Kevin Tetsworth | The University of Queensland, Australia (original) (raw)

Papers by Kevin Tetsworth

Journal of the American Academy of Orthopaedic Surgeons, Sep 15, 2018

Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures... more Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures for which closed treatment is unsuccessful are stabilized using either plates or intramedullary nails. There are shortcomings associated with each technique, including the potential complications of nonunion, infection, shoulder pain, and radial nerve injury. Minimally invasive plate osteosynthesis (MIPO), an innovative alternative treatment, is gaining in popularity. This technique is based on the anterior humeral shaft providing a relatively safe surface for plate application, and limited open exposures proximally and distally allow percutaneous insertion of the necessary implant. More than 40 articles have been published regarding MIPO, and it compares favorably to other available forms of treatment with excellent functional outcomes and a lower rate of iatrogenic radial nerve injury. Larger randomized controlled trials comparing this method with other accepted techniques, including nonsurgical management, are necessary to better define the role of MIPO in the management of humeral shaft fractures.

Jbjs reviews, May 1, 2019

» Deforming forces make it difficult to reduce and maintain reduction of Neer type-II distal clav... more » Deforming forces make it difficult to reduce and maintain reduction of Neer type-II distal clavicular fractures. » Contemporary surgical techniques are associated with high rates of union and good and excellent outcomes. » Plate fixation of distal clavicular fractures does not address horizontal and vertical instability. » Hook-plate fixation has the highest complication rate. » Augmentation of the coracoclavicular ligament is recommended to neutralize the opposing forces. Disclosure: No external funds were received in support of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ JBJSREV/A433).

European Journal of Orthopaedic Surgery and Traumatology, Feb 25, 2023

Introduction The purpose of this study was to perform a systematic review and meta-analysis of bo... more Introduction The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing double-button suture fixation to hook plate fixation for types III-IV acromioclavicular joint dislocation. Methods Systematic review of Medline, Embase, Scopus, and Google Scholar, including all levels 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. MINORS and modified Coleman Methodology Score (CMS) were used to assess within study quality. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ 2 and I 2 statistics. Results Fifteen studies were included. Three of the four included LOE II and eleven of the LOE III studies had a high risk of bias. Study quality was considered poor and fair for 67% by MINORS criteria and 93% for CMS criteria. The pooled estimate (SMD 0.662) for all clinical outcomes was statistically significant and in favor of button repair (p = 0.0001). The pooled estimate (SMD 0.662) for all VAS pain scores was statistically significant, again in favor of button repair (p = 0.001). Conclusions The results of this meta-analysis demonstrated significantly better outcomes of button repair for acute ACJ dislocations when compared to clavicle hook plate. Button repair is also associated with a 2.2 times lower risk for complications. However, risk of bias is high, and study quality within and between studies was low. These results, therefore, must be viewed with caution. Level of evidence Level III; systematic review and meta-analysis.

Journal of limb lengthening & reconstruction, 2022

Orthopaedic Proceedings, Feb 21, 2018

Orthopaedic Proceedings, Feb 21, 2018

Purpose: Malpositioning of the acetabular cup component in total hip arthroplasty can result in i... more Purpose: Malpositioning of the acetabular cup component in total hip arthroplasty can result in increased wear, early nonseptic loosening and is the most common cause of dislocation. Previous research has defined a safe zone with an inclination of 40±10 degrees and anteversion of 15±10 degrees. The purpose of this study was to compare cup placement using imageless navigation to a matched control group using CT based measurements. Methods: 30 patients receiving a primary hip replacement were included. Alignment of the implant is based on the acquisition of landmarks (ASIS and pubic tubercle) and placement of tracking pins into the ASIS. The target position for all patients was 45 degrees of inclination and 15 degrees of anteversion. A multi-slice CT scan was used to assess cup position. Results: There was no significant difference between mean inclination (p=0.11) and anteversion (p=0.24) but a statistically significant difference for mean deviation from the desired position for inclination (p=0.003) and anteversion (p=0.007). There was a significant difference in the percentages of correctly placed cups with inclination (p=0.046) and with anteversion (p=0.006). Combining both anteversion and inclination there was a significant difference (p=0.01). Conclusion: Computer navigation for total joint arthroplasty, if helpful to the surgeon, has to increase reliability of component placement and show a significant reduction in variation compared to freehand techniques. We demonstrated a significant increase in accuracy of placement of acetabular cups within the desired position and safe zone using imageless navigation.

European Journal of Orthopaedic Surgery and Traumatology, May 24, 2018

The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fi... more The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fixation in distal tibia fractures salvaged with hexapod circular fixators. Material and Methods: The database of a specialized limb reconstruction centre was searched for all patients with failed plate fixation undergoing limb reconstruction with a circular external fixator between 2008 and 2017. Patients between the ages of 18-65 years, with a symptomatic distal tibia mal-union or non-union following plate and screw fixation were included. The SF-12 and Foot Function Index (FFI) scoring systems were used to measure clinical and functional outcomes. Results: Ten patients with a mean age of 38±13years met the inclusion criteria. Seven patients had an infected non-union, two hypertrophic non-unions, and one a mal-union. The mean follow-up was 41.7±28.3 months. The mean duration of external fixation was 232.9±146.6 days. The SF-12 demonstrated a mean score of 49.4±7.7 for the physical component, and a mean score of 55.3±8.1 for the mental component. Five patients (50%) scored above 45 points for the SF12 physical component and nine patients (90%) scored above 45 points for the mental component, indicating good outcome can be achieved. The mean FFI score was 24.9±19.9, and six patients had a score below 14 points (good outcome). Radiological union was observed in all 10 patients at a mean of 29+14 months.

Archives of Orthopaedic and Trauma Surgery, Jan 3, 2021

Purpose The common peroneal nerve (CPN) can be injured during fibular-based posterolateral recons... more Purpose The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed. Methods In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1–M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher’s exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages. Results The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8–33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4–24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4–37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively. Conclusion The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit. Clinical Relevance Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.

Journal of Orthopaedic Trauma, Feb 1, 2021

Objectives: To develop a post-traumatic bone defect classification scheme and complete a prelimin... more Objectives: To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability. Design: Retrospective classification. Setting: Tertiary referral trauma center. Patients/Participants: Twenty open fractures with bone loss. Intervention: Assignment of a bone defect classification grade. Main Outcome Measurements: Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1—incomplete defects, D2—minor/subcritical (complete) defects (<2 cm), and D3—segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A—<25% cortical loss, D1B—25%–75% cortical loss, and D1C—>75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A—2 oblique ends allowing for possible overlap, D2B—one end oblique/one end transverse, and D2C—2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A—moderate defects, 2 to <4 cm; D3B—major defects, 4 to <8 cm; and D3C—massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests. Results: Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478–0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421–0.1679), P < 0.00001. Conclusions: This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.

Bone reports, Jun 1, 2023

Research Square (Research Square), Mar 20, 2023

The utilization of bone scaffold implants represents a promising approach for repairing substanti... more The utilization of bone scaffold implants represents a promising approach for repairing substantial bone defects. In recent years, various traditional scaffold structures have been developed and, with the advancements in materials biology and computer technology, novel scaffold designs are being evaluated. This study investigated the effects of a novel scaffold unit cell design (Hexnaoid) through a computational framework, comparing its performance to that of four well-known scaffold designs. A nite element analysis (FEA) numerical simulation and mechanical testing were conducted to analyse the dynamic bone ingrowth process and the mechanical strength of the scaffold designs, respectively. The bone formation within the Ti-6Al-4V metal scaffolds was modelled based on the theory of bone remodelling. The results indicated that the novel scaffold design (Hexnaoid) outperforms conventional unit-cell designs, achieving a high nal bone occupancy (~27%) and comparable mechanical strength to that of human compact bone tissue. While the design is not optimal in every category, it presents a satisfactory overall performance in both crucial aspects of bone scaffolds among the ve scaffold structures evaluated. Although limitations exist in this project, similar methodologies can still be applied in the primary evaluation of new scaffold structures, providing improved e ciency and effectiveness. In future research, the results of this project may be integrated with clinical rehabilitation processes and offering a crucial evaluation and optimization of the novel scaffold unit-cell structure design.

Orthopaedic Proceedings, Aug 7, 2020

Orthopaedic Proceedings, Feb 21, 2018

Purpose: Imageless navigation has improved the accuracy of acetabular cup placement but relies on... more Purpose: Imageless navigation has improved the accuracy of acetabular cup placement but relies on manual identification of pelvic anatomy. Thick soft tissues in obese patients could obscure these landmarks and result in large variances of cup placement. The purpose of this study was to investigate the relationship between BMI, soft tissue thickness, navigated cup and final post-operative cup position. Methods: Thirty patients with an average age of 66.5 years underwent primary navigated THA. Final intra-operative cup position was recorded. Soft tissue thickness and final post-operative cup alignment were measured on a multi-slice pelvis CT scan. Results: There were no significant relationships between the variables for inclination. Larger ranges were observed in the obese group. It reached significance for the difference between the desired and final post-operative cup position (p=0.007). There was a moderately significant relationship (r=0.41, p=0.0002) between soft tissue thickness and final cup anteversion and a strong and near significant correlation (r=0.6, p=0.07) for the difference between the desired and final post-operative cup position for anteversion. Similar to inclination larger ranges were observed in the obese group. However, significant differences were only observed for final post-operative cup position (p=0.002) and the difference between the desired and final post-operative cup position (p=0.0003). Conclusion: Despite the potential introduction of error with acquisition of landmarks, our data suggests that in obese patients the overlying soft-tissue thickness has no significant effect on the accuracy on acetabular cup inclination. In contrast anteversion is influenced by the overlying soft tissue thickness and obesity.

Orthopaedic Proceedings, May 1, 2012

A number of validated knee outcome rating scales are used to assess knee function in the ACL-defi... more A number of validated knee outcome rating scales are used to assess knee function in the ACL-deficient and ACL-reconstructed knee. These scores use a numeric system to rate findings such as pain, swelling, subjective assessment of function and level of activity. However, it is unknown whether there is a correlation between the outcome rating scales and whether they can be used interchangeably. The aim of this study was to investigate the correlation between the four commonly used outcome rating scales (Lysholm, IKDC, Cincinnati and Tegner). Inclusion criteria included physically active patients between the age of 18 and 35 years with isolated ACL injuries. A power calculation for sample size was performed. Selecting an alpha level of 0.05 and power value of 0.8, 24 ACL- deficient and 24 ACL-reconstructed subjects were needed to achieve adequate statistical power. Statistical analysis included the calculation of means and standard deviations for the dependant variables. Pearson9s product moment correlation coefficients were used to establish the strength of the relationships. Forty-four ACL-deficient and 24 ACL reconstructed subjects (mean age 27.0, range 16–49), with a minimum of 12 months post surgery, completed the tests. Pre-operatively, strong significant correlations (r=0.53-0.74, p=0.0001-0.001) between IKDC and the other scoring systems (Cinncinati, Lysholm and Tegner) were observed. The Lysholm score was significantly correlated to IKDC (r=0.74, p=0.0001) and Cinncinati (r=0.60, p=0.001) scores. Non-significant moderate correlations were observed between Lysholm and Tegner (r=0.38, p=0.17) and Cinncinati and Tegner (r=0.36, p=0.18) scores. Post-operatively all scores were strongly related (r=0.61- 0.93). However, only the relationships between Lysholm and IKDC score (p=0.001) and IKDC and Cinncinati score (p=0.01) reached statistical significance. The results of this study indicate that the commonly used rating scales produce interchangeable results in the ACL-deficient patient. In the ACL-reconstructed patient, knee scoring systems seem to measure different aspects of physical activity, physical disability and subjective patient satisfaction—all of which are not interchangeable. As such, the classification of results may vary and may explain the findings.

Orthopaedic Proceedings, Feb 21, 2018

Gait analysis is an important tool to measure function following total knee replacement. It is cu... more Gait analysis is an important tool to measure function following total knee replacement. It is currently unknown whether there is a correlation between subjective and objective outcome variables. The purpose of this study was to analyse relationships between subjective outcome scores and kinematic and kinetic data.25 consecutive patients (15 males, 10 females) were selected (mean age 68 years, BMI 31.8). All subjects were tested a minimum of 24 months following total knee replacement. SF12, Oxford knee score, knee society and KOOS scores were collected. Muscle strength was assessed using a Biodex dynamometer and symmetry indices were analysed. A timed up and go test and KT2000 measurements were performed.Strong correlations (r=0.52–0.74) were found between scoring systems (SF 12, Oxford knee score, knee society score, KOOS score) and the timed up and go test. Moderate correlations (r=0.27–0.35) were found between knee scores and KT2000 measurements. Only weak correlations (r=0.09–0.12) were found between ...

Strategies in Trauma and Limb Reconstruction, Apr 1, 2021

Aim and objectiveThe purpose of this study was to compare clinical results following complex prox... more Aim and objectiveThe purpose of this study was to compare clinical results following complex proximal, midshaft, and distal tibial fractures and investigate whether there are differences in outcomes between these locations.Materials and methodsPatients between 18 years and 65 years of age and minimum follow-up of 12 months with complex tibial fractures treated with a circular ring fixator were included. Functional outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) functional and bone scores, Foot Function Index (FFI), Four Step Square Test (FSST), and Timed Up and Go Test (TUG). Quality of life was assessed by the EQ-5D score.ResultsA total of 45 patients were included: proximal fractures, n = 11; midshaft fractures, n = 17; and distal fractures, n = 17. ASAMI functional (p = 0.8) and bone scores (p = 0.3) were not different. Excellent and good bone scores were achieved in >90% in all groups. FFI was 30.9 + 24.7 in the proximal group, 33.9 + 27.7 in the midshaft group, and 28.8 + 26.9 in the distal group (p = 0.8). TUG was 9.0 + 2.7 sec in the proximal group, 9.0+3.5 in the midshaft group, and 8.5+2.0 in the distal group (p = 0.67). FSST was 10.7 + 2.5 sec in the proximal, 10.3 + 3.8 in the midshaft, and 8.9 + 1.8 in the distal fracture groups (p = 0.5). EQ-5D index value was highest in the distal (0.72), lowest in the proximal (0.55), and 0.70 in the midshaft fracture groups (p = 0.001). EQ-5D VAS was significantly different between the proximal (65) and midshaft (82.3) (p = 0.001) and between the distal (75) and proximal (65) fracture groups (p = 0.001).ConclusionsThe results of this study suggest that the functional outcomes between proximal, midshaft, and distal complex tibial fractures are comparable. Their ability to ambulate afterward is comparable to age-related normative data, but complex tasks are more difficult and better compared to the ambulating ability of a healthy population aged 65 to 80 years. Patients with proximal tibial fractures had significantly more disability by at least one functional level and/or one health dimension.How to cite this articleNaude JJ, Manjra MA, Birkholtz F, et al. Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):32–40.

Journal of the American Academy of Orthopaedic Surgeons, Jul 1, 2018

Background: The purpose of this study was to conduct a bibliometric analysis of orthopaedic acade... more Background: The purpose of this study was to conduct a bibliometric analysis of orthopaedic academic output in the United States. Methods: Publications based on city and state origin, corrected for population size, median household income, total number of surgeons, and the number of various subspecialties were evaluated. The 15 highest-ranked orthopaedic journals were audited from 2010 to 2014 and then subdivided into anatomic regions and 14 subspecialties. Results: A total of 8,100 articles were published during the study period. Most originated from New York, California, Pennsylvania, Massachusetts, and Minnesota. New York published the greatest number by city, followed by Philadelphia, Boston, Chicago, and Rochester. When adjusted for the number of publications per city, surgeons per population, publications per surgeon population, publications per population, and publications per median income per capita, Vail and New York led in two and Stanford in one of the metrics. Conclusions: New York was the leader for the total publications, greatest activity within subspecialties, and publications per surgeon/population and per median income/capita. Vail was the leader for publications/surgeon and population. The top four cities of New York, Philadelphia, Boston, and Chicago were responsible for 28% of the academic output over the 5-year study period. T he publication of research articles is an important aspect for medical professionals, particularly in academic environments. 1 Success for both individuals and faculty groups is often measured by the number of publications, citation counts, and external research funding. 2,3 These bibliometric measures are also frequently assessed when considering academic promotion, grant allocations, or entry into academic organizations. 2-5 Medical journals also use the same measures to define their impact in an attempt to attract a greater number of high-quality

JBJS case connector, 2021

Cases: Three patients with knee-level complex regional pain syndrome type 1 (CRPS1), recalcitrant... more Cases: Three patients with knee-level complex regional pain syndrome type 1 (CRPS1), recalcitrant to conservative interventions, elected for transfemoral amputation and osseointegration. Two patients gained independent ambulation; the third remains on crutches after a disrupted sciatic nerve targeted reinnervation. One uses no pain medication, one is weaning off, and one requires a reduced regimen after revision nerve innervation. Conclusion: Osseointegration seems suitable to optimize rehabilitation after amputation for CRPS1.

Physical and Engineering Sciences in Medicine, Apr 27, 2023

Distal radius fractures (DRFs) are one of the most common types of wrist fracture and can be subd... more Distal radius fractures (DRFs) are one of the most common types of wrist fracture and can be subdivided into intra-and extra-articular fractures. Compared with extra-articular DRFs which spare the joint surface, intra-articular DRFs extend to the articular surface and can be more difficult to treat. Identification of articular involvement can provide valuable information about the characteristics of fracture patterns. In this study, a two-stage ensemble deep learning framework was proposed to differentiate intra-and extra-articular DRFs automatically on posteroanterior (PA) view wrist X-rays. The framework firstly detects the distal radius region of interest (ROI) using an ensemble model of YOLOv5 networks, which imitates the clinicians' search pattern of zooming in on relevant regions to assess abnormalities. Secondly, an ensemble model of EfficientNet-B3 networks classifies the fractures in the detected ROIs into intra-and extra-articular. The framework achieved an area under the receiver operating characteristic curve of 0.82, an accuracy of 0.81, a true positive rate of 0.83 and a false positive rate of 0.27 (specificity of 0.73) for differentiating intra-from extra-articular DRFs. This study has demonstrated the potential in automatic DRF characterization using deep learning on clinically acquired wrist radiographs and can serve as a baseline for further research in incorporating multi-view information for fracture classification.

Journal of the American Academy of Orthopaedic Surgeons, Sep 15, 2018

Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures... more Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures for which closed treatment is unsuccessful are stabilized using either plates or intramedullary nails. There are shortcomings associated with each technique, including the potential complications of nonunion, infection, shoulder pain, and radial nerve injury. Minimally invasive plate osteosynthesis (MIPO), an innovative alternative treatment, is gaining in popularity. This technique is based on the anterior humeral shaft providing a relatively safe surface for plate application, and limited open exposures proximally and distally allow percutaneous insertion of the necessary implant. More than 40 articles have been published regarding MIPO, and it compares favorably to other available forms of treatment with excellent functional outcomes and a lower rate of iatrogenic radial nerve injury. Larger randomized controlled trials comparing this method with other accepted techniques, including nonsurgical management, are necessary to better define the role of MIPO in the management of humeral shaft fractures.

Jbjs reviews, May 1, 2019

» Deforming forces make it difficult to reduce and maintain reduction of Neer type-II distal clav... more » Deforming forces make it difficult to reduce and maintain reduction of Neer type-II distal clavicular fractures. » Contemporary surgical techniques are associated with high rates of union and good and excellent outcomes. » Plate fixation of distal clavicular fractures does not address horizontal and vertical instability. » Hook-plate fixation has the highest complication rate. » Augmentation of the coracoclavicular ligament is recommended to neutralize the opposing forces. Disclosure: No external funds were received in support of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ JBJSREV/A433).

European Journal of Orthopaedic Surgery and Traumatology, Feb 25, 2023

Introduction The purpose of this study was to perform a systematic review and meta-analysis of bo... more Introduction The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing double-button suture fixation to hook plate fixation for types III-IV acromioclavicular joint dislocation. Methods Systematic review of Medline, Embase, Scopus, and Google Scholar, including all levels 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were included. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. MINORS and modified Coleman Methodology Score (CMS) were used to assess within study quality. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ 2 and I 2 statistics. Results Fifteen studies were included. Three of the four included LOE II and eleven of the LOE III studies had a high risk of bias. Study quality was considered poor and fair for 67% by MINORS criteria and 93% for CMS criteria. The pooled estimate (SMD 0.662) for all clinical outcomes was statistically significant and in favor of button repair (p = 0.0001). The pooled estimate (SMD 0.662) for all VAS pain scores was statistically significant, again in favor of button repair (p = 0.001). Conclusions The results of this meta-analysis demonstrated significantly better outcomes of button repair for acute ACJ dislocations when compared to clavicle hook plate. Button repair is also associated with a 2.2 times lower risk for complications. However, risk of bias is high, and study quality within and between studies was low. These results, therefore, must be viewed with caution. Level of evidence Level III; systematic review and meta-analysis.

Journal of limb lengthening & reconstruction, 2022

Orthopaedic Proceedings, Feb 21, 2018

Orthopaedic Proceedings, Feb 21, 2018

Purpose: Malpositioning of the acetabular cup component in total hip arthroplasty can result in i... more Purpose: Malpositioning of the acetabular cup component in total hip arthroplasty can result in increased wear, early nonseptic loosening and is the most common cause of dislocation. Previous research has defined a safe zone with an inclination of 40±10 degrees and anteversion of 15±10 degrees. The purpose of this study was to compare cup placement using imageless navigation to a matched control group using CT based measurements. Methods: 30 patients receiving a primary hip replacement were included. Alignment of the implant is based on the acquisition of landmarks (ASIS and pubic tubercle) and placement of tracking pins into the ASIS. The target position for all patients was 45 degrees of inclination and 15 degrees of anteversion. A multi-slice CT scan was used to assess cup position. Results: There was no significant difference between mean inclination (p=0.11) and anteversion (p=0.24) but a statistically significant difference for mean deviation from the desired position for inclination (p=0.003) and anteversion (p=0.007). There was a significant difference in the percentages of correctly placed cups with inclination (p=0.046) and with anteversion (p=0.006). Combining both anteversion and inclination there was a significant difference (p=0.01). Conclusion: Computer navigation for total joint arthroplasty, if helpful to the surgeon, has to increase reliability of component placement and show a significant reduction in variation compared to freehand techniques. We demonstrated a significant increase in accuracy of placement of acetabular cups within the desired position and safe zone using imageless navigation.

European Journal of Orthopaedic Surgery and Traumatology, May 24, 2018

The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fi... more The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fixation in distal tibia fractures salvaged with hexapod circular fixators. Material and Methods: The database of a specialized limb reconstruction centre was searched for all patients with failed plate fixation undergoing limb reconstruction with a circular external fixator between 2008 and 2017. Patients between the ages of 18-65 years, with a symptomatic distal tibia mal-union or non-union following plate and screw fixation were included. The SF-12 and Foot Function Index (FFI) scoring systems were used to measure clinical and functional outcomes. Results: Ten patients with a mean age of 38±13years met the inclusion criteria. Seven patients had an infected non-union, two hypertrophic non-unions, and one a mal-union. The mean follow-up was 41.7±28.3 months. The mean duration of external fixation was 232.9±146.6 days. The SF-12 demonstrated a mean score of 49.4±7.7 for the physical component, and a mean score of 55.3±8.1 for the mental component. Five patients (50%) scored above 45 points for the SF12 physical component and nine patients (90%) scored above 45 points for the mental component, indicating good outcome can be achieved. The mean FFI score was 24.9±19.9, and six patients had a score below 14 points (good outcome). Radiological union was observed in all 10 patients at a mean of 29+14 months.

Archives of Orthopaedic and Trauma Surgery, Jan 3, 2021

Purpose The common peroneal nerve (CPN) can be injured during fibular-based posterolateral recons... more Purpose The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed. Methods In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1–M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher’s exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages. Results The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8–33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4–24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4–37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively. Conclusion The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit. Clinical Relevance Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.

Journal of Orthopaedic Trauma, Feb 1, 2021

Objectives: To develop a post-traumatic bone defect classification scheme and complete a prelimin... more Objectives: To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability. Design: Retrospective classification. Setting: Tertiary referral trauma center. Patients/Participants: Twenty open fractures with bone loss. Intervention: Assignment of a bone defect classification grade. Main Outcome Measurements: Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1—incomplete defects, D2—minor/subcritical (complete) defects (<2 cm), and D3—segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A—<25% cortical loss, D1B—25%–75% cortical loss, and D1C—>75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A—2 oblique ends allowing for possible overlap, D2B—one end oblique/one end transverse, and D2C—2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A—moderate defects, 2 to <4 cm; D3B—major defects, 4 to <8 cm; and D3C—massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests. Results: Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478–0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421–0.1679), P < 0.00001. Conclusions: This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.

Bone reports, Jun 1, 2023

Research Square (Research Square), Mar 20, 2023

The utilization of bone scaffold implants represents a promising approach for repairing substanti... more The utilization of bone scaffold implants represents a promising approach for repairing substantial bone defects. In recent years, various traditional scaffold structures have been developed and, with the advancements in materials biology and computer technology, novel scaffold designs are being evaluated. This study investigated the effects of a novel scaffold unit cell design (Hexnaoid) through a computational framework, comparing its performance to that of four well-known scaffold designs. A nite element analysis (FEA) numerical simulation and mechanical testing were conducted to analyse the dynamic bone ingrowth process and the mechanical strength of the scaffold designs, respectively. The bone formation within the Ti-6Al-4V metal scaffolds was modelled based on the theory of bone remodelling. The results indicated that the novel scaffold design (Hexnaoid) outperforms conventional unit-cell designs, achieving a high nal bone occupancy (~27%) and comparable mechanical strength to that of human compact bone tissue. While the design is not optimal in every category, it presents a satisfactory overall performance in both crucial aspects of bone scaffolds among the ve scaffold structures evaluated. Although limitations exist in this project, similar methodologies can still be applied in the primary evaluation of new scaffold structures, providing improved e ciency and effectiveness. In future research, the results of this project may be integrated with clinical rehabilitation processes and offering a crucial evaluation and optimization of the novel scaffold unit-cell structure design.

Orthopaedic Proceedings, Aug 7, 2020

Orthopaedic Proceedings, Feb 21, 2018

Purpose: Imageless navigation has improved the accuracy of acetabular cup placement but relies on... more Purpose: Imageless navigation has improved the accuracy of acetabular cup placement but relies on manual identification of pelvic anatomy. Thick soft tissues in obese patients could obscure these landmarks and result in large variances of cup placement. The purpose of this study was to investigate the relationship between BMI, soft tissue thickness, navigated cup and final post-operative cup position. Methods: Thirty patients with an average age of 66.5 years underwent primary navigated THA. Final intra-operative cup position was recorded. Soft tissue thickness and final post-operative cup alignment were measured on a multi-slice pelvis CT scan. Results: There were no significant relationships between the variables for inclination. Larger ranges were observed in the obese group. It reached significance for the difference between the desired and final post-operative cup position (p=0.007). There was a moderately significant relationship (r=0.41, p=0.0002) between soft tissue thickness and final cup anteversion and a strong and near significant correlation (r=0.6, p=0.07) for the difference between the desired and final post-operative cup position for anteversion. Similar to inclination larger ranges were observed in the obese group. However, significant differences were only observed for final post-operative cup position (p=0.002) and the difference between the desired and final post-operative cup position (p=0.0003). Conclusion: Despite the potential introduction of error with acquisition of landmarks, our data suggests that in obese patients the overlying soft-tissue thickness has no significant effect on the accuracy on acetabular cup inclination. In contrast anteversion is influenced by the overlying soft tissue thickness and obesity.

Orthopaedic Proceedings, May 1, 2012

A number of validated knee outcome rating scales are used to assess knee function in the ACL-defi... more A number of validated knee outcome rating scales are used to assess knee function in the ACL-deficient and ACL-reconstructed knee. These scores use a numeric system to rate findings such as pain, swelling, subjective assessment of function and level of activity. However, it is unknown whether there is a correlation between the outcome rating scales and whether they can be used interchangeably. The aim of this study was to investigate the correlation between the four commonly used outcome rating scales (Lysholm, IKDC, Cincinnati and Tegner). Inclusion criteria included physically active patients between the age of 18 and 35 years with isolated ACL injuries. A power calculation for sample size was performed. Selecting an alpha level of 0.05 and power value of 0.8, 24 ACL- deficient and 24 ACL-reconstructed subjects were needed to achieve adequate statistical power. Statistical analysis included the calculation of means and standard deviations for the dependant variables. Pearson9s product moment correlation coefficients were used to establish the strength of the relationships. Forty-four ACL-deficient and 24 ACL reconstructed subjects (mean age 27.0, range 16–49), with a minimum of 12 months post surgery, completed the tests. Pre-operatively, strong significant correlations (r=0.53-0.74, p=0.0001-0.001) between IKDC and the other scoring systems (Cinncinati, Lysholm and Tegner) were observed. The Lysholm score was significantly correlated to IKDC (r=0.74, p=0.0001) and Cinncinati (r=0.60, p=0.001) scores. Non-significant moderate correlations were observed between Lysholm and Tegner (r=0.38, p=0.17) and Cinncinati and Tegner (r=0.36, p=0.18) scores. Post-operatively all scores were strongly related (r=0.61- 0.93). However, only the relationships between Lysholm and IKDC score (p=0.001) and IKDC and Cinncinati score (p=0.01) reached statistical significance. The results of this study indicate that the commonly used rating scales produce interchangeable results in the ACL-deficient patient. In the ACL-reconstructed patient, knee scoring systems seem to measure different aspects of physical activity, physical disability and subjective patient satisfaction—all of which are not interchangeable. As such, the classification of results may vary and may explain the findings.

Orthopaedic Proceedings, Feb 21, 2018

Gait analysis is an important tool to measure function following total knee replacement. It is cu... more Gait analysis is an important tool to measure function following total knee replacement. It is currently unknown whether there is a correlation between subjective and objective outcome variables. The purpose of this study was to analyse relationships between subjective outcome scores and kinematic and kinetic data.25 consecutive patients (15 males, 10 females) were selected (mean age 68 years, BMI 31.8). All subjects were tested a minimum of 24 months following total knee replacement. SF12, Oxford knee score, knee society and KOOS scores were collected. Muscle strength was assessed using a Biodex dynamometer and symmetry indices were analysed. A timed up and go test and KT2000 measurements were performed.Strong correlations (r=0.52–0.74) were found between scoring systems (SF 12, Oxford knee score, knee society score, KOOS score) and the timed up and go test. Moderate correlations (r=0.27–0.35) were found between knee scores and KT2000 measurements. Only weak correlations (r=0.09–0.12) were found between ...

Strategies in Trauma and Limb Reconstruction, Apr 1, 2021

Aim and objectiveThe purpose of this study was to compare clinical results following complex prox... more Aim and objectiveThe purpose of this study was to compare clinical results following complex proximal, midshaft, and distal tibial fractures and investigate whether there are differences in outcomes between these locations.Materials and methodsPatients between 18 years and 65 years of age and minimum follow-up of 12 months with complex tibial fractures treated with a circular ring fixator were included. Functional outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) functional and bone scores, Foot Function Index (FFI), Four Step Square Test (FSST), and Timed Up and Go Test (TUG). Quality of life was assessed by the EQ-5D score.ResultsA total of 45 patients were included: proximal fractures, n = 11; midshaft fractures, n = 17; and distal fractures, n = 17. ASAMI functional (p = 0.8) and bone scores (p = 0.3) were not different. Excellent and good bone scores were achieved in >90% in all groups. FFI was 30.9 + 24.7 in the proximal group, 33.9 + 27.7 in the midshaft group, and 28.8 + 26.9 in the distal group (p = 0.8). TUG was 9.0 + 2.7 sec in the proximal group, 9.0+3.5 in the midshaft group, and 8.5+2.0 in the distal group (p = 0.67). FSST was 10.7 + 2.5 sec in the proximal, 10.3 + 3.8 in the midshaft, and 8.9 + 1.8 in the distal fracture groups (p = 0.5). EQ-5D index value was highest in the distal (0.72), lowest in the proximal (0.55), and 0.70 in the midshaft fracture groups (p = 0.001). EQ-5D VAS was significantly different between the proximal (65) and midshaft (82.3) (p = 0.001) and between the distal (75) and proximal (65) fracture groups (p = 0.001).ConclusionsThe results of this study suggest that the functional outcomes between proximal, midshaft, and distal complex tibial fractures are comparable. Their ability to ambulate afterward is comparable to age-related normative data, but complex tasks are more difficult and better compared to the ambulating ability of a healthy population aged 65 to 80 years. Patients with proximal tibial fractures had significantly more disability by at least one functional level and/or one health dimension.How to cite this articleNaude JJ, Manjra MA, Birkholtz F, et al. Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):32–40.

Journal of the American Academy of Orthopaedic Surgeons, Jul 1, 2018

Background: The purpose of this study was to conduct a bibliometric analysis of orthopaedic acade... more Background: The purpose of this study was to conduct a bibliometric analysis of orthopaedic academic output in the United States. Methods: Publications based on city and state origin, corrected for population size, median household income, total number of surgeons, and the number of various subspecialties were evaluated. The 15 highest-ranked orthopaedic journals were audited from 2010 to 2014 and then subdivided into anatomic regions and 14 subspecialties. Results: A total of 8,100 articles were published during the study period. Most originated from New York, California, Pennsylvania, Massachusetts, and Minnesota. New York published the greatest number by city, followed by Philadelphia, Boston, Chicago, and Rochester. When adjusted for the number of publications per city, surgeons per population, publications per surgeon population, publications per population, and publications per median income per capita, Vail and New York led in two and Stanford in one of the metrics. Conclusions: New York was the leader for the total publications, greatest activity within subspecialties, and publications per surgeon/population and per median income/capita. Vail was the leader for publications/surgeon and population. The top four cities of New York, Philadelphia, Boston, and Chicago were responsible for 28% of the academic output over the 5-year study period. T he publication of research articles is an important aspect for medical professionals, particularly in academic environments. 1 Success for both individuals and faculty groups is often measured by the number of publications, citation counts, and external research funding. 2,3 These bibliometric measures are also frequently assessed when considering academic promotion, grant allocations, or entry into academic organizations. 2-5 Medical journals also use the same measures to define their impact in an attempt to attract a greater number of high-quality

JBJS case connector, 2021

Cases: Three patients with knee-level complex regional pain syndrome type 1 (CRPS1), recalcitrant... more Cases: Three patients with knee-level complex regional pain syndrome type 1 (CRPS1), recalcitrant to conservative interventions, elected for transfemoral amputation and osseointegration. Two patients gained independent ambulation; the third remains on crutches after a disrupted sciatic nerve targeted reinnervation. One uses no pain medication, one is weaning off, and one requires a reduced regimen after revision nerve innervation. Conclusion: Osseointegration seems suitable to optimize rehabilitation after amputation for CRPS1.

Physical and Engineering Sciences in Medicine, Apr 27, 2023

Distal radius fractures (DRFs) are one of the most common types of wrist fracture and can be subd... more Distal radius fractures (DRFs) are one of the most common types of wrist fracture and can be subdivided into intra-and extra-articular fractures. Compared with extra-articular DRFs which spare the joint surface, intra-articular DRFs extend to the articular surface and can be more difficult to treat. Identification of articular involvement can provide valuable information about the characteristics of fracture patterns. In this study, a two-stage ensemble deep learning framework was proposed to differentiate intra-and extra-articular DRFs automatically on posteroanterior (PA) view wrist X-rays. The framework firstly detects the distal radius region of interest (ROI) using an ensemble model of YOLOv5 networks, which imitates the clinicians' search pattern of zooming in on relevant regions to assess abnormalities. Secondly, an ensemble model of EfficientNet-B3 networks classifies the fractures in the detected ROIs into intra-and extra-articular. The framework achieved an area under the receiver operating characteristic curve of 0.82, an accuracy of 0.81, a true positive rate of 0.83 and a false positive rate of 0.27 (specificity of 0.73) for differentiating intra-from extra-articular DRFs. This study has demonstrated the potential in automatic DRF characterization using deep learning on clinically acquired wrist radiographs and can serve as a baseline for further research in incorporating multi-view information for fracture classification.