The Relationship Between Posterior Tibial Slope and Pediatric Tibial Eminence Fractures.

BACKGROUND: Tibial eminence fractures are bony avulsions of the anterior cruciate ligament from its insertion on the intercondylar eminence. Numerous anatomic factors have been associated with anterior cruciate ligament injuries, such as posterior tibial slope, but there are few studies evaluating the association with tibial eminence fracture. PURPOSE: To compare posterior tibial slope of pediatric patients with and without tibial eminence fractures. We hypothesized that a steeper posterior tibial slope would be associated with tibial eminence fracture. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients who underwent surgical treatment of tibial eminence fracture were retrospectively identified between January 2000 and July 2021. Adults aged >20 years and those without adequate imaging were excluded. Controls without gross ligamentous or osseous pathology were identified. Descriptive information and Meyers and McKeever classification were recorded. Posterior tibial slope measurements were obtained by 2 independent orthopaedic surgeons twice, with measurements separated by 3 weeks. Chi-square tests and independent-samples t tests were used to compare posterior tibial slope and patient characteristics. Inter- and intrareviewer variability was determined via the intraclass correlation coefficient. RESULTS: A total of 51 patients with tibial eminence fractures and 57 controls were included. By sex, tibial eminence fractures occurred among 34 male and 17 female patients with a mean age of 10.9 years. The posterior tibial slope among those with tibial eminence fractures (9.7°) was not significantly greater than that of controls (8.8°; P = .07). Male patients with a tibial eminence fracture had significantly steeper slopes compared with controls (10.0° vs 8.4°; P = .006); this difference was not observed between female patients and female controls. Patients with a slope ≥1 SD above the mean (12.0°) had 3.8 times greater odds (95% CI, 1.3-11.6; P = .017) of having a tibial eminence fracture. Male patients with a posterior tibial slope >12° had 5.8 times greater odds (95% CI, 1.1-29.1; P = .034) of having a tibial eminence fracture compared with male controls. CONCLUSION: Male patients undergoing surgical fixation of a tibial eminence fracture had an increased posterior tibial slope as compared with case-controls. Increased posterior tibial slope may be a risk factor for sustaining a tibial eminence fracture, although the clinical significance of this deserves further investigation.

Insurance status is not a predictor of rotator cuff tear magnitude.

Background: Rotator cuff tear (RCT) chronicity is an important factor in considering treatment options and outcomes for surgical repair. Many factors may contribute to delayed treatment, including timely access to care due to insurance status. The purpose of this study was to evaluate the relationship between the magnitude of RCT on presentation and insurance status. We hypothesize that publicly insured patients will have a greater incidence of chronic RCTs and shoulder pathology on initial presentation. Methods: Retrospective chart review of patients undergoing RCT repair at an academic tertiary care institution from 2005 to 2019. Demographic data, including age, race, sex, and insurance carrier, were collected. Insurance carriers were categorized into public (Medicare and Medicaid) or private insurance coverage. Individual magnetic resonance imagings were then reviewed by a board-certified musculoskeletal radiologist for supraspinatus (SS), infraspinatus (IS), subscapularis, and biceps tendon tears, as well as acromioclavicular arthritis. In addition, rotator cuff atrophy was evaluated by the scapular ratio. Univariate analysis of variance and logistic regression analyses were used to compare demographics and rotator cuff pathology between those with Medicaid and Medicare, as well as between publicly and privately insured patients. Results: Of the 492 patients in this study, 192 had private insurance, and 300 had public insurance (Medicaid: 50 and Medicare: 250). Insurance status was not found to be associated with differences in RCTs between Medicare and Medicaid patients. Those with Medicaid or Medicare (public), presented more frequently with SS or IS atrophy (SS atrophy, P = .002; IS atrophy, P = .039) than those with private insurance. However, after adjusting for age, no significant differences in rotator cuff tendon tear or atrophy frequencies were found between insurance groups. Conclusions: Patients with private and public insurance tend to present with similar chronicity and magnitude of RCTs. Insurance status does not appear to influence timely access to surgical care for patients with RCTs at an academic medical center.

A Crowdsourcing Approach to Develop Machine Learning Models to Quantify Radiographic Joint Damage in Rheumatoid Arthritis.

Importance: An automated, accurate method is needed for unbiased assessment quantifying accrual of joint space narrowing and erosions on radiographic images of the hands and wrists, and feet for clinical trials, monitoring of joint damage over time, assisting rheumatologists with treatment decisions. Such a method has the potential to be directly integrated into electronic health records. Objectives: To design and implement an international crowdsourcing competition to catalyze the development of machine learning methods to quantify radiographic damage in rheumatoid arthritis (RA). Design, Setting, and Participants: This diagnostic/prognostic study describes the Rheumatoid Arthritis 2-Dialogue for Reverse Engineering Assessment and Methods (RA2-DREAM Challenge), which used existing radiographic images and expert-curated Sharp-van der Heijde (SvH) scores from 2 clinical studies (674 radiographic sets from 562 patients) for training (367 sets), leaderboard (119 sets), and final evaluation (188 sets). Challenge participants were tasked with developing methods to automatically quantify overall damage (subchallenge 1), joint space narrowing (subchallenge 2), and erosions (subchallenge 3). The challenge was finished on June 30, 2020. Main Outcomes and Measures: Scores derived from submitted algorithms were compared with the expert-curated SvH scores, and a baseline model was created for benchmark comparison. Performances were ranked using weighted root mean square error (RMSE). The performance and reproductivity of each algorithm was assessed using Bayes factor from bootstrapped data, and further evaluated with a postchallenge independent validation data set. Results: The RA2-DREAM Challenge received a total of 173 submissions from 26 participants or teams in 7 countries for the leaderboard round, and 13 submissions were included in the final evaluation. The weighted RMSEs metric showed that the winning algorithms produced scores that were very close to the expert-curated SvH scores. Top teams included Team Shirin for subchallenge 1 (weighted RMSE, 0.44), HYL-YFG (Hongyang Li and Yuanfang Guan) subchallenge 2 (weighted RMSE, 0.38), and Gold Therapy for subchallenge 3 (weighted RMSE, 0.43). Bootstrapping/Bayes factor approach and the postchallenge independent validation confirmed the reproducibility and the estimation concordance indices between final evaluation and postchallenge independent validation data set were 0.71 for subchallenge 1, 0.78 for subchallenge 2, and 0.82 for subchallenge 3. Conclusions and Relevance: The RA2-DREAM Challenge resulted in the development of algorithms that provide feasible, quick, and accurate methods to quantify joint damage in RA. Ultimately, these methods could help research studies on RA joint damage and may be integrated into electronic health records to help clinicians serve patients better by providing timely, reliable, and quantitative information for making treatment decisions to prevent further damage.

Union Rates of Talar Neck Fractures With Substantial Bone Defects Treated With Autograft.

BACKGROUND: This study evaluated the union rate of talar neck fractures with substantial bone defects treated acutely with autologous tibial bone graft during primary osteosynthesis. METHODS: A case series at a level 1 trauma center was performed to identify consecutive patients who underwent operative fixation of talar neck fracture with autograft (Current Procedural Terminology codes 28445 and 20902) between 2015 and 2018. "Substantial bone defect" was defined as a gap greater than 5 mm in the sagittal plane and greater than one-third of width of the talar neck in the coronal plane. Postoperative foot computed tomographic (CT) scans were obtained for all patients. Primary outcome was union, and secondary outcomes were malunion, avascular necrosis (AVN), post-traumatic arthritis (PTA), and patient-reported outcomes (PROs). RESULTS: Twelve patients with 12 fractures were included in the series, with an average length of follow-up of 26 months (range: 7-55) The average age was 34 years (17-59), and the most common mechanism of injury was motor vehicle crash. The Hawkins classification of the fractures was 4 type II (2 type IIA and 2 type IIB) (33%) and 8 type III (67%). Four fractures (33%) were open fractures. Union was achieved in 11 patients (92%). There was 1 malunion (8%). AVN was identified on postoperative CT scans in 11 patients (92%). Three of these 11 eventually showed collapse. Ten patients (83%) had radiographic evidence of some degree of ankle PTA, and 12 patients (100%) had radiographic evidence of some degree of subtalar PTA. Average Patient-Reported Outcomes Measurement Information System-Short Form score was 37 (32-45) and average Foot and Ankle Ability Measure activities of daily living and sports subscale scores were, respectively, 61 (31-87) and 31 (0-71), respectively. Average visual analog scale score was 5 (0-10), and average Foot Function Index was 49 (7-89). SF-36 scores showed fair to poor outcomes in the majority of patients. CONCLUSION: In this relatively small series, tibial autograft in primary osteosynthesis of comminuted talar neck fractures with substantial bone defects is associated with excellent union rates and low malunion rates. Despite high union rates, secondary outcomes of AVN with or without collapse, ankle and subtalar PTA, and relatively low PROs were common. LEVEL OF EVIDENCE: Level IV, case series.

Trainee and Faculty Perceptions of Remote PACS Workstations and Next Steps in a Large US Academic Medical Institution.

OBJECTIVE: Remote workstations were rapidly deployed in our academic radiology practice in late March 2020 in response to the COVID-19 pandemic. Although well-received by faculty, there were concerns for the impact on resident education. MATERIALS AND METHODS: Surveys of the radiology trainees and faculty were conducted online seven- and thirteen-months following workstation deployment as a part of a quality improvement project to assess the impact on radiology education and faculty wellness, as well as assess the desired trajectory of remote work in an academic setting. RESULTS: The majority of trainees (52%) reported the implementation had negatively impacted resident education, greatest among lower level residents (p < .001). This perception did not change despite interventions and perceived improvement in teleconferencing. Greater than 75% of radiologists with remote workstations reported improved wellness and lower stress levels compared to the onsite radiologists. The majority of all respondents voted to continue or expand remote work following the COVID-19 pandemic in both surveys. CONCLUSIONS: Onsite teaching is important for the education of residents, particularly for lower-level residents. However, the adoption of a hybrid model in an academic setting may prove beneficial for faculty wellness and recruitment of the next generation.