Episode Transcript
[00:00:03] Speaker A: Welcome to your Cases on Hold, a JBJS podcast hosted by Antonia Chen and Andrew Stonefield.
[00:00:10] Speaker B: Here we discuss the science of each issue of JBJS with an additional dose of entertainment and pop culture.
[00:00:17] Speaker A: Take us with you in the gym, on the commute, or most certainly whenever your case is on.
[00:00:27] Speaker B: Welcome back to another episode of youf Case is on hold, number 88.
We are here representing JBJS, but the views are our own and do not represent jbjs. I am Antonia Chen, Executive Editor at jbjs, and I have here.
[00:00:43] Speaker A: I'm Andrew Schoenfeld, Deputy Editor for Methods.
[00:00:47] Speaker B: So without further ado, we want to say thank you to JBJS cme. This is sponsored by them. If you need cme. If you need credit to learn, go to the JBJS and you will learn a lot of information to get your continuing medical education credits.
Without further ado, we're going to go to Top of the pile. What's new in Limb Lengthening and Deformity Correction by Flanagan and Kahn. It's permanently free.
Incidence and Prediction of Postoperative Urinary Retention Following Lumbar Decompression by Quas et al. There's also an Institutional Large Language Model for Musculoskeletal MRI Improves Protocol Adherence and Accuracy by Helenon et al.
Of Mice and Men. Nice play on a book. Temporal Comparisons of Femoral Shaft Fracture Healing After Injured Medullary Nailing by Jang et al.
[00:01:36] Speaker A: I suppose that they're nailing mice femurs or something.
[00:01:40] Speaker B: Yeah, of mice and men. That's where the correlation is. Isn't that kind of a cute re correlation there? I thought it was kind of.
[00:01:47] Speaker A: I don't generally think that journalistic titles are that good for scientific work. I. I usually say, like, you know, it could have been just fine with Temporal Comparison of Femoral Shaft Fracture Healing After Intermediately Nailing. We don't need the extra information.
It's not even extra information. It's just like, you know, like tongue in cheek, little werewolves in the. Or does facial hair cause infection? Like, you know, it's like Orthopedic Tattler or the Inquirer.
[00:02:17] Speaker B: They did compare radiographs of mice and human femoral fractures and they said they were to quantify and compare the temporal progression of fracture healing in mice and humans.
Because mice are not humans and humans are not mice.
[00:02:31] Speaker A: Yeah.
So how does, like, how does the healing of mice femurs help inform patient care?
[00:02:42] Speaker B: It's a good question, I think, when it comes to, like, infection work, for example, like mice are not a good hugely great model necessarily because they're able to wall off infection.
[00:02:50] Speaker A: Yeah, no fracture models. Mice aren't. I think mice are good for incubating tissue engineered constructs and like. Then you need a larger animal model for good fracture comparison.
Capra Hercus, the Spanish goat or rabbit models for spinal fusion or. I mean people don't really like using dog models, but I think dog models for femur fractures or tibial fractures and things.
[00:03:19] Speaker B: But go cheap. A lot of good stuff.
[00:03:21] Speaker A: Yeah.
[00:03:22] Speaker B: So anyway. All right, next is Orthopedic Manifestations in Hypermobile Ehlers Danlos Syndrome by Eichinger et al.
The timing of direct oral anticoagulant usage did not impact outcomes Following Hip Arthroplasty for Femoral neck Fractures by Chen et al. Not me. This is a Mayo paper.
The Utility of a Prediction Model Using Neurological Examination Findings for Diagnosing Degenerative Cervical Myelopathy by Funaba et al. There's three evidence based orthopedic articles. One is GLP1 receptor agonist in Orthopedic Implications for Perioperative Care and Outcomes. An Orthopedic Surgeon's Perspective by Ramathanan Evaluating Artificial Intelligence Based Writing Assistance among Published Orthopedic Studies. Detection and Trends for Future Interpretation by Callanan et al. With a commentary with it.
Finally, AoA Critical Issue Symposium how are Orthopedic Leaders Chosen? Competency versus Kingmaker by Weber, Lauria and Marx.
Without further ado, let's go ahead into our headlines. You're going to talk about the cost effectiveness of Continuous pressure Measurement in the Diagnosis of Acute Compartment Syndrome by Bucheloch et al. With an infographic attached to it.
[00:04:43] Speaker A: Yes. So this is a very interesting study that is a cost effectiveness analysis. They do a very good job of following the tenets of classic cost effectiveness papers. So if you're looking for a primer or something to model your future cost effectiveness work on, I think you can kind of use this as a substrate. They really do touch on all the most critical points that you would want to see in a cost effective analysis, including sensitivity tests using deterministic and probabilistic approaches and assessing in as high quality a way as possible and we will get to that the parameters around which cost effectiveness in this domain would be defined.
So as we heard in the title, this is about the diagnosis of acute compartment syndrome and they want to assess continuous pressure measurement versus kind of the standard of care practices and they've done some preliminary work on this.
So they are I think clearly proponents of the continuous pressure measurement in the diagnosis of compartment syndrome and their stance is that continuous pressure measurement has higher specificity.
Therefore it avoids unnecessary fasciotomies in conditions like the typical traditional approach for conditions with acute compartment syndrome, conditions that result in long term, potentially devastating physiologic, neurologic functional effects, is that you want to have a high sensitivity. You'd rather be doing more than what's necessary versus doing less. Like, I don't know about your third year surgical clerkship, but there was like this maximum among like the general surgeons that was like, if you're not, you're not aggressive enough on appendicitis, if you're not taking out some normal appendices.
[00:06:43] Speaker B: Lean margins is the idea.
[00:06:44] Speaker A: Yeah, yeah. So, you know, I thought that was an interesting paradigm because, you know, they're really focused on the specificity and that's sort of their angle here is that we want to avoid unnecessary fasciotomies, which of course you do, but you, you wouldn't want to avoid unnecessary fasciotomies at the expense of missing compartment syndrome. Right. So the first problem that I think with the cost effectiveness is that it's kind of like a one way thing. It's like assuming that no adverse events from this approach are really happening. It's all just to the avoiding unnecessary surgery. Not, oh, we also missed a few, and there are patients with catastrophic effects. That's very hard to model in.
It's not a critique of the study per se. It's more of, you know, kind of the outlook and how you might apply this in clinical practice.
So, you know, the first thing that you learn, and part of my K was in cost effectiveness analysis. So the first thing that you learn formally when you're talking about modeling cost effectiveness is that everyone says, you know, all models are wrong, but some are useful.
So this is just, it's, it's an academic exercise. It's sort of as experimental as experimental can be and you can take with it what you will. The first thing was each cohort they assumed to comprise a mix of tibial plateau and tibial shaft fractures, which I think that was an unnecessary misstep.
The substrate, it doesn't matter what the fracture is that's causing the compartment syndrome. So just have one, I would say, and that eliminates some additional unnecessary variation around this.
So then they said the accuracy of continuous pressure measurement was based on their recent clinical trial data, or at least I believe is partially developed from their work, while the accuracy of the others was based on a weighted Average of multiple retrospective reports, some of which have small samples. So they've got much higher quality data around how their preferred approach performs versus the comparison group. And then the other thing in this kind of situation is that as they recognize, acute compartment syndrome is very rare.
And because of that rarity, you know, you're not going to have like these overwhelming quality adjusted life years that come out of whatever intervention you want to have, really.
So, you know, their gain in qualities is like minuscule.
It's like incredibly small. And that results in the net monetary benefits being very, very modest. You know, we're talking about the net benefit of about $3,000 and you know, less than $5,000 over the lifetime of the patient that's in, you know, medical health expenditures is almost like a rounding error. And they are, you know, talking about dominance, which they do have scenarios where it is dominant, which means like it's basically, it's cheaper and superior. But when you look at like what their estimates for savings would be, the most on the range is like $1,200.
And over the lifetime was basically like 750.
I mean, it's like you can, you can buy an Xbox or a PlayStation with the savings.
So while yes, they are using the terms correctly, there is, there is dominance and then there is dominance. And $750, I think is more like.
It's especially when again, consider that they're using much higher quality data for theirs and the focus is really on not doing a procedure when the procedure is not indicated versus like not doing the procedure and missing a catastrophic event.
So, you know, they say that, you know, their discussion is already very muted. They basically are like stronger. The second sentence is stronger data and cost estimates are needed.
All right, please, yeah, you know, don't take what we have to say like just don't apply to clinical practice. Just listen to what we have to tell you, you know, and they say like, there's limited economic incentive and improving sensitivity as most of the ACS economic burden lies in the lack of specificity.
And probably again, I think that they make that argument because the current standard of care approaches. Individual pressure measurements or with an art line or whatever are already pretty sensitive. Also, they didn't do any physical. There's no physical exam. It's just purely based on their pressure. So it's like you're eliminating the clinical context from this as well.
Once you add in clinical context with your pressure measurements, understanding the patient's trajectory, the appearance of the limb, the underlying injury, you can make more judicious call in terms of the procedure. This has a lot of assumptions and caveats that I think mute the clinical utility of the paper. I mean at the end of the day there's, there's nothing to put on hold here other than is the premise of the paper really a clinical paradigm that's confronting the the zeitgeist or the soul of orthopedic trauma? And I don't think it is not.
[00:12:25] Speaker B: Enough to move the needle.
[00:12:27] Speaker A: Right.
What it's basically saying is like if you want to do their continuous pressure measurements and you know, you went to the board exam part two having done continuous pressure measurements and they ask you about it, you could say, well, you know, it is. The study from Buchluk et al showed that it was actually potentially dominant from a cost effective standpoint, maybe. Wow. Your examiners. But outside of that, you know, it certainly doesn't support that. Like you should replace what you're doing if you're using the standard approaches.
[00:13:00] Speaker B: Great. Can't add a whole lot to that. Well done. All right, I'm going to go something a little bit different here. We're going to talk about A prospective randomized comparison of functional bracing and spica casting for femoral fractures showed equivalent early outcomes. I basically don't need to present this article because I'm done, but it's by Andras et al3 for 30 days and there's an infographic. As a resident I spent many days in the emergency room or many nights in the emergency room putting spicy casts on very unhappy kids. So I'm actually very happy to see this prospective randomized comparison of functional bracing and spicy casting for femoral fractures. The biggest patient that I spike at was a 16 year old male who is bigger than me.
Needless to say, it was not fun.
So the AOS clinical practice guidelines recommend spicy casting for the treatment of femoral fractures in children 6 months to 5 years of age with less than 2 cm of shortening. But there are complications of hygiene, transport and skin complications with spike casting.
The purpose of the study was to compare the outcomes of treatment with prefabricated braces as opposed to custom braces with those of spicy casting, reducing the necessity potentially for anesthesia and operating room placement of the spicacast. Authors conducted a randomized prospective study of patients 6 months to 5 years within that AOS clinical practice guideline timeframe who were managed with functional bracing or spike casting for the treatment of diaphyseal fractures at two pediatric trauma centers. They excluded comminuted and or high energy fractures, polytrauma medical comorbidities impacting fracture healing or less than six weeks of follow up and randomization was performed per site.
For spicacast. They were all placed in the operating room with the patient under general anesthesia by an attending physician. Functional braces on the other hand replaced at bedside with an orthotist and a member of the orthopedic team. It could be a resident, a fellow, a physician assistant or the attending surgeon.
Now there are four standardized sizes for the functional bracing developed on the basis of measurements from prior patients who are managed with custom made braces. You can make adjustments to the length or width of the cuff prior to application and it would be templated from the contralateral leg.
So even though an anesthetic or sedative is not used for functional bracing, weight based analgesia, typically morphine with or without a muscle relaxant such as diazepam were utilized.
They used stockinette still when they were doing the functional bracing. It was cut to the length of the leg and placed while applying gentle traction for stabilization through the foot. The brace was slid onto the torso and leg which then were lowered into the brace and they allowed for sitting. Flexion at the hip was fixed between 30 and 60 degrees and abduction was fixed between 20 and 40 degrees to prevent slippage.
At four weeks the functional brace was unlocked at the hip joint to allow for more motion and ease of ambulation.
They looked at radiographic union defined as callous that bridged the fracture at greater than or equal to 3 cortices.
Non union was diagnosed if bridging callous at 3 cortices was not evidenced by 12 weeks. Null union was defined as greater than 30 degrees of varus or valgus, 30 degrees of procurvatum or greater than 15 millimeters of shortening in a patient age 66 months to less than or equal to 2 years, 15 degrees of varus or valgusa greater than 20 degrees of procurvatum or Greater than 20 millimeter shortening in a patient age greater than 2 years to 5 years.
They used a pediatric outcomes data collection instrument or a PODCI as an additional custom questionnaire to assess functional outcomes and satisfaction at six weeks and one year after injury. The target sample size was 40 per grouped based on a 28% versus 45% rate of skin problems with two independent samples Alpha 0.05 and beta of 0.8.
So 90 patients were initially randomized to be treated with the brace with 45 in the brace and 45 in the spike of cast. Nine patients did not complete the six week follow up and one was excluded because of a neuromuscular condition, leaving 80 patients for analysis, 40 in the spica group and 40 in the functional bracing group which was their target sample size. Interestingly enough, 115 patients declined participation, so more declined participation than were enrolled in the study, which I find surprising because if bracing was the only other option and this is the only way of getting it, then I would probably be more likely to enroll. But who knows what the discussions were. The mean age in the casting group was 2 and 2.3 years in the bracing group. Similar the radiographs demonstrated similar shortening, varus angulation and procurvatum in the casting and bracing group. There were no intraoperative complications occurred during spicacast placement. All braces were successfully placed at bedside. There were brace issues. Interestingly enough, six patients they'd include Unlocking of the brace at the hip was one patient. Loosening was one patient exchange of the brace for a larger size at the time of follow up one patient mold development, tasty one patient and screw fallout two patients. An additional patient removed the brace at four weeks at home without authorization, but there were no complications or changes in outcomes due to these issues.
At six weeks all 80 fractures healed. There were no differences in shortening, baris angulation or procurvatum in both groups. There was no non union. There was one malunion in the bracing group because the shortening was 4 millimeters greater than the criteria for malunion in the casting group in one person had rashes and mild skin breakdown in the bracing group. Nine patients had rashes or mild skin breakdown because of the rash. One patient was started on oral antibiotics. One patient had skin irritation and a screw replaced in a brace. All skin issues did resolve with local wound care. Two spica casts were soiled and three needed cast wedging.
They did those extra surveys. They were parental surveys. Only 54 of the 80 patients completed the parental survey. Parent satisfaction with treatment was high for both groups. 84% of patients in the casting group and 76% of the patients in the bracing group had 10 out of 10 scores. There are no differences between groups with the perception of the stressfulness of this experience.
The ability to use the child's regular car seat was more limited in the casting group 40% versus 86% in the bracing group. For parents reporting missing work, the median number of missed days was 17 days for casting and only five days for the bracing group but were not significantly different.
Parents reported that patients in the casting group had more difficulty moving independently versus the bracing group. At one year, 51 patients had one year follow up and there were no differences in terms of shortening varus angulation. There was a slight difference in pro carvatum. There's a little bit more pro carvatum in the casting group than in the bracing group of almost 12 degrees versus 5 degrees. Only 30 parents completed the survey. At the one year follow up, the satisfaction remained high in both groups. Not different between groups. And looking at the PODCI scores that greater than one year, the bracing group reported almost no pain and the score was better than the score. It was 99.5 versus 89.44 for the casting group. So less pain in the bracing group, but there were no really significant other differences between groups. So in this prospective randomized control trial, patients who were treated with functional bracing had equivalent outcomes to those who were treated with spicy casting. Prefabricated functional braces provided a viable alternative and avoided the cost of anesthesia. Which in my residency we didn't do all the spiked casts in the operating room. We, we did some of those in the ED under sedation, so we didn't have to do that per se. But there is a lot of more work with the cast placement potentially than off the shelf brace placement. So I like seeing prospective randomized control trials, studies like this in the areas that can actually change clinical management. So I found this study of interest and could potentially change what we do for these femur fractures.
[00:21:07] Speaker A: Yeah, I mean, the thought of being in a spica Casper femur fracture sounds miserable. I don't, you know, unless it's the smallest of children who I feel like can adapt to just about anything, they're very pliable. Like anything over four years old, I just can't imagine.
[00:21:33] Speaker B: So I'm with you. So, yeah, hopefully a game changer in that way.
[00:21:37] Speaker A: When I was in residency, we universally did all of them in the or.
[00:21:40] Speaker B: The. Did you really?
[00:21:42] Speaker A: Yeah.
[00:21:43] Speaker B: Interesting.
[00:21:44] Speaker A: Never, never did a spike of cast in the. In the ED.
[00:21:48] Speaker B: I will say most of them were in the OR, but we definitely did ED1.
[00:21:51] Speaker A: You got to get that little like, like the platform.
[00:21:55] Speaker B: Yeah, yeah, yeah, we stole that definitely from the or.
All right, so now are your cases on hold? Featurette? It's myocardial infarction prior to total knee arthroplasty is associated with increased risk of medical and surgical complications. And in a time dependent manner by Holly et al. There's a commentary and a visual summary.
If a patient has an MI prior to a total knee replacement, do they do worse after surgery.
Logically, one would say that increased comorbidities are more likely to correlate with worst post operative outcomes. Already this is just not a surprising find for me. The prevalence of myocardial infarction in general is high, with nearly 10% of the population greater than 60 years of age having experienced an MI. But there's minimal literature showing how previous MI influences outcomes after total knee arthroplasty. Previous studies evaluated the impact of preoperative MI on postoperative mi but not necessarily other medical and surgical complications, which is what this study did. They looked at postoperative cardiac complications, general medical complications, surgical complications using the Pearl Diver database from 2010 to 2022. There is an implosion of these studies when it comes to more and more database studies. They identified primary TKA using CPT codes and then they looked at ICD10 procedural codes. If they had any infectious process, fracture or malignancy prior to the index procedure, they were excluded. They did match laterality of surgical complications. Patient who underwent a contralateral TK within two years after the index procedure were excluded to limit transfer bias. Only patients with active data for two years before and two years after the index procedure were included. Patients who experienced MI within two years before TKA were identified and were matched one to four with patients who have not had an mi. This is based on age, sex, Alexis, comorbidity index and multiple comorbidities.
Patients who had a prior MI were stratified into four groups based on the timing of MI0 to less than 6 months, 6 months to less than 12 months, 12 months to less than 18 months and 18 months to 24 months before total knee replacement. They also looked at stratification of MI. There's a type 1 MI which is an acute plaque rupture or thrombo and thrombosis. Type 2 MI is a mismatch between myocardial oxygen supply and demand. Patients who had a non STEMI or a stemi, which is a ST elevation MI patients who are treated with percutaneous coronary intervention and those who are not patients who are treated with guideline directed medical therapy, which is DDMT including beta blockers and those who are not patients who are treated with dual antiplatelet therapy and those who are not, patients who had anterior MI and those who had inferior mi. So basically every single possible delineation and slicing of MI was evaluated here and looked at rates of postoperative cardiac, general medical and surgical complications looking at 90 days and two years. And they did do the Subgroup analysis based on the prior MI type, treatment and location after matching there were 8,810 patients who had a prior MI with a control group of 34,905.
Coronary artery disease, congestive heart failure, pacemaker placement were similar between groups. Prior MI was not surprisingly associated with increased risk of post operative MI, heart failure and 90 day mortality. The risk of postoperative MI was highest for those with MI within six months before total knee arthroplasty. The post operative MI risk did decrease with increasing time between the prior MI and total knee replacement.
What was linked to elevated postoperative MI and two year mortality with timing closer to surgery. Type 1 Michigan STEMI, non STEMI and anterior and inferior Michigan patients who had a non STEMI prior to total knee had a higher rates of acute kidney injury, heart failure and pneumonia. Percutaneous coronary intervention within six months before total knee arthroplasty also had increased risk of postoperative mi, heart failure and two year mortality. Patients who had PCI within one year before total knee arthroplasty had significant higher rates of mortality. If you had greater than one year the mortality risk was no different than controls.
Type 2 Michigan within six months of total knee had an increased risk of periprosthetic joint infection compared to controls. The same type 2 Michigan patients had higher rates of heart failure but no differences in postoperative MI or mortality.
Patients who had a prior MI without PCI had higher rates of postoperative MI, heart failure and 2 year mortality compared to controls up to 18 months between MI and total knee arthroplasty.
Patients who were given the guideline directed medical therapy including beta blockers after a prior MI continue to have higher rates of postoperative MI and 90 day mortality. Patients who have been prescribed this GDTM after an MI06 months prior to total neoplasty had a higher rate of infection and 90 day mortality compared with controls. Patients who had MI within 18 months before total neonplasty had increased risk of 2 year mortality compared to controls only. Patients with an anterior MI within six months before total knee arthroplasty and those with an inferior MI within 12 months before total knee optoplasty had an increased risk of postoperative mi.
That was a lot of words. There's all these different time frames and in theory you could use it.
[00:27:26] Speaker A: So dense and chewy.
[00:27:28] Speaker B: Very very dense, very chewy. And whether that's going to help you say well you're six months from your surgery. Am I I'm going to hold off.
It makes for very convoluted guidelines.
[00:27:41] Speaker A: There's no guideline here. It's just like we did every possible iteration that we could think of of myocardial infarction and outcome, like every possible moving shell game parameter and just report everything that we find. And here you go. And it was done with Pearl Diver and its claims based data.
I mean what, like what in your practice is somebody has a history of MI and what in your practice when that patient comes in and they need a total knee besides getting the cardiac clearance? And I do want to come back to that, like what else is it? Like what else is there?
[00:28:21] Speaker B: Typically you wait at least six months before any mi. So that's just a good guideline and if you'll be really safe, you wait a year. But six months is kind of just already a known factor to everyone. Basically follows, I would say.
[00:28:34] Speaker A: Okay, so I mean what I think here is that like they completely missed the missed opportunities, right, because they're doing propensity score matching, which is a causal inference technique. And there, there isn't real causal inference. In their motivating hypothesis, patients who did not have an MI prior to the index procedure were propensity matched with those who did.
So you're basically like if we look at this as a randomized trial, you're randomizing people to MI or not.
Right, but that's not a causal inference.
What they could have done that I thought would have been more interesting would have been do propensity score matching around the guideline directive management.
So you know, the patient's already had a heart attack propensity score match on that piece or propensity score match on the MI location even, although I think that's a little bit less. But, but certainly the pci. How about. Yeah, pci. Right. And that's one of their take home points that they infer. They were like, well, the patients with PCI have a higher risk of adverse events because it's probably more severe. Well, you could have gotten, you could have drilled down on that by doing, making that the focus of the study. Instead of this big kind of patients who had MI versus those who didn't, those who didn't versus those who did is not really a good comparison because you can't tell a patient, well, you know, your outcomes are so much worse as compared to this other person who didn't have the condition that you have. That goes back to our Donnie Brasco paradigm. Right. Like the person who had an MI wants to talk about Their unique clinical context, you don't bring in like, well, if you didn't have the mi. Well they did have the mi, so talking about them not having the mi, how does that help anything? Right?
So you know, all of these comparisons that they're making within the context of just the propensity score match is not addressing any of this stuff. It's just subset analysis of the group. They could have done a causal inference test that would have had value. In this case, it's just this group versus that group. Here's the outcome. These ones infection, these ones mortality, these ones, whatever it may be, you know, mortality at a different time point. And it just becomes this like litany of outcomes, outcomes, outcomes, outcomes. And there's no cogent, like, okay, what are we supposed to do with this? So what do they tell you we're supposed to do with this? What's the concluding statement?
It highlights the importance of optimizing the timing and obtaining cardiac clearance. Now which one of these patients, these thousands of patients that were done or even just the ones that you know were in the match? The 8,860 patients who had an MI within two years before the total knee. How many of those patients do you think had, didn't have cardiac clearance?
I would say it's zero. I'd be shocked if it was anything other than they all got cardiac clearance.
[00:31:36] Speaker B: They didn't change the thing. And that's the thing.
[00:31:39] Speaker A: But that's not what cardiac clearance is for.
Cardiac clearance is to provide to some degree medical, legal coverage and to see if there's anything you can do to optimize the patient to the fullest extent possible, such that you're having the lowest risk. It's not no risk, it's not minimal risk, it's not better risk as compared to the person who doesn't have a heart problem or heart history. It's just the lowest risk possible.
So telling us that we should, your conclusion being get cardiac clearance is, is the, the absolute greatest non sequitur of all time.
[00:32:15] Speaker B: As far as it sounds like an orthopedic answer, like anseth.
[00:32:20] Speaker A: Yeah, I mean, you know, when it comes to like that kind of thing too. Like I have a whole soapbox around just the, the social media popular conception of like orthopedic surgeons as complete morons and like knuckle dragging Neandert types. Because just look at the board scores and the performance rates of people who go into orthopedic surgery for probably the last three decades, if not more. And it is among the most Competitive specialties.
You have very smart people in orthopedics and the whole like, ortho bro culture again, you know, you worked in this department here in Boston and I know the people in your department in Texas. Are there people who work out? Yeah. Are there? Ortho bro? I don't know a single. I couldn't name you an ortho bro actually anywhere that I know of. I don't know anyone like that. And I know a lot of people in orthopedics.
[00:33:16] Speaker B: I do work out. Is that okay?
[00:33:18] Speaker A: Yeah, no, I work out too. But, but, but that's not, it's not, it's not working out. It's. It's.
It's like this sort of, you know, amalgamation between like CRO Magnon man and like a California surfer sort of into this like, stereotype of like, all you care about is how much you bench and like doing scopes or something. Or I don't. You know what I mean? Like, it's just, it's, it's. The stereotype is silly.
The idea that orthopedic surgeons are not smart people is patently absurd.
And then when it comes back to this, like, oh, like all they care about is Ancef and say, get cardiac clearance. I mean, I don't agree with that either, but when you write that, you're not helping things by writing it at the end of your paper. I'll tell you that.
[00:34:12] Speaker B: No, definitely not. Completely agree.
All right, excellent.
Now for some honorable mentions.
The future is mobile.
Pilot validation study of Apple Health metrics and orthopedic trauma by Brodke et al. There's a commentary and it's free for 30 days.
This study evaluated the ability of Apple Health to track mobility after lower extremity fractures in 107 patients. There was a 93% reduction in daily step count from the pre injury period to the immediate post injury period and other gait parameters also showed increased impairment from pre injury to post injury. Not surprisingly, however, by six months, step count improved sixfold relative to the immediate post injury period but still remained 52% below baseline. Promised physical function correlated moderately with step count and weakly with other gait parameters. Patients with a known non union had a 55% slower recovery of step count than those without a nonunion. The Apple Health mobility parameters captured charges or captured changes in mobility following lower extremity fracture and throughout the subsequent recovery period. Also distinguishing between non unions and unions.
A deep learning based clinical classification system for differential diagnosis of hip prosthesis failures using radiographs, a multicenter study by Wu et al. A deep learning based clinical classification system called HIPNET was developed to classify multiple causes of total hip arthroplasty failure including periprosthetic joint infection, aseptic loosening, dislocation, periprosthetic fracture and polyethylene wear. The hip NET demonstrated strong generalizability across different settings, effectively distinguishing between five common types of hip prosthesis failures with an accuracy of 0.904 and an area under the receiving operating characteristic curve OR AUC of 0.937 which is quite high in the external cohort.
The model generated individual PGI risk scores exhibited a positive correlation with C reactive protein level and erythrocyte sedimentation rate.
Finally, comparing the in vitro efficacy of commonly used surgical irrigants for the treatment of implant associated infections by Hamad et al. Which is permanently free, this study compared the efficacy of surgical irrigants in vitro against Staph aureus alone and in combination with candidate albicons in both planktonic and biofilm states.
Full strength bacon solution 0.35% povidone iodine, 10% povidone iodine, 3% hydrogen peroxide and a one to one combination of 10% povidone iodine and 3% hydrogen peroxide. Intercept experience back to sure and normal saline solutions were tested.
The combination of povidone iodine and hydrogen peroxide and bactosure were the only irrigants to eradicate Staph aureus in both planktonic and biofilm states. The povidone iodine and hydrogen peroxide combination was the only irrigant to eradicate polymicrobial Staph aureus and C. Albican's bioburden in both states. Thanks so much for dialing in. We look forward to seeing you next time.
