Edmund Campion

Postarthroscopy analgesia with bupivacaine A prospective, randomized, blinded evaluation

The analgesic effect of intraarticular bupivacaine in jected at the conclusion of knee arthroscopy done under general anesthesia was investigated in a pro spective, randomized, and blinded fashion. Pain scores, the use of analgesic medications, crutch use, weight bearing, activity level, and difficulty sleeping the night after surgery were all unaffected by the use of bupiva caine. The apparent lack of effect is most likely due to rapid clearance from the knee, leaving only a transient, 1 to 2 hours of potential benefit. In this study, the patients were already quite comfortable during this time period due to the routine use of intraoperative narcotics. The preoperative level of knee discomfort was found to be a major determinant of postoperative discomfort. Other much less important factors were synovial and chondral shaving, sex of the patient, and experience of the surgeon.

Resident selection and predictors of performance: can we be evidence based?

Selection of orthopaedic residents can be a difficult process; we have endeavored to make it more objective by developing a scoring methodology for screening applications. The purpose of this investigation is to determine if an academic score, using objective elements only, will discriminate among applicants and will correlate with outcomes. Applications to our orthopaedic residency program for 2004 and 2005 were assigned an academic score as a screening tool in the residency selection process. Data was analyzed for the entire group both by gender and whether the applicant had interviewed for the program. Additionally, the applications of program graduates over the past 5 years were retrospectively assigned academic scores, which were compared with outcomes of the training program. Academic scores for applicants formed a generally normal distribution, and residents training in the program generally had higher scores. The distribution of scores for female applicants was similar to male applicants; however, a greater percentage of female applicants interviewed for the program. Scores on the OITE and ABOS examinations tended to parallel academic scores, but faculty ratings of performance in the program showed no difference between those with high and low academic scores. Calculating academic scores makes the application screening process more objective but does not appear to correlate with outcomes of the training program.

Residual bone-mineral density and muscle strength after fractures of the tibia or femur in children

This study compared the bone-mineral density in the proximal part of the femur and the flexion and extension strength of the knee in the fractured and the non-fractured limbs after an uncomplicated fracture of the tibia or femur in children. Thirty-eight children, whose ages ranged from two to fifteen years at the time of the injury, were evaluated at an average of 2.3 years after the injury. The mean difference in bone-mineral density between the fractured and non-fractured limbs was 3.3 per cent (p = 0.004). There was no significant difference between the bone-mineral density of the limbs that had been immobilized for less than four weeks and that of the contralateral, non-fractured limbs. However, the mean difference between the bone-mineral density of the limbs that had been immobilized for more than eight weeks and that of the contralateral limbs was 4.3 per cent (p = 0.006). There was little or no relationship between the time since the injury and the difference in bone-mineral density between the two limbs of the patient at the intervals of follow-up that were studied. No residual weakness in flexion and extension of the knee was detected, and no relationship was established between the limb-to-limb differences in strength and the limb-to-limb differences in bone-mineral density. The residual bone-mineral deficit was found to be minimum after an uncomplicated fracture. This difference, while statistically significant, is unlikely to be clinically important in the long term. However, the fact that there was a deficit raises a potential concern for children who have more severe or repeated injuries.

Repair of peripheral nerves with the argon laser. A functional and histological evaluation.

A technique for repair of peripheral nerves with the argon laser was evaluated with regard to functional and histological recovery. The results were compared with those of reconstruction by a microsurgical epineurial-suture technique. The terminal branch of the peroneal nerve to the extensor digitorum longus in thirty-three New Zealand White rabbits served as the experimental model. Histology and neuromuscular function were evaluated at one, two, and six months after repair. When the diameters of the axons and the morphology distal to the site of repair were evaluated, the nerves that had been repaired with the laser more closely resembled those of the control rabbits. Examination of the site of repair also revealed less foreign-body reaction and axonal outgrowth in the laser-repaired nerves than in those that had been reconstructed with epineurial suture. Neuromuscular function was evaluated by measurement of the force of contraction of the extensor digitorum longus after electrical stimulation of the nerve proximal to the site of repair. Functional recovery paralleled the histological findings. At one month, there was no difference in the neuromuscular function that had been achieved with either technique. At two months, the laser-repaired nerves began to show increased muscular strength at higher frequencies of stimulation (sixteen and thirty-two hertz). Six months postoperatively, the nerves that had been repaired with the laser had consistently better neuromuscular function than those that had been repaired by epineurial suture. The improvement was most marked at higher voltages of stimulation (threshold multiplied by ten) and at frequencies of stimulation of more than sixteen hertz.

Orthopaedic surgeons as educators. Applying the principles of adult education to teaching orthopaedic residents.

Teaching residents the knowledge, skills, and ethical values of orthopaedic surgery is critical to our profession. Currently, the standards for orthopaedic residency training are set by the Orthopaedic Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education and the American Board of Orthopaedic Surgery. However, the means by which those standards are to be achieved is largely left up to individual residency programs. This article considers how we might improve the quality and effectiveness of orthopaedic education if we apply to residency programs the core principles of adult education. These core principles form the central theme of the American Academy of Orthopaedic Surgeons (AAOS) Course for Orthopaedic Educators, the first course among all medical specialties to be devoted entirely to education and the longest-running continuing medical education course offered by the AAOS. This article reviews the critical elements involved in educating orthopaedic residents, applying the core educational principles established by the Course for Orthopaedic Educators. We suggest that if orthopaedic educators understand the educational process and the principles that underlie it, they will be able to improve the quality and effectiveness of residency education and thus ultimately improve the profession. This article presents eight core principles of adult education and outlines how they can be applied by orthopaedic educators—both by program planners and by physician-teachers. Cognitive psychologists and educational scholars have generated a large body of peer-reviewed research on effective techniques of adult education1-3. This research established a set of core educational principles (Table I) that can be used by orthopaedic educators to improve resident learning. The eight core principles presented here are not the only ones that might be applied to medical education. However, they are featured in the AAOS Course for Orthopaedic Educators because they capture key themes in current research …

Hemiepiphyseodesis for Late-Onset Tibia Vara

Background: The amount of correction obtained with tibial and/or femoral hemiepiphyseodesis in late-onset tibia vara is quite variable. The purpose of this study is to identify preoperative factors which might help to predict the amount of correction that is obtainable. Methods: Fifty-three patients (67 knees) have been treated with hemiepiphyseodesis and followed until skeletal maturity or a secondary realignment procedure before maturity. The amount of correction obtained was correlated with multiple preoperative factors including age, body weight, and degree of deformity. Results: In 65 limbs treated with tibial hemiepiphyseodesis, the average correction in the tibia was 9 degrees, ranging widely from 33 degrees of correction to 6 degrees worsening of the deformity. In 22 limbs treated with femoral hemiepiphyseodesis, the average correction in the femur was 8 degrees (range, 0-19 degrees). Ultimately, 19 of the 67 limbs have been treated with an osteotomy and 10 more were left with greater than 10 degrees of varus deformity at maturity. In addition, 14 of the 67 limbs overcorrected into excessive valgus and/or required medial hemiepiphyseodesis procedures to prevent overcorrection. Using multiple regression analysis it was found that younger age and lesser deformity were weakly predictive of greater correction with tibial hemiepiphyseodesis. No factors were statistically significant predictors of femoral correction. Conclusions: Variable amounts of correction are obtained with hemiepiphyseodesis in patients with late-onset tibia vara. Even very large amounts of correction may be obtainable in some cases, but unfortunately preoperative factors such as age, weight, and degree of deformity cannot be relied upon in clinical practice to predict outcome. Surgical decision making must weigh the safety and simplicity of this procedure against the much more extensive but much more predicable realignment obtained with osteotomy procedures. Level of Evidence: Level IV; retrospective and prospective longitudinal evaluation of a case series.