Thierry Guitton | University of Groningen (original) (raw)

Papers by Thierry Guitton

Journal of Bone and Joint Surgery, 2013

Background: Interobserver reliability for the classification of proximal humeral fractures is lim... more Background: Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Methods: Members of the Science of Variation Group-fully trained practicing orthopaedic and trauma surgeons from around the world-were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (k) measure. Results: Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from ''slight'' to ''fair.'' A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (k = 0.35 compared with 0.30, p < 0.001) and on the AO classification (k = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Conclusions: Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that continued

Cancer, 2005

The research was conducted under the auspices of the American College of Radiology Imaging Networ... more The research was conducted under the auspices of the American College of Radiology Imaging Network (ACRIN; grant U01 CA80098/U01 CA79778), a National Cancer Institute (NCI) clinical trials group. This study was conducted with the cooperation of the Radiation Therapy Oncology Group (RTOG), using data from patients enrolled in an RTOG-sponsored Phase III trial (RTOG-91-11) supported by grants U10 CA21661, U10 CA37422, and U10 CA32115 awarded by the National Cancer Institute.

Fragestellung: Ziel der vorliegenden Studie ist die Erfassung von Faktoren, die die Wahl der Ther... more Fragestellung: Ziel der vorliegenden Studie ist die Erfassung von Faktoren, die die Wahl der Therapie (Ersatz versus Rekonstruktion) komplexer Frakturen des proximalen Humerus beeinflussen. Methodik: Mittels eines online Fragebogens evaluierten 217 Chirurgen und Orthopäden, 10 Fallbeschreibungen[for full text, please go to the a.m. URL]

Journal of Hand and Microsurgery, 2018

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the... more Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to “eyeball” measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (k = 0.34). Agreement on the location of bony bridging was slight (k = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level III, diagnostic study.

Fragestellung: Ziel der vorliegenden Studie ist die Evaluation der Reliabilität und Zuverlässigke... more Fragestellung: Ziel der vorliegenden Studie ist die Evaluation der Reliabilität und Zuverlässigkeit der Diagnose scapholunärer (SL-) Bandverletzungen im Rahmen intraartikulärer Radiusfrakturen (AO Typ C). Methodik: Mittels eines online Fragebogens evaluierten 217 Chirurgen, 21[for full text, please go to the a.m. URL]

Journal of Orthopaedic Trauma, 2014

OBJECTIVES:There is substantial variation in the classification and the management of scapula fra... more OBJECTIVES:There is substantial variation in the classification and the management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO and the New International Classification of scapula fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN:: Web-based reliability study SETTING:: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS:One-hundred and three orthopaedic surgeons evaluated 35 movies of 3DCT-reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS:Fleiss' kappa () was used to assess the reliability of agreement between the surgeons. RESULTS:: The overall agreement on the OTA/AO Classification was moderate for the types (A, B, and C, = 0.54) with a 71% proportion of rater agreement (PA) as well as for the nine groups (A1 to C3, = 0.47) with a 57% PA. For the New International Classification, the agreement about the intra-articular extension of the fracture (Fossa (F), = 0.79) was substantial, the agreement about a fractured body (Body (B), = 0.57) or process was moderate (Process (P), = 0.53), however PAs were more than 81%. The agreement on the treatment recommendation was moderate (= 0.57) with a 73% PA. CONCLUSIONS:The New International Classification was more reliable. Body and process fractures generated more disagreement than intra-articular fractures and need further clear definitions.

The Journal of Hand Surgery, 2012

Purpose We tested the hypothesis that there are no differences between apparently isolated fractu... more Purpose We tested the hypothesis that there are no differences between apparently isolated fractures of the radial diaphysis and isolated fractures of the radial diaphysis with concomitant dislocation of the distal radioulnar joint (DRUJ) in function, disability, and DRUJ stability more than 13 years after near-anatomic open reduction with plate and screw fixation. Methods We evaluated 17 adult patients with a diaphyseal fracture of the radius without a fracture of the ulna an average of 19 years after surgery (range, 13-33 y). Of these patients, 7 had concomitant dislocation of the DRUJ (Galeazzi fracture). At the long-term follow-up, we evaluated function with several composite scores, stability of the DRUJ, and arm-specific disability by using the Disabilities of Arm, Shoulder, and Hand questionnaire. Results The average scores were 96 (range, 85-100) on the Mayo Modified Wrist Score, 95 (range, 80-100) on the Mayo Elbow Performance Index, and 5 (range, 0-33) on the Disabilities of Arm, Shoulder, and Hand questionnaire. There were no significant differences between patients with and without DRUJ dislocation. No patients had greater laxity of the DRUJ than the opposite uninjured side. Conclusions Near-anatomic open reduction and internal fixation of diaphyseal radius fractures with and without associated DRUJ dislocation have comparable long-term results.

The Journal of Hand Surgery, 2013

To address the factors that surgeons use to decide between 2 options for treatment when the evide... more To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most

The Journal of Hand Surgery, 2013

Purpose To evaluate the reliability and accuracy of diagnosis of scapholunate dissociation (SLD) ... more Purpose To evaluate the reliability and accuracy of diagnosis of scapholunate dissociation (SLD) among AO type C (compression articular) fractures of the distal radius. Methods A total of 217 surgeons evaluated 21 sets of radiographs with type C fractures of the distal radius for which the status of the scapholunate interosseous ligament was established by preoperative 3-compartment computed tomographic arthrography with direct operative visualization of diagnosed SLD (reference standard). Observers were asked whether SLD was present, and if yes, whether they would recommend operative treatment. Diagnostic performance characteristics were calculated with respect to the reference standard. We assessed interobserver reliability using the Fleiss generalized kappa. Results The interobserver agreement for radiographic diagnosis of SLD was moderate (ϭ 0.44). Correct diagnosis for a given set of radiographs ranged from 8% to 98% (average, 79%) of observers. Diagnostic performance characteristics were: 69% sensitivity, 84% specificity, 84% accuracy, 68% positive predictive value, and 84% negative predictive value. Based on a prevalence of 5%, Bayes adjusted positive and negative predictive values were 18% and 98%, respectively. Raters recommended operative treatment in 74% to 100% of patients diagnosed with SLD. Conclusions Radiographs are moderately reliable and are better at ruling out than ruling in SLD associated with type C fracture of the distal radius.

Clinical Orthopaedics and Related Research®, 2012

Background Studies of traumatic elbow instability suggest that recognition of a pattern in the co... more Background Studies of traumatic elbow instability suggest that recognition of a pattern in the combination and character of the fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic elbow instability, but there is no evidence that patterns can be identified reliably. Questions/Purposes We therefore determined (1) the interobserver reliability of identifying specific patterns of traumatic elbow instability on radiographs for subgroups of orthopaedic surgeons; and (2) the diagnostic accuracy of radiographic diagnosis. Methods Seventy-three orthopaedic surgeons evaluated 53 sets of radiographs and diagnosed one of five common patterns of traumatic elbow instability by using a webbased survey. The interobserver reliability was analyzed using Cohen's multirater kappa. Intraoperative diagnosis was the reference for fracture pattern in calculations of the sensitivity, specificity, accuracy, and positive predictive and negative predictive values of radiographic diagnosis. Results The overall interobserver reliability for patterns of traumatic elbow instability on radiographs was j = 0.41. Treatment of greater than five such injuries a year was associated with greater interobserver agreement, but years in practice were not. Diagnostic accuracy ranged from 76% to 93% and was lowest for the terrible triad pattern of injury. Conclusions Specific patterns of traumatic elbow instability can be diagnosed with moderate interobserver reliability and reasonable accuracy on radiographs. Level of Evidence Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical Orthopaedics and Related Research®, 2010

Background Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization ... more Background Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear. Questions/purpose We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery. Patients and Methods We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI. Results Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3-3.8); (2) number of operations OR 3.4, 95% CI (2.0-6.0); (3) diabetes, OR 2.1, 95% CI (1.2-3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3-6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3-4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1-4.7). Conclusion The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain). Level of Evidence Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. This is an Institutional Review Board (IRB) approved study.

Clinical Orthopaedics and Related Research®, 2012

Clinical Orthopaedics and Related Research®, 2011

Journal of hand and microsurgery, 2013

Trapeziometacarpal arthrosis is expected with advancing age and a limited percentage of people se... more Trapeziometacarpal arthrosis is expected with advancing age and a limited percentage of people seek medical attention for it. We studied patients after their first appointment to address trapeziometacarpal arthrosis with a hand surgeon to determine factors associated with return for a second visit and eventual election of operative treatment. A billing database identified 306 patients in the practice of three hand surgeons with a new diagnosis of TMC arthrosis and no associated diagnoses. Bivariate and multivariable logistic regression analyses sought factors associated with a second visit and operative treatment among demographic and visit related factors. One hundred and forty-three patients (47 %) returned for one or more additional visits and 46 (15 %) eventually elected operative treatment within the study period. Independent predictors of a return visit included injection at first visit, splint at first visit, and doctor's recommendation for a return visit. The predictors ...

Hand (New York, N.Y.), 2012

Several studies support the use of CT for diagnosing coronal fractures of the distal radius but t... more Several studies support the use of CT for diagnosing coronal fractures of the distal radius but the inter-observer reliability of these observations is less well studied. We tested the null hypothesis that radiographs alone and the combination of radiographs and two-dimensional computed tomography scans (2DCT) have the same inter-observer variation for the diagnosis of coronal articular fracture lines in the distal radius. Using a web-based survey, 63 surgeons were randomized to evaluate 16 fractures of the distal radius on radiographs alone or radiographs and 2DCT for the presence or absence of a coronal fracture line of the lunate facet and, if present, the stability of the fracture. The kappa multirater measure was calculated to estimate agreement between observers. The inter-observer variation in diagnosis of a coronal fracture line was fair with both radiographs and 2DCT, as was the diagnosis of instability of the volar lunate facet fracture when present. Two-dimensional comput...

The Journal of bone and joint surgery. American volume, Jan 15, 2015

Many strategies have been introduced to improve safety in health care, but it is not clear that t... more Many strategies have been introduced to improve safety in health care, but it is not clear that these efforts have reduced errors. This study assessed the experienced safety culture and preferred means of improving safety among orthopaedists. Members of the Science of Variation Group and Ankle Platform were invited to complete an eighty-nine-question survey. Outcomes measured were the modified Patient Safety Climate in Healthcare Organizations (PSCHO) questionnaire, which measures safety as perceived by hospital personnel, and the degree of enthusiasm expressed for seventeen means of improving safety. The questionnaire was completed by 387 (92%) of the 422 participants. The rate of problematic responses, those implying a lack of safety climate, in the modified PSCHO questionnaire was 18%. In multivariable linear regression analysis, working in a non-teaching hospital (β, 3.7; 95% confidence interval [95% CI], 1.3 to 6.2; p = 0.003), having a safety program (β, 4.8; 95% CI, 0.74 to 8...

This thesis shows that advancements in technical head fractures analysis, imaging modalities, inc... more This thesis shows that advancements in technical head fractures analysis, imaging modalities, increased interest in psychosocial aspects of treatment and the availability of long-term outcome data can help improve classification, treatment and outcome in fractures of the radial head. It is science that created these advancements and through adequate scientific evaluation of these advancements we can continue creating more effective treatments for patients.

Journal of Wrist Surgery

Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonu... more Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonunion and avascular necrosis. Distinction of scaphoid proximal pole fractures from waist fractures is important for management but it is unclear if the distinction is reliable. Methods A consecutive series of 29 scaphoid fractures from one tertiary hospital was collected consisting of 5 scaphoid proximal pole and 24 scaphoid waist fractures. Fifty-seven members of the Science of Variation Group (SOVG) were randomized to diagnose fracture location and displacement by using radiographs alone or radiographs and a computed tomography (CT) scan. Results Observers reviewing radiographs alone and observers reviewing radiographs and CT scans both had substantial agreement on fracture location (κ = 0.82 and κ = 0.80, respectively; p = 0.54). Both groups had only fair agreement on fracture displacement (κ = 0.28 and κ = 0.35, respectively; p = 0.029). Conclusion Proximal pole fractures are sufficie...

Journal of Bone and Joint Surgery, 2013

Background: Interobserver reliability for the classification of proximal humeral fractures is lim... more Background: Interobserver reliability for the classification of proximal humeral fractures is limited. The aim of this study was to test the null hypothesis that interobserver reliability of the AO classification of proximal humeral fractures, the preferred treatment, and fracture characteristics is the same for two-dimensional (2-D) and three-dimensional (3-D) computed tomography (CT). Methods: Members of the Science of Variation Group-fully trained practicing orthopaedic and trauma surgeons from around the world-were randomized to evaluate radiographs and either 2-D CT or 3-D CT images of fifteen proximal humeral fractures via a web-based survey and respond to the following four questions: (1) Is the greater tuberosity displaced? (2) Is the humeral head split? (3) Is the arterial supply compromised? (4) Is the glenohumeral joint dislocated? They also classified the fracture according to the AO system and indicated their preferred treatment of the fracture (operative or nonoperative). Agreement among observers was assessed with use of the multirater kappa (k) measure. Results: Interobserver reliability of the AO classification, fracture characteristics, and preferred treatment generally ranged from ''slight'' to ''fair.'' A few small but statistically significant differences were found. Observers randomized to the 2-D CT group had slightly but significantly better agreement on displacement of the greater tuberosity (k = 0.35 compared with 0.30, p < 0.001) and on the AO classification (k = 0.18 compared with 0.17, p = 0.018). A subgroup analysis of the AO classification results revealed that shoulder and elbow surgeons, orthopaedic trauma surgeons, and surgeons in the United States had slightly greater reliability on 2-D CT, whereas surgeons in practice for ten years or less and surgeons from other subspecialties had slightly greater reliability on 3-D CT. Conclusions: Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. This may contribute to the similarly poor interobserver reliability that continued

Cancer, 2005

The research was conducted under the auspices of the American College of Radiology Imaging Networ... more The research was conducted under the auspices of the American College of Radiology Imaging Network (ACRIN; grant U01 CA80098/U01 CA79778), a National Cancer Institute (NCI) clinical trials group. This study was conducted with the cooperation of the Radiation Therapy Oncology Group (RTOG), using data from patients enrolled in an RTOG-sponsored Phase III trial (RTOG-91-11) supported by grants U10 CA21661, U10 CA37422, and U10 CA32115 awarded by the National Cancer Institute.

Fragestellung: Ziel der vorliegenden Studie ist die Erfassung von Faktoren, die die Wahl der Ther... more Fragestellung: Ziel der vorliegenden Studie ist die Erfassung von Faktoren, die die Wahl der Therapie (Ersatz versus Rekonstruktion) komplexer Frakturen des proximalen Humerus beeinflussen. Methodik: Mittels eines online Fragebogens evaluierten 217 Chirurgen und Orthopäden, 10 Fallbeschreibungen[for full text, please go to the a.m. URL]

Journal of Hand and Microsurgery, 2018

Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the... more Computed tomography (CT) is increasingly used not just to diagnose union but also to estimate the percentage of the fracture gap that is bridged by healing bone. This study tested the primary null hypothesis that there is no agreement between observers on the extent of union of a scaphoid waist fracture on CT. CT scans of 13 nondisplaced scaphoid waist fractures treated nonoperatively were rated by 145 observers. CT scans were done 10 to 12 weeks after injury. Observers were asked to “eyeball” measure percentage of union. We found that there was a moderate agreement on the categorical degree of partial union of a scaphoid waist fracture on CT (k = 0.34). Agreement on the location of bony bridging was slight (k = 0.31). We concluded that there is limited reliability of diagnosis of partial union of a scaphoid waist fracture on CT and that this should be taken into account in both patient care and research. This is a Level III, diagnostic study.

Fragestellung: Ziel der vorliegenden Studie ist die Evaluation der Reliabilität und Zuverlässigke... more Fragestellung: Ziel der vorliegenden Studie ist die Evaluation der Reliabilität und Zuverlässigkeit der Diagnose scapholunärer (SL-) Bandverletzungen im Rahmen intraartikulärer Radiusfrakturen (AO Typ C). Methodik: Mittels eines online Fragebogens evaluierten 217 Chirurgen, 21[for full text, please go to the a.m. URL]

Journal of Orthopaedic Trauma, 2014

OBJECTIVES:There is substantial variation in the classification and the management of scapula fra... more OBJECTIVES:There is substantial variation in the classification and the management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO and the New International Classification of scapula fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN:: Web-based reliability study SETTING:: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS:One-hundred and three orthopaedic surgeons evaluated 35 movies of 3DCT-reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS:Fleiss' kappa () was used to assess the reliability of agreement between the surgeons. RESULTS:: The overall agreement on the OTA/AO Classification was moderate for the types (A, B, and C, = 0.54) with a 71% proportion of rater agreement (PA) as well as for the nine groups (A1 to C3, = 0.47) with a 57% PA. For the New International Classification, the agreement about the intra-articular extension of the fracture (Fossa (F), = 0.79) was substantial, the agreement about a fractured body (Body (B), = 0.57) or process was moderate (Process (P), = 0.53), however PAs were more than 81%. The agreement on the treatment recommendation was moderate (= 0.57) with a 73% PA. CONCLUSIONS:The New International Classification was more reliable. Body and process fractures generated more disagreement than intra-articular fractures and need further clear definitions.

The Journal of Hand Surgery, 2012

Purpose We tested the hypothesis that there are no differences between apparently isolated fractu... more Purpose We tested the hypothesis that there are no differences between apparently isolated fractures of the radial diaphysis and isolated fractures of the radial diaphysis with concomitant dislocation of the distal radioulnar joint (DRUJ) in function, disability, and DRUJ stability more than 13 years after near-anatomic open reduction with plate and screw fixation. Methods We evaluated 17 adult patients with a diaphyseal fracture of the radius without a fracture of the ulna an average of 19 years after surgery (range, 13-33 y). Of these patients, 7 had concomitant dislocation of the DRUJ (Galeazzi fracture). At the long-term follow-up, we evaluated function with several composite scores, stability of the DRUJ, and arm-specific disability by using the Disabilities of Arm, Shoulder, and Hand questionnaire. Results The average scores were 96 (range, 85-100) on the Mayo Modified Wrist Score, 95 (range, 80-100) on the Mayo Elbow Performance Index, and 5 (range, 0-33) on the Disabilities of Arm, Shoulder, and Hand questionnaire. There were no significant differences between patients with and without DRUJ dislocation. No patients had greater laxity of the DRUJ than the opposite uninjured side. Conclusions Near-anatomic open reduction and internal fixation of diaphyseal radius fractures with and without associated DRUJ dislocation have comparable long-term results.

The Journal of Hand Surgery, 2013

To address the factors that surgeons use to decide between 2 options for treatment when the evide... more To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most

The Journal of Hand Surgery, 2013

Purpose To evaluate the reliability and accuracy of diagnosis of scapholunate dissociation (SLD) ... more Purpose To evaluate the reliability and accuracy of diagnosis of scapholunate dissociation (SLD) among AO type C (compression articular) fractures of the distal radius. Methods A total of 217 surgeons evaluated 21 sets of radiographs with type C fractures of the distal radius for which the status of the scapholunate interosseous ligament was established by preoperative 3-compartment computed tomographic arthrography with direct operative visualization of diagnosed SLD (reference standard). Observers were asked whether SLD was present, and if yes, whether they would recommend operative treatment. Diagnostic performance characteristics were calculated with respect to the reference standard. We assessed interobserver reliability using the Fleiss generalized kappa. Results The interobserver agreement for radiographic diagnosis of SLD was moderate (ϭ 0.44). Correct diagnosis for a given set of radiographs ranged from 8% to 98% (average, 79%) of observers. Diagnostic performance characteristics were: 69% sensitivity, 84% specificity, 84% accuracy, 68% positive predictive value, and 84% negative predictive value. Based on a prevalence of 5%, Bayes adjusted positive and negative predictive values were 18% and 98%, respectively. Raters recommended operative treatment in 74% to 100% of patients diagnosed with SLD. Conclusions Radiographs are moderately reliable and are better at ruling out than ruling in SLD associated with type C fracture of the distal radius.

Clinical Orthopaedics and Related Research®, 2012

Background Studies of traumatic elbow instability suggest that recognition of a pattern in the co... more Background Studies of traumatic elbow instability suggest that recognition of a pattern in the combination and character of the fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic elbow instability, but there is no evidence that patterns can be identified reliably. Questions/Purposes We therefore determined (1) the interobserver reliability of identifying specific patterns of traumatic elbow instability on radiographs for subgroups of orthopaedic surgeons; and (2) the diagnostic accuracy of radiographic diagnosis. Methods Seventy-three orthopaedic surgeons evaluated 53 sets of radiographs and diagnosed one of five common patterns of traumatic elbow instability by using a webbased survey. The interobserver reliability was analyzed using Cohen's multirater kappa. Intraoperative diagnosis was the reference for fracture pattern in calculations of the sensitivity, specificity, accuracy, and positive predictive and negative predictive values of radiographic diagnosis. Results The overall interobserver reliability for patterns of traumatic elbow instability on radiographs was j = 0.41. Treatment of greater than five such injuries a year was associated with greater interobserver agreement, but years in practice were not. Diagnostic accuracy ranged from 76% to 93% and was lowest for the terrible triad pattern of injury. Conclusions Specific patterns of traumatic elbow instability can be diagnosed with moderate interobserver reliability and reasonable accuracy on radiographs. Level of Evidence Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Clinical Orthopaedics and Related Research®, 2010

Background Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization ... more Background Orthopaedic surgical-site infections prolong hospital stays, double rehospitalization rates, and increase healthcare costs. Additionally, patients with orthopaedic surgical-site infections (SSI) have substantially greater physical limitations and reductions in their health-related quality of life. However, the risk factors for SSI after operative fracture care are unclear. Questions/purpose We determined the incidence and quantified modifiable and nonmodifiable risk factors for SSIs in patients with orthopaedic trauma undergoing surgery. Patients and Methods We retrospectively indentified, from our prospective trauma database and billing records, 1611 patients who underwent 1783 trauma-related procedures between 2006 and 2008. Medical records were reviewed and demographics, surgery-specific data, and whether the patients had an SSI were recorded. We determined which if any variables predicted SSI. Results Six factors independently predicted SSI: (1) the use of a drain, OR 2.3, 95% CI (1.3-3.8); (2) number of operations OR 3.4, 95% CI (2.0-6.0); (3) diabetes, OR 2.1, 95% CI (1.2-3.8); (4) congestive heart failure (CHF), OR 2.8, 95% CI (1.3-6.5); (5) site of injury tibial shaft/plateau, OR 2.3, 95% CI (1.3-4.2); and (6) site of injury, elbow, OR 2.2, 95% CI (1.1-4.7). Conclusion The risk factors for SSIs after skeletal trauma are most strongly determined by nonmodifiable factors: patient infirmity (diabetes and heart failure) and injury complexity (site of injury, number of operations, use of a drain). Level of Evidence Level II, prognostic study. See the Guideline for Authors for a complete description of levels of evidence. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Each author certifies that his or her institution approved or waived approval for the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research. This is an Institutional Review Board (IRB) approved study.

Clinical Orthopaedics and Related Research®, 2012

Clinical Orthopaedics and Related Research®, 2011

Journal of hand and microsurgery, 2013

Trapeziometacarpal arthrosis is expected with advancing age and a limited percentage of people se... more Trapeziometacarpal arthrosis is expected with advancing age and a limited percentage of people seek medical attention for it. We studied patients after their first appointment to address trapeziometacarpal arthrosis with a hand surgeon to determine factors associated with return for a second visit and eventual election of operative treatment. A billing database identified 306 patients in the practice of three hand surgeons with a new diagnosis of TMC arthrosis and no associated diagnoses. Bivariate and multivariable logistic regression analyses sought factors associated with a second visit and operative treatment among demographic and visit related factors. One hundred and forty-three patients (47 %) returned for one or more additional visits and 46 (15 %) eventually elected operative treatment within the study period. Independent predictors of a return visit included injection at first visit, splint at first visit, and doctor's recommendation for a return visit. The predictors ...

Hand (New York, N.Y.), 2012

Several studies support the use of CT for diagnosing coronal fractures of the distal radius but t... more Several studies support the use of CT for diagnosing coronal fractures of the distal radius but the inter-observer reliability of these observations is less well studied. We tested the null hypothesis that radiographs alone and the combination of radiographs and two-dimensional computed tomography scans (2DCT) have the same inter-observer variation for the diagnosis of coronal articular fracture lines in the distal radius. Using a web-based survey, 63 surgeons were randomized to evaluate 16 fractures of the distal radius on radiographs alone or radiographs and 2DCT for the presence or absence of a coronal fracture line of the lunate facet and, if present, the stability of the fracture. The kappa multirater measure was calculated to estimate agreement between observers. The inter-observer variation in diagnosis of a coronal fracture line was fair with both radiographs and 2DCT, as was the diagnosis of instability of the volar lunate facet fracture when present. Two-dimensional comput...

The Journal of bone and joint surgery. American volume, Jan 15, 2015

Many strategies have been introduced to improve safety in health care, but it is not clear that t... more Many strategies have been introduced to improve safety in health care, but it is not clear that these efforts have reduced errors. This study assessed the experienced safety culture and preferred means of improving safety among orthopaedists. Members of the Science of Variation Group and Ankle Platform were invited to complete an eighty-nine-question survey. Outcomes measured were the modified Patient Safety Climate in Healthcare Organizations (PSCHO) questionnaire, which measures safety as perceived by hospital personnel, and the degree of enthusiasm expressed for seventeen means of improving safety. The questionnaire was completed by 387 (92%) of the 422 participants. The rate of problematic responses, those implying a lack of safety climate, in the modified PSCHO questionnaire was 18%. In multivariable linear regression analysis, working in a non-teaching hospital (β, 3.7; 95% confidence interval [95% CI], 1.3 to 6.2; p = 0.003), having a safety program (β, 4.8; 95% CI, 0.74 to 8...

This thesis shows that advancements in technical head fractures analysis, imaging modalities, inc... more This thesis shows that advancements in technical head fractures analysis, imaging modalities, increased interest in psychosocial aspects of treatment and the availability of long-term outcome data can help improve classification, treatment and outcome in fractures of the radial head. It is science that created these advancements and through adequate scientific evaluation of these advancements we can continue creating more effective treatments for patients.

Journal of Wrist Surgery

Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonu... more Purpose Fractures of the proximal pole of the scaphoid are prone to adverse outcomes such as nonunion and avascular necrosis. Distinction of scaphoid proximal pole fractures from waist fractures is important for management but it is unclear if the distinction is reliable. Methods A consecutive series of 29 scaphoid fractures from one tertiary hospital was collected consisting of 5 scaphoid proximal pole and 24 scaphoid waist fractures. Fifty-seven members of the Science of Variation Group (SOVG) were randomized to diagnose fracture location and displacement by using radiographs alone or radiographs and a computed tomography (CT) scan. Results Observers reviewing radiographs alone and observers reviewing radiographs and CT scans both had substantial agreement on fracture location (κ = 0.82 and κ = 0.80, respectively; p = 0.54). Both groups had only fair agreement on fracture displacement (κ = 0.28 and κ = 0.35, respectively; p = 0.029). Conclusion Proximal pole fractures are sufficie...