Sanaz Hariri

Evaluation of a surgical simulator for learning clinical anatomy.

Background  New techniques in imaging and surgery have made 3‐dimensional anatomical knowledge an increasingly important goal of medical education. This study compared the efficacy of 2 supplemental, self‐study methods for learning shoulder joint anatomy to determine which method provides for greater transfer of learning to the clinical setting.

The 2007 ABJS Marshall Urist award: The impact of direct-to-consumer advertising in orthopaedics

Direct-to-consumer advertising (DTCA) has become an influential factor in healthcare delivery in the United States. We evaluated the influence of DTCA on surgeon and patient opinions and behavior in orthopaedics by surveying orthopaedic surgeons who perform hip and knee arthroplasties and patients who were scheduled to have hip or knee arthro-plasty. Respondents were asked for their opinions of and experiences with DTCA, including the influence of DTCA on surgeon and patient decision making. Greater than 98% of surgeon respondents had experience with patients who were exposed to DTCA. The majority of surgeon respondents reported DTCA had an overall negative impact on their practice and their interaction with patients (74%), and their patients often were confused or misinformed about the appropriate treatment for their condition based on an advertisement (77%). Fifty-two percent of patient respondents recalled seeing or hearing advertisements related to hip or knee arthroplasty. These patients were more likely to request a specific type of surgery or brand of implant from their surgeon and to see more than one surgeon before deciding to have surgery. Direct-to-consumer advertising seems to play a substantial role in surgeon and patient decision making in orthopaedics. Future efforts should be aimed at improving the quality and accuracy of information contained in consumer-directed advertisements related to orthopaedic implants and procedures.

Medicare Physician Reimbursement: Past, Present, and Future

Recent proposals in the United States to cut Medicare physician-reimbursement rates for certain orthopaedic procedures, particularly in the field of hip and knee arthroplasty, have heightened the general orthopaedic communitys interest in Medicare physician-reimbursement policy. Familiarizing oneself with Medicare physician-reimbursement policies in particular is important as most private and public insurers base their payments on Medicare fee schedules and regulations. The 2004 American Academy of Orthopaedic Surgeons (AAOS) Physician Census revealed that >90% of orthopaedists in private practice identified insurance or Medicare and Medicaid reimbursement levels and increasing practice expenses as major concerns1. Medicare and Medicaid accounted for an average of 33% of an orthopaedists practice in 2006, having risen steadily from 26% in 19882. This article is a primer on the history of the Medicare Physician Fee Schedule, its current status, and issues that are currently at the forefront of Medicare health policy agendas in the United States. We conclude with a discussion of the proposed changes to the sustained growth rate formula and the design and implementation of pay-for-performance programs. The AAOS has led the charge in representing orthopaedic interests in Washington, DC, and in keeping its membership updated on issues through bulletins and legislative updates. However, for physicians and researchers interested in understanding the issues surrounding Medicare, the task of sifting through and integrating the myriad of academic, governmental, and organizational resources available is daunting. We aim to organize these sources into an accessible, unified format. We also present the orthopaedic surgeon with opportunities to become involved in shaping future policy at a range of commitment levels. In 1965, President Lyndon B. Johnson signed the Title XVIII Amendment to the 1933 Social Security Act, creating Medicare as the first major federal health insurance entitlement program. The programs original goal was to reduce the …

A Clinical Comparison of Screw and Suture Fixation of Anterior Cruciate Ligament Tibial Avulsion Fractures

Background Screw and suture fixations are the most commonly used methods of fixation in treatment of anterior cruciate ligament tibial avulsion fractures. Even though a few biomechanical studies have compared the stability of the 2 fixation techniques, a clinical comparison has not yet been reported. Hypothesis The authors hypothesized that both fixations would be identical in all studied clinical outcome measures at a minimum 2-year follow-up. Study Design Cohort study; Level of evidence, 3. Materials and Methods Thirty-three patients treated with either screw fixation (16 patients) or suture fixation (17 patients) within 1 month of the anterior cruciate ligament tibial avulsion fracture (type II or III) without associated ligamentous injury were included. All patients were evaluated at a minimum 2-year follow-up in terms of Lysholm knee scores and return to preinjury activities. Knee stability was compared based on the Lachman test and stress radiography. Results No significant differences were found between the 2 groups in terms of average Lysholm knee scores (91.7 in the screw group and 92.7 in the suture group, P = .413) at follow-up. All patients except 2 (1 in each group) returned to preinjury activity levels. However, flexion contractures (5° to 10°) were found in 3 patients in the screw group and 2 patients in the suture group without significant intergroup difference. Stabilities based on the Lachman test and instrumented stress radiography were also similar between the 2 groups at follow-up. However, 2 patients in the screw group and 1 in the suture group showed more than 5 mm laxity compared with the contralateral knee on stress radiographs. Conclusion Both the screw and suture fixation techniques for the anterior cruciate ligament tibial avulsion fracture produced relatively good results in terms of functional outcomes and stability without any significant differences. However, some patients in both groups showed residual laxity or flexion contractures.

Ulnar Collateral Ligament Injury in the Overhead Athlete

The ulnar collateral ligament (UCL), particularly the anterior portion of the anterior oblique ligament, is the primary static contributor to elbow valgus stability. UCL injuries are most common in athletes participating in overhead sports. Acute and chronic injuries to the UCL result in valgus instability, which may predispose the athlete to the development of disabling secondary elbow conditions. Provocative physical examination maneuvers include the valgus abduction test, the modified milking maneuver, and the moving valgus stress test. Plain radiographs and magnetic resonance imaging are the most common imaging modalities, although ultrasonography and computed tomography arthrograms can alternatively be used. UCL injuries can be treated initially with rest, anti-inflammatory medications, bracing, and/or physical therapy. Acute avulsion injuries can be repaired, especially in those under 20 years of age, but most UCL tears are now treated with reconstruction. Modifications of the Jobe figure-of-8 technique, and now the Altchek docking technique, are the most common reconstruction techniques. Many new and hybrid techniques have been described with limited clinical experience in the literature. Current techniques offer the athlete a greater than 90% chance of return to play at their preinjury level.

An anatomic study of the coracoid process as it relates to bone transfer procedures

INTRODUCTION The Latarjet and Bristow procedures address recurrent anterior shoulder instability in the context of a significant bony defect. However, the bony and soft tissue anatomy of the coracoid as they relate to coracoid transfer procedures has not yet been defined. The purpose of this study was to describe the soft tissue attachments of the coracoid as they relate to the bony anatomy and to define the average amount of bone available for use in coracoid transfer. METHODS Ten paired fresh frozen shoulders from deceased donors were dissected, exposing the coracoid, lateral clavicle, and acromion, along with the coracoid soft tissue attachments. The bony dimensions of the coracoid and the locations and sizes of the soft tissue footprints of the coracoid were measured. RESULTS The mean maximum length of the coracoid available for transfer (ie, distance from the coracoid tip to the anterior border of the coracoclavicular ligament) was 28.5 mm. The mean distance from the coracoid tip to the anterior pectoralis minor was 4.6 mm, to the posterior pectoralis minor was 17.7 mm, to the anterior coracoacromial ligament was 7.8 mm, and to the posterior coracoacromial ligament was 25.7 mm. CONCLUSION Average dimensions of the bony coracoid and average locations and sizes of coracoid soft tissue footprints are provided. This anatomic description of the coracoid bony anatomy and its soft tissue insertions allows surgeons to correlate the location of their coracoid osteotomy with the soft tissue implications of the coracoid transfer as the native anatomy is manipulated in these nonanatomic procedures.

Career Plans of Current Orthopaedic Residents with a Focus on Sex-Based and Generational Differences

BACKGROUND An orthopaedic workforce shortage has been projected. The purpose of this study is to analyze the supply side of this shortage by ascertaining the career plans of current orthopaedic residents, comparing these plans with the career patterns of practicing orthopaedists, and identifying career-plan differences according to sex. METHODS An online, self-administered survey was e-mailed to U.S. orthopaedic residents in postgraduate year three or higher, querying them about their fellowship specialty choice and their career plans. RESULTS A total of 498 residents completed the online survey; 430 respondents (86%) were male, sixty-three (13%) were female, and five (1%) did not provide information regarding sex. Ninety-one percent of the residents were planning to enroll in a fellowship, with some respondents indicating more than one subspecialty choice: 28% intended to choose sports; 21%, arthroplasty; 14%, hand surgery, 12%, trauma; 8%, pediatrics; 8%, shoulder and elbow surgery; 8%, spine surgery; 6%, foot and ankle surgery; and 2%, oncology. With regard to the top career priorities of residents in selecting a fellowship specialty, 40% indicated intellectual priorities; 36%, educational; 21%, lifestyle; and 4%, economic. Significantly more women than men were planning on pursuing a pediatric fellowship (24% versus 6%, respectively, p < 0.05) and significantly fewer were planning on pursuing a sports fellowship (11% versus 31%, respectively, p < 0.05). Significantly more women than men planned on a subspecialty-only practice (62% versus 34%, respectively, p < 0.05). The projected retirement age of sixty-four years for current residents is roughly equal to that of the previous generation. There was no difference between men and women with regard to leadership and research aspirations, projected retirement age, and projected workdays per week. However, significantly more women than men (65% versus 47%, respectively) planned on reducing their work hours or changing to part-time status at some time during their careers. There is a higher percentage of female residents (13%) than female practicing orthopaedists (4%) in the United States. CONCLUSIONS We should continue efforts to collect workforce data and be proactive to avert or minimize the effect of impending orthopaedic workforce shortages on our patients. Given the trend toward an increasing proportion of female orthopaedists and the higher likelihood that they will reduce their work hours during portions of their career, policymakers should consider training more orthopaedists to ensure patient access to timely, quality orthopaedic care.

Treatment of Recalcitrant Iliotibial Band Friction Syndrome With Open Iliotibial Band Bursectomy: Indications, Technique, and Clinical Outcomes

Background Iliotibial band friction syndrome (ITBFS) is an overuse injury causing lateral knee pain. There is evidence that the pathological lesion is in fact an inflamed bursa underlying the iliotibial band (ITB) rather than an inflamed ITB itself. Hypothesis Resection of the bursa underlying the ITB in ITBFS patients will relieve their pain and allow them to return to their preinjury activity level. Study Design Case series; Level of evidence, 4. Methods We describe the technique of ITB bursectomy and report a minimal 20-month follow-up of patients who had ITB bursectomies performed by a single surgeon. The patients completed a survey detailing their preoperative and postoperative symptoms and activities. Results The senior author performed 12 consecutive cases of ITB bursectomies (12 patients). One was excluded from the study (previous microfracture). The average age at surgery was 32 years (standard deviation, 5; range, 24-41). There were 7 men and 4 women. Postoperatively, patients were able to return to their preinjury Tegner activity levels, and the visual analog pain scores decreased by an average of 6 points (P < .001). Six patients were completely satisfied with the surgical outcome, 3 were mostly satisfied, 2 were somewhat satisfied, and none were dissatisfied. Nine of 11 patients said that knowing what they know now, they would have the surgery performed again for the same problem. Conclusion Iliotibial band bursectomy successfully reduces knee pain in patients with ITBFS and allows them to return to their preinjury level of activity. The great majority of patients were satisfied with the results of the procedure.

A resident survey study of orthopedic fellowship specialty decision making and views on arthroplasty as a career.

A dramatic shortage of total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgeons has been projected because fewer residents enter arthroplasty fellowships, and the demand for THAs/TKAs is rising. The purposes of this study were to ascertain the future supply of THA/TKA surgeons, to identify the criteria residents use to choose their fellowship specialty, and to assess resident perceptions of an arthroplasty career. Four hundred ninety-eight post-graduate year 3 and above residents completed the online survey. Residents most highly prioritize intellectual factors and role models/mentors in determining their fellowship specialty. In the face of a looming patient access-to-care crisis, the data from this study support a policy of highlighting the intellectual challenges and satisfaction of THA/TKA as a career and encouraging mentorship early in a residents training.

Nerve injuries about the elbow.

The ulnar, radial, median, medial antebrachial cutaneous, and lateral antebrachial cutaneous nerves are subject to traction and compression in athletes who place forceful, repetitive stresses across their elbow joint. Throwing athletes are at greatest risk, and cubital tunnel syndrome (involving the ulnar nerve) is clearly the most common neuropathy about the elbow. The anatomy and innervation pattern of the nerve involved determines the characteristic of the neuropathy syndrome. The most important parts of the work-up are the history and physical examination as electrodiagnostic testing and imaging are often not reliable. In general, active rest is the first line of treatment. Tailoring the surgery and rehabilitation protocol according to the functional requirements of that athletes sport(s) can help optimize the operative outcomes for recalcitrant cases.