) of both-bone forearm fractures to reduce the risk of skin necrosis and subsequent infection caused by excessive swelling. However, no studies we are aware of have evaluated factors associated with the use of delayed wound closure after ORIF. QUESTIONS/PURPOSES: (1) What proportion of patients undergo delayed wound closure after ORIF of adult both-bone forearm fractures? (2) What factors are associated with delayed wound closure? METHODS: The medical records of all patients who underwent ORIF with plate fixation for both-bone fractures by the adult orthopaedic trauma service at our institution were considered potentially eligible for analysis. Between January 2010 and April 2022, we treated 74 patients with ORIF for both-bone forearm fractures. Patients were excluded if they had fractures that were fixed more than 2 weeks from injury (six patients), if their fracture was treated with an intramedullary nail (one patient), or if the patient experienced compartment syndrome preoperatively (one patient). No patients with Gustilo-Anderson Type IIIB and C open fractures were included. Based on these criteria, 89% (66 of 74) of the patients were eligible. No further patients were excluded for loss of follow-up because the primary endpoint was the use of delayed wound closure, which was performed at the time of ORIF. However, one further patient was excluded for having bilateral forearm fractures to ensure that each patient had a single fracture for statistical analysis. Thus, 88% (65 of 74) of patients were included in the analysis. These patients were captured by an electronic medical record search of CPT code 25575. The mean ± SD age was 34 ± 15 years and mean BMI was 28 ± 7 kg/m 2 . The mean follow-up duration was 4 ± 5 months. The primary endpoint was the use of delayed wound closure, which was determined at the time of definitive fixation if tension-free closure could not be achieved. All surgeons used a volar Henry or modified Henry approach and a dorsal subcutaneous approach to the ulna for ORIF. Univariate logistic regression was used to identify which factors might be associated with delayed wound closure. A multivariable logistic regression analysis was then performed for male gender, open fractures, age, and BMI. RESULTS: Twenty percent (13 of 65) of patients underwent delayed wound closure, 18% (12 of 65) of which occurred in patients who had high-energy injuries and 14% (nine of 65) in patients who had open fractures. Being a man (adjusted odds ratio 9.9 [95% confidence interval 1 to 87]; p = 0.04) was independently associated with delayed wound closure, after adjusting for open fractures, age, and BMI. CONCLUSION: One of five patients had delayed wound closure after ORIF of both-bone forearm fractures. Being a man was independently associated with greater odds of delayed wound closure. Surgeons should counsel all patients with these fractures about the possibility of delayed wound closure, with particular attention to men with high-energy and open fractures. Future larger-scale studies are necessary to confirm which factors are associated with the use of delayed wound closure in ORIF of both-bone fractures and its effects on fracture healing. LEVEL OF EVIDENCE: Level III, therapeutic study.

Surgeon-specific factors have a larger impact on decision-making for the management of proximal humerus fractures than patient-specific factors: a prospective cohort study.

BACKGROUND: There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs. METHODS: We performed a prospective cohort investigation in 2 groups of surgeons-traumatologists (N = 25) and shoulder & elbow/sports surgeons (SES) (N = 26)-and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data. RESULTS: Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) vs. 51% ORIF (SES, P < .001), 8% arthroplasty (traumatologists) vs. 17% (SES, P < .001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making. CONCLUSIONS: As physicians strive to advance the treatment for PHFs and optimize patient outcomes, our findings highlight the complex overlap between surgeon-, fracture-, and patient-specific factors in the final decision-making process.

Orthopedic surgeons and physical therapists differ regarding rehabilitative needs after lower extremity fracture repair.

BACKGROUND: Little evidence is available to guide physical therapy (PT) following lower extremity fracture repair distal to the hip. As such, variability has been reported in the way PT is utilized post-operatively. Examination of current practice by orthopedic surgeons (OS) and physical therapists is needed to inform clinical practice guidelines in this area. OBJECTIVE: To describe current PT referral practices among OS, identify patient and clinical factors that affect PT referral, and examine differences between OS and physical therapists with regard to visit frequency, duration, and use of specific PT interventions. METHODS: Provider surveys. RESULTS: Surveys were completed by 100 OS and 347 physical therapists. Over half (54%) of OS reported referring "most patients" to PT and identified joint stiffness and strength limitations as top reasons for PT referral. Over 80% of OS and physical therapists indicated that joint stiffness, strength limitations, and patients' functional goals affected their recommendations for PT visit frequency. More physical therapists than OS reported that pain severity (55% vs 25%, p < .001), maladaptive pain behaviors (64% vs. 33%, p < .001), and patient self-efficacy (70% vs. 49%, p = .003) affected their visit frequency recommendations. While OS recommended more frequent PT for patients with peri-articular fractures, fracture type had minimal impact on the visit frequencies recommended by physical therapists. CONCLUSION: OS and physical therapists consider similar physical impairments when determining the need for PT and visit frequencies, however, physical therapists consider pain and psychosocial factors more often, with OS focusing more on injury type.

ChatGPT Performs at the Level of a Third-Year Orthopaedic Surgery Resident on the Orthopaedic In-Training Examination.

Introduction: Publicly available AI language models such as ChatGPT have demonstrated utility in text generation and even problem-solving when provided with clear instructions. Amidst this transformative shift, the aim of this study is to assess ChatGPT's performance on the orthopaedic surgery in-training examination (OITE). Methods: All 213 OITE 2021 web-based questions were retrieved from the AAOS-ResStudy website (https://www.aaos.org/education/examinations/ResStudy). Two independent reviewers copied and pasted the questions and response options into ChatGPT Plus (version 4.0) and recorded the generated answers. All media-containing questions were flagged and carefully examined. Twelve OITE media-containing questions that relied purely on images (clinical pictures, radiographs, MRIs, CT scans) and could not be rationalized from the clinical presentation were excluded. Cohen's Kappa coefficient was used to examine the agreement of ChatGPT-generated responses between reviewers. Descriptive statistics were used to summarize the performance (% correct) of ChatGPT Plus. The 2021 norm table was used to compare ChatGPT Plus' performance on the OITE to national orthopaedic surgery residents in that same year. Results: A total of 201 questions were evaluated by ChatGPT Plus. Excellent agreement was observed between raters for the 201 ChatGPT-generated responses, with a Cohen's Kappa coefficient of 0.947. 45.8% (92/201) were media-containing questions. ChatGPT had an average overall score of 61.2% (123/201). Its score was 64.2% (70/109) on non-media questions. When compared to the performance of all national orthopaedic surgery residents in 2021, ChatGPT Plus performed at the level of an average PGY3. Discussion: ChatGPT Plus is able to pass the OITE with an overall score of 61.2%, ranking at the level of a third-year orthopaedic surgery resident. It provided logical reasoning and justifications that may help residents improve their understanding of OITE cases and general orthopaedic principles. Further studies are still needed to examine their efficacy and impact on long-term learning and OITE/ABOS performance.

Rate of Tibiotalocalcaneal (TTC) Fusion Using the Surgical Implant Generation Network (SIGN) Intramedullary Nail in Developing Countries.

Outcomes of the Surgical Implant Generation Network (SIGN) nail have been reported for femur and tibial fractures, but its use in tibiotalocalcaneal arthrodesis (TTCA) is not well studied. Radiographic and clinical outcomes of TTCA using the SIGN database in patients with > 6 months of radiographic follow up were analyzed. Rates of tibiotalar (TT) fusion and subtalar (ST) fusion at final follow up were assessed by two independent reviewers. Of the 62 patients identified, use of the SIGN nail for TCCA resulted in 53% rate of fusion in the TT joint and 20% in the ST joint. Thirty-seven patients (60%) demonstrated painless weight bearing at final follow up. There were no differences in incidence of painless weight bearing between consensus fused and not fused cohorts for TT and ST joints (p > 0.05). There were five implant failures, no cases of infection, and seven cases of reoperation. (Journal of Surgical Orthopaedic Advances 32(3):187-192, 2023).

Quantification of manipulation forces needed for robot-assisted reduction of the ankle syndesmosis: an initial cadaveric study.

PURPOSE: Manual surgical manipulation of the tibia and fibula is necessary to properly align and reduce the space in ankle fractures involving sprain of the distal tibiofibular syndesmosis. However, manual reduction is highly variable and can result in malreduction in about half of the cases. Therefore, we are developing an image-guided robotic assistant to improve reduction accuracy. The purpose of this study is to quantify the forces associated with reduction of the ankle syndesmosis to define the requirements for our robot design. METHODS: Using a cadaveric specimen, we designed a fixture jig to fix the tibia securely on the operating table. We also designed a custom fibula grasping plate to which a force-torque measuring device is attached. The surgeon manually reduced the fibula utilizing this construct while translational and rotational forces along with displacement were being measured. This was first performed on an intact ankle without ligament injury and after the syndesmosis ligaments were cut. RESULTS: Six manipulation techniques were performed on the three principal directions of reduction at the cadaveric ankle. The results demonstrated the maximum force applied to the lateral direction to be 96.0 N with maximum displacement of 8.5 mm, applied to the anterior-posterior direction to be 71.6 N with maximum displacement of 10.7 mm, and the maximum torque applied to external-internal rotation to be 2.5 Nm with maximum rotation of 24.6°. CONCLUSIONS: The specific forces needed to perform the distal tibiofibular syndesmosis manipulation are not well understood. This study quantified these manipulation forces needed along with their displacement for accurate reduction of ankle syndesmosis. This is a necessary first step to help us define the design requirements of our robotic assistance from the aspects of forces and displacements.

Is Psychiatric Illness Associated With Worse Outcomes Following Pilon Fracture?

Background: Patients with psychiatric comorbidities represent a significant subset of those sustaining pilon fractures. The purpose of this study is to examine the association of psychiatric comorbidities (PC) in patients with pilon fractures and clinical outcomes. Methods: A multi-institution, retrospective review was conducted. Inclusion/exclusion criteria were skeletally mature patients with a tibia pilon fracture (OTA Type 43B/C) who underwent definitive fracture fixation utilizing open reduction internal fixation (ORIF) with a minimum of 24 weeks of follow-up. Patients were stratified into two groups for comparison: PC group and no PC group. Results: There were 103 patients with pilon fractures that met the inclusion/exclusion criteria of this study. Of these patients, 22 (21.4%) had at least one psychiatric comorbidity (PC) and 81 (78.6%) did not have psychiatric comorbidities (no PC). There was a higher percentage of female patients (PC: 59.1% vs no PC: 25.9%, p=0.0.005), smokers (PC: 40.9% vs no PC: 16.0%, p=0.02), and drug users (PC: 22.7% vs no PC: 8.6%, p=0.08) amongst PC patients. Fracture comminution (PC: 54.5% vs no PC: 32.1%, p=0.05) occurred more frequently in PC patients. The PC group had a higher incidence of weightbearing noncompliance (22.7% vs 7.5%, p=0.04) and reoperation (PC: 54.5% vs no PC: 29.6%, p=0.03). Conclusion: Patients with psychiatric comorbidities represent a significant percentage of pilon fracture patients and appear to be at higher risk for postoperative complication. Risk factors that may predispose patients in the PC group include smoking/substance use, weightbearing noncompliance, and fracture comminution. Level of Evidence: III.

Is there an increased risk for subtrochanteric stress fracture with the Femoral Neck System versus multiple cannulated screws fixation?

Purpose: This study sought to compare the risk of subtrochanteric stress-riser fractures and biomechanical stability of the Femoral Neck System (FNS) versus multiple screw fixation (MSF). Methods: Eight paired cadaveric femurs were randomly assigned to FNS or MSF. Physiologic load mimicking single leg stance at the subtrochanteric region was applied to the constructs. Results: No constructs failed in the subtrochanteric region during loading. There was no significant difference in force (P = 0.364) or loading cycles (P = 0.348) between groups. Conclusion: FNS constructs were not associated with an increased incidence of iatrogenic subtrochanteric fractures or biomechanical stability versus MSF.

Chemoprophylaxis for venous thromboembolism in pelvic and/or acetabular fractures: A systematic review.

BACKGROUND: It is unclear which pharmacological agents, and at what dosage and timing, are most effective for venous thromboembolism (VTE) prophylaxis in patients with pelvic/acetabular fractures. METHODS: We searched the Cochrane Database of Systematic Reviews, Embase, Web of Science, EBSCO, and PubMed on October 3, 2020, for English-language studies of VTE prophylaxis in patients with pelvic/acetabular fractures. We applied no date limits. We included studies that compared efficacy of pharmacological agents for VTE prophylaxis, timing of administration of such agents, and/or dosage of such agents. We recorded interventions, sample sizes, and VTE incidence, including deep vein thrombosis (DVT) and pulmonary embolism. RESULTS: Two studies (3604 patients) compared pharmacological agents, reporting that patients who received direct oral anticoagulants (DOACs) were less likely to develop DVT than those who received low molecular weight heparin (LMWH) (p < 0.01). Compared with unfractionated heparin (UH), LMWH was associated with lower odds of VTE (odds ratio [OR] = 0.37, 95% confidence interval [CI]: 0.22-0.63) and death (OR = 0.27, 95% CI: 0.10-0.72). Three studies (3107 patients) compared timing of VTE prophylaxis, reporting that late prophylaxis was associated with higher odds of VTE (OR = 1.9, 95% CI: 1.2-3.2) and death (OR = 4.0, 95% CI: 1.5-11) and higher rates of symptomatic DVT (9.2% vs. 2.5%, p = 0.03; and 22% vs. 3.1%, p = 0.01). One study (31 patients) investigated dosage of VTE prophylaxis, reporting that a higher proportion of patients with acetabular fractures were underdosed (23% of patients below range of anti-Factor Xa [aFXa] had acetabular fractures vs. 4.8% of patients within adequate range of aFXa, p<0.01). CONCLUSIONS: Early VTE chemoprophylaxis (within 24 or 48 h after injury) was better than late administration in terms of VTE and death. Many patients with acetabular fractures are underdosed with LMWH, with inadequate aFXa levels. Compared with UH, LMWH was associated with lower odds of VTE and death. DOACs were associated with lower risk of DVT compared with LMWH. LEVEL OF EVIDENCE: III, systematic review of retrospective cohort studies.