Daniel Guss

Hinged Elbow External Fixation for Severe Elbow Contracture

BACKGROUND When it was first introduced, it was hoped that hinged external fixation with a built-in gear mechanism for applying passive motion and static progressive stretch by turning a dial would improve the arc of ulnohumeral motion, by gradually stretching contracted muscles, after open release of a severe elbow contracture. METHODS Forty-two patients were evaluated at an average of thirty-nine months after operative release of a severe posttraumatic elbow contracture (defined as < or =40 degrees of motion). Twenty-three patients had been treated, during the early part of the study, with a hinged external fixator that incorporated a worm gear to apply static progressive stretch postoperatively. These patients were compared with nineteen patients who had been treated without hinged external fixation during the later part of the study, when the hinge was used less frequently. The operative techniques did not otherwise change during the study period. Demographic and injury characteristics as well as associated problems were comparable between the two groups. RESULTS The average gain in the range of motion after the index procedure was 89 degrees in the patients treated with a hinge and 78 degrees in those treated without a hinge, an insignificant difference with the numbers available (p = 0.175). Complications associated with use of the hinge included five pin-track infections, one case of pin-track osteomyelitis, one ulnar fracture through a pin site, two broken Schanz screws, and two cases of irritation of the ulnar nerve. CONCLUSIONS Open release of a severe elbow contracture results in a substantial gain in motion, with or without hinged elbow fixation. The slightly greater improvement in motion provided by the hinge does not justify the associated increase in risk, expense, and complications.

Idiopathic Arm Pain

BACKGROUND Arm pain with little or no objective abnormality (referred to herein as idiopathic arm pain) is a common and frustrating problem for both patients and physicians. We investigated the relative effect of idiopathic arm pain and arm pain due to a discrete diagnosis on upper-extremity-specific health status. METHODS The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was completed by 3888 patients seen over a twelve-month period. Scores for the entire sample, for 496 patients diagnosed with idiopathic arm pain, and for 1379 patients diagnosed with one of twenty-one discrete conditions were compared. RESULTS Patients with idiopathic pain reported substantial and highly variable upper-limb-specific dysfunction (average DASH score [and standard deviation], 36 +/- 24 points). Patients with discrete diagnoses also exhibited substantial variation (average standard deviation, 25; range, 6 to 27) as well as long right tails indicating floor effects, particularly for less severe conditions (Pearson correlation of r = -0.87 between the mean DASH score and skewness). Analysis of variance confirmed the ability of the DASH instrument to discriminate among groups of diagnoses of varying severity, but post hoc Tukey analysis identified ten subgroups with substantial overlap of the DASH scores. CONCLUSIONS Patients with idiopathic arm pain report substantial and highly variable upper-extremity dysfunction. The wide variations observed in the DASH scores of the patients with idiopathic pain and those with discrete diagnoses are greater than would be expected on the basis of the variations in the objective pathological conditions and may reflect the strong influence of psychological and sociological factors on health status measures.

Concomitant Arthroscopic SLAP and Rotator Cuff Repair

BACKGROUND The outcomes of combined arthroscopic repairs of a SLAP (superior labral anterior-posterior) lesion and a rotator cuff tear are not known. We compared the outcomes in a cohort of patients who had undergone concomitant arthroscopic repairs of a SLAP lesion and a rotator cuff tear with those in a cohort of patients with a stable biceps anchor who had undergone an isolated rotator cuff repair. We hypothesized that the results would be similar between the two cohorts with respect to the range of motion and preoperative and postoperative function. METHODS Thirty-four patients (average age, 56.9 years) underwent an arthroscopic repair of an unstable SLAP lesion along with a concomitant arthroscopic rotator cuff repair. Twenty-eight patients (average age, 59.6 years) underwent an isolated arthroscopic rotator cuff repair. The average durations of follow-up for the two groups were 40.9 and 42.7 months, respectively. All patients in both groups had a symptomatic full-thickness rotator cuff tear for which initial conservative treatment had failed. Patients with advanced supraspinatus fatty infiltration or advanced muscle atrophy were excluded from the study. American Shoulder and Elbow Surgeons (ASES) and Constant scores were determined preoperatively and postoperatively, as were measurements of the ranges of forward flexion, abduction, external rotation, and internal rotation. Dynamometer strength testing was performed on all patients as an adjunct to qualitative assessments, and normalized Constant scores were calculated to perform sex and age-matched functional assessments. RESULTS In the group treated with concomitant repairs of a SLAP lesion and a rotator cuff tear, the average ASES score improved from 22.6 to 96.4 points and the average normalized Constant score improved from 55.1 to 101.0 points. In the group treated with an isolated arthroscopic rotator cuff repair, the average ASES score improved from 34.3 to 92.3 points and the average normalized Constant score improved from 60.7 to 95.8 points. The average preoperative ASES score in the group with the concomitant repairs was significantly worse than that in the group with the isolated rotator cuff repair (p = 0.027). This difference is also probably clinically relevant. There was no significant difference between the groups with regard to the preoperative normalized Constant scores, but postoperatively the normalized Constant score was significantly higher in the group with the concomitant repairs (p = 0.006). The active range of motion did not differ between the groups, preoperatively or postoperatively. CONCLUSIONS Controversy surrounds the treatment of a SLAP lesion with concomitant treatment of a full-thickness rotator cuff tear. This study suggests that, in middle-aged patients, the results of combined SLAP lesion and rotator cuff repair can be comparable with those achieved with rotator cuff repair alone.

Reconstruction of the Coronoid Process Using a Fragment of Discarded Radial Head

Maintaining ulnohumeral stability can be difficult when either the coronoid is too fragmented for primary repair or operative delay makes repair difficult or impossible. In addition to ligament repair, restoration of radiocapitellar contact using radial head arthroplasty, and hinged external fixation, reconstruction of the coronoid using a fragment of the discarded radial head-a technique described in this report-can help restore elbow stability and function.

A Faculty Development Program to Train Tutors to Be Discussion Leaders Rather Than Facilitators

Purpose During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. Method During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students’ overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. Results In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. Conclusions The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam’s mean score.

Effect of Delay to Definitive Surgical Fixation on Wound Complications in the Treatment of Closed, Intra-articular Calcaneus Fractures.

Background: There are conflicting data regarding the benefits of delaying operative fixation of calcaneus fractures to decrease wound complication rates. The purpose of this study was to examine the effect of delaying fixation on wound complication rates as well as to identify other risk factors. Methods: A retrospective review at 4 institutions, including 24 surgeons, identified 405 closed, operatively treated, intra-articular calcaneus fractures. We compared fractures with and without wound complications with regards to patient demographics, medical risk factors, fracture severity, time to fixation, operative approach, primary subtalar arthrodesis, and surgeon experience. Results: Wound complications were observed in 21% (87/405) of fractures, of which 33% (29/87) required operative intervention. Male sex (P = .032), smoking (P = .028), and the extensile lateral approach (P < .001) were associated with higher complication rates. Fractures treated with an extensile lateral approach had an overall wound complication rate of 32.1%, while those treated with a sinus tarsi or percutaneous approach had an overall wound complication rate of 8.3% (odds ratio [OR], 5.3; 95% confidence interval [CI], 2.9-9.5; P < .001). Among patients treated with an extensile lateral approach, delayed operative fixation did not decrease wound complication rates despite comparable fracture severity across time points. In contrast, among fractures treated with less invasive approaches, delayed fixation beyond 2 weeks resulted in a significantly increased wound complication rate of 15.2% as compared to a wound complication rate of only 2.1% among fractures treated within a week of injury (OR, 3.2; 95% CI, 1.3-9.5; P = .01). This was observed despite similar fracture severity across time points. Primary subtalar arthrodesis did not impact complication rates. A higher wound complication rate among senior surgeons was likely secondary to their predilection for the extensile lateral approach. Conclusion: Delaying definitive fixation of closed, intra-articular calcaneus fractures did not decrease wound complication rates when using the extensile lateral approach, and we found an increased wound complication rate when using less invasive approaches. Level of Evidence: Level III, observational study.

Internet information quality for ten common foot and ankle diagnoses

BACKGROUND Patients use the Internet regularly to access health-related information. This studys goal was to assess the quality and content of Internet-based information for common foot and ankle diagnoses. METHODS We identified the ten most common foot and ankle diagnoses in our academic foot and ankle practice. Ten websites for each diagnosis were identified using two large Internet search engines. A custom grading form was used to determine website quality, based upon the Health On the Net Foundation (HON) principles, and information content. Four independent reviewers graded each website. RESULTS One hundred thirty-six unique websites were reviewed. Average HON score was 62.4 (range, 52.3-68.8) and content score was 49.7 (range, 33.8-62.1) out of a maximum of 100. Interobserver variability was low. CONCLUSIONS The overall quality of Internet information for common foot and ankle diagnoses is variable, raising concerns about what information is currently available to patients.

Resident education versus fellowship training-conflict or synergy? AOA critical issues.

The fundamental mission of graduate medical education is to train young professionals to become future practitioners and academicians. Orthopaedic surgery training programs are primarily directed toward resident education. The subspecialty training of fellows, however, is arguably equally important. Thus, two constituencies that may compete for educational experience, attention, and resources are inherent to many training programs. We developed a survey to explore this issue prior to a symposium on this topic presented at the American Orthopaedic Association (AOA) meeting in June of 2009. Questions concerning the relationship between resident and fellowship education were distributed to orthopaedic residents in their fourth postgraduate year (PGY-4) of training who attended the Resident Leadership Forum at the 2009 AOA meeting. Responses were obtained from seventy-seven resident participants, a number that represents 12% of the total PGY-4 orthopaedic residents in 2009. The same survey was distributed to orthopaedic surgery department chairs, program directors, and fellowship directors across the United States. One hundred sixty-nine of this “faculty” group responded, a number that was 41.6% of the possible total. In the nineteenth century, surgeons generally were self-trained or learned by way of an apprenticeship1. No formal system was in place and few surgeons spent more than one or two years in a hospital setting. In 1889, with the founding of The Johns Hopkins Hospital, Dr. William Halsted transformed surgical training from its loosely organized structure to a university-sponsored, hospital-based model with graduated responsibility that culminated in a period of near autonomy. Formalization of the qualifications requisite of surgical subspecialties soon followed, largely to assure the public of a specialist’s preparation and skill2. The American Board of Orthopaedic Surgery (ABOS) was incorporated on February 4, 1934, and gave its first certification examination in 19353. Oversight of board certification implied the need for …

Effect of Sequential Sectioning of Ligaments on Syndesmotic Instability in the Coronal Plane Evaluated Arthroscopically

Background: Arthroscopic evaluation of the syndesmosis allows direct visualization of syndesmotic instability. The purpose of this study was to determine the minimum degree of ligamentous injury necessary to destabilize the syndesmosis in the coronal plane when assessed arthroscopically and pinpoint where such instability should be measured within the incisura. Methods: Fourteen cadaveric specimens were divided into 2 groups and arthroscopically assessed first with the syndesmosis intact and then following serial differential ligamentous transection. Group 1 (n = 7): anterior-inferior tibiofibular (AITFL), interosseous (IOL), posterior-inferior tibiofibular (PITFL), and deltoid (DL) ligament. Group 2 (n = 7): PITFL-IOL-AITFL-DL. At each step, a standard 100-N lateral hook test was applied and tibiofibular coronal plane diastasis measured arthroscopically at both the anterior and posterior third of the incisura. These measurements were in turn compared with those of the stressed intact ligamentous state. Results: There was no significant syndesmotic instability measured at either the anterior or posterior margin of the incisura after transection of a singular ligament (AITFL or PITFL) or after the IOL was additionally transected. Diastasis at the posterior margin was significantly increased when all syndesmotic ligaments were sectioned (group 1: P = .018; group 2: P = .008), but this was not noted along the anterior margin. Diastasis at the anterior margin reached significance only with complete transection of syndesmosis and DL (group 1: P < .001; group 2: P = .044). Conclusion: Under arthroscopic evaluation, the syndesmosis becomes unstable in the coronal plane only when all syndesmotic ligaments are transected, which should preferentially be measured at the posterior margin of the incisura. Anteriorly, diastasis becomes apparent only with addition of DL disruption, although this added finding may aid in diagnosis of occult deltoid injury. Clinical Relevance: AITFL, IOL, and PITFL need to be injured to produce coronal plane syndesmotic instability. Arthroscopic assessment of such instability should occur along the posterior margin of the incisura. When they exist, similar findings anteriorly suggest concomitant deltoid injury.

Retromalleolar Groove Deepening in Recurrent Peroneal Tendon Dislocation: Technique Tip:

Peroneal tendon dislocations are most prevalent in the active and athletic population, so accurate diagnosis and management are essential for optimal return of function. Although many nonoperative and surgical management options have been described, the optimal treatment method continues to be debated. In this technique article, a modified retromalleolar groove–deepening technique is described for addressing all anatomic variations of the posterior distal fibula and retromalleolar groove without unduly disturbing the important anatomic facets meant for retention in this region. This technique is indicated for chronic dislocated peroneal tendons, recurrent dislocating peroneal tendons, and dislocation of the tendons after acute injury with a shallow fibular peroneal groove. Although it remains unclear what effect a cortically abraded fibular gliding surface or forceful cortical impaction on the fibrocartilage gliding surface might have on peroneal tendon integrity and function long term, it would seem preferable to avoid such techniques if reliable alternatives are available.