bluuebunny/crossref_metadata_2025_split huggingface dataset:
Total shoulder arthroplasty: risk factors for a prolonged length of stay. A retrospective cohort study
Authors: Hartwell Matthew J. , Nelson Patrick , Johnson Daniel J. , Nicolay Richard W. , Christian Robert A. , Selley Ryan S. , Terry Michael A. , Tjong Vehniah K. 
Published: September 2019

Background:
Recent studies describe safe outcomes for outpatient total shoulder arthroplasty. This study identifies risk factors for hospital admissions exceeding 24 hr.

Methods:
The National Surgical Quality Improvement Program database was queried for billing codes related to total shoulder arthroplasty. Patients were grouped according to length of stay, ≤24 hr or >24 hr. Univariate and multivariate analyses were used to identify patient demographics, preoperative comorbidities, and intraoperative risk factors for prolonged hospitalizations.

Results:
Of the 14,339 patients who met the inclusion criteria, 6,507 patients (45.3%) had a length of stay ≤24 hr. Multivariate analysis identified age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.03), American Society of Anesthesiology classification (OR, 1.5; 95% CI, 1.4-1.6), diabetes (OR, 1.7; 95% CI, 1.4-2.0), chronic obstructive pulmonary disease (OR, 1.4; 95% CI, 1.2-1.6), congestive heart failure (OR, 2.7; 95% CI, 1.3-5.3), dialysis (OR, 2.5; 95% CI, 1.3, 4.8), history of a bleeding disorder (OR, 1.5; 95% CI, 1.2-1.9), and operative time (OR, 1.01; 95% CI, 1.01-1.01) as risk factors for prolonged hospitalization. Male gender was a protective factor for prolonged hospitalization (OR, 0.50; 95% CI, 0.46-0.53).

Conclusions:
Female gender, increasing age, American Society of Anesthesiology classification, operative time, or a history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, or a bleeding disorder are risk factors for prolonged hospitalization following total shoulder arthroplasty.

Level of Evidence:
Level III.
Factors influencing time to union of diaphyseal humeral fractures after plate fixation: A retrospective cohort study
Authors: Frantz Travis L. , Meschbach Nicole T. , Niedermeier Steven R. , Pettit Robert J. , Plummer Darren R. , Harrison Ryan K. 
Published: September 2019

Background:
We sought to determine time to union of diaphyseal humeral fractures treated with plate fixation and to identify underlying contributing factors.

Methods:
A retrospective cohort study of patients at a Level 1 trauma center from January, 2006 to December, 2016 was performed. The clinical intervention studied was surgical plate fixation, and the main outcome measure was time to union.

Results:
One hundred and thirty-five patients were included, with mean age of 40.67 (range: 18-90) and body mass index of 29.8 (range: 18.5-74.4). The mean time to union was 19.0 wk with a nonneurological complication rate of 8.9% (eight nonunions [5.95%], one malunion, one implant failure, and two infections). There was no correlation between age or body mass index and time to union. No difference was seen in time to union when comparing males versus females (17.9 vs. 20.1; P=0.3477), smokers versus nonsmokers (22.8 vs. 20.3, P=0.4237), anterior versus posterior approach (18.5 vs. 19.3; P=0.5798), and bridging versus rigid technique (17.6 vs. 19.6; P=0.4453). There was no difference in time to union between proximal, middle, or distal diaphyseal fracture location. There was a trend toward longer time to union in open fractures versus closed and a significantly increased risk of nonunion in open fractures (22.2% vs. 3.4%; P=0.0110). Overall time to union is slightly increased when compared to previously published data.

Conclusions:
Open fracture results in both increased time to union and rate of nonunion after plate fixation. There is no difference in time to union between surgical approaches and techniques, as well as in age, body mass index, gender, smoking, or fracture location.

Level of Evidence:
Level III.
Clinical significance of bone morphogenetic protein in osteosarcoma: A systematic review
Authors: Lin James S. , Santiago Juan E. , Mayerson Joel L. , Scharschmidt Thomas J. 
Published: September 2019

Background:
The literature suggests that endogenous bone morphogenetic proteins (BMP) have both beneficial and deleterious effects on osteosarcoma. Therapeutic use of exogenous BMP after osteosarcoma resection to enhance skeletal reconstruction is controversial.

Methods:
We conducted a systematic review to determine the association of endogenous BMP expression and overall survival for osteosarcoma patients to determine the association of BMP expression and metastasis, and to evaluate the extent of clinical evidence regarding use of recombinant human BMP (rhBMP) in patients with osteosarcoma.

Results:
Eight studies were included; all except one reported on endogenous BMPs or BMP receptor. The four clinical studies on an association between BMPs and prognosis had mixed results; one associated BMP-7 expression with improved overall survival (OS) in osteosarcoma, while another found no correlation between BMP-6, 7, or 8 with OS. In contrast, one found a negative correlation between BMP expression and prognosis. The final study of these four investigated BMP-2 single nucleotide polymorphisms (SNP) in osteosarcoma and reported an association of a specific SNP mutation with improved prognosis. All three studies addressing metastasis reported increased risk for metastasis of osteosarcoma with either BMP-2 receptor or BMP-2 or 4 expression. Only one study evaluated application of therapeutic rhBMP-2 after osteosarcoma resection, finding no effect on clinical outcomes and no detrimental effects such as tumor recurrence.

Conclusions:
Endogenous BMP or BMP receptor expression may be associated with osteosarcoma metastasis but are of uncertain prognostic significance. Any harmful or beneficial effects of exogenous therapeutic BMP application in this setting are unproven.
Proximal femoral reconstructions: A European “Italian” experience. A case series
Authors: Trovarelli Giulia , Pala Elisa , Cappellari Alessandro , Angelini Andrea , Ruggieri Pietro 
Published: September 2019

Background:
The aim of the study was to analyze our experience with a single system of modular proximal femoral replacement, evaluating oncologic results, complications, and functional results.

Methods:
We reviewed data on 38 patients (21 men and 17 women; mean age 59 y) treated with proximal femoral reconstructions by two orthopaedic surgeons. Reconstruction was performed in all patients with a MUTARS® modular proximal femoral prosthesis and an acetabular reconstruction in eight patients. Diagnoses included primary bone sarcomas (21), bone metastases (15), and radioinduced osteonecrosis (2). The stem was press fit in 11 patients and cemented in 27.

Results:
At a mean follow-up of 1.9 yr, 12 patients were alive with no evidence of disease, three have no evidence of disease after treatment of a recurrence or metastasis, 12 were alive with disease, and nine had died. The two with osteonecrosis were not included in this analysis. Complications occurred in seven patients: four type I (wound dehiscence in one and dislocation in three), one type II, one type IV, and one type V failures, while type III failures did not occur. At last follow-up, 89% of patients (34/38) had retained their implant. The mean Musculoskeletal Tumor Society (MSTS) score was 24.7 (14-30), with excellent or good results in all patients except one.

Conclusion:
The overall survival of this prosthesis was satisfactory with good implant survival in proximal femoral reconstruction. The most frequent cause of failure was dislocation. The incidence of infection was low. Functional results were good or excellent.

Level of Evidence:
IV; case series.
Validated Radiographic Scoring System for Lateral Compression Type 1 Pelvis Fractures
Authors: Beckmann James , Haller Justin M. , Beebe Michael , Ali Ashley , Presson Angela , Stuart Ami , Sagi Henry Claude , Kubiak Erik 
Published: September 2019

Objectives:
To develop a radiographic fracture scoring system for lateral compression type 1 (LC-1) pelvic fractures based on OTA/AO survey data and to preliminarily evaluate this system within an LC-1 pelvis fracture cohort.

Design:
Survey study with validation patient cohort.

Setting:
Two Level 1 academic trauma centers.

Patients/Participants:
Attendings (n=111) at the 2013 OTA/AO national meeting reviewed imaging from 27 LC-1 fractures and indicated surgical recommendations (“yes/no”). A separate LC-1 fracture cohort (33 patients) was used to evaluate the scoring system.

Intervention:
The LC-1 scoring system (range: 5–14) based on radiographic morphology of sacral, superior ramus (SR), and inferior ramus (IR) fracture components.

Main Outcome Measurement:
Numeric scores were compared against (1) OTA/AO attendees' operative recommendations and (2) LC-1 cohort treatment and outcomes.

Results:
Operative tendency of OTA/AO survey respondents—defined as the percent of “yes” responses to recommend surgical stabilization—was highly correlated with radiographic findings: sacral displacement {odds ratio (OR) = 18.9 [95% confidence interval (CI): 11.7–30.6]}; sacral column 2–3 versus 1 [OR = 5.7 (95% CI: 3.9–8.3)]; Denis classification [OR = 10 (95% CI: 6.7–14.9); IR displacement OR = 3.4 (95% CI: 2.3–4.8)]; and SR fracture [OR = 1.9 (95% CI: 1.3–2.8)]. Total scores <7 were 81% accurate in predicting nonoperative treatment. Total scores >9 were 89% accurate in predicting an operative recommendation. In the LC-1 cohort, scoring accuracy was 100% (95% CI: 85%–100%).

Conclusions:
Based on survey results and patient cohort data, scores <7 predict nonoperative treatment recommendation, scores >9 indicate surgical recommendations, and scores 7–9 indicate indeterminate stability that should be further evaluated.
Concomitant Posterolateral Corner Injuries in Skeletally Immature Patients With Acute Anterior Cruciate Ligament Injuries
Authors: Kinsella Stuart D. , Rider Sean M. , Fury Matthew S. , Tepolt Frances A. , Ecklund Kirsten , Kocher Mininder S. 
Published: September 2019

Background:
Missed posterolateral corner (PLC) injuries are a known cause of anterior cruciate ligament reconstruction (ACL) failure in the adult population. Failed ACL reconstruction causes significant morbidity in the skeletally immature pediatric population. There is little literature on the character and potential significance of PLC injuries in skeletally immature patients.

Methods:
Magnetic resonance imaging studies of the knee at a tertiary care children’s hospital for patients who underwent an ACL reconstruction without PLC surgery were retrospectively reviewed. Demographic variables were obtained through chart review, and magnetic resonance imaging studies were evaluated for PLC (popliteus, fibular collateral ligament, popliteofibular ligament, and arcuate ligament) injury, and ACL, medial collateral ligament (MCL), bone bruise, fracture, and meniscal pathology by an experienced pediatric musculoskeletal radiologist.

Results:
A total of 50 patients with a mean age at 13.3 years at injury were analyzed. PLC injuries were found in 26 patients (52%), with 7 patients (14%) having a complete tear of a component of the PLC. There was no association between sex (P=0.35), Segond fracture (P=0.09), meniscus injury (P=0.92), or MCL injury (P=0.24) with the risk of PLC injury. There was an association between patient age and PLC injury (P=0.02). For each additional year of age, the odds of PLC injury increased by 1.8 times (odds ratio, 1.8; 95% confidence interval, 1.4-2.2). There was no association between PLC injury and ACL graft failure (P=0.19).

Conclusions:
Missed PLC injuries are a significant source of morbidity and poor clinical outcomes in the management of concomitant ACL injuries in adults. This study demonstrates the prevalence of PLC injuries in the setting of concomitant ACL injuries in the unique skeletally immature patient population. Incomplete PLC injuries are relatively common. Complete PLC injuries are relatively uncommon. PLC injury was more common in older patients. No other concomitant injury predicted the likelihood of PLC injury. Further research is needed regarding the risk of ACL reconstruction failure from associated PLC injury and the indications for PLC reconstruction in skeletally immature patients.

Level of Evidence:
Level IV—diagnostic study.
Does Early Proximal Femoral Varus Osteotomy Shorten the Duration of Fragmentation in Perthes Disease? Lessons From a Prospective Multicenter Cohort
Authors: Sankar Wudbhav N. , Lavalva Scott M. , Mcguire Molly F. , Jo Chanhee , Laine Jennifer C. , Kim Harry K.W. 
Published: September 2019

Background:
The prognosis of Legg-Calvé-Perthes disease (LCPD) is dependent upon several factors, with the length and severity of the fragmentation stage among the most important. Previous retrospectively collected data from a single center have suggested that early proximal femoral varus osteotomy (PFO) may shorten the length of fragmentation and allow 34% of patients to bypass fragmentation altogether resulting in less femoral head deformity. The purpose of this study was to validate these findings in a prospectively collected multicenter cohort.

Methods:
Patients with LCPD treated with early PFO (during Waldenström stage I) were prospectively followed with serial radiographs at 3-month intervals until a minimum of 2-year follow-up. Waldenström stages and lateral pillar class were determined by mode assessments from 3 pediatric orthopaedic surgeons. The duration of fragmentation was defined as the interval between the first radiographs demonstrating features of stage IIa and stage IIIa. “Complete” bypass was defined as the absence of stage IIa or IIb findings on sequential radiographs with no development of femoral head deformity or collapse. “Partial” bypass was defined as the absence of advanced features of fragmentation and femoral head collapse (stage IIb).

Results:
Forty-six patients (80% male individuals) with initial stage LCPD and a mean age of 8.2±1.2 years were identified. The weighted kappa statistics for Waldenström staging and lateral pillar classifications showed excellent (0.833) and substantial (0.707) agreement, respectively. Ninety-eight percent of patients (45/46) underwent some period of fragmentation lasting between 91 and 518 days; the median duration was 206 days (interquartile range, 181 to 280). One patient (2%) bypassed fragmentation completely; 8 patients (17%) demonstrated partial bypass. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016) and shorter fragmentation duration (P=0.001).

Conclusions:
In this prospective multicenter cohort, we found a lower rate of fragmentation bypass than previously reported. Nonetheless, our data support the previous contention that early PFO may shorten fragmentation and minimize collapse in LCPD compared with historical controls. Further study with larger cohorts and a more rigorous definition of what constitutes bypass is warranted to clarify the effect of early PFO on the reparative biology of LCPD.

Level of Evidence:
Level IV—therapeutic study.
Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids’ Inpatient Database
Authors: Sessions William C. , Nickel Amanda J. , Truong Walter H. , McMahon Ryan D. , Finch Michael D. , Georgiadis Andrew G. 
Published: September 2019

Background:
Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment.

Methods:
A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids’ Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates.

Results:
A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012.

Conclusions:
Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications.

Level of Evidence:
Level III—case series, database study.
Transphyseal Humeral Separations: What Can We Learn? A Retrospective, Multicenter Review of Surgically Treated Patients Over a 25-Year Period
Authors: Hariharan Arun R. , Ho Christine , Bauer Andrea , Mehlman Charles T. , Sponseller Paul D. , O’Hara Nathan , Elliott Mariyln , Abzug Joshua M. 
Published: September 2019

Purpose:
Transphyseal humeral separations (TPHS) are rare injuries with only case reports and small series reported in the literature. This multicenter study aimed to assess the various patient characteristics, injury patterns, treatments, outcomes, and complications in a large series of these injuries.

Methods:
A retrospective review was conducted at 5 pediatric institutions to identify TPHS that were treated surgically in patients 0 to 3 years of age over a 25-year period. Patient demographics, mechanisms of injury, Child Protective Services involvement, diagnostic modalities, time to surgery, pin size and configuration, time to fracture union, and complications were recorded.

Results:
A total of 79 patients aged 0 to 46 months, with a mean of 17.6 months, were identified and followed for a median of 57 days postoperatively. The most common mechanism of injury was accidental trauma (n=49), followed by nonaccidental trauma (n=21), cesarean section (n=6), and vaginal delivery (n=3). Child Protective Services were involved in 30 cases (38%). Additional injuries were reported in 19 of the patients; most commonly additional fractures including the humerus, rib, and skull fractures. All patients had elbow radiographs, whereas 4 patients had an elbow ultrasound and/or a magnetic resonance imaging. Time to surgery was greater than 24 hours in 62% of patients (n=49). Intraoperatively, 87% of patients underwent an arthrogram (n=69), 78% of patients had lateral pins only (n=62), averaging utilization of 2.2 pins, and 2 patients underwent an open reduction. In total, 11 complications (14%) were noted, including decreased range of motion (n=4), cubitus varus/valgus (n=6), and need for additional surgery (n=1). No cases of avascular necrosis or physeal arrest were found. No losses of reduction were noted.

Conclusions:
This multicenter review provides the largest known demographic and outcomes data on TPHS. TPHS have excellent outcomes in the vast majority of patients when treated surgically. Nonaccidental trauma accounted for 27% of these injuries so it needs to remain high on the differential diagnosis.

Level of Evidence:
Level III—retrospective cohort study.
Effective Prevention of Proximal Junctional Failure in Adult Spinal Deformity Surgery Requires a Combination of Surgical Implant Prophylaxis and Avoidance of Sagittal Alignment Overcorrection
Authors: Line Breton G. , Bess Shay , Lafage Renaud , Lafage Virgine , Schwab Frank , Ames Christopher , Kim Han Jo , Kelly Michael , Gupta Munish , Burton Douglas , Hart Robert , Klineberg Eric , Kebaish Khaled , Hostin Richard , Mundis Gregory , Eastlack Robert , Shaffrey Christopher , Smith Justin S. 
Published: September 2019

Study Design.
Propensity score matched analysis of a multi-center prospective adult spinal deformity (ASD) database.

Objective.
Evaluate if surgical implant prophylaxis combined with avoidance of sagittal overcorrection more effectively prevents proximal junctional failure (PJF) than use of surgical implants alone.

Summary of Background Data.
PJF is a severe form of proximal junctional kyphosis (PJK). Efforts to prevent PJF have focused on use of surgical implants. Less information exists on avoidance of overcorrection of age-adjusted sagittal alignment to prevent PJF.

Methods.
Surgically treated ASD patients (age ≥18 yrs; ≥5 levels fused, ≥1 year follow-up) enrolled into a prospective multi-center ASD database were propensity score matched (PSM) to control for risk factors for PJF. Patients evaluated for use of surgical implants to prevent PJF (IMPLANT) versus no implant prophylaxis (NONE), and categorized by the type of implant used (CEMENT, HOOK, TETHER). Postoperative sagittal alignment was evaluated for overcorrection of age-adjusted sagittal alignment (OVER) versus within sagittal parameters (ALIGN). Incidence of PJF was evaluated at minimum 1 year postop.

Results.
Six hundred twenty five of 834 eligible for study inclusion were evaluated. Following PSM to control for confounding variables, analysis demonstrated the incidence of PJF was lower for IMPLANT (n = 235; 10.6%) versus NONE (n = 390: 20.3%; P < 0.05). Use of transverse process hooks at the upper instrumented vertebra (HOOK; n = 115) had the lowest rate of PJF (7.0%) versus NONE (20.3%; P < 0.05). ALIGN (n = 246) had lower incidence of PJF than OVER (n = 379; 12.0% vs. 19.2%, respectively; P < 0.05). The combination of ALIGN-IMPLANT further reduced PJF rates (n = 81; 9.9%), while OVER-NONE had the highest rate of PJF (n = 225; 24.2%; P < 0.05).

Conclusion.
Propensity score matched analysis of 625 ASD patients demonstrated use of surgical implants alone to prevent PJF was less effective than combining implants with avoidance of sagittal overcorrection. Patients that received no PJF implant prophylaxis and had sagittal overcorrection had the highest incidence of PJF.

Level of Evidence: 3