Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background The role of warfarin in anterior ST-segment elevation myocardial infarction (STEMI) complicated by left ventricular (LV) dysfunction in patients treated with primary percutaneous coronary intervention (PCI) and dual antiplatelet therapy (DAPT) is unclear. Warfarin may prevent cardioembolic events but significantly increases bleeding in the setting of DAPT. Hypothesis The incidence of LV thrombus in anterior STEMI patients treated with PCI is low and clinical predictors might be valuable in determining patents at risk. Methods We performed a retrospective, single center study of 687 consecutive patients with anterior STEMI treated with PCI from 2006 to 2013. Baseline variables were evaluated in 310 patients at high risk for LV thrombus based on echocardiographic criteria. Patients with definite, probable and no LV thrombus were compared by ANOVA, chi squared or T-test where appropriate. Logistic regression analysis was performed. Results The incidence of LV thrombus was 15% (n=47 probable/definite thrombus). Cardiac arrest was the only independent characteristic associated with increased risk of LV thrombus (OR 4.06, 1.3–12.7). Trends were observed for a lower risk in cardiogenic shock (OR 0.33, 0.10–1.05) and aspirin use at baseline (OR 0.43, 0.17–1.1). Treatment variables associated with LV thrombus included unfractionated heparin use post PCI (OR 2.43, 1.16–5.1), and use of balloon angioplasty without stent. Conclusions In contemporary practice with primary PCI, definite LV thrombus following anterior STEMI with LV dysfunction is challenging to predict. Further investigation is needed to determine if there is a subset of patients that should be treated with prophylactic warfarin.

Prognostic Level III.

No abstract

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Burnout is an occupational hazard for physicians at all stages of training and medical practice. The purpose of the current study was to determine whether residency factors, with the use of an activity monitor, including the amount of exercise, have any impact on burnout among orthopaedic surgery residents in varying years of training. Methods: Orthopaedic residents at a single institution were recruited immediately before beginning a new clinical rotation and followed for four weeks. On enrollment, the participants were given a wrist-worn activity monitor (Fitbit Flex) and instructed on its use for tracking physical activity. REDCap was used to collect burnout levels (as assessed by using the Maslach Burnout Inventory and the Patient Health Questionnaire-9), which were completed a total of five times, once at enrollment and weekly during the study period. Results: Twenty-seven residents were enrolled, including 13 junior residents (interns and second years) and 14 senior residents (third, fourth, and fifth years). Seven residents were on fracture rotations, whereas 20 were not. As measured by using the Maslach Burnout Inventory, juniors were more emotionally exhausted (P = 0.01) and depersonalized (P = 0.027). No difference in the objective physical activity data as measured by using the Fitbit Flex and no difference in the self-reported hours of sleep were observed. Residents on orthopaedic trauma rotations also reported significantly higher rates of emotional exhaustion and depersonalization (P < 0.001) than other residents and were more physically active on average (P < 0.030). Discussion: Although depersonalization and depression are common symptoms seen among orthopaedic surgery residents, this study demonstrated that quality of life improves markedly as they progress through their residency training. Residents on orthopedic trauma rotations have greater levels of emotional exhaustion and depersonalization. This pilot study suggests that burnout prevention programs should begin at the start of training to provide residents with strategies to combat and then reinforced while on orthopaedic trauma rotations. Level of Evidence: Level III Diagnostic Study

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Successful arthroplasty of the knee requires a stable foundation for implant placement, adequate mechanical alignment, and durable fixation. In the revision setting, the later may be difficult to obtain, especially in the setting of significant bone loss. While augments, cones, and sleeves have greatly enhanced the modern knee surgeon's ability to gain fixation in metaphyseal bone, stems continue to be a cornerstone tool in revision arthroplasty to bypass deficient or damaged bone surfaces to enhance structural stability of a revision construct. When placing a revision construct, there remains two options to assist with fixation, either fully cementing the entire implant or using a “hybrid” system, which combines an uncemented press-fit diaphyseal stem with cement in both the metaphysis and metaphysis–diaphysis junction of the keel. In this review, we discuss the history of these two techniques, evaluate the theoretical benefits and pitfalls, and assess the best evidence supporting each in the literature. To conclude, we will examine future directions and questions needed to better elucidate the best treatment options in a variety of revision scenarios.