Clinical Orthopaedics & Related Research最新文献

{"title":"CORR Insights®: Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-Tissue Sarcomas? A SEER Database Study.","authors":"M. Scarborough","doi":"10.1097/CORR.0000000000000932","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000932","url":null,"abstract":"The US healthcare financial system is a complicated maze of government and insurance regulations. Put simply, most veterans and people older than 65 years of age are covered by government-provided insurance. The majority of Americans 64 years of age and younger obtain insurance through their employer either directly or as a family plan. The remainder of the population in the United States qualifies for Medicaid, the Children’s Health Insurance Program (CHIP), purchases insurance through the exchanges (via the Affordable Care Act [ACA]), or is uninsured. To qualify for Medicaid, a family and/or an individual must have a very low income. The income levels and disabilities for qualification vary by state. In the 36 states that have expanded Medicaid by accepting federal dollars for the program, the income level for qualification increases and the number of uninsured people decreases correspondingly. Those that do not qualify for Medicaid and do not have employer-based coverage, or another source of insurance represent the majority of millions of uninsured Americans (27.4 million, in 2017) [3]. In the current study, Smartt and colleagues [8] used data from the Surveillance, Epidemiology, and End Results (SEER) database to investigate cancer-related outcomes of patients with bone or soft-tissue sarcomas stratified by insurance status. This study provides an interesting snapshot into the complicated US healthcare system by focusing on outcomes of these rare diseases [1]. The authors looked at three important clinical outcomes in patients with a bone or soft-tissue sarcoma: (1) Presence of metastasis at the time of diagnosis; (2) rates of limb salvage compared to amputation; and (3) death related to cancer. The authors then correlated those cancer-related outcomes to insurance status and found that a patient with Medicaid who is diagnosed with sarcoma is more likely to present with metastases, have an amputation, and/or die of their disease compared to patients with non-Medicaid insurance. Their findings support those of other cancer-related outcome studies [1, 2].","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"28 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88491522","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is There an Association Between Insurance Status and Survival and Treatment of Primary Bone and Extremity Soft-Tissue Sarcomas? A SEER Database Study.","authors":"Anne A. Smartt, Eugene S. Jang, W. Tyler","doi":"10.1097/CORR.0000000000000889","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000889","url":null,"abstract":"BACKGROUND\u0000Several recently published population-based studies have highlighted the association between insurance status and survival in patients with various cancers such as breast, head and neck, testicular, and lymphoma [22, 24, 38, 41]. Generally, these studies demonstrate that uninsured patients or those with Medicaid insurance had poorer survival than did those who had non-Medicaid insurance. However, this discrepancy has not been studied in patients with primary bone and extremity soft-tissue sarcomas, a unique oncological population that typically presents late in the disease course and often requires referral and complex treatment at tertiary care centers-issues that health insurance coverage disparities could aggravate.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What is the relationship between insurance status and cause-specific mortality? (2) What is the relationship between insurance status and the prevalence of distant metastases? (3) What is the relationship between insurance status and the proportion of limb salvage surgery versus amputation?\u0000\u0000\u0000METHODS\u0000The Surveillance, Epidemiology, and End Results database (SEER) was used to identify a total of 12,008 patients: 4257 patients with primary bone sarcomas and 7751 patients with extremity soft-tissue sarcomas, who were diagnosed and treated between 2007 and 2014. Patients were categorized into one of three insurance groups: insured with non-Medicaid insurance, insured with Medicaid, and uninsured. Patients without information available regarding insurance status were excluded (2.7% [113 patients] with primary bone sarcomas and 3.1% [243 patients] with extremity soft-tissue sarcomas.) The association between insurance status and survival was assessed using a Cox proportional hazards regression analysis adjusted for patient age, sex, race, ethnicity, extent of disease (lymph node and metastatic involvement), tumor grade, tumor size, histology, and primary tumor site.\u0000\u0000\u0000RESULTS\u0000Patients with primary bone sarcomas with Medicaid insurance had reduced disease-specific survival than did patients with non-Medicaid insurance (hazard ratio 1.3 [95% confidence interval 1.1 to 1.6]; p = 0.003). Patients with extremity soft-tissue sarcomas with Medicaid insurance also had reduced disease-specific survival compared with those with non-Medicaid insurance (HR 1.2 [95% CI 1.0 to 1.5]; p = 0.019). Patients with primary bone sarcomas (relative risk 1.8 [95% CI 1.3 to 2.4]; p < 0.001) and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.1]; p < 0.001) who had Medicaid insurance were more likely to have distant metastases at the time of diagnosis than those with non-Medicaid insurance. Patients with primary bone sarcomas (RR 1.8 [95% CI 1.4 to 2.1]; p < 0.001), and extremity soft-tissue sarcomas (RR 2.4 [95% CI 1.9 to 3.0]; p < 0.001) that had Medicaid insurance were more likely to undergo amputation than patients with non-Medicaid insurance. Patients with primary bone and extremity soft-tissue sarcomas who were un","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"7 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75252810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"PROMIS Function Scores Are Lower in Patients Who Underwent More Aggressive Local Treatment for Desmoid Tumors.","authors":"E. Newman, Jonathan Lans, Jason Kim, M. Ferrone, J. Ready, J. Schwab, K. Raskin, S. Calderón","doi":"10.1097/CORR.0000000000000918","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000918","url":null,"abstract":"BACKGROUND\u0000Desmoid tumors of the extremities often present with pain and functional limitation, but treatment can lead to morbidity and recurrence is common. The impact of treatment with respect to traditional \"oncologic\" metrics (such as recurrence rate) has been studied extensively, with a shift in recent years away from local therapies as first-line management; however, little is known about the association between treatment modality and long-term functional outcomes for patients with this benign disease.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000In a retrospective review of consecutive patients treated at two institutions, we asked: (1) Is event-free survival (EFS) different between patients who undergo local treatment and those who do not for primary as well as for recurrent desmoid tumors? (2) What treatment-related factors are associated with worse Patient-reported Outcomes Measurement Information System (PROMIS) function scores at a minimum of 1 year after treatment?\u0000\u0000\u0000METHODS\u0000Between 1991 and 2017, 102 patients with desmoid tumors of the extremities (excluding those of the hands and feet) were treated at two institutions; of those, 85 patients with 90 tumors were followed clinically for at least 1 year (median [range] 59 months follow-up [12 to 293]) and were included in the present analysis. We attempted to contact all patients for administration of PROMIS function (Physical Function Short Form [SF] 10a and Upper Extremity SF v2.0 7a) and Pain Interference (SF 8a) questionnaires. Complete survey data (minimum 1 year follow-up) were available for 46% (39 of 102) of patients with 40 tumors at a median of 125 months follow-up; only these patients were included in PROMIS data analyses. Though there was no formal institutional treatment algorithm in place during the study period, surgical resection typically was the preferred modality for primary tumors; radiation therapy and systemic treatments (including cytotoxic or hormonal agents earlier in the study period, and tyrosine kinase inhibitors later) were often added for recurrent or very symptomatic disease. We coded treatment for each patient into discrete episodes, each defined by a particular treatment strategy: local treatment only (surgery and/or radiation), systemic treatment only, local plus systemic treatment, or observation; treatment episodes rendered at other institutions (that is, before referral) were not included in the analyses. Treatment failure was defined as recurrence after surgical resection, or clinically significant radiologic and/or symptomatic progression after systemic treatment, and EFS was defined as time from treatment initiation to treatment failure or final follow-up. Episodes of treatment for recurrent tumors were analyzed in a pooled fashion, wherein discrete treatment episodes for patients with multiple recurrences were included separately as independent events. We analyzed 56 primary tumors (54 patients), and 101 discrete treatment episodes for recurrent tumors (88 patients). K","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"338 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80711615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Are Accelerometer-based Functional Outcome Assessments Feasible and Valid After Treatment for Lower Extremity Sarcomas?","authors":"S. Furtado, A. Godfrey, S. Del Din, L. Rochester, C. Gerrand","doi":"10.1097/CORR.0000000000000883","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000883","url":null,"abstract":"BACKGROUND\u0000Aspects of physical functioning, including balance and gait, are affected after surgery for lower limb musculoskeletal tumors. These are not routinely measured but likely are related to how well patients function after resection or amputation for a bone or soft tissue sarcoma. Small, inexpensive portable accelerometers are available that might be clinically useful to assess balance and gait in these patients, but they have not been well studied.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000In patients treated for lower extremity musculoskeletal tumors, we asked: (1) Are accelerometer-based body-worn monitor assessments of balance, gait, and timed up-and-go tests (TUG) feasible and acceptable? (2) Do these accelerometer-based body-worn monitor assessments produce clinically useful data (face validity), distinguish between patients and controls (discriminant validity), reflect findings obtained using existing clinical measures (convergent validity) and standard manual techniques in clinic (concurrent validity)?\u0000\u0000\u0000METHODS\u0000This was a prospective cross-sectional study. Out of 97 patients approached, 34 adult patients treated for tumors in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) were included in this study. Twenty-seven had limb-sparing surgery and seven underwent amputation. Patients performed standard activities while wearing a body-worn monitor on the lower back, including standing, walking, and TUG tests. Summary measures of balance (area [ellipsis], magnitude [root mean square {RMS}], jerkiness [jerk], frequency of postural sway below which 95% of power of acceleration power spectrum is observed [f95 of postural sway]), gait [temporal outcomes, step length and velocity], and TUG time were derived. Body-worn monitor assessments were evaluated for feasibility by investigating data loss and patient-reported acceptability and comfort. In addition, outcomes in patients were compared with datasets of healthy participants collected in parallel studies using identical methods as in this study to assess discriminant validity. Body-worn monitor assessments were also investigated for their relationships with routine clinical scales (the Musculoskeletal Tumour Society Scoring system [MSTS], the Toronto Extremity Salvage Score [TESS], and the Quality of life-Cancer survivors [QoL-CS)] to assess convergent validity and their agreement with standard manual techniques (video and stopwatch) to assess concurrent validity.\u0000\u0000\u0000RESULTS\u0000Although this was a small patient group, there were initial indications that body-worn monitor assessments were well-tolerated, feasible to perform, acceptable to patients who responded (95% [19 of 20] of patients found the body-worn monitor acceptable and comfortable and 85% [17 of 20] found it user-friendly), and produced clinically useful data comparable with the evidence. Balance and gait measures distinguished patients and controls (discriminant validity), for instance balance outcome (ellipsis) in patients (0.0475","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"111 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79181411","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CORR Insights®: Are Accelerometer-based Functional Outcome Assessments Feasible and Valid After Treatment for Lower Extremity Sarcomas?","authors":"J. Mayerson","doi":"10.1097/CORR.0000000000000933","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000933","url":null,"abstract":"Physicians often use performancebased clinical assessments like physical therapist evaluations or standardized scoring systems to assess function in our patients. Modern technology is impacting health care in many ways, but little is known about how we might use wearable technology to devise new clinical assessments of function for patients with sarcoma. Traditional functional outcome measures in sarcoma care include the Musculoskeletal Tumor Society Functional Assessment Score [3] and the Toronto Extremity Salvage Score [2]. Generally, gait has been studied in a laboratory using force plates that include costly equipment not easily used by the general public [1]. But recently, we have seen tremendous growth in personal wearable technology, including a number of devices that give users a somewhat-accurate assessment of the distance, time, places, and types of activities that we participate in. Other wearable devices canmeasure heart rate, the number of steps we take, and the number of stairs we climb. It seems reasonable, therefore, for clinicianscientists to explore the breadth of disease processes that can be analyzed with wearable technology [5, 7]. In the current study, Furtado and colleagues [4] bring wearable technology into the clinical realm of sarcoma care. To my knowledge, they are the first to report accelerometerbased body-worn monitor assessments of balance, gait, and timed upand-go tests to produce clinically useful data. Furtado and colleagues [4] demonstrate in a small subset of patients that wearable devices can be used to discriminate balance and gait differences between controls and limb salvage patients.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"32 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77744936","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preoperative Activities of Daily Living Dependency is Associated With Higher 30-Day Readmission Risk for Older Adults After Total Joint Arthroplasty.","authors":"J. Falvey, M. Bade, C. Hogan, Jeri E. Forster, J. Stevens-Lapsley","doi":"10.1097/CORR.0000000000001040","DOIUrl":"https://doi.org/10.1097/CORR.0000000000001040","url":null,"abstract":"BACKGROUND\u0000With recent Medicare payment changes, older adults are increasingly likely to be discharged home instead of to extended care facilities after total joint arthroplasty (TJA), and may therefore be at increased risk for readmissions. Identifying risk factors for readmission could help re-align care pathways for vulnerable patients; recent research has suggested preoperative dependency in activities of daily living (ADL) may increase perioperative and postoperative surgical complications. However, the proportion of older surgical patients with ADL dependence before TJA, and the impact of ADL dependency on the frequency and timing of hospital readmissions is unknown.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) What proportion of older adults discharged home after TJA have preoperative ADL dependency? (2) Is preoperative ADL dependency associated with increased risk of hospital readmissions at 30 days or 90 days for older adults discharged home after TJA?\u0000\u0000\u0000METHODS\u0000This was a retrospective cohort analysis of 6270 Medicare fee-for-service claims from 2012 from a 5% national Medicare sample for older adults (older than 65 years) receiving home health care after being discharged to the community after elective TJA. Medicare home health claims were used for two reasons: (1) the primary population of interest was older adults and (2) the accompanying patient-level assessment data included an assessment of prior dependency on four ADL tasks. Activities of daily living dependency was dichotomized as severe (requiring human assistance with all four assessed tasks) or partial/none (needing assistance with three or fewer ADLs); this cutoff has been used in prior research to evaluate readmission risk. Multivariable logistic regression models, clustered at the hospital level and adjusted for known readmission risk factors (such as comorbidity status or age), were used to model the odds of 30- and 90- day and readmission for patients with severe ADL dependence.\u0000\u0000\u0000RESULTS\u0000Overall, 411 patients were hospitalized during the study period. Of all readmissions, 64% (262 of 411) occurred within the first 30 days, with a median (interquartile range [IQR]) time to readmission of 17 days (5 to 46). Severe ADL dependency before surgery was common for older home health recipients recovering from TJA, affecting 17% (1066 of 6270) of our sample population. After adjusting for clinical covariates, severe ADL dependency was not associated with readmissions at 90 days (adjusted odds ratio = 1.20 [95% CI 0.93 to 1.55]; p = 0.15). However, severe preoperative ADL dependency was associated with higher odds of readmission at 30 days (adjusted OR = 1.45 [95% CI 1.11 to 1.99]; p = 0.008).\u0000\u0000\u0000CONCLUSIONS\u0000Severe preoperative ADL dependency is modestly associated with early but not late hospital readmission after TJA. This work demonstrates that it may important to apply a simple screening of ADL dependency preoperatively so that surgeons can guide changes in care planning for older adults undergoin","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"142 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77459970","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Development and Internal Validation of Machine Learning Algorithms for Preoperative Survival Prediction of Extremity Metastatic Disease.","authors":"Q. Thio, A. Karhade, Paul T. Ogink, J. Bramer, M. Ferrone, S. Calderón, K. Raskin, J. Schwab","doi":"10.1097/CORR.0000000000000997","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000997","url":null,"abstract":"BACKGROUND\u0000A preoperative estimation of survival is critical for deciding on the operative management of metastatic bone disease of the extremities. Several tools have been developed for this purpose, but there is room for improvement. Machine learning is an increasingly popular and flexible method of prediction model building based on a data set. It raises some skepticism, however, because of the complex structure of these models.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000The purposes of this study were (1) to develop machine learning algorithms for 90-day and 1-year survival in patients who received surgical treatment for a bone metastasis of the extremity, and (2) to use these algorithms to identify those clinical factors (demographic, treatment related, or surgical) that are most closely associated with survival after surgery in these patients.\u0000\u0000\u0000METHODS\u0000All 1090 patients who underwent surgical treatment for a long-bone metastasis at two institutions between 1999 and 2017 were included in this retrospective study. The median age of the patients in the cohort was 63 years (interquartile range [IQR] 54 to 72 years), 56% of patients (610 of 1090) were female, and the median BMI was 27 kg/m (IQR 23 to 30 kg/m). The most affected location was the femur (70%), followed by the humerus (22%). The most common primary tumors were breast (24%) and lung (23%). Intramedullary nailing was the most commonly performed type of surgery (58%), followed by endoprosthetic reconstruction (22%), and plate screw fixation (14%). Missing data were imputed using the missForest methods. Features were selected by random forest algorithms, and five different models were developed on the training set (80% of the data): stochastic gradient boosting, random forest, support vector machine, neural network, and penalized logistic regression. These models were chosen as a result of their classification capability in binary datasets. Model performance was assessed on both the training set and the validation set (20% of the data) by discrimination, calibration, and overall performance.\u0000\u0000\u0000RESULTS\u0000We found no differences among the five models for discrimination, with an area under the curve ranging from 0.86 to 0.87. All models were well calibrated, with intercepts ranging from -0.03 to 0.08 and slopes ranging from 1.03 to 1.12. Brier scores ranged from 0.13 to 0.14. The stochastic gradient boosting model was chosen to be deployed as freely available web-based application and explanations on both a global and an individual level were provided. For 90-day survival, the three most important factors associated with poorer survivorship were lower albumin level, higher neutrophil-to-lymphocyte ratio, and rapid growth primary tumor. For 1-year survival, the three most important factors associated with poorer survivorship were lower albumin level, rapid growth primary tumor, and lower hemoglobin level.\u0000\u0000\u0000CONCLUSIONS\u0000Although the final models must be externally validated, the algorithms showed good performance ","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90215117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CORR Insights®: Does Robotic-assisted TKA Result in Better Outcome Scores or Long-Term Survivorship Than Conventional TKA? A Randomized, Controlled Trial.","authors":"L. Dorr","doi":"10.1097/CORR.0000000000000969","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000969","url":null,"abstract":"Inmy experience, a successful total knee replacement is determined by implant positioning, leg alignment, and soft-tissue balance, which includes medial-lateral and AP stability. My definition of a well-done TKA has not changed since the early 1980s, when our specialty—and patients’ lives— were improved by the development of precision mechanical alignment guides, and by the tireless work of David S. Hungerford MD who taught surgeons how to use them. The principles of successful rotational alignment of the implants, and soft-tissue treatment and balance were taught by Chitranjan S. Ranawat MD, and John N. Insall MD for posterior cruciate ligament sacrificing knees, andRichard D. ScottMD and Tom S. Thornhill MD for posteriorcruciate ligament retaining knees. These principles of total knee replacement have not appreciably changed through four decades, nor has implant design resulted in anything other than evolutionary change. The authors of the current study do not change the principles of the operation, but describe more-precise instrumentation, specifically for the bone cuts in the coronal plane [4]. Since the success of total knee replacement is dependent on rotational mating of the femoral and tibial implants, and the soft-tissue balance of the knee, both of which remain dependent on surgeon decisions no matter the instrumentation, it is unreasonable to expect a difference in clinical scores or revisions between a surgeon who performed 340 total knee replacements per year (as did the surgeon in this study) and the use of high-tech instruments. Indeed, no difference was found. But that does not mean that robotic instrumentation offers no value to low volume or inexperienced surgeons.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"128 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73879716","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures? A Systematic Review and Network Meta-analysis of 22 Randomized Controlled Trials.","authors":"D. Axelrod, Seper Ekhtiari, A. Bozzo, M. Bhandari, H. Johal","doi":"10.1097/CORR.0000000000000986","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000986","url":null,"abstract":"BACKGROUND\u0000Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints.\u0000\u0000\u0000METHODS\u0000MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively.\u0000\u0000\u0000RESULTS\u0000Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and C","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"14 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84017238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"CORR Insights®: Is Spinal Anesthesia Safer than General Anesthesia for Patients Undergoing Revision THA? Analysis of the ACS-NSQIP Database.","authors":"Charles N Cornell","doi":"10.1097/CORR.0000000000000937","DOIUrl":"10.1097/CORR.0000000000000937","url":null,"abstract":"","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":"88-89"},"PeriodicalIF":0.0,"publicationDate":"2020-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000046/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81917819","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}