The Cliff Sign: A New Radiographic Sign of Hip Instability.

BACKGROUND: The preoperative diagnosis of hip microinstability is challenging. Although physical examination maneuvers and magnetic resonance imaging findings associated with microinstability have been described, there are limited reports of radiographic features. In patients with microinstability, we observed a high incidence of a steep drop-off on the lateral edge of the femoral head, which we have named the "cliff sign." PURPOSE: (1) To determine the relationship of the cliff sign and associated measurements with intraoperative microinstability and (2) to determine the interobserver reliability of these measurements. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 115 consecutive patients who underwent hip arthroscopy were identified. Patients with prior hip surgery, Legg-Calve-Perthes disease, fractures, pigmented villonodular synovitis, or synovial chondromatosis were excluded, resulting in the inclusion of 96 patients in the study. A perfect circle around the femoral head was created on anteroposterior pelvis radiographs. If the lateral femoral head did not completely fill the perfect circle, it was considered a positive cliff sign. Five additional measurements relating to the cliff sign were calculated. The diagnosis of microinstability was made intraoperatively by the (1) amount of traction required to distract the hip, (2) lack of hip reduction after initial traction release following joint venting, or (3) intraoperative findings consistent with hip microinstability. Continuous variables were analyzed through use of unpaired t tests and discrete variables with Fisher exact tests. Interobserver reliability (n = 3) was determined for each measurement. RESULTS: Overall, 89% (39/44) of patients with microinstability had a cliff sign, compared with 27% of patients (14/52) without instability (P < .0001). Conversely, 74% of patients with a cliff sign had microinstability, while only 12% of patients without a cliff sign had instability (P < .0001). In women younger than 32 years with a cliff sign, 100% (20/20) were diagnosed with instability. No differences were found in any of the 5 additional measurements. Excellent interobserver reliability was found for the presence of a cliff sign and the cliff angle measurement. CONCLUSION: We have identified a radiographic finding, the cliff sign, that is associated with the intraoperative diagnosis of hip microinstability and has excellent interobserver reliability. Results showed that 100% of young women with a cliff sign had intraoperative microinstability. The cliff sign may be useful in the preoperative diagnosis of hip microinstability.

Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues: AOA Critical Issues.

Burnout, depression, suicidal ideation, and dissatisfaction with work-life balance have been reported in all medical specialties and at all stages of medical education and practice experience. Burnout consists of progressive emotional, attitudinal, and physical exhaustion. Physicians with burnout may treat patients as objects and feel emotionally depleted. Burnout is characterized by a loss of enthusiasm for work (emotional exhaustion), feelings of cynicism (depersonalization), and a low sense of personal accomplishment. The most complete study of emotional burnout among different medical specialties demonstrated that orthopaedic surgery is one of the specialties with the highest burnout rate. Qualitative descriptive studies are available. There was a 45.8% burnout rate among physicians in the U.S. in 2012, and a 2014 update suggested even higher rates. Burnout has a correlation with medical education. Burnout rates are similar to those in the general population when medical students enter school, and increase steadily through medical education prior to residency. Burnout rates in residents are high, reported to be between 41% and 74% across multiple specialties. This impacts our young physician workforce in orthopaedics. The purpose of this review is to provide the available information that characterizes burnout and addresses the issues inherent to preventing burnout, and to build awareness in orthopaedic surgeons. Wellness "goes beyond merely the absence of distress and includes being challenged, thriving, and achieving success in various aspects of personal and professional life." The challenge for the orthopaedic community is to develop interventions and strategies that are personalized to the individuals in this specialty.

Avoiding Failure in Hip Arthroscopy: Complications, Pearls, and Pitfalls.

Although most patients have successful outcomes after hip arthroscopy, a minority of patients experience complications that may impact their recovery and long-term benefit. As most of these complications can be minimized by appropriate surgical technique, many tips have been recommended. Additionally, the reasons behind clinical failure postoperatively have been scrutinized, which include, most commonly, incomplete correction of osseous pathomorphology, underappreciated preexisting hip osteoarthritis, and/or an incorrect preoperative diagnosis. Meticulous preoperative planning, evaluation of advanced imaging studies, and proper patient selection will help to reduce the number of postoperative failures and increase the chance of a successful outcome following hip arthroscopy.

Management of Posterior Cruciate Ligament Injuries: An Evidence-Based Review.

Isolated injuries of the posterior cruciate ligament are uncommon, are often caused by a posteriorly directed force to the proximal tibia, and result in abnormal knee kinematics and function. A thorough clinical evaluation, including history, physical examination, and imaging, is required to rule out a concomitant structural knee injury. No clear prognostic factors predict outcomes, and ideal management remains uncertain. Nonsurgical management is advocated for isolated grade I or II posterior cruciate ligament injuries or for grade III injuries in patients with mild symptoms or low activity demands. Surgical management is reserved for high-demand athletes or patients in whom nonsurgical management has been unsuccessful. Although biomechanical studies have identified differences between single-bundle, double-bundle, transtibial, and tibial inlay reconstruction techniques, the optimal surgical technique has not been established. No high-quality evidence is available regarding immobilization, weight-bearing, bracing, or rehabilitation protocols for patients treated either nonsurgically or surgically. Additional long-term clinical studies with homogeneous patient populations are needed to identify the ideal management of these injuries.

Evaluation of American Academy of Orthopaedic Surgeons Appropriate Use Criteria for the management of full-thickness rotator cuff tears.

BACKGROUND: The American Academy of Orthopaedic Surgeons (AAOS) recently released Appropriate Use Criteria (AUC) to aid in determining the appropriateness of treatment options. This study compares AAOS AUC recommendations with a cohort of patients treated for known full-thickness rotator cuff tears (RCTs). METHODS: Prospectively collected demographic information, treatment allocation, and American Shoulder and Elbow Surgeons (ASES) shoulder and Western Ontario Rotator Cuff Index scores of 134 patients were retrospectively reviewed. Other criteria required by the AAOS AUC were collected by retrospective record review. Criteria were entered into the AAOS AUC Web-based application to rate the "appropriateness" of treatment options. Ratings were compared with actual treatments and outcomes at 32- or 48-week follow-up. RESULTS: There was excellent agreement between the AUC recommendations and the actual treatment administered (κ = .945; 95% confidence interval, 0.892-1.000; P <.0001). The administered treatment was "appropriate" for 79% of patients, "may be appropriate" for 19%, and "rarely appropriate" for 2%. Response to previous treatment (P <.0001), American Society of Anesthesiologists Physical Status Classification (P <.0001), and presence of muscle atrophy or fatty infiltration (P = .047) were the only variables that significantly and independently predicted discordance between treatment and the AUC recommendation. In the cases (n = 3) of discordance, the American Shoulder and Elbow Surgeons score improved significantly more (P = .049) than when there was agreement. CONCLUSIONS: Improved clinical outcomes may be achieved for full-thickness RCTs when AAOS AUC recommendations are followed; however, because improved clinical outcomes may also be achieved when the recommendations are not followed, further investigation is needed in a population of patients in whom there is discordance between AAOS AUC recommendations and the treatment administered.

Computer-Simulated Arthroscopic Knee Surgery: Effects of Distraction on Resident Performance.

Orthopedic surgeons cite "full focus" and "distraction control" as important factors for achieving excellent outcomes. Surgical simulation is a safe and cost-effective way for residents to practice surgical skills, and it is a suitable tool to study the effects of distraction on resident surgical performance. This study investigated the effects of distraction on arthroscopic knee simulator performance among residents at various levels of experience. The authors hypothesized that environmental distractions would negatively affect performance. Twenty-five orthopedic surgery residents performed a diagnostic knee arthroscopy computer simulation according to a checklist of structures to identify and tasks to complete. Participants were evaluated on arthroscopy time, number of chondral injuries, instances of looking down at their hands, and completion of checklist items. Residents repeated this task at least 2 weeks later while simultaneously answering distracting questions. During distracted simulation, the residents had significantly fewer completed checklist items (P<.02) compared with the initial simulation. Senior residents completed the initial simulation in less time (P<.001), with fewer chondral injuries (P<.005) and fewer instances of looking down at their hands (P<.012), compared with junior residents. Senior residents also completed 97% of the diagnostic checklist, whereas junior residents completed 89% (P<.019). During distracted simulation, senior residents continued to complete tasks more quickly (P<.006) and with fewer instances of looking down at their hands (P<.042). Residents at all levels appear to be susceptible to the detrimental effects of distraction when performing arthroscopic simulation. Addressing even straightforward questions intraoperatively may affect surgeon performance.

Evaluation of Quality of Lower Limb Arthroplasty Observational Studies Using the Assessment of Quality in Lower Limb Arthroplasty (AQUILA) Checklist.

UNLABELLED: This study used the assessment of quality in lower limb arthroplasty (AQUILA) checklist to assess the quality of lower limb arthroplasty observational studies. Among 132 studies the mean reporting quality score was 5.4 (SD=1.2) out of 8 possible points. Most studies adequately reported reasons for revisions (98%) and prosthesis brand and fixation (95%) in sufficient detail. Only 3% of studies adequately reported the number of patients unwilling to participate, 15% stated a clear primary research question or hypothesis, 11% reported a worst-case analysis or competing risk analysis for endpoints, and 42% reported more than 5% of patients were lost to follow-up. There is significant room for improvement in the reporting and methodology of lower limb arthroplasty observational studies. LEVEL OF EVIDENCE: Level III.

Range of motion in a modular femoral stem system with a variety of neck options.

Modular femoral stem systems decouple leg length, offset, and version. The hip ROM and type of impingement for 162 femoral head/neck combinations were measured at four extreme hip positions in a Sawbones pelvis and femur to identify constructs that lead to early impingement. Hip ROM increased in all positions with increasing head size and neck length. We identified a new type of impingement created by the build-up of the proximal femoral stem: femoral stem on acetabular liner impingement. Seventy percent of neutral neck options achieved our definition of acceptable ROM. In general, when utilizing a modular femoral stem, surgeons can minimize impingement by choosing the longest femoral neck that does not over-lengthen the limb, using the largest femoral head accommodated by the cup, and avoiding neck version unless the cup or stem is malaligned.

Varicella outbreak among Afghan National Civil Order Police recruits-Herat Regional Military Training Center, Herat, Afghanistan, 2010.

In December 2010, an outbreak of varicella was reported among student recruits enrolled at the Afghan National Civil Order Police Herat Regional Military Training Center. The outbreak had an overall attack rate of 9.8% (31 of 316 recruits) with primary, secondary, and tertiary attack rates of 6.3% (20 of 316), 3.4% (10 of 296), and 0.35% (1 of 286). Fortunately, the outbreak did not lead to any deaths or serious complications. However, it significantly interfered with Afghan National Civil Order Police training by causing a loss of 378 person-days of training. Medical personnel from the Afghan National Police, DynCorp International, Government of the Islamic Republic of Afghanistan Ministry of Public Health, and NATO Training Mission-Afghanistan Herat Joint Medical Operation Cell joined together to control and characterize the outbreak and prepare and disseminate recommendations for preventing future outbreaks. Control measures were quickly implemented, but less than ideal. Varicella vaccine was not available in Afghanistan to immunize exposed recruits. The outbreak was reported to medical authorities through a slow and convoluted process. And the majority of varicella cases did not self-report for care. Rather, medical personnel diagnosed most cases only after recruits were directed to report for a physical examination.

Pediatric burn-related scalp alopecia treated with tissue expansion and the incidence of associated facial burn injuries.

In the pediatric population, cutis aplasia, scalp avulsion, and burn injuries are the leading causes of scalp alopecia that is evaluated for reconstruction by plastic surgeons. Scalp alopecia is seen in 25% of children who suffer burn injuries of the head and neck. These injuries are rarely isolated to the scalp, and the adjacent structures are often affected. This may complicate reconstruction surgery and necessitate multiple reconstructive procedures. A retrospective chart was performed of all cases of staged scalp tissue-expansion cases performed for the reconstruction of burn-related scalp alopecia by the two senior authors at the Shriner's Hospital for Children of Boston between 2003 and 2007. In each case, the incidence and severity of burn-related deformities of the nose, eyebrows, and ears as seen in clinical photographs were documented. Between 2003 and 2007, 96 scalp tissue expanders were placed in 78 patients for the treatment of scalp alopecia. Of these patients, associated adjacent burn deformities were commonly found involving the ear, nose, and eyebrow. These injuries included ear deformity (46%), nasal deformity (27%), and eyebrow deformity (46%). In planning the surgical reconstruction for pediatric scalp alopecia, it is helpful to evaluate each patient for adjacent structure burn injuries requiring reconstruction. It is our belief that the stages of tissue expansion surgery can be combined with the reconstruction of associated burn injuries sometimes using the region of expected alopecia excision.