Journal of the American Academy of Orthopaedic Surgeons最新文献

{"title":"Risk Factors of Diaphyseal Femoral Nonunions: A Systematic Review and Meta-analysis.","authors":"Tyler K Williamson, Jonathan G Eastman, Timothy Achor, Stephen J Warner","doi":"10.5435/JAAOS-D-24-01064","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-01064","url":null,"abstract":"<p><strong>Background: </strong>Intramedullary nailing of diaphyseal femur fractures often results in reliable union, with union rates ranging from 96% to 100%. However, femoral nonunions (FNUs) can be a debilitating clinical condition for patients. The purpose of this review was to identify and characterize the predictors of nonunion after femoral midshaft fractures.</p><p><strong>Methods: </strong>A systematic search was conducted using key terms \"femoral shaft non-union,\" \"femoral diaphyseal non-union,\" \"femoral shaft fracture,\" \"femoral diaphysis fracture,\" and \"femoral midshaft fracture\" published before June 2024. Human studies describing risk factors associated with development of FNUs were included. Articles were excluded if not able to assess risk factors of FNUs. Data synthesis summarized outcome measures and study designs appropriately in the results. SPSS meta-analysis function was used to calculate the mean effect size estimate (MESE) and 95% confidence intervals for each outcome.</p><p><strong>Results: </strong>This search yielded a total of 7,879 studies, and after exclusion criteria were assessed, 26 articles comprising 14,170 patients with diaphyseal femoral fractures were included. These studies included 973 fractures developing nonunions after surgical intervention. A total of 25 factors were assessed. Age (MESE = 1.33 [0.92 to 1.74]; P < 0.001) and type 2 diabetes (MESE = 1.77 [1.03 to 2.52]; P < 0.001) were significant patient-specific risk factors. Arbeitsgemeinschaft Osteosynthesefragen/Orthopaedic Trauma Association 32B (MESE = 0.94 [0.35 to 1.53]; P < 0.001) and Winquist-Hansen type 3 (MESE = 1.45 [0.63 to 2.26]; P < 0.001) were significant injury-specific factors, along with butterfly fragment size and displacement and open fractures. Open reduction (MESE = 0.80 [0.30 to 1.30]; P < 0.001) and postoperative nonsteroidal anti-inflammatory drug use (MESE = 1.17 [0.08 to 2.27]; P = 0.04) were significant surgical-specific and management-specific risk factors, along with external fixation and iatrogenic comminution.</p><p><strong>Discussion: </strong>Age, diabetes, fracture classification grading, and postoperative nonsteroidal anti-inflammatory drug use were among the factors placing patients at the highest risk of femoral diaphyseal nonunions, including other patient-specific, injury-specific, surgical, and management factors. Future studies are warranted to use a prospective study design, identify diaphyseal nonunion-specific risk factors, and implement evidence-based prevention strategies.</p><p><strong>Level of evidence: </strong>III.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143702066","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Local Subcutaneous Fat Depth Is Associated With Increased Complications After Total Shoulder Arthroplasty.","authors":"Lucas R Haase, Molly M Piper, Margaret A Sinkler, John T Strony, Kira L Smith, Robert J Gillespie, Raymond E Chen","doi":"10.5435/JAAOS-D-24-01288","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-01288","url":null,"abstract":"<p><strong>Background: </strong>Increased body mass index (BMI) is a well-documented risk factor for complications after lower extremity arthroplasty. The literature in total shoulder arthroplasty (TSA) displays notable variation. The utility of BMI in predicting complications in TSA may be limited because of differences in weight distribution. Prior studies in spine surgery have demonstrated increased complications based on subcutaneous fat depth at the incision site. The purpose of this study was to determine whether tissue depth may be associated with an increased risk of complication after primary TSA.</p><p><strong>Methods: </strong>A retrospective study was done on all patients undergoing primary TSA between January 2018 and December of 2021. Postoperative complications of superficial surgical site infection, prosthetic joint infection stress fracture, and implant instability were recorded. Preoperative advanced imaging was used to measure total tissue depth and subcutaneous fat depth at the level of the coracoid and bicipital groove. A combination of univariate and multivariate statistics was used to determine association between tissue depth and postoperative complication.</p><p><strong>Results: </strong>A total of 219 patients were included in the study. Twenty-nine patients experienced a total of 31 complications. The complication group had a higher percentage of reverse TSA to anatomic. The complication group had a markedly higher depth of subcutaneous fat tissue at the coracoid and bicipital groove (18.82 and 17.53 mm, respectively) compared with the control group (15.05 mm and 11.77; P = 0.046 and P = 0.005). On multivariate analysis, these differences remained statistically significant.</p><p><strong>Conclusion: </strong>Local subcutaneous fat depth at the coracoid process and bicipital groove was associated with increased rates of complications. In addition, BMI did not demonstrate an association with complications. It is possible that different weight distributions within the upper extremity limit the utility of BMI in risk stratification.</p><p><strong>Level of evidence: </strong>III.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143702063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Treatment of Femoral Neck Fracture Depends on Surgeon Subspecialty Training.","authors":"Matthew T Kingery, Bradley A Lezak, Charles C Lin, Utkarsh Anil, Joseph Bosco","doi":"10.5435/JAAOS-D-24-00750","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-00750","url":null,"abstract":"<p><strong>Background: </strong>Femoral neck fractures pose a notable health challenge globally, with a projected rise in cases due to aging populations. While treatment protocols are established, the effect of surgeon training on treatment decisions, particularly trauma versus arthroplasty fellowship training, remains less clear.</p><p><strong>Methods: </strong>This study, using data from the Statewide Planning and Research Cooperative System in New York State, examined 26,761 patients meeting inclusion criteria. Among 951 treating surgeons, 20.6% had no subspecialty fellowship training while 4.6% had training in multiple subspecialties, with arthroplasty (232 surgeons, 24.4%), sports (230 surgeons, 24.2%), and trauma (93 surgeons, 9.8%) being the most common.</p><p><strong>Results: </strong>Analysis revealed notable differences in surgical treatments based on subspecialty, with trauma surgeons favoring fixation and arthroplasty surgeons favoring total hip arthroplasty (THA). Even after adjusting for covariates, patients treated by arthroplasty-trained surgeons were more likely to receive THA. In addition, there was consistency between trauma and arthroplasty surgeons in treating lower functional demand patients with hemiarthroplasty. While trauma surgeons performed more fixations and arthroplasty surgeons more THAs, baseline characteristics and perioperative outcomes between fixation and THA patients were similar, indicating comparable baseline health despite treatment differences. Multivariable logistic regression confirmed that treatment by an arthroplasty surgeon markedly increased the odds of receiving THA.</p><p><strong>Conclusion: </strong>This study underscores the complexity added by surgeon subspecialty in femoral neck fracture management and emphasizes the importance of recognizing how surgeon-specific factors influence treatment decisions. Understanding these nuances can inform training optimization and promote collaborative approaches within the orthopaedic community, ultimately contributing to enhanced patient outcomes as femoral neck fracture management evolves.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143702080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Access to Orthopaedic Care in Rural America.","authors":"Lisa Ronback, Tamara Huff, Mark Reis, Kimberly Templeton","doi":"10.5435/JAAOS-D-24-01004","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-01004","url":null,"abstract":"<p><p>Medical care, including orthopaedic care, is suffering from a dearth of physicians in rural America. This affects access to local care in these communities and the viability of rural hospitals and undermines efforts to achieve healthcare equity. The relative lack of orthopaedic surgeons in rural areas stems from many issues including an aging rural orthopaedic workforce, fewer medical students from rural backgrounds, lack of notable exposure to rural practice during residency, increased subspecialization of trainees, and limited local community and health system opportunities, as well as financial issues. Robust surgery programs, including orthopaedic surgery programs, help rural hospitals stay open and provide critically needed services. This is a complex problem rural communities cannot solve on their own. Effecting change begins with awareness and data collection. There is also a need to create a pipeline of orthopaedic talent committed to rural practice. Rural orthopaedic surgeons need support from hospitals, industry, healthcare systems, professional organizations, government, and academic institutions to thrive and bring orthopaedic care to these underserved communities.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143674842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Artificial Intelligence in Personal Statements Within Orthopaedic Surgery Residency Applications.","authors":"Yagiz Ozdag, Mahmoud Mahmoud, Joel C Klena, Louis C Grandizio","doi":"10.5435/JAAOS-D-24-01285","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-01285","url":null,"abstract":"<p><strong>Purpose: </strong>Artificial intelligence (AI) has been increasingly studied within medical education and clinical practice. At present, it remains uncertain if AI is being used to write personal statements (PSs) for orthopaedic surgery residency applications. Our purpose was to analyze PS that were submitted to our institution and determine the rate of AI utilization within these texts.</p><p><strong>Methods: </strong>Four groups were created for comparison: 100 PS submitted before the release of ChatGTP (PRE-PS), 100 PS submitted after Chat Generative Pre-Trained Transformers introduction (POST-PS), 10 AI-generated PS (AI-PS), and 10 hybrid PS (H-PS), which contained both human-generated and AI-generated text. For each of the four groups, AI detection software (GPT-Zero) was used to quantify the percentage of human-generated text, \"mixed\" text, and AI-generated text. In addition, the detection software provided level of confidence (highly confident, moderately confident, uncertain) with respect to the \"final verdict\" of human-generated versus AI-generated text.</p><p><strong>Results: </strong>The percentage of human-generated text in the PRE-PS, POST-PS, H-PS, and AI-PS groups were 94%, 93%, 28%, and 0% respectively. All 200 PS (100%) submitted to our program had a final verdict of \"human\" with verdict confidence of >90%. By contrast, all AI-generated statements (H-PS and AI-PS groups) had a final verdict of \"AI.\" Verdict confidence for the AI-PS group was 100%.</p><p><strong>Conclusion: </strong>Orthopaedic surgery residency applicants do not appear, at present, to be using AI to create PS included in their applications. AI detection software (GPTZero) appears to be able to accurately detect human-generated and AI-generated PSs for orthopaedic residency applications. Considering the increasing role and development of AI software, future investigations should endeavor to explore if these results change over time. Similar to orthopaedic journals, guidelines should be established that pertain to the use of AI on postgraduate training applications.</p><p><strong>Level of evidence: </strong>V-Nonclinical.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143659731","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Examining the Outliers: Characteristics of the Most and Least Diverse Programs in Orthopaedics.","authors":"Akinola Oladimeji, Monique Chambers, Tyler N Kelly, Chisa Hidaka, Gabriella E Ode","doi":"10.5435/JAAOS-D-24-00475","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-00475","url":null,"abstract":"<p><strong>Introduction: </strong>In 2021, the American Orthopaedic Association (AOA) Orthopaedic Research Information Network (ORIN)was created to give applicants insight into orthopaedic surgery residency programs nationwide. This study uses this database to investigate the characteristics of residency programs based on their proportion of female and underrepresented minority in medicine (URiM) trainees.</p><p><strong>Methods: </strong>The number and proportion of URiM and female residents at 172 programs during the 2020-2021 academic year and 179 programs each during the 2021-2022 and 2022-2023 academic years were recorded. Each program was ranked based on the proportion of URiM or female residents and grouped into quintiles and deciles. Characteristics of programs (institution type, proportion of URiM or female faculty, United States Medical Licensing Exam (USMLE) scores, American Board of Orthopedic Surgery (ABOS) Part I board pass rates) were compared between the top and bottom deciles or quintiles.</p><p><strong>Results: </strong>Programs among the top decile for URiM representation had a mean 35% representation, whereas representation in the bottom decile ranged from 0% to 7%. Programs within the top decile for female representation ranged from a mean of 35% to 40%. The mean proportion of female residents among the bottom decile ranged from 0% to 7%. Top decile programs for racial diversity had a greater proportion of URiM faculty, whereas those in the top decile for female representation had more female faculty compared with bottom decile counterparts. Only four programs were in the top decile for both URiM and female representation. Top and bottom decile programs differed little regarding USMLE scores or ABOS Part I pass rates of their residents.</p><p><strong>Discussion: </strong>The results of this study support the notion that recruitment and retention methods among programs with more female and URiM representation are potentially different. In addition, programs with more diverse faculties tend to have more diverse residency classes and that programs with the highest and lowest diversity do not differ regarding standardized testing scores among matriculated residents.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":""},"PeriodicalIF":2.6,"publicationDate":"2025-03-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143658171","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Native American Representation and Diversity Initiatives Within Orthopaedic Surgery: An Update and Road Map to Success.","authors":"Zachary Jodoin, Tyler Williamson, Selina Poon, Sekinat McCormick","doi":"10.5435/JAAOS-D-24-00873","DOIUrl":"https://doi.org/10.5435/JAAOS-D-24-00873","url":null,"abstract":"<p><p>Orthopaedic surgery lags behind other specialties in terms of diversity. This lack of representation is especially evident within the Native American population. Native American/Alaskan Natives represent approximately 2.9% of the overall US population but comprise just 0.4% of orthopaedic surgeons within the United States. Currently, no Native American-specific orthopaedic inclusion or recruitment programs exist. There are a multitude of programs that exist to recruit Native American applicants into health care. These include pipeline programs and scholarships from the Indian Health Service (IHS), mentorship programs from a multitude of Native American medical societies, and IHS recruitment programs targeted at Native American preferential hiring. Dozens of grants and national diversification programs that are not specific to Native Americans are also available. Programs such as the AAOS IDEA Grant, Nth Dimensions, and The Perry Initiative have been successful in diversifying the orthopaedic surgery pipeline. This review highlights the paucity of Native American representation within orthopaedics and identifies current programs and resources for Native Americans. This article serves as a guide for Native Americans pursuing a career in orthopaedic surgery, as well as inspiration for future programs directed at increasing Native American representation.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":"33 6","pages":"e312-e318"},"PeriodicalIF":2.6,"publicationDate":"2025-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143574617","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Microbiological Differences Among Age Groups in Patients Diagnosed With Periprosthetic Joint Infection: A Database Analysis of 2,392 Patients.","authors":"Seper Ekhtiari, Franka Mai, Taner Karlidag, Thorsten Gehrke, Mustafa Citak","doi":"10.5435/JAAOS-D-24-00214","DOIUrl":"10.5435/JAAOS-D-24-00214","url":null,"abstract":"<p><strong>Introduction: </strong>Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) poses substantial economic and quality-of-life challenges. With the rising incidence of hip and knee arthritis globally, understanding the changing profile of PJIs across different age groups becomes crucial. While various studies have explored risk factors, the influence of age on PJI remains debated, with potential bimodal relationships. This study aims to investigate the causative organisms of PJIs in patients of different age groups undergoing TJA.</p><p><strong>Methods: </strong>Conducted as a retrospective cohort study at a high-volume PJI referral center, the study adhered to Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data spanned from January 1, 2001, to December 31, 2022, including patients with documented PJI undergoing revision TJA. Patients were categorized into age quintiles, and outcomes analyzed included causative organisms, difficult-to-treat infections, antimicrobial resistance, and Gram stain characteristics. Statistical analyses used descriptive statistics, chi-square tests, and sensitivity analyses for hip and knee patients separately.</p><p><strong>Results: </strong>The study comprised 2,392 patients, with 60.7% undergoing hip arthroplasty and 39.3% undergoing knee arthroplasty. 1,080 women (45.2%) and 1,312 men (54.8%) were included. Older patients were markedly more likely to have gram-negative infections and atypical infections. Patients in the youngest age group had the lowest rates of methicillin-resistant Staphylococcus aureus infection. Results were similar between hip and knee PJIs.</p><p><strong>Conclusions: </strong>The study reveals age-related variations in the characteristics of PJIs after TJA, emphasizing higher risks of atypical and resistant infections in older patients. These findings underscore the importance of tailored preventive measures and potential considerations for adjunctive or prolonged antibiotic therapies, especially in the elderly population. Recognizing the unique infection patterns in older patients may inform better prevention and treatment strategies, with implications for enhanced patient care and outcomes. Future directions should focus on patient-specific strategies for preventing and treating PJIs, particularly in high-risk populations.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":"313-318"},"PeriodicalIF":2.6,"publicationDate":"2025-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142134398","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Can Artificial Intelligence Deceive Residency Committees? A Randomized Multicenter Analysis of Letters of Recommendation.","authors":"Samuel K Simister, Eric G Huish, Eugene Y Tsai, Hai V Le, Andrea Halim, Dominick Tuason, John P Meehan, Holly B Leshikar, Augustine M Saiz, Zachary C Lum","doi":"10.5435/JAAOS-D-24-00438","DOIUrl":"10.5435/JAAOS-D-24-00438","url":null,"abstract":"<p><strong>Introduction: </strong>The introduction of generative artificial intelligence (AI) may have a profound effect on residency applications. In this study, we explore the abilities of AI-generated letters of recommendation (LORs) by evaluating the accuracy of orthopaedic surgery residency selection committee members to identify LORs written by human or AI authors.</p><p><strong>Methods: </strong>In a multicenter, single-blind trial, a total of 45 LORs (15 human, 15 ChatGPT, and 15 Google BARD) were curated. In a random fashion, seven faculty reviewers from four residency programs were asked to grade each of the 45 LORs based on the 11 characteristics outlined in the American Orthopaedic Associations standardized LOR, as well as a 1 to 10 scale on how they would rank the applicant, their desire of having the applicant in the program, and if they thought the letter was generated by a human or AI author. Analysis included descriptives, ordinal regression, and a receiver operator characteristic curve to compare accuracy based on the number of letters reviewed.</p><p><strong>Results: </strong>Faculty reviewers correctly identified 40% (42/105) of human-generated and 63% (132/210) of AI-generated letters ( P < 0.001), which did not increase over time (AUC 0.451, P = 0.102). When analyzed by perceived author, letters marked as human generated had significantly higher means for all variables ( P = 0.01). BARD did markedly better than human authors in accuracy (3.25 [1.79 to 5.92], P < 0.001), adaptability (1.29 [1.02 to 1.65], P = 0.034), and perceived commitment (1.56 [0.99 to 2.47], P < 0.055). Additional analysis controlling for reviewer background showed no differences in outcomes based on experience or familiarity with the AI programs.</p><p><strong>Conclusion: </strong>Faculty members were unsuccessful in determining the difference between human-generated and AI-generated LORs 50% of the time, which suggests that AI can generate LORs similarly to human authors. This highlights the importance for selection committees to reconsider the role and influence of LORs on residency applications.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":"e348-e355"},"PeriodicalIF":2.6,"publicationDate":"2025-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142856459","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Beyond the Usual Significance: Fragility Indices of Randomized Controlled Trials in Top General Orthopaedic Journals.","authors":"Mohammad Poursalehian, Mahdi Sahebi, Mahboobeh Tajvidi, Amirhosein Sabaghian, Amir-Mohammad Asgari, Sean A Tabaie, Mohit Bhandari, Amir Human Hoveidaei","doi":"10.5435/JAAOS-D-24-00691","DOIUrl":"10.5435/JAAOS-D-24-00691","url":null,"abstract":"<p><strong>Introduction: </strong>Understanding the reliability of outcomes in randomized controlled trials (RCTs) is crucial, as standard metrics, such as P- value do not fully capture result fragility. This led to the adoption of specific indices: the fragility index (FI), which measures the strength of trial through significant results by calculating the minimum number of patient status changes from nonevent to event required to make the results statistically insignificant; reverse fragility index (RFI), used for insignificant results; and continuous fragility index (CFI), which acts similar to FI for significant continuous outcomes. The objective is to assess the robustness of orthopaedics RCTs using these indices across leading orthopaedic journals.</p><p><strong>Methods: </strong>A systematic review of RCTs published between 2019 and 2023 in the top five general orthopaedic journals, identified through Scientific Journal Rankings, was done. Data extraction focused on FI, RFI, and CFI and related measures for 160 RCTs. The indices were calculated using established methodologies, with sample size adjustments.</p><p><strong>Results: </strong>22 RCTs had statistically significant dichotomous primary outcomes and 17 studies had notable dichotomous secondary outcomes. Twenty-nine had negligible (insignificant) dichotomous primary outcomes, and 92 reported notable continuous outcomes. Only one RCT reported a FI in the article. The median FI was 5 with a median sample size of 142 for dichotomous outcomes. The median RFI was 3 with a median sample size of 100 for negligible outcomes, and the median CFI was 13 with a median sample size of 86.5 for continuous outcomes, showing dichotomous outcomes to be more fragile than continuous ones.</p><p><strong>Discussion: </strong>Continuous outcomes are less fragile than dichotomous outcomes, with negligible dichotomous outcomes being particularly more fragile. This fragility stems from small sample sizes and limited outcome events. Using these indices, especially when considering patient loss to follow-up, can improve the reliability of findings.</p><p><strong>Level of evidence: </strong>I.</p>","PeriodicalId":51098,"journal":{"name":"Journal of the American Academy of Orthopaedic Surgeons","volume":" ","pages":"e340-e347"},"PeriodicalIF":2.6,"publicationDate":"2025-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142873431","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}