Steven L. Frick

An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education.

In 2006, after many months of consideration, the Association of American Medical Colleges (AAMC) recommended that medical schools in the United States increase their enrollment by 30% by 2015 and that residency positions be increased to accommodate the growth in U.S. medical school graduates1. This recommendation is based on the belief that there will be a substantial physician workforce shortage in the future as the economy continues to expand, physicians retire, and patients continue to demand more specialized care. How this prediction will affect the workforce dynamic of orthopaedic surgery and other specialties must be examined carefully. Orthopaedic surgery, like most specialties, has an interest in better understanding how many physicians will be required in the specialty in the future. This is not to suggest that there is one single correct number of physicians in a specialty; in fact, the medical system has proven to be highly adaptive. However, it is in the publics interest to have a distribution of orthopaedic surgeons that promotes high-quality care. Furthermore, it is in the specialtys interest that the number of physicians be sufficient to provide the services that the specialty is best qualified to perform but not so many that physicians are underutilized. Having too few orthopaedic surgeons can lead to access problems for patients and/or to less qualified providers caring for patients with particular problems. Having too many can increase competition, flatten incomes, and reduce procedural volume for individual surgeons and thereby affect quality and outcomes— not to mention possibly increasing unnecessary operations to maintain income levels. Therefore, it is beneficial to both the public and the orthopaedic surgery specialty to have a supply that is close to expected utilization. Achieving balance is easier said than done given the many factors that could influence future supply and demand. One must …

Ponseti management of clubfoot in older infants.

Treatment of clubfoot with the Ponseti method is successful when performed immediately after birth. We treated 23 infants (36 feet) who presented to us after casting, applied at other institutions, failed or after 3 months of age. Twenty-two infants had serial casting started during the first 2 months, and one infant who was 6 months old at presentation had not received previous treatment. The original orthopaedists of 18 patients advised posteromedial release. The parameter studied was the need for posteromedial release (ie, failure of Ponseti casting and percutaneous Achilles tenotomy to obtain satisfactory clinical appearance). Only one (2.8%) of 36 feet required open surgical release (posterior only). Thirty-five feet required percutaneous Achilles tenotomy. A mean of six Ponseti casts were applied before tenotomy. Two feet (two infants) required anterior tibialis transfer for mild relapse; three other feet (two infants) required repeat casting for mild relapse. Most pediatric orthopaedists think that successful clubfoot casting depends on treatment started immediately after birth. Our data suggest that older infants with clubfoot can be treated successfully without extensive surgery. Our results in older infants are similar to the results of a previous study we conducted with younger infants. In that study, one (2.9%) of 34 feet required posteromedial release surgery.Level of Evidence: Therapeutic study, Level IV (Case series). See the Guidelines for Authors for a complete description of levels of evidence.

Lumbar intervertebral disc transfer : a canine study

Study Design. Degenerative lumber disc disease has been implicated as s cause of low back pain. Current treatment options for low back pain involve nonphysiologic fusion of the involved segments and have variable success rates. This is an experimental study of lumbar intervertebral disc transplantation using a canine surgical model. Objectives. This study evaluated the feasibility of lumbar disc transplantation and its effects on disc metabolism and morphology. Method. Eight mature mongrel dogs underwent disc transfer surgeries, in which the L2-L3 and L4-L5 intervertebral discs, with a small segment of adjacent superior and inferior vertebral body, were removed and transposed. The transplanted discs were stabilized by plates or by a flexible cable wire construct using Songer cables (DANEK, Inc. Memphis, TN). Unrestricted activity was allowed postoperatively. At 4 months, the spines were harvested, and the transplanted discs were evaluated biochemically and histologically. Intervening non transplanted discs served as viable controls and thrice-frozen discs served as nonviable controls. Cell viability was assessed by measuring proteoglycan synthesis and DNA content. Results. Proteoglycan synthesis (38S uptake normalized to DNA content) was maintained in transplanted anulus fibroses tissue, but was decreased in nucleus pulposus samples (P < 0.05), DNA content was not altered significantly in the transplanted discs. Histologic analysis of the transplanted discs showed revascularization and remodeling of the bone adjacent to the disc and preservation of the lamellar architecture of the anulus fibrosus. The transplanted nucleus pulposus samples had chondrocyte-like cells present, but the staining characteristics of the nucleus material was variable. The contour of the transplanted disc endplates was irregular in all specimens. Conclusions. The structure and function of autograft intervertebral discs wore maintained after disc transfer surgery; the transplant discs, however, ware not completely normal in either their morphology or their metabolic functioning.

Gene expression during fracture healing in rats comparing intramedullary fixation to plate fixation by DNA microarray.

Objective: This study was designed to compare mRNA gene expression in healing diaphyseal femoral fractures between those injuries treated with intramedullary nails and those treated with internal plate fixation. Design: RNA gene expression was measured at 1 day, 3 days, and 1, 2, 4, and 6 weeks after surgery in the fracture callus of rats randomized to femoral shaft fracture with intramedullary nail fixation, rigid plate fixation, or sham fracture. Setting: AAALAC-accredited vivarium of an independent academic medical center. Animals: Fifty-seven, adult, female, Sprague-Dawley rats at 16 weeks of age. Intervention: Femoral fracture with intramedullary nail fixation, femoral fracture with plate and screw fixation, or sham surgery with no fracture. Main Outcome Measurements: RNA expression for 8700 genes was measured with 19 Affymetrix U34A microarrays. The fracture callus was significantly larger with intramedullary nail fixation than with plate fixation. Most genes responded to fracture with a change in mRNA expression. Most of the responding genes followed the same time course for both fixation methods. This included genes related to growth factors, bone matrix, mast cells, most nerve factors, and hematopoiesis. The intramedullary nail group had significantly greater up-regulation for transcripts related to cartilage, cell division, inflammation, and the acetylcholine receptor. There was significantly greater up-regulation in the plate group for genes related to macrophage activity. Conclusions: There were differentially expressed genes present between the 2 surgical groups that may give insight into the control of fracture repair.

Surgical correction of residual hip dysplasia in two pediatric age-groups.

Background: The goal of operative treatment of hip dysplasia or subluxation in children is to normalize the hip joint to delay or prevent the premature onset of osteoarthritis. In theory, intervention in early childhood, when the remodeling potential is greater, should provide the best opportunity for the development of a normal joint. Methods: To determine the efficacy of early surgical intervention in restoring the normal morphology of the hip, according to radiographic criteria, we reviewed the cases of thirty-six children (fifty hips) with residual dysplasia or subluxation who were managed with either a femoral and/or a pelvic osteotomy when they were between two and eight years old (Group I). The average age at the time of surgery was 3.7 years, and the average duration of follow-up was 4.3 years. We compared these results with those achieved in fourteen patients (eighteen hips) with residual hip dysplasia or subluxation who were treated surgically at an older age, between eight and eighteen years old (Group II). The outcome was assessed with use of clinical as well as multiple radiographic criteria. We believe that a normal relationship between the acetabulum and the femoral head was established when there was an acetabular index of <20° or a Sharp angle of <42°, a center-edge angle of >20°, and an intact Shentons line. Results: At the time of the latest follow-up, sixteen of the seventeen hips with residual dysplasia that had been treated with pelvic osteotomy alone in Group I and three of four such hips in Group II had a normal relationship between the acetabulum and the femoral head. Normal radiographic findings were noted in fifteen of the seventeen hips with residual subluxation that had been treated with combined femoral and pelvic osteotomies in Group I compared with four of eight such hips in Group II. Conclusions: We found that residual hip dysplasia or subluxation could be more predictably corrected, with normal radiographic results and with less morbidity and fewer complications, in children who were between two and eight years old than in those who were between eight and eighteen years old. Long-term follow-up is required to confirm whether the improved anatomy and function of the hip that resulted from early correction of residual dysplasia or subluxation lasts into adulthood.

Obesity in Pediatric Orthopaedics

Obesity is a rapidly expanding health problem in children and adolescents and is the most prevalent nutritional problem for children in the United States. Some believe that obesity has become a major epidemic in American children, with the prevalence having more than doubled since 1980. This epidemic has led to a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from

Femoral anteversion in children with cerebral palsy. Assessment with two and three-dimensional computed tomography scans.

125.9 million to

Altered Fibular Growth Patterns After Tibiofibular Synostosis in Children

237.6 million between 2001 and 2005. This article describes some of the orthopaedic conditions commonly encountered in overweight/obese children and adolescents, classically infantile and adolescent tibia vara and slipped capital femoral epiphysis. Also discussed are genu valgum, which has been associated with obesity, and other difficulties encountered in providing orthopaedic care to obese children.

Pre- and postoperative three-dimensional computed tomography analysis of triple innominate osteotomy for hip dysplasia.

Background: Assessment of femoral anteversion in children with cerebral palsy with two or three-dimensional computed tomography scans may be limited by both positional and anatomic variables. Three-dimensional computed tomography techniques are considered to be more accurate than two-dimensional imaging when the femur is not optimally positioned in the gantry or when the neck-shaft angle is increased. Methods: Computed tomography scanning was performed on a series of nine model femora with anteversion ranging from 20° to 60° and neck-shaft angles ranging from 120° to 160°. Each femoral model was scanned in two holding devices, the first of which held the femur in optimal alignment (normal model) and the second of which held the femur in flexion, adduction, and internal rotation (cerebral palsy model) relative to the gantry. Femoral anteversion was calculated for each model from two and three-dimensional computed tomography scans by four examiners on two separate occasions. The intraobserver and interobserver reliability, the accuracy, and the effect of increasing the neck-shaft angle on the accuracy of the measurements made on the two and three-dimensional scans of the normal and cerebral palsy models were then examined. Results: The mean differences in the measurements of femoral anteversion made by the same examiner (intraobserver reliability) were <2° for the two-dimensional scans of the normal and cerebral palsy models and the three-dimensional scans of the normal models, and the mean difference was <4° for the three-dimensional scans of the cerebral palsy models. The mean differences among examiners (interobserver reliability) were <3° for the two-dimensional scans of the normal and cerebral palsy models and the three-dimensional scans of the normal models, and the mean difference was <6° for the three-dimensional scans of the cerebral palsy models. The accuracy of the assessments of femoral anteversion of the normally aligned models was comparable between the two and three-dimensional scans. However, the three-dimensional assessment was significantly more accurate than the two-dimensional assessment for measurement of anteversion of the cerebral palsy models (p = 0.003). Accuracy within 5° was comparable between the two and three-dimensional scans for measurement of the normally aligned models, with 86% of the two-dimensional measurements and 78% of the three-dimensional measurements falling within 5° of the actual measurements. However, the accuracy within 5° was significantly compromised when the models were placed in cerebral palsy alignment. Only 3% of the two-dimensional measurements and 14% of the three-dimensional measurements fell within 5° of the actual measurements, with three-dimensional assessment being significantly better than two-dimensional assessment (p = 0.006). Increasing the neck-shaft angle did not significantly compromise the accuracy of measurement of femoral anteversion with either the two-dimensional or the three-dimensional technique (p > 0.05 for all comparisons). Conclusions: When adequate alignment of the femur in the computed tomography scanner was possible, a simple two-dimensional technique exhibited excellent intraobserver and interobserver reliability and clinically acceptable accuracy within the relevant ranges of anatomic variability tested (neck-shaft angles of 120° to 160° and femoral anteversion of 20° to 60°). When optimal alignment of the femur in the scanner was not possible, neither two-dimensional nor three-dimensional techniques exhibited clinically acceptable accuracy for the measurement of femoral anteversion.

Modular tibial augmentations in total knee arthroplasty

Background: Iatrogenic synostosis of the tibia and fibula following an operation on the leg in a child has been reported rarely in the literature, and the effects of this complication on future growth, alignment, and function are not known. This is a retrospective case series, from one institution, of crossunions of the distal parts of the tibia and fibula complicating operations on the leg in children. The purpose is to alert surgeons to this possible complication. Methods: The senior author identified eight cases of iatrogenic tibiofibular synostosis seen in children since 1985. The patients had various diagnoses and were from the practices of four pediatric orthopaedic surgeons. Synostosis developed in six patients after osteotomies of the distal parts of the tibia and fibula, in one after internal fixation of distal tibial and fibular metaphyseal fractures through a single incision, and in one after posterior transfer of the anterior tibialis tendon through the interosseous membrane combined with peroneus brevis transfer to the calcaneus. Medical records were reviewed, and preoperative and follow-up radiographs were analyzed for changes in the relative positions of the proximal and distal tibial and fibular physes and in the alignment of the ankle. Results: Five patients were symptomatic after crossunion; they presented with prominence of the proximal part of the fibula, ankle deformity, or ankle pain. Three patients were asymptomatic, and a synostosis was identified on routine follow-up radiographs. Intraoperative technical errors caused two of the crossunions; the cause of the others was unknown. Following tibiofibular synostosis, growth disturbances were noted radiographically in every patient. The normal growth pattern of distal migration of the fibula relative to the tibia was reversed, resulting in a decreased distance between the proximal physes of the tibia and fibula as well as proximal migration of the distal fibular physis relative to the distal part of the tibia. Shortening of the lateral malleolus led to greater valgus alignment of the ankle. Conclusions: Tibiofibular synostosis can complicate an operation on the leg in a child. After crossunion, the normal distal movement of the fibula relative to the tibia is disrupted, resulting in shortening of the lateral malleolus and ankle valgus as well as prominence of the fibular head at the knee. The synostosis also interferes with the normal motion that occurs between the tibia and fibula with weight-bearing, potentially leading to ankle pain.