The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year. METHODS: In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women). RESULTS: At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSIONS: This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Prediction of in-hospital deterioration in normotensive pulmonary embolism remains elusive: external validation of the calgary acute pulmonary embolism score.

Acute pulmonary embolism (PE) is a frequently diagnosed condition. Prediction of in-hospital deterioration is challenging with current risk models. The Calgary Acute Pulmonary Embolism (CAPE) score was recently derived to predict in-hospital adverse PE outcomes but has not yet been externally validated. Retrospective cohort study of normotensive acute pulmonary embolism cases diagnosed in our emergency department between 2017 and 2019. An external validation of the CAPE score was performed in this population for prediction of in-hospital adverse outcomes and a secondary outcome of 30-day all-cause mortality. Performance of the simplified Pulmonary Embolism Severity Index (sPESI) and Bova score was also evaluated. 712 patients met inclusion and exclusion criteria, with 536 patients having a sPESI score of 1 or more. Among this population, the CAPE score had a weak discriminative power to predict in-hospital adverse outcomes, with a calculated c-statistic of 0.57. In this study population, an external validation study found weak discriminative power of the CAPE score to predict in-hospital adverse outcomes among normotensive PE patients. Further efforts are needed to define risk assessment models that can identify normotensive PE patients at risk for in hospital deterioration. Identification of such patients will better guide intensive care utilization and invasive procedural management of PE.

Heterotopic Ossification Prophylaxis in Acetabular Fracture Surgery: A Systematic Review.

Heterotopic ossification (HO) following acetabular fracture surgery is relatively common. The purpose of this study was to perform a systematic review of the literature regarding HO rates following acetabular surgery and the effectiveness of the various prophylactic measures taken to prevent its occurrence. A search of PubMed, MEDLINE, and Cochrane Database of Systematic Reviews was performed using the search terms ("Acetabular" OR "Acetabulum") AND ("Heterotopic Ossification" OR "HO" OR "Ectopic Ossification"). Inclusion criteria included articles published in English reporting on HO in acetabular fracture surgery. Descriptive statistics were calculated with categorical data presented as frequency with percentages and continuous data as means. Standard weighted means were calculated for all parameters. Sixty-six articles were included in this study with a total of 5,028 patients. HO was identified in 1,511 (30%) of fractures. Indomethacin (27%) and radiation therapy (24%) demonstrated decreased rates of HO formation versus no prophylaxis (36%). In particular, rates of severe HO formation were substantially decreased with radiation therapy (3%) and indomethacin (7%) compared to no prophylaxis (18%). Indomethacin and radiation therapy both appear to decrease HO formation and severity without substantially increasing surgical morbidity. (Journal of Surgical Orthopaedic Advances 32(4):217-224, 2023).

Review of Cancer-Specific Quality Measures Promoting the Avoidance of Low-Value Care.

BACKGROUND: With rising healthcare costs and campaigns aimed at avoiding low-value care, reducing cancer overtreatment has emerged as an important measure of cancer care quality. The extent to which avoidance of low-value care has been incorporated in cancer-specific quality measures is unknown. We aimed to identify and characterize cancer quality measures that promote the avoidance of low-value care, and identify gaps that may guide future measure development. METHODS: We systematically identified cancer-specific quality measures from leading quality measure organizations [e.g., National Quality Forum (NQF), National Quality Measures Clearinghouse (NQMC)]. We reviewed measures promoting the avoidance of low-value cancer care and subclassified them into disease site- or non-disease site-specific categories and the phase of care they targeted. RESULTS: We reviewed 313 quality measures from six organizations. Of these, 18% (n = 55) focused on avoidance of low-value care. Quality measures focused on end-of-life care were most likely to focus on low-value care [n = 13 (50%)], followed by breast [n = 12 (18%)], lung [n = 9 (31%)], colon [n = 8 (20%)], prostate [n = 5 (38%)], general cancer care [n = 4 (3%)], symptoms and toxicities [n = 2 (40%)], and palliative cancer care [n = 2 (11%)] measures. The phases of care quality measures targeted included low-value screening [n = 5 (9%)], diagnostic testing and staging [n = 7 (13%)], treatment [n = 19 (34%)], surveillance [n = 6 (11%)], and clinical outcomes [n = 18 (33%)]. All categories had a treatment-specific quality measure, but no category had a representative measure for every phase of care. DISCUSSION: A minority of cancer quality measures are aimed at avoiding low-value care, and multiple evidence-based recommendations targeting low-value care have not been incorporated.

Assessment of Psychological Factors in Short-Stay Total Hip Arthroplasty Protocol.

BACKGROUND: Several variables are known to correlate with the successful completion of short-stay total hip arthroplasty (THA) protocols. The role of psychological factors remains unclear. We investigated the interaction between patient-reported measures of psychological fitness and successful completion of a short-stay THA protocol. METHODS: We performed a prospective cohort study of patients undergoing elective anterior total hip arthroplasty enrolled in a short-stay protocol (success defined as LOS ≤1 midnight versus failed, LOS >1 midnight). Psychological fitness was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) domains for self-efficacy, depression, anxiety, emotional support, and the ability to participate in social roles. PROMIS scores, patient demographics, and surgical factors were assessed for a relationship with failure to complete short-stay protocol. RESULTS: Patients that failed to complete the short-stay protocol had higher mean pre-operative PROMIS depression scores (50.8 vs 47.1, P = .025) and anxiety scores (53.6 vs 49.2, P = .008) and higher postoperative PROMIS depression (48.19 vs 43.49, P = .003) and anxiety scores (51.7 vs 47.1, P = .01). Demographic and surgical variables did not correlate with the successful completion of the short-stay protocol. That seventy-six percent of the patients did not adhere to the short-stay protocol was due to the inability to complete a physical therapy standardized safety assessment. CONCLUSION: Higher levels of preoperative and postoperative anxiety and depression in otherwise psychologically healthy patients, is associated with an increased risk of failure to complete a short-stay protocol following THA. Targeted interventions are needed to facilitate rapid recovery in patients with psychological barriers to early mobilization.

Quantitative Effect of Pelvic Position on Radiographic Assessment of Acetabular Component Position.

BACKGROUND: Intraoperative fluoroscopy aims to improve component position in total hip arthroplasty. Measurement bias related to image quality, however, has not been quantified. We aim to quantify measurement bias in the interpretation of acetabular component position as a function of pelvis and fluoroscopic beam position in a simulated supine total hip arthroplasty model. METHODS: Posterior-anterior pelvis and hip images were obtained using a previously described pelvic model with known acetabular component position. Pelvic position was varied in 5° increments of pelvis rotation (iliac-obturator) and tilt (inlet-outlet), and in 1 cm increments from beam center in cranial-caudal and medial-lateral planes. Multiple regression analyses were conducted to evaluate the relationship between the resulting bias in interpretation of component position relative to pelvis position. RESULTS: Anteversion and abduction measurement bias increased exponentially with increasing deviation in rotation and tilt. Greater bias occurred for anteversion than for abduction. Hip centered images were less affected by pelvis malposition than pelvis centered images. Deviations of beam center within 5 cm in the coronal plane did not introduce measurement bias greater than 5°. An arbitrarily defined acceptable bias of ±5° for both abduction and anteversion was used to identify a range of optimum pelvic positioning each for hip and pelvis centered imaging. CONCLUSION: Accurate measurement of acetabular component abduction and anteversion, especially anteversion, is sensitive to proper pelvic position relative to the chosen radiographic plane. An acceptable measurement bias of ±5° is achieved when the pelvis is oriented within a newly identified range of optimum pelvic positioning.

Early diagnosis of septic arthritis in immunocompromised patients.

OBJECTIVES: Septic arthritis results in rapid joint destruction if not properly diagnosed and treated. A work up for septic arthritis includes a peripheral white blood cell count, inflammatory markers, and a joint aspiration. In the general population, the interpretation of these labs has been well-defined by prior studies. To this point, no study has determined how immunosuppressive states affect this work up. METHODS: Patients with immunosuppressive conditions who received a joint aspiration for a painful joint were retrospectively identified. Laboratory results from their work up were gathered and analyzed. RESULTS: 216 patients were included in the study, 21 of whom were diagnosed with septic arthritis. The average aspiration WBC count was 74,190 with 88% PMNs. 81% had a positive gram stain. DISCUSSION: Laboratory values for immunosuppressed patients with septic arthritis were similar to those associated with septic arthritis in historical general population controls.

Acetabular Fractures: A Problem-Oriented Approach.

The main goals of acetabular fracture management are to restore the congruity and stability of the hip joint. These goals are the same for all patients who have an acetabular fracture, regardless of the morphology or etiology of the fracture. Nevertheless, certain acetabular fracture types and several patient factors pose management challenges for surgeons. Therefore, surgeons who manage acetabular fractures must understand the distinctive features of acetabular fractures as well as the soft-tissue and patient-related factors that play a critical role in patient outcomes. Particular challenges in the management of acetabular fractures include acetabular fracture types that involve the posterior wall, acetabular fractures with soft-tissue concerns, acetabular fractures in patients with multiple injuries, and acetabular fractures in the geriatric population. Although the well-known protocols that were established by Judet and Letournel continue to be important guidelines for the management of acetabular fractures, the injury characteristics of acetabular fractures, the demographics of the patients in whom acetabular fractures occur, and the treatment options for acetabular fractures have evolved. Therefore, surgeons must be aware of new and more recently published information on acetabular fractures.

Current management of posterior wall fractures of the acetabulum.

The general goals for treating an acetabular fracture are to restore congruity and stability of the hip joint. These goals are no different from those for the subset of fractures of the posterior wall. Nevertheless, posterior wall fractures present unique problems compared with other types of acetabular fractures. Successful treatment of these fractures depends on a multitude of factors. The physician must understand their distinctive radiologic features, in conjunction with patient factors, to determine the appropriate treatment. By knowing the important points of posterior surgical approaches to the hip, particularly the posterior wall, specific techniques can be used for fracture reduction and fixation in these often challenging fractures. In addition, it is important to develop a complete grasp of potential complications and their treatment. The evaluation and treatment protocols initially developed by Letournel and Judet continue to be important; however, the surgeon also should be aware of new information published and presented in the past decade.

Femoral vein blood flow during a total hip arthroplasty using a modified Heuter approach.

Several modifications to traditional surgical approaches for total hip arthroplasty (THA) have been introduced in an attempt to improve upon minimally invasive approaches and enhance short-term recovery. However, minimally invasive approaches are not without risk, including that of postoperative venous thromboembolism (VTE). There has been no published literature evaluating the femoral vein during an anterior approach. We aimed to study femoral vein blood flow using duplex ultrasonography during THA performed through a modified Heuter approach. Peek flow and vessel cross-sectional area were affected by limb position as well as acetabular and femoral retractor placement. No VTE was observed, but there was observed femoral vein compression, which may represent a risk of postoperative VTE similar to that seen in standard surgical approaches for THA.

Investigation of bone quality of the first and second sacral segments amongst trauma patients: concerns about iliosacral screw fixation.

BACKGROUND: Iliosacral screw fixation has become a common method for surgical stabilization of acute disruptions of the pelvic ring. Placement of iliosacral screws into the first sacral (S1) body is the preferred method of fixation, but size limitations and sacral dysmorphism may preclude S1 fixation. In these clinical situations, fixation into the second sacral (S2) body has been recommended. The objective of this study was to evaluate the bone quality of the S1 compared to S2 in the described "safe zone" of iliosacral screw fixation in trauma patients. MATERIALS AND METHODS: The pelvic computed tomography scans of 25 consecutive trauma patients, ages 18-49, at a level 1 trauma center were prospectively analyzed. Hounsfield units, a standardized computed tomography attenuation coefficient, was utilized to measure regional cancellous bone mineral density of the S1 and S2. No change in the clinical protocol or treatment occurred as a consequence of inclusion in this study. RESULTS: A statically significant difference in bone quality was found when comparing the first and second sacral segment (p = 0.0001). Age, gender, or smoking status did not independently affect bone quality. CONCLUSION: In relatively young, otherwise healthy trauma patients there is a statistically significant difference in the bone density of the first sacral segment compared to the second sacral segment. This study highlights the need for future biomechanical studies to investigate whether this difference is clinically relevant. Due to the relative osteopenia in the second sacral segment, which may impact the quality of fixation, we feel this technique should be used with caution.

Trends, demographics and reoperation rates of periacetabular osteotomy: an analysis from the PearlDiver database.

This study aims to examine the trends and demographics of periacetabular osteotomy (PAO) in the United States from 2016 to 2020 using a large healthcare database analysis. The PearlDiver database was queried for patients who underwent a PAO procedure starting with current procedural terminology (CPT) codes 27299, S2115 and 27146. Subsequently, the population was filtered for patients being ages 12-50, having an inpatient charge-type and those having a length of stay of at least 1 day. Patients with total hip arthroplasty were filtered out, and the resulting population was filtered by ICD-10 diagnosis codes. The providers of each patient were also examined to ensure their history of treating hip dysplasia. Student t and multiple regression analysis tests were used for statistical comparisons and trends analysis (P < 0.05 reported as significant). A total of 535 consecutive patients were analyzed over the study period. There was a higher incidence of PAO in females compared with males (P < 0.001) and a higher incidence of PAO in patients aged 15-19 years compared with older age groups (P = 0.017). Within the first year after the index PAO, 171 of the 535 patients, almost one-third (32%), received a reoperation. Of the 171 reoperations, 115 were deep removal of implant, 55 were a hip arthroscopy and 1 patient had a bone excision for heterotopic ossification. Similar studies should be carried out using other large health databases to confirm the external validity of these trends and rates across the United States.

Peri-Operative Management of Periacetabular Osteotomy: A Report of Current Practices from the Anchor Group, Supporting Literature, and Areas for Future Investigation.

Background: Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia, but very few studies report the impact of peri-operative management strategies on early pain and function. The purpose of this study is to describe peri-operative management variability among a group of experienced surgeons and review the literature supporting these practice patterns. Methods: We surveyed 16 surgeons that perform PAO to document various aspects of peri-operative management at four stages: pre-operative, intra-operative, post-operative in the hospital, and at discharge. Our goal was to report current surgical pain management strategies, adjunct medications, type of anesthesia, deep venous thrombosis and heterotopic ossification prophylaxis strategies, initiation of physical therapy, and use of continuous passive motion (CPM). We reviewed current literature to identify studies supporting these perioperative strategies and identify knowledge gaps that would benefit from further investigation. Results: Of the 16 surgeons surveyed, 75% had been in practice greater than 10 years and most had not altered their post-operative protocol for more than 3 years. 15/16 surgeons felt that length of stay could be reduced at their institution with improved peri-operative pain management. 6/16 were considering or had already implemented outpatient PAO as a part of their practice. We found significant variability in the pain medications provided at all peri-operative stages. 14/16 utilized general anesthesia, and many utilized epidural or peripheral nerve blocks. 6/16 surgeons utilized surgical field block (also referred to as periarticular block). These surgeons advocated that surgical field block was an effective intervention with no/minimal complication risk. There is very little literature critically evaluating efficacy of these perioperative management strategies for PAO. Conclusion: There is significant practice variability in peri-operative management of PAO surgery. We report various strategies utilized by a group of experienced surgeons and review supporting literature. There are significant knowledge gaps in best surgical pain management strategies, adjunct medications, surgical field blocks, and use of CPM that need further investigation. Level of Evidence: IV.

Effect of pulmonary embolism response team on advanced therapies administered: The University of Michigan experience.

BACKGROUND: Pulmonary Embolism Response Teams (PERT) were employed at multiple institutions to bridge the gap between varied treatment options for acute PE and unclear evidence for optimal management. There is limited data regarding the impact of PERT on the use of advanced therapies and clinical outcomes. METHODS: We performed a retrospective single-center cohort study comparing patients that presented to the ED with an acute PE before and after the creation of PERT in June 2017 at our institution. We assessed utilization of advanced therapies, LOS, and mortality. RESULTS: A total of 817 patients (168 pre-PERT, 649 post-PERT) were evaluated in the ED with an acute PE between October 2016 and December 2019. Both groups were similar in demographics, comorbidities, and PESI score. There was a decrease in advanced therapy use (16 % vs. 7.5 %, p = 0.006) after PERT creation. Most notable decreases were in catheter-based therapies (8.5 % vs. 2.2 %, p = 0.008) and IVC filter placement (5.3 % vs. 3.2 %, p < 0.001). Median ICU LOS (2.5 days vs. 2.3 days, p = 0.55) and hospital LOS (3.1 vs. 3.0, p = 0.92) did not vary pre-PERT vs. post-PERT. In-hospital mortality (8.5 % vs. 5.0 %, p = 0.29) and 30-day all-cause mortality (1.2 % vs. 0.5 %, p = 0.28) were not different between the two groups as well. CONCLUSION: At our institution, PERT was associated with a decrease in advanced therapies administered to acute PE patients without affecting mortality or LOS. Additional studies to assess impact of this multi-disciplinary care team model on interventional therapies and clinical outcomes for PE at a broader level are necessary.

Adverse Clinical Outcomes Among Patients With Acute Low-risk Pulmonary Embolism and Concerning Computed Tomography Imaging Findings.

Importance: Most patients presenting to US emergency departments (EDs) with acute pulmonary embolism (PE) are hospitalized, despite evidence from multiple society-based guidelines recommending consideration of outpatient treatment for those with low risk stratification scores. One barrier to outpatient treatment may be clinician concern regarding findings on PE-protocol computed tomography (CTPE), which are perceived as high risk but not incorporated into commonly used risk stratification tools. Objective: To evaluate the association of concerning CTPE findings with outcomes and treatment of patients in the ED with acute, low-risk PE. Design, Setting, and Participants: This cohort study used a registry of all acute PEs diagnosed in the adult ED of an academic medical center from October 10, 2016, to December 31, 2019. Acute PE cases were divided into high- and low-risk groups based on PE Severity Index (PESI) class alone or using a combination of PESI class and biomarker results. The low-risk group was further divided based on the presence of concerning CTPE findings: (1) bilateral central embolus, (2) right ventricle-to-left ventricle ratio greater than 1.0, (3) right ventricle enlargement, (4) septal abnormality, or (5) pulmonary infarction. Data analysis was conducted from June to October 2022. Main Outcomes and measures: The primary outcome was all-cause mortality at 7 and 30 days. Secondary outcomes included hospitalization, length of stay, need for intensive care, use of echocardiography and/or bedside ultrasonography, and activation of the PE response team (PERT) . Results: Of 817 patients (median [IQR] age, 58 [47-71] years; 417 (51.0%) female patients; 129 [15.8%] Black and 645 [78.9%] White patients) with acute PEs, 331 (40.5%) were low risk and 486 (59.5%) were high risk by PESI score. Clinical outcomes were similar for all low-risk patients, with no 30-day deaths in the low-risk group with concerning CTPE findings (0 of 151 patients) vs 4 of 180 (2.2%) in the low-risk group without concerning CTPE findings and 88 (18.1%) in the high-risk group (P < .001). Low-risk patients with concerning CTPE findings were less frequently discharged from the ED than those without concerning CTPE findings (3 [2.0%] vs 14 [7.8%]; P = .01) and had more frequent echocardiography (87 [57.6%] vs 49 [27.2%]; P < .001) and PERT activation for consideration of advanced therapies (34 [22.5%] vs 11 [6.1%]; P < .001). Conclusions and Relevance: In this single-center study, CTPE findings widely believed to confer high risk were associated with increased hospitalization and resource utilization in patients with low-risk PE but not short-term adverse clinical outcomes.

One Health assessment of persistent organic chemicals and PFAS for consumption of restored anadromous fish.

BACKGROUND: Restoration efforts have led to the return of anadromous fish, potential source of food for the Penobscot Indian Nation, to the previously dammed Penobscot River, Maine. OBJECTIVE: U.S. Environmental Protection Agency (EPA), Penobscot Indian Nation's Department of Natural Resources (PINDNR), and Agency for Toxic Substances and Disease Registry (ATSDR), measured contaminants in six species of anadromous fish. Fish tissue concentrations were then used, along with exposure parameters, to evaluate potential human and aquatic-dependent wildlife risk. METHODS: PINDNR collected, filleted, froze, and shipped fish for analysis of polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), dioxins/furans, and per- and polyfluoroalkyl substances (PFAS). Contaminant levels were compared to reference doses (where possible) and wildlife values (WVs). RESULTS: Chemical concentrations ranged from 6.37 nanogram per gram (ng/g) wet weight (ww) in American Shad roe to 100 ng/g ww in Striped Bass for total PCBs; 0.851 ng/g ww in American Shad roe to 5.92 ng/g ww in large Rainbow Smelt for total PBDEs; and 0.037 ng/g ww in American Shad roe to 0.221 ng/g ww in Striped Bass for total dioxin/furans. PFAS concentrations ranged between 0.38 ng/g ww of PFBA in Alewife to 7.86 ng/g ww of PFUnA in Sea Lamprey. Dioxin/furans and PFOS levels indicated that there are potential human health risks. The WV for mink for total PCBs (72 ng/g) was exceeded in Striped Bass and the WV for Kestrel for PBDEs (8.7 ng/g) was exceeded in large Rainbow Smelt. Mammalian wildlife consuming Blueback Herring, Striped Bass, and Sea Lamprey may be at risk based on PFOS WVs from Canada. IMPACT: Anadromous fish returning to the Penobscot River potentially could represent the restoration of a major component of tribal traditional diet. However, information about contaminant levels in these fish is needed to guide the tribe about consumption safety. Analysis of select species of fish and risk calculations demonstrated the need for a protective approach to consumption for both humans and wildlife. This project demonstrates that wildlife can also be impacted by contamination of fish and their risks can be as great or greater than those of humans. A One Health approach addresses this discrepancy and will lead to a healthier ecosystem.

What is the infection rate of the posterior approach to type C pelvic injuries?

BACKGROUND: Pelvic ring injuries with complete disruption of the posterior pelvis (AO/OTA Type C) benefit from reduction and stabilization. Open reduction in early reports had high infectious complications and many surgeons began using closed reduction and percutaneous fixation. Multiple smaller studies have reported low infection rates after a posterior approach, but these rates are not confirmed in larger series of diverse fractures. QUESTIONS/PURPOSES: We therefore determined (1) the incidence of surgical site infectious complications after a posterior approach to the pelvis; and (2) whether secondary procedures other than surgical débridement are necessary as a result of the approach-related complications. METHODS: We retrospectively reviewed all 236 patients (268 surgical approaches) with C type injuries treated with a posterior approach at six institutions before 1998 and at one institution from 1998 to 2005. Posterior injuries were classified anatomically as described by Letournel and the AO/OTA system. We recorded wound complications after surgery. RESULTS: Surgical site infection occurred in eight of the 236 patients (3.4%) in the multicenter analysis. Treatment consisted of surgical débridement, wound closure, and antibiotics. No patients required soft tissue reconstruction as a result of the approach or infection. CONCLUSION: Our data suggest with proper patient selection and the described surgical technique, there should be minimal risk for catastrophic wound complications or high infection rates as reported by others. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Highly Cited Articles in Periacetabular Osteotomy Research.

Purpose: The aim of this study is to identify highly cited articles and examine trends and characteristics in research on periacetabular osteotomy. Materials and Methods: The 50 most highly cited articles on periacetabular osteotomy research were identified using Scopus. Data regarding article demographics and publication were collected from each article and an analysis was performed. Results: The mean citation count was 125±37. The article with the highest total citation count (796), five-year citation count (327), and five-year citation density (65/year) was reported by Reinhold Ganz. The five-year citation density showed strong correlation with total citation density (r=0.930, P<0.001). Reinhold Ganz, the most productive author, was listed on 13 articles in the cohort with 455 weighted citation points. Conclusion: This study provides a collection of articles examining periacetabular osteotomies and demonstrates that citation count can be regarded as an acceptable measure of the contemporary academic influence of an article.

Accuracy of Radiographic Displacement Measurement in a Pelvic Ring Injury Model.

BACKGROUND: Pelvic ring injury outcome studies rely on radiographic assessment. To date, no study investigates the accuracy of radiographic measurement. The aim of this study was to assess the accuracy and interobserver reliability of pelvic ring displacement measurement in an injury model. We hypothesize that current radiographic measurement methods do not accurately quantify the three-dimensional pelvic ring displacement. METHODS: Ten orthopaedic traumatologists evaluated 12 pelvic ring injury model displacements using AP, inlet, and outlet radiographs and axial CT images. Observers completed a survey of demographic and treatment approach strategies. Radiographic displacement measurements in axial, coronal, and sagittal planes were analyzed for accuracy using. Absolute displacement measurements were categorized with Matta and Tornetta grading system for Fleiss Kappa inter-reliability correlation evaluation. RESULTS: The mean age of orthopaedic traumatologists was 47.5 years (range 36 to 59) with a mean 15.3 years (range 4 to 27) of pelvic fracture surgery experience. Radiographic measurement of isolated uniplanar of pelvic displacement in axial, sagittal, or coronal plane alone was more accurate than multiplanar pelvic displacements with more than one plane of displacement, 6.6 ± 5.7 mm error compared with 9.6 ± 6.3 mm error, respectively (P = 0.0035). Measurement accuracy was greater with isolated coronal plane (4 ± 3.5 mm error) compared with isolated axial plane (9.9 ± 7.1 mm error) or isolated sagittal plane displacement (6.7 ± 4 mm error). Interrater reliability for the radiographic displacement measurement by observers showed an overall poor agreement with 0.24. CONCLUSION: Radiographic displacement measurement in these modeled pelvic ring injuries has notable inaccuracy among various measurement methods. Coronal and sagittal plane radiographic displacement measurements are more accurate compared with axial plane measurement. The reporting of radiographic displacement measurement outcomes in clinical research studies should be critically evaluated, and standardization of pelvic ring injury displacement may not be achievable with radiography. LEVEL OF EVIDENCE: Level V.

Thymic Stromal Lymphopoietin Induction Suppresses Lung Cancer Development.

Lung cancer is the leading cause of cancer deaths in the United States and across the world. Immunotherapies, which activate tumor-infiltrating cytotoxic T lymphocytes, have demonstrated efficacy for the treatment of advanced-stage lung cancer. However, the potential for harnessing the immune system against the early stages of lung carcinogenesis to prevent cancer development and recurrence remains unexplored. Using a mouse model of lung adenocarcinoma, we investigated the effects of thymic stromal lymphopoietin (TSLP) induction on early cancer development in the lungs. Herein, we demonstrate that systemic TSLP induction suppressed spontaneous lung cancer development in KrasG12D mice. TSLP drove a significant CD4+ T cell response to block lung cancer progression from atypical alveolar hyperplasia to adenocarcinoma. Our findings suggest that TSLP can be used in the early stages of lung cancer development to trigger a lasting immunity in the tissue and prevent the development of advanced disease.