Kienböck Disease in a Patient with Congenital Synostosis of the Lunate and the Triquetrum: A Case Report.

CASE: We describe the case of a 40-year-old man with Minnaar type-III congenital synostosis of the lunate and the triquetrum who presented with Lichtman stage-I Kienböck disease. Surgical treatment consisted of capitate shortening with a capitate-hamate fusion. CONCLUSION: This case demonstrates the tenuous regional nature of the vascularity to the lunate, even in the setting of a complete lunotriquetral synostosis.

Long-term Outcomes Following Syme's Amputation.

BACKGROUND: The metabolic cost of walking after Syme's ankle disarticulation amputation is minimally more than that for nonamputation. The ability to end weightbearing makes prosthetic fitting relatively simple, and very few patients require extensive rehabilitation or placement in a skilled nursing or rehabilitation facility. In spite of these potential benefits, there is a paucity of objective information on the actual long-term outcomes. METHODS: Fifty-one patients were identified who underwent single-stage Syme's ankle disarticulation amputation with excision of the lateral and medial malleoli by a single surgeon during a 23-year period. None of these patients had sufficient tissue to allow amputation at the transmetatarsal or tarsometatarsal levels. Thirty-three underwent amputation due to a diabetic forefoot infection, 11 secondary to a crush injury, 3 for a nondiabetic infection, 3 for a noncorrectable acquired deformity, and 1 for neoplasm. The average age at surgery for the diabetic patients was 62.1 years (range, 36-81 years), with an average follow-up of 6.8 years (range, 4.0-11.6 years). The nondiabetic patients had an average age of 37.8 years (range, 21-65 years), with an average follow-up of 9.3 years (range, 2.2-25.0 years). Patients who were alive and could be contacted were invited to complete the Short Musculoskeletal Function Assessment (SMFA) questionnaire that was scored for functional, mobility, and bothersome indices. RESULTS: Seventeen of the 33 diabetic patients died. Four (12.1%) were converted to transtibial amputation. One of the nondiabetic patients died, and 1 (5.5%) was converted to transtibial amputation. Eleven of the 33 patients who were contacted completed the SMFA. All of these patients demonstrated favorable outcome scores in the mobility, functional, and bothersome indices (average mobility index of 17.2, functional index of 14.7, and bothersome index of 16.7 for nondiabetic patients compared to 34.7, 29.9, and 30.6 for diabetic patients, respectively). CONCLUSION: The objective information derived from this investigation supports the opinion that patients who underwent Syme's ankle disarticulation amputation appear to fare better than similar patients with transtibial amputation. These data also refute the notion of high complication rates and difficulties with prosthetic fitting. These patients required less rehabilitation and achieved improved levels of functional independence as demonstrated by favorable functional, mobility, and bothersome indices. LEVEL OF EVIDENCE: Therapeutic Level IV, retrospective series.

Dysregulation of Tissue Factor, Thrombin-Activatable Fibrinolysis Inhibitor, and Fibrinogen in Patients Undergoing Total Joint Arthroplasty.

Total joint arthroplasty (TJA) of the hip or knee (THA, TKA) has become an increasingly common procedure. While TJA is a successful treatment for individuals experiencing degenerative joint diseases, it is well known that one of the most common perioperative complications of TJA is deep venous thrombosis (DVT). To profile tissue factor (TF), microparticle-tissue factor (MP-TF), thrombin-activatable fibrinolysis inhibitor (TAFI), and fibrinogen levels in patients undergoing TJA to determine potential preexisting Hemostatic dysregulation. De-identified blood samples were obtained from patients undergoing TJA 1 day pre- and 1 day postprocedure. Plasma samples were analyzed using enzyme-linked immunosorbent assay kits for fibrinogen, TAFI, TF, and MP-TF; fibrinogen levels were also assessed using a clot-based activity assay. In comparison with healthy controls, there were significant increases of fibrinogen and MP-TF levels, while there were significant decreases in TF and TAFI levels in the preoperative and postoperative patients. Comparing the pre versus postoperative patients, no significant differences were found; interestingly, however, surgical intervention exacerbated the changes found in the preoperative samples compared to the controls. The results of this study confirm that patients undergoing TJA have preexisting alterations in the fibrinolytic system. Surgical intervention tended to exacerbate these changes. The alterations observed in this study may provide insight as to why TJA is associated with higher rates of DVT and thromboembolism.

The Economic Burden of Orthopedic Surgery Residency Interviews on Applicants.

BACKGROUND: The intense competition for orthopedic surgery residency positions influences the interview process. The financial impact on residency applicants is less well understood. The purpose of the present study was to define the economic burden of the orthopedic surgery residency interview process while additionally describing how applicants finance the expense. METHODS: We distributed surveys to 48 nonrotating applicants at our institution's residency interview days for the 2015 match year. The survey consisted of eleven questions specific to the costs of interviewing for orthopedic surgery residency positions. RESULTS: The survey response rate was 90% (43/48). Applicants applied to a median of 65 orthopedic surgery residency programs (range 21-88) and targeted a median of 15 interviews (range 12-25). The mean cost estimate for a single interview was $450 (range $200-800) and the cost estimate for all interviews was $7,119 (range $2,500-15,000). Applicants spent a mean of $344 (range $0-750) traveling to our interview. Seventy-two percent borrowed money to finance their interview costs and 28% canceled interviews for financial reasons. CONCLUSIONS: The financial cost of interviewing for orthopedic surgery is substantial and a majority of applicants add to their educational debt by taking out loans to finance interviews. Future considerations should be made to minimize these costs for an already financially burdened population.

Factors influencing the number of applications submitted per applicant to orthopedic residency programs.

BACKGROUND: From 2002 to 2014, the orthopedic surgery residency applicant pool increased by 25% while the number of applications submitted per applicant rose by 69%, resulting in an increase of 109% in the number of applications received per program. OBJECTIVE: This study aimed to identify applicant factors associated with an increased number of applications to orthopedic surgery residency programs. DESIGN: An anonymous survey was sent to all applicants applying to the orthopedic surgery residency program at Loyola University. Questions were designed to define the number of applications submitted per respondent as well as the strength of their application. Of 733 surveys sent, 140 (19.1%) responses were received. SETTING: An academic institution in Maywood, IL. PARTICIPANTS: Fourth-year medical students applying to the orthopedic surgery residency program at Loyola University. RESULTS: An applicant's perception of how competitive he or she was (applicants who rated themselves as 'average' submitted more applications than those who rated themselves as either 'good' or 'outstanding', p=0.001) and the number of away rotations (those who completed >2 away rotations submitted more applications, p=0.03) were significantly associated with an increased number of applications submitted. No other responses were found to be associated with an increased number of applications submitted. CONCLUSION: Less qualified candidates are not applying to significantly more programs than their more qualified counterparts. The increasing number of applications represents a financial strain on the applicant, given the costs required to apply to more programs, and a time burden on individual programs to screen increasing numbers of applicants. In order to stabilize or reverse this alarming trend, orthopedic surgery residency programs should openly disclose admission criteria to prospective candidates, and medical schools should provide additional guidance for candidates in this process.

Pin Tract Infection Following Correction of Charcot Foot With Static Circular Fixation.

BACKGROUND: The traditional nonsurgical accommodative treatment for diabetes-associated Charcot foot arthropathy has been unsuccessful in improving the quality of life in affected individuals. This has led to the growing interest in surgical correction of the acquired deformity with either "super construct" internal fixation implants or fine-wire static circular external fixation. The use of static circular external fixation without implants has been demonstrated to achieve high rates of deformity correction with low complication rates. The goal of this investigation was to assess the risk of pin site infection in this high-risk patient population. METHODS: Over an 11-year period, 283 consecutive diabetic patients underwent single-stage correction of Charcot foot deformity with static fine-wire circular external fixation and no internal fixation devices. Pin care was minimal. RESULTS: Fifty-nine (20.8%) patients developed clinical signs of pin tract infection in at least 1 pin site. Forty-nine occurred in patients undergoing surgical correction of deformity in the foot. Eight occurred in patients undergoing surgical correction at the ankle level and 2 in patients undergoing complex reconstruction for combined foot and ankle deformity. Higher rates of pin site infections were observed in patients with osteomyelitis present at the time of surgery (25.6%) as compared with patients without evidence of infection (17.8%), although the difference was not statistically significant (P = .1184). There was no correlation between body mass index and pin site infection (P = .288). There was a statistically significant trend (P < .05) for higher rates of pin site infection in patients with elevated hemoglobin A1C levels. Erythema and drainage resolved in all patients with local pin care and empiric oral antibiotic therapy. None of the wires were removed prematurely, and all infections resolved following removal of the circular external fixator at the scheduled time for removal. CONCLUSIONS: Pin site infection was common following surgical correction of the acquired deformity associated with Charcot foot. These acquired pin site infections were a nuisance but did not appear to add permanent morbidity or require additional surgery to resolve. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Rate of weight loss can be predicted by patient characteristics and intervention strategies.

BACKGROUND: Although dietary weight-loss counseling usually employs a 500 to 1,000 kcal/day energy deficit to induce weight loss of 0.5 to 1 kg/week, this rate of weight loss is rarely achieved in research settings. Biological factors, such as changes in metabolic rate, are partly responsible, but would only account for a small deviation from expected weight loss. There must be other factors, behavioral or related to study design and implementation, that affect the rate of weight loss observed. OBJECTIVE: To examine factors that influence the rate of weight loss obtained in clinical studies. DESIGN: Thirty-five weight-loss studies published between 1995 and 2009 were identified that used dietary counseling to induce weight loss in healthy subjects. Studies were included if they had a duration of at least 6 weeks, used a strategy to counsel subjects to reduce free-living energy intakes, and reported weight-loss data based on a completers analysis. Variables that were associated with the rate of weight loss among age, sex (percent female subjects), initial body weight, frequency of dietary counseling, placebo use, exercise level, study length, and prescribed energy deficit were examined using linear regression analysis. RESULTS: Study length was negatively related to the rate of weight loss (P<0.0001), whereas subject age (P<0.002), subject age squared (P=0.0073), initial body weight (P=0.0003), frequency of dietary counseling (P=0.0197), and prescribed energy deficit (P<0.0001) were positively related to the rate of weight loss observed in clinical studies. CONCLUSIONS: These findings provide a tool for investigators and clinical dietitians to predict the rate of weight loss that can be expected within a population given the age, initial body weight, frequency of dietary counseling, and energy deficit prescription. These data from clinical studies suggest that the rate of weight loss is greater in older and heavier subjects and with higher contact frequency and caloric restriction.

Paternal age and assisted reproductive technology outcome in ovum recipients.

This study suggests that paternal age may be inversely associated with reproductive outcome, as demonstrated by a decline in fertilization, blastocyst formation, implantation and cryopreservation rates with advancing age.