Julie Balch Samora

Efficacy of Core Decompression as Treatment for Osteonecrosis of the Hip: A Systematic Review:

Core decompression (CD) for the treatment of osteonecrosis of the hip has been a surgical option since the 1960s. We performed a systematic review to evaluate CD with regard to pain relief, need for total hip arthroplasty (THA), and lesion size and Ficat stage. Only four articles of level IV evidence (139 total cases) met inclusion criteria. Three reported improvement in outcomes. Overall average outcomes were only “good” in one study and either “fair” or “poor” in the others. One-fourth (25.8%) of patients required THA. Patients with necrotic lesion size <50% had best outcomes with CD. Although CD may become a standard treatment option to prevent THA in early stages of ON, there are not currently rigorous studies that provide long-term outcome measures.

Femoroacetabular impingement: a common cause of hip pain in young adults.

Objective:Femoroacetabular impingement (FAI) is a common cause of hip discomfort in young adults. Recently, a better understanding of the pathomechanics and morphologic abnormalities in the hip has implicated FAI as a possible factor in early osteoarthrosis. The clinical presentation, physical examination findings, and radiographic features are discussed in this article. Data Sources:PubMed was searched using words and terms including femoacetabular impingement, hip osteoarthritis, hip arthroscopy, early osteoarthrosis, and hip dislocation. References of relevant studies were searched by hand. Study Selection:All studies directly involving the treatment of FAI were reviewed by 3 authors and selected for further analysis, including expert opinion and review articles. Data Synthesis:The quality of each study was assessed, and the results were summarized. Conclusions:Conservative measures, including physical therapy, restriction of activities, core strengthening, improvement of sensory-motor, and control and nonsteroidal anti-inflammatories are the mainstays of nonsurgical treatment. However, surgical management is often necessary to allow full return to activity with options including surgical dislocation of the hip, hip arthroscopy, periacetabular and rotational osteotomies, and combined hip arthroscopy with a limited open exposure. Although the literature is replete with short-term evidence to support surgical treatment, there are currently no long-term prospective data or natural history studies examining the implications of FAI and effects of early intervention.

Outcomes after injury to the thumb ulnar collateral ligament--a systematic review.

Objectives:Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction. Data Sources:A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Main Results:Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Complications after surgery were rare. Conclusions:This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Septic Arthritis of the Neonatal Hip: Acute Management and Late Reconstruction

Abstract Septic arthritis of the hip in neonates is rare but can have devastating consequences. Presenting signs and symptoms may differ from those encountered in older children, which may result in diagnostic challenge or delay. Many risk factors predispose neonates to septic arthritis, including the presence of transphyseal vessels and invasive procedures. Bacterial infection of the joint occurs via hematogenous invasion, extension from an adjacent site, or direct inoculation. A strong correlation exists between younger age at presentation and severity of residual hip deformity. Diagnosis is based on clinical examination, laboratory markers, and ultrasound evaluation. Early management includes parenteral antibiotics and surgical drainage. Late‐stage management options include femoral and pelvic osteotomies, trochanteric arthroplasty, arthrodesis, pelvic support procedures, and nonsurgical measures. Early diagnosis and management continues to be the most important prognostic factor for a favorable outcome in the neonate with septic arthritis.

Physician-Rating Web Sites: Ethical Implications

PURPOSE To understand the ethical and professional implications of physician behavior changes secondary to online physician-rating Web sites (PRWs). METHODS The American Society for Surgery of the Hand (ASSH) Ethics and Professionalism Committee surveyed the ASSH membership regarding PRWs. We sent a 14-item questionnaire to 2,664 active ASSH members who practice in both private and academic settings in the United States. RESULTS We received 312 responses, a 12% response incidence. More than 65% of the respondents had a slightly or highly unfavorable impression of these Web sites. Only 34% of respondents had ever updated or created a profile for PRWs, although 62% had observed inaccuracies in their profile. Almost 90% of respondents had not made any changes in their practice owing to comments or reviews. One-third of respondents had solicited favorable reviews from patients, and 3% of respondents have paid to improve their ratings. CONCLUSIONS PRWs are going to become more prevalent, and more research is needed to fully understand the implications. There are several ethical implications that PRWs pose to practicing physicians. We contend that it is morally unsound to pay for good reviews. The recourse for physicians when an inaccurate and potentially libelous review has been written is unclear. Some physicians have required patients to sign a waiver preventing them from posting negative comments online. We propose the development of a task force to assess the professional, ethical, and legal implications of PRWs, including working with companies to improve accuracy of information, oversight, and feedback opportunities. CLINICAL RELEVANCE It is expected that PRWs will play an increasing role in the future; it is unclear whether there will be a uniform reporting system, or whether these online ratings will influence referral patterns and/or quality improvement.

Septic Arthritis in Infants Younger Than 3 Months: A Retrospective Review.

Septic arthritis in infants is rare and can be difficult to diagnose. This study reviewed a series of patients younger than 3 months to identify factors that may assist in early diagnosis and treatment. A query of records at a large Midwestern pediatric hospital (1994-2010) was performed to identify all patients younger than 3 months at the time of diagnosis. Analysis included birth history, joint involvement, physical examination findings, laboratory results, imaging results, method of treatment, and outcome. In 14 cases (11 boys, 3 girls; mean age at diagnosis, 42.2 days), complete records were available for review. Involved joints included the knee, hip, and shoulder. The most common findings on physical examination were decreased range of motion (100%), tenderness (100%), and swelling (71.4%). Mean temperature was 38.5°C. Mean white blood cell count was 18.5 K/µL, mean erythrocyte sedimentation rate was 48.9 mm/h, and mean C-reactive protein level was 6.1 mg/dL. More than half (57.1%) of joint aspirates grew positive cultures, and 41.7% of blood cultures had positive results. Causative organisms were group B streptococcus, methicillin-sensitive Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Salmonella enterica, and Candida albicans. The most common physical examination findings in infants younger than 3 months with septic arthritis include tenderness, decreased range of motion, and swelling. White blood cell count, C-reactive protein level, and erythrocyte sedimentation rate are likely to be elevated, but these findings should be used in combination with findings on physical examination and radiographic studies to aid in diagnosis.

Is there still a place for cast wedging in pediatric forearm fractures

Background: Forearm fractures are common skeletal injuries in childhood and can usually be treated nonoperatively with closed reduction and casting. Trends toward increasing operative treatment of these fractures have emerged. We aim to demonstrate the safety and efficacy of cast wedging for treatment of pediatric forearm fractures. Methods: We performed a prospective chart review of patients with forearm fractures, including distal radius (DR) fractures, treated with cast wedging at a single large pediatric hospital from June 2011 to September 2012. Inclusion criteria specified open distal radial physis, closed injury, loss of acceptable reduction, and availability of clinical and radiographic data from injury to cast removal. Exclusion criteria included pathologic fractures, neurovascular injury, fracture dislocations, open fractures, and closed DR physis. Reductions were performed and patients followed according to standard protocol at our institution, including placement into long-arm casts, initial follow-up visit within 5 to 10 days postinjury, and weekly visits for 2 weeks thereafter. If alignment were deemed unacceptable within 3 weeks of injury, cast wedging was utilized. Radiographic measurements of alignment included both radius and ulna on the injury film, postreduction, prewedge, postwedge, and final films. Radiographic technique was standardized, with repeatability testing demonstrating a precision of ±2 degrees. Results: Over 15 months, our hospital treated 2124 forearm or DR fractures with closed reduction and casting. There were 60 fractures treated either with percutaneous fixation (36) or open treatment (24). A total of 79 forearm or DR fractures were treated with cast wedging secondary to loss of reduction, of which 70 patients had complete clinical and radiographic data. Average age was 8.4 years (range, 3 to 14 y), with 25 females and 45 males. Significant improvement in angulation for both-bone forearm fracture from prewedge to final films was seen in 69 children, with no major complications. One patient failed wedging and required surgical reduction and fixation. Conclusions: Cast wedging is a simple, safe, noninvasive, and effective method for treatment of excessive angulation in pediatric forearm fractures. Level of Evidence: Level IV.

Orthopaedic Graduate Medical Education: A Changing Paradigm

Orthopaedic surgeons traditionally have been trained with use of an apprenticeship model, with experience being measured on the basis of case log documentation and with competency being determined by senior mentors. Over the past decade, medical education has undergone a major paradigm shift, with increasing emphasis on teaching toward competence as a specialist, including operative skills, essential knowledge for practice, professionalism, and the use of evaluation methods thought to be credible, accurate, reproducible, and transparent. The primary use of an apprenticeship model may result in graduates never having performed some procedures or never having managed patients with certain diagnoses. Alternatively, the competency model may result in graduates performing well on certain standard procedures but perhaps not demonstrating competency on relatively rare entities. While the provision and assessment of medical education have become more complex in proportion to advanced technologies and novel procedures, delivering excellence in education itself has become increasingly difficult as a result of duty-hour restrictions, …

Orthopaedic Quality Reporting: A Comprehensive Review of the Current Landscape and a Roadmap for Progress

Passage of the Patient Protection and Affordable Care Act in 2010 mandated sweeping changes to the United States health-care system1. The Patient Protection and Affordable Care Act has vastly expanded the government’s involvement in tracking and reporting quality measures for physicians and hospitals, creating a dizzying array of stakeholders in this complex policy arena (Fig. 1). Quality measures are now increasingly tied to reimbursement, potentially redefining payment models for physicians and hospitals across the country. Medicare alone will base 9% of hospital payments on performance by 20172. Fig. 1 Roadmap and relationships of major quality stakeholders. ACS = American College of Surgeons, AHRQ = Agency for Healthcare Research and Quality, AAOS = American Academy of Orthopaedic Surgeons, CDC = Centers for Disease Control and Prevention, CMS = Centers for Medicare & Medicaid Services, HACs = hospital-acquired conditions, HHS = U.S. Dept. of Health & Human Services, MAP = Measure Applications Partnership, NIH = National Institutes of Health, NPP = National Priorities Partnership, NSQIP = National Surgical Quality Improvement Project, NQF = National Quality Forum, PQRS = Physician Quality Reporting System, PROMIS = Patient-Reported Outcomes Measurement Information System, and SCIP = Surgical Care Improvement Project. Quality measurement has …

Surgical and Nonsurgical Management of Mallet Finger: A Systematic Review

PURPOSE The current literature describes multiple surgical and nonsurgical techniques for the management of mallet finger injuries, and there is no consensus on the indications for surgical treatment. The objective of this study was to determine, through a literature review, if any conclusions can be drawn concerning the indications for surgery in mallet finger injuries; the treatment outcomes of surgical versus nonsurgical management; the most effective methods of surgical and nonsurgical treatment; and the most common treatment complications of mallet finger injuries. METHODS A systematic review of multiple databases was performed. English language clinical studies evaluating therapeutic interventions for mallet fingers that reported objective, standardized outcome measures were included. Basic science studies, cadaveric studies, conference abstracts, level V evidence studies, studies lacking statistical data, and tendinous injuries other than mallet fingers were excluded. Salvage procedures and studies evaluating exclusively chronic lesions were also excluded. RESULTS Forty-four studies that reported clinical outcomes for the treatment of mallet finger injuries, 22 evaluating surgical treatments and 17 studies investigating nonsurgical treatments were included. The average distal interphalangeal joint extensor lag was 5.7° after surgical treatment and 7.6° after nonsurgical treatment. Complication rates of surgical and nonsurgical interventions were comparable (14.5% and 12.8%, respectively). Five studies directly compared the outcomes of surgical with nonsurgical management, with mixed results and recommendations. CONCLUSIONS Both surgical and nonsurgical treatments of mallet finger injuries lead to excellent clinical outcomes. Insufficient evidence is available to determine when surgical intervention is indicated. Based on our literature review, it appears that these treatments are equivalent and should be individualized to the patient. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.