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Kocan J, Joseph E, Mercado P, Haider MN, Pavlesen S, Rohrbacher B. Computed Tomography Scans and Fixation Rates for Trimalleolar Ankle Fractures Over 10 Years at a Level 1 Trauma Center. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114231216984. [PMID: 38223655 PMCID: PMC10785731 DOI: 10.1177/24730114231216984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Background The posterior malleolus component of the trimalleolar ankle fracture has posed a controversial topic for diagnostic imaging and surgical management. Preoperative computed tomography (CT) scans are used to better appreciate fracture morphology and may affect management techniques. No prior study has investigated the trend in preoperative CT scan use and the rates of posterior and syndesmotic fixation for trimalleolar injuries. Methods This retrospective cohort study evaluated the use of preoperative CT scans and the rates of posterior and syndesmotic fixation for trimalleolar ankle fractures over a 10-year period at an adult level 1 trauma center. Patients surgically managed for ankle fractures with OTA/AO classifications of 44B3, 44C3.3, 44C1.3, 44C2.3, and 44A3 were identified and included using Current Procedural Terminology codes and a prospectively collected fracture registry. Demographic information, comorbidities, fixation methods, and use of preoperative CT scan were recorded. Comparative analyses were performed to assess for yearly differences in demographic characteristics along with changes in trends of preoperative CT scans and posterior and syndesmotic fixation. Results A total of 1191 patients were included in the analyses. OTA/AO 44B3.2 fractures were the most common injuries (yearly range of 59.4%-80.1%). The rate of posterior fixation did not significantly increase during the study interval (1.4% growth per year [95% CI -0.27, 3.07]). However, the rate of preoperative CT scan use significantly increased by 2.76% (95% CI 1.99, 3.52) per year and the rate of syndesmotic fixation increased by 2.58% (95% CI 1.17, 3.99) per year. Fixation methods for both the syndesmosis and posterior malleolus changed during the study timeline. Conclusion Despite a relatively stable rate of posterior fixation, the frequency of preoperative CT scans and use of syndesmotic fixation increased significantly over a 10-year study period. Level of Evidence Level IV, descriptive pilot study.
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Affiliation(s)
- Joseph Kocan
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Elias Joseph
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Paul Mercado
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Mohammad N. Haider
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Sonja Pavlesen
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
| | - Bernard Rohrbacher
- Department of Orthopaedics, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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Kakar S, Burnier M, Atzei A, Ho PC, Herzberg G, Del Piñal F. Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders. J Hand Surg Am 2020; 45:341-353. [PMID: 32122689 DOI: 10.1016/j.jhsa.2020.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 01/20/2020] [Accepted: 01/24/2020] [Indexed: 02/02/2023]
Abstract
The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.
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Affiliation(s)
- Sanjeev Kakar
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN.
| | - Marion Burnier
- Service Chirurgie Orthopédique Membre Supérieur, Hôpital Edouard Herriot, Lyon, France
| | - Andrea Atzei
- Hand Surgery Unit, Policlinico G.B. Rossi, Verona, Italy
| | - P C Ho
- Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Guillaume Herzberg
- Service Chirurgie Orthopédique Membre Supérieur, Hôpital Edouard Herriot, Lyon, France
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Does arthroscopic assistance improve reduction in distal articular radius fracture? A retrospective comparative study using a blind CT assessment. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:405-411. [DOI: 10.1007/s00590-018-2348-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 11/25/2018] [Indexed: 10/27/2022]
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Wichlas F, Tsitsilonis S, Kopf S, Krapohl BD, Manegold S. Fracture heuristics: surgical decision for approaches to distal radius fractures. A surgeon's perspective. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2017; 6:Doc08. [PMID: 28580225 PMCID: PMC5442450 DOI: 10.3205/iprs000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Introduction: The aim of the present study is to develop a heuristic that could replace the surgeon’s analysis for the decision on the operative approach of distal radius fractures based on simple fracture characteristics. Patients and methods: Five hundred distal radius fractures operated between 2011 and 2014 were analyzed for the surgeon’s decision on the approach used. The 500 distal radius fractures were treated with open reduction and internal fixation through palmar, dorsal, and dorsopalmar approaches with 2.4 mm locking plates or underwent percutaneous fixation. The parameters that should replace the surgeon’s analysis were the fractured palmar cortex, and the frontal and the sagittal split of the articular surface of the distal radius. Results: The palmar approach was used for 422 (84.4%) fractures, the dorsal approach for 39 (7.8%), and the combined dorsopalmar approach for 30 (6.0%). Nine (1.8%) fractures were treated percutaneously. The correlation between the fractured palmar cortex and the used palmar approach was moderate (r=0.464; p<0.0001). The correlation between the frontal split and the dorsal approach, including the dorsopalmar approach, was strong (r=0.715; p<0.0001). The sagittal split had only a weak correlation for the dorsal and dorsopalmar approach (r=0.300; p<0.0001). Discussion: The study shows that the surgical decision on the preferred approach is dictated through two simple factors, even in the case of complex fractures. Conclusion: When the palmar cortex is displaced in distal radius fractures, a palmar approach should be used. When there is a displaced frontal split of the articular surface, a dorsal approach should be used. When both are present, a dorsopalmar approach should be used. These two simple parameters could replace the surgeon’s analysis for the surgical approach.
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Affiliation(s)
- Florian Wichlas
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Serafim Tsitsilonis
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Sebastian Kopf
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Björn Dirk Krapohl
- Department for Plastic Surgery and Hand Surgery, St. Marien Hospital, Berlin, Germany
| | - Sebastian Manegold
- Center for Musculoskeletal Surgery, Charité - University Medicine Berlin, Berlin, Germany
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Kleinlugtenbelt YV, Madden K, Groen SR, Ham SJ, Kloen P, Haverlag R, Simons MP, Bhandari M, Goslings JC, Scholtes VAB, Poolman RW. Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures? Strategies Trauma Limb Reconstr 2017; 12:91-97. [PMID: 28439818 PMCID: PMC5505880 DOI: 10.1007/s11751-017-0283-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 04/03/2017] [Indexed: 11/29/2022] Open
Abstract
There are no clear guidelines when an additional CT scan should be obtained for the treatment of displaced intra-articular distal radius fractures (DRF). This study aimed to investigate whether surgeons can predict the usefulness of CT scans to facilitate choice of treatment plan and/or pre-operative planning for DRF. Four surgeons evaluated 51 patients with displaced DRF. The choice of treatment (operative or nonoperative) was based on conventional radiographs. Subsequently, the surgeons were asked whether they would have requested an additional CT scan to determine this treatment choice, and also whether they required a CT scan for pre-operative planning. After 4 weeks, the additional CT scan was provided and the cases were assessed again. Based on these data, we calculated the number needed to scan (NNS) and number needed to harm (NNH) for two decision models. Model 1: Only provide a CT scan if the surgeon requested one based on their judgment of the X-rays. Model 2: CT scans for all displaced intra-articular DRF. For choice of treatment, the NNS was lower for model 1 than for model 2 (2.6 vs. 4.3) and the NNH is higher for model 1 (3.1 vs. 1.3). For pre-operative planning, the NNS (1.3 vs. 1.4) and NNH (3.7 vs. 3.4) were comparable for both models. Surgeons are able to predict the usefulness of an additional CT scan for intra-articular displaced DRF for OR indication. However, for pre-operative planning the usefulness of a CT scan is much harder to predict.
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Affiliation(s)
- Y V Kleinlugtenbelt
- Department of Orthopaedic and Trauma Surgery, Joint Research OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands. .,Department of Orthopaedic and Trauma Surgery, Deventer Ziekenhuis, Nico Bolkesteinlaan 75, 7416 SE, Deventer, The Netherlands. .,Division of Orthopaedic Surgery, McMaster University, 293 Wellington St N Suite 110, Hamilton, ON, L8L 8E7, Canada.
| | - K Madden
- Division of Orthopaedic Surgery, McMaster University, 293 Wellington St N Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - S R Groen
- Department of Orthopaedic and Trauma Surgery, Joint Research OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - S J Ham
- Department of Orthopaedic and Trauma Surgery, Joint Research OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - P Kloen
- Department of Orthopaedic and Trauma Surgery, Academic Medical Centre, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - R Haverlag
- Department of General and Trauma Surgery, OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - M P Simons
- Department of General and Trauma Surgery, OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - M Bhandari
- Division of Orthopaedic Surgery, McMaster University, 293 Wellington St N Suite 110, Hamilton, ON, L8L 8E7, Canada
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - V A B Scholtes
- Department of Orthopaedic and Trauma Surgery, Joint Research OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - R W Poolman
- Department of Orthopaedic and Trauma Surgery, Joint Research OLVG, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
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Kleinlugtenbelt YV, Hoekstra M, Ham SJ, Kloen P, Haverlag R, Simons MP, Bhandari M, Goslings JC, Poolman RW, Scholtes VAB. Spectrum bias, a common unrecognised issue in orthopaedic agreement studies: do CT scans really influence the agreement on treatment plans in fractures of the distal radius? Bone Joint Res 2015; 4:190-4. [PMID: 26625876 PMCID: PMC5001195 DOI: 10.1302/2046-3758.412.2000433] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objectives Current studies on the additional benefit of using computed tomography
(CT) in order to evaluate the surgeons’ agreement on treatment plans
for fracture are inconsistent. This inconsistency can be explained
by a methodological phenomenon called ‘spectrum bias’, defined as
the bias inherent when investigators choose a population lacking
therapeutic uncertainty for evaluation. The aim of the study is
to determine the influence of spectrum bias on the intra-observer
agreement of treatment plans for fractures of the distal radius. Methods Four surgeons evaluated 51 patients with displaced fractures
of the distal radius at four time points: T1 and T2: conventional
radiographs; T3 and T4: radiographs and additional CT scan (radiograph
and CT). Choice of treatment plan (operative or non-operative) and
therapeutic certainty (five-point scale: very uncertain to very
certain) were rated. To determine the influence of spectrum bias,
the intra-observer agreement was analysed, using Kappa statistics,
for each degree of therapeutic certainty. Results In cases with high therapeutic certainty, intra-observer agreement
based on radiograph was almost perfect (0.86 to 0.90), but decreased
to moderate based on a radiograph and CT (0.47 to 0.60). In cases
with high therapeutic uncertainty, intra-observer agreement was slight
at best (-0.12 to 0.19), but increased to moderate based on the
radiograph and CT (0.56 to 0.57). Conclusion Spectrum bias influenced the outcome of this agreement study
on treatment plans. An additional CT scan improves the intra-observer
agreement on treatment plans for a fracture of the distal radius
only when there is therapeutic uncertainty. Reporting and analysing
intra-observer agreement based on the surgeon’s level of certainty
is an appropriate method to minimise spectrum bias. Cite this article: Bone Joint Res 2015;4:190–194.
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Affiliation(s)
- Y V Kleinlugtenbelt
- Deventer Ziekenhuis, Nico Bolkesteinlaan 75, 7416 SE Deventer, The Netherlands
| | - M Hoekstra
- JointResearch Onze Lieve Vrouwe Gasthuis, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - S J Ham
- JointResearch Onze Lieve Vrouwe Gasthuis, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - P Kloen
- Academic Medical Centre, P.O. Box 22660, 1100, DD, Amsterdam, The Netherlands
| | - R Haverlag
- JointResearch Onze Lieve Vrouwe Gasthuis, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - M P Simons
- JointResearch Onze Lieve Vrouwe Gasthuis, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - M Bhandari
- McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Ontario, Canada
| | - J C Goslings
- Academic Medical Center, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - R W Poolman
- JointResearch Onze Lieve Vrouwe Gasthuis, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
| | - V A B Scholtes
- JointResearch Onze Lieve Vrouwe Gasthuis, Oosterpark 9, P.O. Box 95500, 1090 HM, Amsterdam, The Netherlands
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