Neal C. Chen

The Management of Labral Tears and Femoroacetabular Impingement of the Hip in the Young, Active Patient

PURPOSE The purpose of this systematic review was to determine (1) the quality of the literature assessing outcomes after surgical treatment of labral tears and femoroacetabular impingement (FAI), (2) patient satisfaction after open or arthroscopic intervention, and (3) differences in outcome with open or arthroscopic approaches. METHODS Computerized literature databases were searched to identify relevant articles from January 1980 to May 2008. Studies were eligible for inclusion if they had a level I, II, III, or IV study design and if the patient population had a labral tear and/or FAI as the major diagnosis. Patients with severe pre-existing osteoarthritis or acetabular dysplasia were excluded. RESULTS Of the 19 articles with reported outcomes after surgery, none used a prospective study design and only 1 met the criteria for level III basis of evidence. Open surgical dislocation with labral debridement and osteoplasty is successful, with a good correlation between patient satisfaction and favorable outcome scores. The studies reviewed support that 65% to 85% of patients will be satisfied with their outcome at a mean of 40 months after surgery. A common finding in all series, however, was an increased incidence of failure among patients with substantial pre-existing osteoarthritis. Arthroscopic treatment of labral tears is also effective, with 67% to 100% of patients being satisfied with their outcomes. CONCLUSIONS The quality of literature reporting outcomes of surgical intervention for labral tears and FAI is limited. Although open surgical dislocation with osteoplasty is the historical gold standard, the scientific data do not show that open techniques have outcomes superior to arthroscopic techniques. LEVEL OF EVIDENCE Level IV, systematic review.

Management of Distal Radial Fractures

Interest in one of the most common injuries to the musculoskeletal system—the distal radial fracture—has been renewed. Literature over the past two centuries had even led some to believe that the distal radial fracture was a solved problem. In contrast, we are now confronted with a marked swing toward stable internal fixation being touted by some authors as the treatment of choice for all but the most stable, aligned fractures. Instructional courses, symposia, and skills courses worldwide are now oversubscribed, bearing witness to these changing perspectives. It is surprising that, despite this aggressive push toward internal fixation, there is no convincing evidence that supports this approach in the contemporary literature. To what can we attribute this dramatic shift in the management of the distal radial fracture? In this review, we will attempt to answer this question by looking in depth at a number of contributing factors—changing epidemiologic patterns; a growing understanding of the injury mechanism; the development of enhanced imaging techniques; novel plate designs, especially those featuring …

Internal morphology of human cervical pedicles.

STUDY DESIGN The internal architecture of cervical spine pedicles was investigated by thin sectioning and digitization of radiographic images. OBJECTIVES To provide quantitative information on the internal dimensions and cortical shell thicknesses of the middle and lower cervical pedicles. SUMMARY OF BACKGROUND DATA Although there have been a number of studies presenting data on the external dimensions of the cervical pedicle, little is known regarding its internal architecture and cortical shell thickness along the pedicle axis. METHODS Twenty-five human cervical vertebrae (C3-C7) were secured to a thin-sectioning machine to produce three 0.7-mm-thick pedicle slices along its axis. Plain radiographs of the pedicle slices were scanned and digitized to facilitate measurement of the internal dimensions. Computer software was specifically developed to determine the external dimensions (i.e., pedicle height and width) and the internal dimensions (i.e., cortical shell thicknesses of the superior, inferior, lateral, and medial walls and the cancellous core height and width) of cervical pedicles. RESULTS Superior and inferior wall cortical thicknesses of pedicle thin slices were similar, whereas the lateral wall cortical thickness was significantly smaller than the medial wall thickness. The medial cortical shell (average value range: 1.2-2.0 mm) was measured to be 1.4 to 3.6 times as thick as the lateral cortical shell (average value range: 0.4-1.1 mm). When medial and lateral cortical thicknesses were normalized for external dimensions, the combined cortical shell thickness was thinnest at C7 (average value range: 18. 6-25.6% of the external width), and this result was statistically significant when compared with other vertebral levels. CONCLUSIONS The cervical pedicle is a complex, three-dimensional structure exhibiting extensive variability in internal morphology. Characteristics of the cervical pedicle at different spinal levels must be noted before transpedicular screw fixation.

Cost-Effectiveness of Open Partial Fasciectomy, Needle Aponeurotomy, and Collagenase Injection for Dupuytren Contracture

PURPOSE We undertook a cost-utility analysis to compare traditional fasciectomy for Dupuytren with 2 new treatments, needle aponeurotomy and collagenase injection. METHODS We constructed an expected-value decision analysis model with an arm representing each treatment. A survey was administered to a cohort of 50 consecutive subjects to determine utilities of different interventions. We conducted multiple sensitivity analyses to assess the impact of varying the rate of disease recurrence in each arm of the analysis as well as the cost of the collagenase injection. The threshold for a cost-effective treatment is based on the traditional willingness-to-pay of

The cortical shell architecture of human cervical vertebral bodies.

50,000 per quality-adjusted life years (QALY) gained. RESULTS The cost of open partial fasciectomy was

Preoperative three-dimensional CT predicts intraoperative findings in hip arthroscopy.

820,114 per QALY gained over no treatment. The cost of needle aponeurotomy was

Analysis of Transfusion Predictors in Shoulder Arthroplasty

96,474 per QALY gained versus no treatment. When we performed a sensitivity analysis and set the success rate at 100%, the cost of needle aponeurotomy was

Physician Empathy as a Driver of Hand Surgery Patient Satisfaction

49,631. When needle aponeurotomy was performed without surgical center or anesthesia costs and with reduced hand therapy, the cost was

A Primer on Use of Decision Analysis Methodology in Hand Surgery

36,570. When a complete collagenase injection series was priced at

Surgical Treatment for Osteochondritis Dissecans of the Capitellum

250, the cost was