Smith-Petersen Versus Watson-Jones Approach Does Not Affect Quality of Open Reduction of Femoral Neck Fracture.

OBJECTIVE: To compare immediate quality of open reduction of femoral neck fractures by alternative surgical approaches. DESIGN: Retrospective cohort study. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Eighty adults 18-65 years of age with isolated, displaced, OTA/AO type 31-B2 or -B3 femoral neck fractures treated with internal fixation. INTERVENTION: Thirty-two modified Smith-Petersen anterior approaches versus 48 Watson-Jones anterolateral approaches for open reduction performed by fellowship-trained orthopaedic trauma surgeons. MAIN OUTCOME: Reduction quality as assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: No difference was observed in the rate of acceptable reduction by modified Smith-Petersen (81%) versus Watson-Jones (81%) approach (risk difference null, 95% confidence interval -17.4% to 17.4%, P = 1.00) with 90.4% panel agreement (Fleiss' weighted κ = 0.63, P < 0.01). Stratified analyses did not identify a significant difference in the rate of acceptable reduction between approaches when stratified by Pauwels angle, basicervical or transcervical fracture location, or posterior comminution. The Smith-Petersen approach afforded a better reduction when preoperative skeletal traction was not applied (RR = 1.67 [95% CI 1.10-2.52] vs. RR = 0.87 [95% CI 0.70-1.08], P = 0.006). CONCLUSIONS: No difference was observed in the quality of open reduction of displaced femoral neck fractures in young adults when a Watson-Jones anterolateral approach versus a modified Smith-Petersen anterior approach was performed by orthopaedic trauma surgeons. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open Reduction Is Associated With Greater Hazard of Early Reoperation After Internal Fixation of Displaced Femoral Neck Fractures in Adults 18-65 Years.

OBJECTIVES: To determine (1) which factors are associated with the choice to perform an open reduction and (2) by adjusting for these factors, if the choice of reduction method is associated with reoperation. DESIGN: Retrospective cohort study with radiograph and chart review. SETTING: Twelve Level 1 North American trauma centers. PATIENTS: Two hundred thirty-four adults 18-65 years of age with an isolated, displaced, OTA/AO type 31-B2 or type 31-B3 femoral neck fracture treated with internal fixation with minimum of 6-month follow-up or reoperation. Exclusion criteria were pathologic fractures, associated femoral head or shaft fractures, and primary arthroplasty. INTERVENTION: Open or closed reduction technique during internal fixation. MAIN OUTCOME: Cox proportional hazard of reoperation adjusting for propensity score for open reduction based on injury, demographic, and medical factors. Reduction quality was assessed by 3 senior orthopaedic traumatologists as "acceptable" or "unacceptable" on AP and lateral postoperative radiographs. RESULTS: Median follow-up was 1.5 years. One hundred six (45%) patients underwent open reduction. Reduction quality was not significantly affected by open versus closed approach (71% vs. 69% acceptable, P = 0.378). The propensity to receive an open reduction was associated with study center; younger age; male sex; no history of injection drug use, osteoporosis, or cerebrovascular disease; transcervical fracture location; posterior fracture comminution; and surgery within 12 hours. A total of 35 (33%) versus 28 (22%) reoperations occurred after open versus closed reduction (P = 0.056). Open reduction was associated with a 2.4-fold greater propensity-adjusted hazard of reoperation (95% confidence interval 1.3-4.4, P = 0.004). A total of 35 (15%) patients underwent subsequent total hip arthroplasty or hemiarthroplasty. CONCLUSIONS: Open reduction of displaced femoral neck fractures in nonelderly adults is associated with a greater hazard of reoperation without significantly improving reduction. Prospective randomized trials are indicated to confirm a causative effect of open versus closed reduction on outcomes after femoral neck fracture. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rapid Complete Acetabular Destruction in Metal-on-Metal Total Hip Arthroplasty.

Adverse local tissue reaction, osteolysis, and subsequent increased incidence of failure have been associated with metal-on-metal (MoM) total hip arthroplasty (THA). We present the case of a 68-year-old woman with rheumatoid arthritis who has undergone left THA with a MoM bearing. Seven years postoperatively, she presented with 6 weeks of severe left hip pain. Sequential radiographs and advanced imaging demonstrated a rapid onset of extensive acetabular osteolysis with pelvic discontinuity and pseudotumor formation. She underwent revision THA using a cup-cage construct with a satisfactory outcome. In this article, we review current evidence-based management options for pelvic discontinuity, as well as other complications related to MoM THA.

Weight- perception in male career firefighters and its association with cardiovascular risk factors.

BACKGROUND: The prevalence of obesity has reached epidemic proportions worldwide, and is also increasing among public safety professionals like firefighters who are expected to be fit and more active. The present study evaluates the associations among Body Mass Index (BMI), weight perception and cardiovascular risk factors in 768 male career firefighters from two Midwestern states in the United States. METHODS: A physical examination was performed and fasting blood samples were taken. Cardio-respiratory fitness (CRF) was determined from symptom- limited maximal treadmill exercise testing with electrocardiogram (ECG) monitoring and estimation of oxygen consumption (metabolic equivalents, METS) using the Bruce protocol. A health and lifestyle questionnaire was administered with standardized written instructions for completion. Self-reports of weight perception were extracted from responses to the completed multiple choice questionnaire. Baseline characteristics were described using the mean (standard deviation) for continuous variables and frequency for categorical variables. Group comparisons were calculated using analysis of variance (ANOVA). Linear models and logistic regression models were used to adjust for possible confounders. Logistic regression analyses were used to calculate the odds ratios of underestimating one's weight category. RESULTS: A high proportion of overweight and obese male career firefighters underestimate their weight categories (68%). The risk of underestimating one's weight category increased by 24% with each additional unit of increasing BMI after adjustment for age and CRF. When divided into six groups based on combinations of measured BMI category and weight perception, there were significant differences among the groups for most cardiovascular risk factors. After adjustment for age and BMI, these differences remained statistically significant for CRF, amount of weekly exercise, prevalence of Metabolic Syndrome (MetSyn), body fat percentage and cholesterol measurements. CONCLUSION: A high proportion of overweight and obese male career firefighters underestimate their measured BMI categories. As a result, they are unlikely to fully appreciate the negative health consequences of their excess weight. The results of this study emphasize the importance of objectively measuring BMI and then informing patients of their actual weight status and the associated disease risks.

Cardiorespiratory fitness predicts cardiovascular risk profiles in career firefighters.

OBJECTIVE: Evaluate the association between cardiovascular disease (CVD) risk factors and cardiorespiratory fitness (CRF) in firefighters. METHODS: Cross-sectional study of 968 male career firefighters. Cardiorespiratory fitness was measured by maximal exercise tolerance tests. Cardiovascular disease risk parameters included body composition, resting vital signs, and metabolic profiles. Group comparisons were performed using χ test, analysis of variance, and general linear regression with/without adjustment for age and body mass index (BMI). RESULTS: Higher metabolic equivalents categories were significantly associated with lower diastolic blood pressure, body fat, triglycerides, low-density lipoprotein cholesterol and total/high-density cholesterol ratio, and higher high-density lipoprotein (P ≤ 0.0272, age and BMI adjusted). CONCLUSIONS: Increasing CRF has beneficial independent effects on CVD risk factor profiles among firefighters. Higher CRF was beneficial regardless of BMI; nevertheless, increasing BMI had strong independent unfavorable effects. Firefighters should be encouraged to increase their CRF to decrease their future risk of CVD.

Cardiovascular disease in US firefighters: a systematic review.

Cardiovascular disease (CVD) is the leading cause of on-duty death among firefighters (45% of on-duty fatalities) and a major cause of morbidity. CVD in the fire service also has adverse public safety implications as well as significant cost impacts on government agencies. Over the last decade, our understanding of CVD among firefighters has significantly improved and provides insight into potential preventive strategies. The physiology of cardiovascular arousal and other changes that occur in association with acute firefighting activities have been well-characterized. However, despite the strenuous nature of emergency duty, firefighters' prevalence of low fitness, obesity, and other CVD risk factors are high. Unique statistical approaches have documented that on-duty CVD events do not occur at random in the fire service. They are more frequent at certain times of day, certain periods of the year, and are overwhelmingly more frequent during strenuous duties compared with nonemergency situations. Moreover, as expected on-duty CVD events occur almost exclusively among susceptible firefighters with underlying CVD. These findings suggest that preventive measures with proven benefits be applied aggressively to firefighters. Furthermore, all fire departments should have entry-level medical evaluations, institute periodic medical and fitness evaluations, and require rigorous return to work evaluations after any significant illness. Finally, on the basis of the overwhelming evidence supporting markedly higher relative risks of on-duty death and disability among firefighters with established coronary heart disease, most firefighters with clinically significant coronary heart disease should be restricted from participating in strenuous emergency duties.

Firefighters' physical activity: relation to fitness and cardiovascular disease risk.

PURPOSE: Cardiovascular disease (CVD) accounts for 44% of on-duty deaths among US firefighters with a markedly higher event risk during strenuous duties compared with nonemergencies. Sedentary persons are most susceptible to such CVD "event-triggering" due to irregular bouts of vigorous physical activity (PA). Conversely, regular PA and increased levels of cardiorespiratory fitness (CRF) protect against CVD triggering. Therefore, the present study evaluates PA measures in structural firefighters and their relationship to CRF and CVD risk factors. METHODS: Cross-sectional cohort study of 527 Midwestern career firefighters. PA frequency, duration, and intensity measures from a questionnaire along with total weekly aerobic exercise were analyzed. CRF was measured by maximal exercise tolerance testing. CVD risk parameters included body composition, blood pressure, and metabolic profiles. Group differences were compared using general linear models. RESULTS: Measures of increasing frequency, duration, intensity of PA, and total weekly exercise (min) were significantly associated with higher CRF (P < 0.001) after adjustment for age, body mass index (BMI), and smoking status. After multivariate adjustment, increasing PA frequency was significantly associated with reduced total cholesterol-HDL ratio, triglycerides, and glucose, as well as HDL increments. Increasing BMI category was associated with significant decrements in CRF and unfavorable dose-response trends in CVD risk factors (P < 0.001), even for those reporting very frequent, sustained, and intense PA. CONCLUSIONS: Increasing PA has beneficial independent effects on CRF, and PA frequency has similar favorable effects on CVD risk profiles. Whereas PA was beneficial regardless of BMI category, increasing BMI category had strong independent unfavorable effects. PA should be strongly encouraged for all firefighters with the highest priority given to PA frequency, followed by PA duration and intensity.

Screening for obstructive sleep apnea during commercial driver medical examinations.

OBJECTIVE: To evaluate consensus criteria for screening commercial drivers for obstructive sleep apnea (OSA). METHODS: Consecutive drivers underwent OSA screening using Joint Task Force consensus criteria at commercial driver medical examinations. Outcomes included: clinical yield of screening; and drivers' compliance with polysomnography (PSG) referrals and OSA treatment. RESULTS: Among 456 drivers, 53 (12%) were referred for PSG, and 20/20 were confirmed to have OSA, supporting a high positive predictive value. The other 33 drivers referred for PSG were lost to follow-up but demonstrated no significant differences from those with confirmed OSA. After diagnosis, only one of 20 drivers with confirmed OSA demonstrated treatment compliance. CONCLUSIONS: Drivers identified by the consensus criteria have a high likelihood of OSA. Drivers' poor compliance with PSGs and OSA treatment support federally mandated screening of commercial drivers.

The obesity epidemic and future emergency responders.

Emergency responders should be fit to safely perform strenuous duties. In particular, young recruits are expected to be at or near peak career fitness. We studied the prevalence and health associations of excess weight among 370 consecutive emergency responder candidates for fire and ambulance services in Massachusetts. The mean age and BMI of the recruits were 26.3 (3.8) years and 28.5 (4.9) kg/m(2), respectively. Seventy-seven percent had BMI >or=25 kg/m(2), and 33% were obese (BMI >or=30 kg/m(2)). After multivariate adjustment, both higher BMI categories and unit increases in BMI were significantly associated with higher blood pressures, worse metabolic profiles, and lower exercise tolerance. Excess weight is highly prevalent and associated with elevated cardiovascular risk among future emergency responders. These findings in a population expected to perform demanding duties supporting public safety merit prompt public health intervention.

Blood pressure in firefighters, police officers, and other emergency responders.

Elevated blood pressure is a major risk factor for cardiovascular morbidity and mortality. Increased risk begins in the prehypertensive range and increases further with higher pressures. The strenuous duties of emergency responders (firefighters, police officers, and emergency medical services (EMS) personnel) can interact with their personal risk profiles, including elevated blood pressure, to precipitate acute cardiovascular events. Approximately three-quarters of emergency responders have prehypertension or hypertension, a proportion which is expected to increase, based on the obesity epidemic. Elevated blood pressure is also inadequately controlled in these professionals and strongly linked to cardiovascular disease morbidity and mortality. Notably, the majority of incident cardiovascular disease events occur in responders who are initially prehypertensive or only mildly hypertensive and whose average premorbid blood pressures are in the range in which many physicians would hesitate to prescribe medications (140-146/88-92). Laws mandating public benefits for emergency responders with cardiovascular disease provide an additional rationale for aggressively controlling their blood pressure. This review provides a background on emergency responders, summarizes occupational risk factors for hypertension and the metabolic syndrome, their prevalence of elevated blood pressure, and evidence linking hypertension with adverse outcomes in these professions. Next, discrepancies between relatively outdated medical standards for emergency responders and current, evidence-based guidelines for blood pressure management in the general public are highlighted. Finally, a workplace-oriented approach for blood pressure control among emergency responders is proposed, based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.