Ronak M. Patel

Wound Complications in Joint Arthroplasty: Comparing Traditional and Modern Methods of Skin Closure

Various methods of skin closure exist in joint replacement surgery. Although subcuticular skin closure techniques offer an aesthetic advantage over conventional skin stapling, no measurable differences have been reported. Furthermore, newer barbed sutures, such as the V-Loc absorbable suture (Covidien, Mansfield, Massachusetts), theoretically distribute tension evenly through the wound and help decrease knot-related complications. The purpose of this study was to evaluate whether wound complication rates were (1) lower in V-Loc closure cases as theoretically suggested, (2) lower for subcuticular closure vs staples, and (3) significantly different for knee and hip joint reconstruction.A retrospective chart review was conducted of 278 consecutive cases of primary joint reconstruction performed by a single surgeon (L.P.). The study group comprised 106 men and 161 women. Average patient age at surgery was 63 years (range, 18-92 years), and average body mass index of the cohort was 33.7 kg/m(2) (range, 25-51 kg/m(2)). Skin was closed via staple gun or subcuticular stitch (3-0 Biosyn [Covidien] vs V-Loc). Seven (3.9%) wound complications occurred in 181 cases closed with staples. Four (7.8%) wound complications occurred in 51 cases closed via subcuticular Biosyn suture. Six (13.0%) wound complications occurred in 46 cases closed with V-Loc suture. The staple group had a lower rate of complications when compared with the suture group as a whole (P=.033) and when compared specifically with the V-Loc suture group (P=.017).

Internet search term affects the quality and accuracy of online information about developmental hip dysplasia.

Background: The recent emphasis on shared decision-making has increased the role of the Internet as a readily accessible medical reference source for patients and families. However, the lack of professional review creates concern over the quality, accuracy, and readability of medical information available to patients on the Internet. Methods: Three Internet search engines (Google, Yahoo, and Bing) were evaluated prospectively using 3 difference search terms of varying sophistication (“congenital hip dislocation,” “developmental dysplasia of the hip,” and “hip dysplasia in children”). Sixty-three unique Web sites were evaluated by each of 3 surgeons (2 fellowship-trained pediatric orthopaedic attendings and 1 orthopaedic chief resident) for quality and accuracy using a set of scoring criteria based on the AAOS/POSNA patient education Web site. The readability (literacy grade level) of each Web site was assessed using the Fleisch-Kincaid score. Results: There were significant differences noted in quality, accuracy, and readability of information depending on the search term used. The search term “developmental dysplasia of the hip” provided higher quality and accuracy compared with the search term “congenital hip dislocation.” Of the 63 total Web sites, 1 (1.6%) was below the sixth grade reading level recommended by the NIH for health education materials and 8 (12.7%) Web sites were below the average American reading level (eighth grade). Conclusions: The quality and accuracy of information available on the Internet regarding developmental hip dysplasia significantly varied with the search term used. Patients seeking information about DDH on the Internet may not understand the materials found because nearly all of the Web sites are written at a level above that recommended for publically distributed health information. Clinical Relevance: Physicians should advise their patients to search for information using the term “developmental dysplasia of the hip” or, better yet, should refer patients to Web sites that they have personally reviewed for content and clarity. Orthopaedic surgeons, professional societies, and search engines should undertake efforts to ensure that patients have access to information about DDH that is both accurate and easily understandable.

Does the Quality, Accuracy, and Readability of Information about Lateral Epicondylitis on the Internet Vary with the Search Term Used?

BackgroundConcern exists over the quality, accuracy, and accessibility of online information about health care conditions. The goal of this study is to evaluate the quality, accuracy, and readability of information available on the internet about lateral epicondylitis.MethodsWe used three different search terms (“tennis elbow,” “lateral epicondylitis,” and “elbow pain”) in three search engines (Google, Bing, and Yahoo) to generate a list of 75 unique websites. Three orthopedic surgeons reviewed the content of each website and assessed the quality and accuracy of information. We assessed each website’s readability using the Flesch–Kincaid method. Statistical comparisons were made using ANOVA with post hoc pairwise comparisons.ResultsThe mean reading grade level was 11.1. None of the sites were under the recommended sixth grade reading level for the general public. Higher quality information was found when using the terms “tennis elbow” and “lateral epicondylitis” compared to “elbow pain” (p < 0.001). Specialty society websites had higher quality than all other websites (p < 0.001). The information was more accurate if the website was authored by a health care provider when compared to non-health care providers (p = 0.003). Websites seeking commercial gain and those found after the first five search results had lower quality information.ConclusionsReliable information about lateral epicondylitis is available online, especially from specialty societies. However, the quality and accuracy of information vary significantly with the search term, website author, and order of search results. This leaves less educated patients at a disadvantage, particularly because the information we encountered is above the reading level recommended for the general public.

Stable, Dependable Fixation of Short-stem Femoral Implants at 5 Years

Conventional uncemented femoral implants provide dependable long-term fixation in patients with a wide range of clinical function. However, challenges with proximal-distal femoral mismatch, preservation of bone stock, and minimally invasive approaches have led to exploration into various other implant designs. Short-stem designs focusing on a stable metaphyseal fit have emerged to address these challenges in total hip arthroplasty (THA). The purpose of this study was to present the 5-year clinical and radiographic results of a computed tomography-based, custom-made, metaphyseal-engaging short-stem femoral implant.Sixty-one patients with an average age of 61 years (range, 22-75 years) and average body mass index of 28.9 kg/m(2) (range, 20.3-44.1 kg/m(2)) at follow-up underwent 69 THAs with the metaphyseal-engaging short stem. Clinical performance was evaluated using the Harris Hip Score and Western Ontario and McMaster Universities Arthritis Index score, and radiographs were reviewed for stability and bony ingrowth. Harris Hip Score averaged 55 (range, 20-90) preoperatively and 96 (range, 55-100) postoperatively. Western Ontario and McMaster Universities Arthritis Index score averaged 51 (range, 13-80) preoperatively and 3 (range, 0-35) postoperatively. No cases of subsidence were observed, and no revision surgeries were performed. Bone remodeling was typified by endosteal condensation and cortical hypertrophy in Gruen zones 2, 3, 5, and 6. At 5-year follow-up, the uncemented, metaphyseal-engaging short stem was stable and exhibited proximal bone remodeling closer to the metaphysis than conventional stems. Short-stem, metaphyseal-engaging femoral implants can meet the goals of a successful THA.

The Impact of the Multicenter Orthopaedic Outcomes Network (MOON) Research on Anterior Cruciate Ligament Reconstruction and Orthopaedic Practice

With an estimated 200,000 anterior cruciate ligament reconstructions performed annually in the United States, there is an emphasis on determining patient-specific information to help educate patients on expected clinically relevant outcomes. The Multicenter Orthopaedic Outcomes Network consortium was created in 2002 to enroll and longitudinally follow a large population cohort of anterior cruciate ligament reconstructions. The study group has enrolled >4,400 anterior cruciate ligament reconstructions from seven institutions to establish the large level I prospective anterior cruciate ligament reconstruction outcomes cohort. The group has become more than a database with information regarding anterior cruciate ligament injuries; it has helped to establish a new benchmark for conducting multicenter, multisurgeon orthopaedic research. The changes in anterior cruciate ligament reconstruction practice resulting from the group include the use of autograft for high school, college, and competitive athletes in their primary anterior cruciate ligament reconstructions. Other modifications include treatment options for meniscus and cartilage injuries, as well as lifestyle choices made after anterior cruciate ligament reconstruction.

Functional and Radiographic Outcomes of Juvenile Osteochondritis Dissecans of the Knee Treated With Extra-Articular Retrograde Drilling

Background: Osteochondritis dissecans (OCD) lesions of the medial femoral condyle in the adolescent population can cause significant impairment and restriction in physical activity. Studies have established the efficacy of transarticular antegrade drilling for juvenile OCD lesions of the knee, although concerns of consequences from drilling through the articular cartilage remain. Alternatively, retrograde extra-articular drilling avoids drilling the cartilage while ensuring adequate channels for revascularization and healing. Purpose: The authors present the results of 31 skeletally immature patients who underwent retrograde drilling of OCD lesions of the knee with an average follow-up of 4 years. Study Design: Case series; Level of evidence, 4. Methods: The procedure consisted of a standard arthroscopic evaluation of the knee and subsequent percutaneous retrograde drilling obliquely through the condylar epiphysis starting distal to the physis and ending in the center-center of the OCD lesion. Outcome measures included radiographic signs of healing, Lysholm scoring and the Tegner activity scale to measure performance and activity restriction, and visual analog scale (VAS) pain scores. Results: Average follow-up for the 31 patients was 4 years (range, 1.5-7 years). Sixteen of the 34 lesions were grade I or II based on radiographic findings with signs and symptoms greater than 6 months. The remaining 18 were grade III secondary to a sclerotic rim surrounding the defect. Overall, improvement in Lysholm scores (70 to 95; standard deviation [SD] ± 14.95), Tegner scores (4 to 7; SD ± 2.31), and VAS pain scores (6.9 to 1.3; SD ± 2.16) were found to be statistically significant. Radiographs showed stable or improved lesions in all cases. Conclusion: Retrograde extra-articular drilling provided clinical and radiographic improvement in most juveniles with OCD lesions who failed nonoperative management. This method serves to decompress the lesion and allow revascularization without disrupting the articular cartilage surface in stable OCD lesions.

The short stem: promises and pitfalls

Conventional uncemented femoral implants provide dependable long-term fixation in patients with a wide range of functional requirements. Yet challenges associated with proximal-distal femoral dimensional mismatch, preservation of bone stock, and minimally invasive approaches have led to exploration into alternative implant designs. Short stem designs focusing on a stable metaphyseal fit have emerged to address these issues in total hip replacement (THR). Uncemented metaphyseal-engaging short stem implants are stable and are associated with proximal bone remodeling closer to the metaphysis when compared with conventional stems and they also have comparable clinical performances. Short stem metaphyseal-engaging implants can meet the goals of a successful THR, including tolerating a high level of patient function, as well as durable fixation.

The Thrower’s Elbow

Overhead throwing activities expose the elbow to tremendous valgus stress, making athletes vulnerable to a specific constellation of injuries. Although baseball players, in particular pitchers, are the athletes affected most commonly, overhead throwing athletes in football, volleyball, tennis, and javelin tossing also are affected. The purpose of this review is to review the anatomy, biomechanics, pathophysiology, and treatment of elbow disorders related to overhead throwing athletes. Although focus is on management of ulnar collateral ligament injuries, all common pathologies are discussed.

The rationale for short uncemented stems in total hip arthroplasty.

Uncemented femoral implants of various designs have proved to provide stable initial and long-term fixation in patients who undergo total hip arthroplasty. Challenges in primary total hip arthroplasty have led to the evolution of short stem designs. These challenges include proximal/metaphyseal and distal/diaphyseal mismatch; facilitation of less-invasive surgical exposures, especially the direct anterior approach; and bone preservation for potential revision surgery.

Flexor pollicis longus dysfunction after volar plate fixation of distal radius fractures

PURPOSE To evaluate the natural history and etiology of decreased thumb interphalangeal (IP) joint flexion after volar plate fixation of distal radius fractures. METHODS A total of 46 patients who underwent volar plating of 48 distal radius fractures by a single surgeon were retrospectively studied. Of those patients, 24 (24 wrists) exhibited loss of thumb IP joint flexion (group 1) and 22 (24 wrists) retained thumb IP joint flexion (group 2) with attempted thumb opposition to the small finger after surgery. All patients were seen at regular intervals until IP joint flexion returned and fracture healing was confirmed radiographically. Patient demographics, fracture patterns, surgical variables, and final radiographs were compared between groups. Twenty patients in group 1 were seen after a mean of 6.5 months (range, 5-12 mo) for specific outcome measurements. Eight cadaveric specimens were used to replicate the flexor carpi radialis approach to the distal radius and evaluate flexor pollicis longus tendon excursion. RESULTS There were no significant differences in fracture pattern, patient age or sex, injured extremity dominance, time to surgery, incision length, plate composition, plate length, tourniquet time, or final wrist radiographs between groups. In group 1, active thumb IP joint flexion returned on average 52 days (range, 19-143 d) postoperatively. At final evaluation in this group, mean IP joint flexion was 11° less than the contralateral thumb IP joint; however, patient-determined outcomes were favorable in most cases. In the cadaveric specimens, excursion of the flexor pollicis longus tendon decreased with sequential soft tissue dissection and retraction. CONCLUSIONS Loss of thumb IP joint flexion after volar plating of distal radius fractures was common, and motion returned to near normal in most cases within 2 months. Partial stripping of the flexor pollicis longus muscle from investing fascia and bone and retraction of soft tissues are likely etiological factors.