Health Literacy Awareness Among Orthopaedic Surgery Residents: A COERG Survey.

Musculoskeletal health literacy (HL) is an emerging concept in orthopaedic patient care. Estimated rates of low musculoskeletal HL in patients surpass those of general HL. Studies in other specialties suggest that medical trainees are ill equipped to interact with low HL patients, often with detrimental patient outcomes. The purpose of this study was to (1) establish the current state of HL awareness among orthopaedic surgery trainees, (2) characterize the current state of HL training in orthopaedic surgery programs, and (3) evaluate the desire for formalized HL training among orthopaedic surgery trainees. Methods: This study was endorsed by the Collaborative Orthopaedic Education Research Group board. A 17-item questionnaire was administered anonymously to orthopaedic residents through a secure online platform in the 2020 to 2021 academic year. All participation was voluntary. Results: One hundred ninety-two residents (42%) from 19 orthopaedic programs completed the survey. Most residents felt "somewhat comfortable" with issues related to HL. Most residents reported no specific training in HL issues during residency (77.5%). Of the 43 residents (22.3%) who did receive formal training, most of these individuals felt that the training is effective (N = 42, 97.7%). Role playing/standardized patient encounters were reported as the most effective form of HL training. Residents felt it was somewhat important to receive formal HL training in residency (median = 4.0, interquartile range = 3.0-5.0), and there was a modest desire for formalized training (39%). Discussion: This study is the first to characterize orthopaedic resident perceptions of HL issues in practice and training. Residents were somewhat confident in their understanding of HL concepts, and those who received formal training felt it was effective. However, there remains a low rate of formal orthopaedic resident training in HL issues, which may be an area for improvement in orthopaedic training paradigms.

Resident Education and Wellness: A Strategy for Future Pandemics.

The Coronavirus Disease 2019 (COVID-19) pandemic presented a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation dramatically affected resident training. The objective of this article is to develop new strategies to maintain a healthy, competent residency program while combating the unique challenges to resident education and wellness. In 2020, our institution implemented a revolving 3-Team system. While the "Inpatient-Team" delivered direct care, the "Back-up Team" and "Quarantine-Team" managed the telemedicine virtual clinic and education-wellness strategy, respectively. Our 3-Team system allowed delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. The efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represent an opportunity for lasting improvement. (Journal of Surgical Orthopaedic Advances 31(3):150-154, 2022).

Hold the Antibiotics: Are Preoperative Antibiotics Unnecessary in the Treatment of Pediatric Supracondylar Humerus Fractures?

BACKGROUND: Supracondylar humerus (SCH) fracture is the most common elbow injury in children and often treated with closed reduction and percutaneous pinning (CRPP). There is little published evidence supporting or refuting the use of perioperative prophylactic antibiotics for SCH CRPP in the pediatric population. The purpose of this study is to evaluate the rate of surgical site infection for patients with and without preoperative antibiotics. METHODS: A retrospective chart review was conducted of patients less than or equal to 16 years from 2012 to 2018 who underwent primary CRPP. Open fractures, multilimbed polytraumas, and immunodeficient patients were excluded. Infection rates were compared using a noninferiority test assuming a 3% infection rate and a predefined noninferiority margin of 4%. A total of 255 patients were needed to adequately power the study. RESULTS: Of the 1253 cases identified, 845 met eligibility criteria. A total of 337 received antibiotics, and 508 did not. Preoperative nerve injury (P=0.0244) and sterilization technique (P<0.0001) were associated with antibiotic use: 4 patients developed an infection; there were successfully treated superficial infections, and 1 was a deep infection requiring a formal debridement. There were 8 patients that had a recorded mal-union, and 6 patients required additional procedures; 1 patient had a postoperative compartment syndrome on postoperation day 1. The infection rates among patients treated with and without antibiotics were 0.60% and 0.40%, respectively. The absence of antibiotics was not clinically inferior to using antibiotics (P=0.003). CONCLUSIONS: Infection remains a rare complication following CRPP of SCH fractures. According to our current data, not giving perioperative antibiotics was not inferior to using perioperative antibiotics for preventing superficial or deep infection in patients undergoing CRPP of SCH fractures. With the increase in attention to antibiotic stewardship, it is important to eliminate unnecessary antibiotic use while continuing to maintain a low rate of surgical site infection. LEVEL OF EVIDENCE: Level IV-case series. This is a therapeutic study that investigates the results from a case series.

Characteristics of Pyogenic Musculoskeletal Infections in Older Children and Adolescents.

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.].

Appropriate Use Criteria for Treatment of Pediatric Supracondylar Humerus Fractures With Vascular Injury: Do Our Hospital Practice Patterns Agree With Current Recommendations?

BACKGROUND: Managing the pulseless pediatric supracondylar humerus fracture (PSHF) remains a significant clinical decision-making challenge for the treating surgeon. The purpose of the study is to determine frequency of the treatments according to the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) for the PSHF with vascular injury and evaluate the appropriateness of these interventions. METHODS: We identified all PSHF with concern for vascular injury at one high volume, level 1 trauma center managed by 6 fellowship-trained pediatric orthopaedic surgeons over 4.5 years. Demographic information and other injury and treatment variables were obtained. Each patient was classified as 1 of the 6 patient scenarios specified by the AAOS AUC. Each of the 18 interventions identified in the AUC were documented, including the level of "appropriateness" as specified by AAOS AUC. RESULTS: A total of 638 PSHF were managed identified; of these, 52 were pink, pulseless, or dysvascular (8.2%). Only 7 of the 18 treatment options suggested by the AUC were used in this cohort. Across all 7 interventions used in this cohort, 20.2% (17/84) of interventions were "appropriate," 52.4% (44/84) were "maybe appropriate," 22.6% (19/84) were "rarely appropriate," and 4.8% (4/84) were not listed in treatment options. CONCLUSIONS: Supracondylar fractures are the most common injury to the elbow seen in children and are variable in presentation and management. The pink, pulseless fracture continues to be a major topic for research and discussion due to the morbidity if not treated "appropriately." The AUC were created to help guide practitioners when strong evidence is lacking. In this study at a single, pediatric hospital, there was variation and disagreement with "appropriateness" of treatments that were performed but this discrepancy did not result in any poor outcomes. Although the AUC do offer valuable guidance, our findings highlight a need for continued research in this area to help validate the AUC and help strengthen the recommendations moving forward. LEVEL OF EVIDENCE: Level III-retrospective.

Pediatric Open Both-Bone Forearm Fracture Stabilized with Titanium and Stainless Steel Stacked Extension Internal Plating: A Case Report.

CASE: A 12-year-old male patient sustained a multisegmental both-bone forearm fracture. Definitive stabilization was ulna intramedullary pinning, with stainless steel plating of the radius followed by a titanium plate stacked atop and extending internal fixation. Currently, 36 months after surgery, he experiences no limitations or complications. All hardware remains in situ. CONCLUSION: We believe this is the first description of different material plates in direct contact, of stacked plates, and of 1 plate extending another's fixation. No adverse effects developed.

Matching in Orthopaedic Surgery.

In 2016, 1,137 fourth year medical students submitted applications for orthopedic surgery residency positions. Students applied to an average of 79 programs, resulting in in a total of 89,846 applications being submitted for 727 first year residency positions. This ratio of 124 applications per position is two SDs above the mean relative to other medical specialties. The average applicant for orthopaedic surgery residency attends 2.4 away rotations, as attending 2 away rotations increases an applicant's odds of matching, and submits 83 applications. This excessive number of applications overburdens programs, subjects applicants to considerable costs, and diminishes the quality of fit between interviewees and programs. Eighty-three percent of program directors use step 1 United States Medical Licensing Examination scores as a screening tool to decrease the number of applications necessary for review. The average matched applicant attended 11.5 interviews, and Step 1 scores, research productivity, and Alpha Omega Alpha (AOA) status can be used to predict the number of applications necessary to obtain 12 interviews. AOA membership has the strongest influence on interview yield. Applicants report spending an average of approximately $7,000 on the interview process, and 72% borrow money to cover these costs. Post-interview contact, although forbidden by the National Resident Matching Program , has been reported by 60% to 64% of applicants.

Obstacles Affecting the Implementation of the O-SCORE for Assessment of Orthopedic Surgical Skills Competency.

OBJECTIVES: There is a need for meaningful and reliable measures of surgical competency in residency education. The goal of the current study is to incorporate the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) into the process of resident evaluation at our institution and to assess the feasibility and effectiveness of its use through a web-based platform. DESIGN: This is a feasibility study that prospectively assesses the implementation of a web-based O-SCORE at our institution. Over a 16-week period, 19 orthopedic surgery residents (PGY2-PGY5) participated in a quality improvement study, which involved collecting 2 feedback forms per week. Each form consisted of a resident form and a linked attending form. At the conclusion of the 16-week trial period, residents and faculty members were asked to complete a survey about their perceptions of the O-SCORE program. SETTING: An academic medical center. PARTICIPANTS: The study included only residents in postgraduate training years (PGY) 2 through 5 (n = 20) and attendings (n = 37). RESULTS: During the 16-week study period, 608 resident surveys were requested for the 19 participating residents, of which 404 surveys (66.5%) were completed. Faculty completed 207 of 326 surveys for an overall compliance rate of 63.5%. The O-SCORE was able to significantly differentiate between all training years (p < 0.0001) with the exception of PGY3 residents when compared to PGY4 residents. Overall, residents and faculty found the program valuable and feasible. Resident and faculty perception of the value of the O-SCORE correlated with compliance rate of the O-SCORE surveys. CONCLUSIONS: This study demonstrates that implementation of an immediate feedback program utilizing an electronic platform is achievable and offers reproducible construct validity. However, issues affecting compliance among both residents and faculty physicians must temper optimism for the program and should be systematically addressed to allow for successful implementation.

Development and Implementation of a Pediatric Trauma Survivors Network Program.

: The Trauma Survivors Network (TSN) was developed as a program of the American Trauma Society (ATS) to support recovery for adult trauma patients. However, the children of adult trauma patients, families of pediatric trauma patients, and pediatric trauma patients previously had scarce resources. Our institution, in collaboration with the ATS, sought to expand the TSN to support pediatric trauma patients, caregivers, and family members. We aimed to determine whether the TSN could be transferred to the pediatric population. Focus groups identified psychosocial needs of younger survivors, children of adult survivors, and caregivers. A Pediatric TSN Coordinator was hired, Pediatric TSN Peer Visitors were recruited and trained, and Pediatric TSN Activity Hour was implemented for pediatric patients and families. Since implementation 1 year ago, 26 peer visitors have been trained and have conducted approximately 200 visitations. In total, 93 patients and family members have attended Pediatric TSN Activity Hour. TSN services can be adapted to address psychosocial needs of pediatric trauma survivors, families, and children of trauma survivors. When possible, sharing resources between an existing adult TSN program and a pediatric program is valuable to facilitate expansion. TSN complements and strengthens the care offered at our institution by providing patient-centered and family-centered care services for the entire family at various stages of development. The implementation of this program might be different at sites without an existing adult TSN with established resources and support. This article describes the development and implementation of the program; we did not assess outcomes.

Effectiveness of a Low Fidelity Cast Removal Module in Orthopaedic Surgical Simulation.

OBJECTIVE: The purpose of this study is to determine if an educational model during a surgical skills laboratory results in a significant reduction in cast saw blade temperatures generated during cast removal. DESIGN: As part of an orthopedic resident surgical skills laboratory an Institutional Review Board-approved study was performed. A total of 17 study subjects applied a short arm cast. Everyone removed 1 short arm cast with temperatures recorded on the saw blade. Following cast removal, an educational session was conducted on proper cast removal and blade cooling techniques. Everyone then removed a second cast. Blade temperatures were recorded. To assess reproducibility, the 5 PGY-1 orthopedic residents removed a short arm cast 3 months later. SETTING: Carolinas Medical Center, Charlotte, NC, tertiary care center PARTICIPANTS: A total of 17 study subjects with minimal casting experience (5 PGY-1 orthopedic residents and 12 senior medical students) applied a short arm cast. RESULTS: Following the educational session there was a significant reduction in mean and mean maximum blade temperatures (p < 0.05). During the second round of cast removal assessment of blade temperatures and specific techniques to cool the blade were observed among all participants. At 3 months' time, the mean and mean maximum blade temperatures remained significantly lower than before the educational session (p < 0.05). CONCLUSIONS: The intervention in this study reduced the maximum blade temperatures to levels below the threshold known to cause burns. This simple, low cost, and easily reproducible model can easily be disseminated across institutions and simulation laboratories.

Opioid Prescribing in the Pediatric Orthopaedic Trauma Population.

The purpose of this article is to describe opioid prescribing patterns for children with orthopaedic injuries. A retrospective chart review was conducted on pediatric orthopaedic trauma patients (n = 124) who were discharged from the hospital or emergency department or had a clinic visit during a 1-month period. Patient demographics, prescription specifics, injury details, and fracture fixation information were collected. Results show that most children received opioids after injury (82.3%). While children undergoing operative fixation typically received opioids, only 39.5% with closed reduction did. Hydrocodone- acetaminophen accounted for 93% of prescriptions, but adolescents were more likely to receive other drugs. There was a significant trend of increasing daily dosage with increased age; 36.73% of adolescents received > 50 morphine milligram equivalents per day. Children with orthopaedic injuries are typically prescribed opioids; older children more commonly receive higher dosages. Further study is needed to define prescribing trends across facility and specialty types to aid in development of standardized prescribing guidelines. (Journal of Surgical Orthopaedic Advances 27(4):269-273, 2018).

Pediatric Flatfoot: Pearls and Pitfalls.

Pediatric flatfeet are common, are usually asymptomatic, and typically improve over time as young children age. It is critical to differentiate flexible from rigid flatfeet and to assess for associated Achilles contracture with a careful history, physical examination, and initial radiographs. Although there are limited data, nonsurgical management of symptomatic flatfeet, both flexible and rigid, should be exhausted before considering surgical intervention. If patients fail conservative treatment, surgical management with joint-preserving, deformity-corrective techniques is typically used for pediatric flexible flatfeet in conjunction with deformity-specific soft tissue procedures.

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

BACKGROUND: The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period. METHODS: This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated. RESULTS: There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%). CONCLUSIONS: Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates. LEVEL OF EVIDENCE: Level IV-therapeutic.

Effectiveness of a Low-Cost Drilling Module in Orthopaedic Surgical Simulation.

INTRODUCTION: Financial pressures and resident work hour regulations have led to adjunct means of resident education such as surgical simulation. The purpose of this study is to determine the effectiveness of a hands-on training session in orthopaedic drilling technique educational model during a surgical simulation on reducing drill plunging depth and to determine the effectiveness of senior residents teaching a hands-on training session in orthopaedic drilling technique. METHODS: A total of 13 participants (5 orthopaedic interns and 8 medical students) drilled until they penetrated the far cortex of a synthetic bone model and the plunging depth (PD) was measured. They were then randomized and underwent an education session with an attending orthopaedic surgeon or a senior resident. Next, the subjects drilled again with the PD being calculated. The preeducational and posteducational session were compared to determine if there was any improvement in PD and if there was a difference between educators. The cost of the model was also determined. RESULTS: The mean maximum PD and mean PD before the education session was 1.58 (1.40-2.10) and 1.50cm (1.36-1.76), respectively. Following the educational session, the mean maximum PD and mean PD were 0.53 (0.42-0.75) and 0.50cm (0.40-0.72), respectively. These were both significantly lower than before the education session (p <0.05). After the educational session taught by the attending versus the session taught by the resident, the mean maximum PD was 0.59 (0.42-0.75) and 0.49cm. (0.45-0.75), respectively (p = 0.44). After the educational session taught by the attending versus the session taught by the resident, the mean PD was 0.54 (0.40-0.72) and 0.47cm. (0.40-0.65), respectively (p = 0.44). The cost of the station per participant was $5.44. CONCLUSION: This study demonstrated a significant reduction in drilling PD with use of a low-cost training model and a formal didactic and skills session on proper drilling technique that can effectively be led by senior residents.

Adolescent Distal Humerus Fractures: ORIF Versus CRPP.

BACKGROUND: Although supracondylar humerus fractures are common in young children, the incidence in adolescents is much lower. As a result, there is a paucity of literature to guide treatment. The purpose of this study was to review the treatment and outcomes for a consecutive series of distal humerus fractures in adolescents and to compare outcomes between patients treated with percutaneous skeletal fixation and those treated with open reduction and fixation. METHODS: A retrospective review of patients 10 to 17 years of age who underwent surgical treatment for a distal humerus fracture from 2005 to 2014 was performed. Patients with medial epicondyle fractures and those with insufficient follow-up to document union or return of motion were excluded. Medical records were reviewed to collect demographic data as well as operative approach and method of fixation. Clinical outcomes included range of motion, time to maximum motion, and complications [nerve dysfunction, heterotopic ossification (HO), need for secondary surgery]. Radiographs were reviewed to determine time to union as well as coronal and sagittal alignment. RESULTS: One hundred eighteen adolescents with displaced distal humerus fractures were identified. Eighty-one met inclusion criteria. Forty-four of these were classified as extra-articular [Orthopaedic Trauma Association (OTA) 13-A], and 37 were intra-articular fractures (10 OTA 13-B and 27 OTA 13-C).Although not statistically significant, closed treatment with percutaneous fixation of extra-articular fractures resulted in greater flexion-extension arc of motion at final follow-up (128 vs. 119 degrees, P=0.17) and demonstrated more rapid return of motion (2.8 vs. 3.9 mo, P=0.05) when compared with open treatment despite a longer duration of immobilization and less formal physical therapy. Complications such as HO (P=0.05), nerve dysfunction (P=0.02), and secondary surgery (P=0.001) were more common in the open treatment group.Closed treatment with percutaneous fixation of intra-articular fractures was performed in younger patients of similar size (12.8 vs. 14.4 y, P<0.01; 154 vs. 142 lbs, P=0.5). There were no significant differences between groups in regard to outcomes or complications. There were trends toward increased frequency of HO, nerve dysfunction, and secondary surgery in the open treatment group.Patients with intra-articular fractures were older (14.2 vs. 11.5 y, P<0.001) and heavier (144 vs. 94 lbs, P<0.001) than patients with extra-articular fractures and were more likely to be treated open (74% vs. 11%, P<0.001). Extra-articular fractures demonstrated a greater total arc of motion (126 vs. 118 degrees, P=0.04) at final follow-up despite longer duration of immobilization (23 vs. 15 d, P=0.002), and less physical therapy (27% vs. 73%, P<0.001). Radiographic carrying angle (16.6 vs. 22.3 degrees, P=0.08) and anterior humeral line (95% vs. 81%, P=0.07) trended toward more anatomic alignment in the extra-articular group. Secondary surgery was more common after intra-articular fracture (24% vs. 7%, P=0.03). CONCLUSIONS: Closed reduction and pinning of extra-articular distal humerus fractures in adolescents resulted in predictable clinical and radiographic outcomes and allowed for earlier return of motion and fewer complications when compared with open treatment. Intra-articular distal humerus fractures occur more frequently in older adolescents and are more likely to require open reduction and internal fixation to obtain joint congruity. Patients with intra-articular injuries should be cautioned that regaining full elbow motion may be more difficult, and there is an increased risk for complications and need for additional surgery. Closed reduction and percutaneous fixation of intra-articular injuries appears to be a reasonable option in select patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

A Comprehensive, High-Quality Orthopedic Intern Surgical Skills Program.

OBJECTIVES: To design and implement a month-long, low-cost, comprehensive surgical skills curriculum built to address the needs of orthopedic surgery interns with high satisfaction among both interns and faculty. DESIGN: The study design was retrospective and descriptive. SETTING: The study was conducted at tertiary care referral center with a medium sized orthopedic residency surgery program (5 residents/year). PARTICIPANTS: Totally 5 orthopedic surgery residents and 16 orthopedic surgery faculty participated. RESULTS: A general mission was established-to orient the resident to the postgraduate year 1 and prepare them for success in residency. The basic tenets of the American Board of Orthopaedic Surgeons surgical skills program framework were built. Curricular additions included anatomic study, surgical approaches, joint-specific physical examination, radiographic interpretation, preoperative planning, reduction techniques, basic emergency and operating room procedures, cadaveric procedure practice, and introduction to arthroplasty. The program was held in August during protected time for intern participants. In total, 16 orthopedic surgeons instructed 85% of the educational sessions. One faculty member did most of the preparation and organization to facilitate the program. The program ran for a cumulative 89 hours, including 14.5 hours working with cadaveric specimens. The program cost a total of $8100. The average module received a 4.15 rating on a 5-point scale, with 4 representing "good" and 5 representing "excellent." CONCLUSIONS: The program was appropriately timed and addressed topics relevant to the intern without sacrificing clinical experience or burdening inpatient services with interns' absence. The program received high satisfaction ratings from both the interns as well as the faculty. Additionally, the program fostered early relationships between interns and faculty-an unforeseen benefit. In the future, our program plans to better integrate validated learning metrics and improve instruction pertaining to both fluoroscopic examination and arthrocentesis.

Cartilage Degeneration, Subchondral Mineral and Meniscal Mineral Densities in Hartley and Strain 13 Guinea Pigs.

Osteoarthritis is a joint disease involved in articular cartilage, subchondral bone, meniscus and synovial membrane. This study sought to examine cartilage degeneration, subchondral bone mineral density (BMD) and meniscal mineral density (MD) in male Hartley, female Hartley and female strain 13 guinea pigs to determine the association of cartilage degeneration with subchondral BMD and meniscal MD. Cartilage degeneration, subchondral BMD and meniscal MD in 12 months old guinea pigs were examined with histochemistry, X-ray densitometry and calcium analysis. We found that male Hartley guinea pigs had more severe cartilage degeneration, subchondral BMD and meniscal MD than female Hartley guinea pigs, but not female strain 13 guinea pigs. Female strain 13 guinea pigs had more severe cartilage degeneration and higher subchondral BMD, but not meniscal MD, than female Hartley guinea pigs. These findings indicate that higher subchondral BMD, not meniscal MD, is associated with more severe cartilage degeneration in the guinea pigs and suggest that abnormal subchondral BMD may be a therapeutic target for OA treatment. These findings also indicate that the pathogenesis of OA in the male guinea pigs and female guinea pigs are different. Female strain 13 guinea pig may be used to study female gender-specific pathogenesis of OA.

Although inconvenient, baclofen pumps do not complicate scoliosis surgery in patients with cerebral palsy.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To compare patients with operative cerebral palsy with and without an intrathecal baclofen pump (ITB) to determine whether an ITB increases the complexity of scoliosis surgery and/or increases the risk of wound complications. SUMMARY OF BACKGROUND DATA: Options for baclofen pump placement include before, during, or after scoliosis surgery. There is some concern that prior placement of an ITB and catheter can further complicate cerebral palsy scoliosis surgery and increase the risk for wound complications. METHODS: Prospectively collected cases from a multicenter cerebral palsy scoliosis database were reviewed for patients who underwent posterior spinal instrumentation and fusion for a major coronal deformity. These patients were then divided on the basis of whether they had ITB at the time of initial scoliosis surgery. The 2 groups were compared to determine differences in demographics, operative parameters, radiographical outcomes, and rates of wound complications. RESULTS: Of 187 patients identified, 32 had an ITB previously placed (ITB group) and 155 did not (non-ITB group). Both groups were similar in regard to age, sex, Gross Motor Function Classification Scale score, and preoperative Cobb magnitude. When comparing operative parameters, there were no differences in the total operating room time (ITB = 375 ± 127 min, non-ITB = 423 ± 178 min; P = 0.149) or total estimated blood loss (ITB = 2323 ± 1489 mL, non-ITB = 2081 ± 1572 mL; P = 0.424). Postoperatively, the 2 groups had similar correction rates (71% vs. 67%, P = 0.303). As for perioperative wound complications, there were no differences in rates (P = 0.546) between the ITB (16%) and non-ITB group (15%). CONCLUSION: Although it may be inconvenient for the surgeon, ITBs do not increase the complexity of surgery or the risk for wound complications. When counseling patients and their caregivers on the timing of pump placement, it does not seem to compromise the care of the patient if the baclofen pump is placed first. Further study is needed to evaluate the safety of pump placement during or after scoliosis surgery. LEVEL OF EVIDENCE: 4.

Biomechanical comparison of hamstring tendon fixation devices for anterior cruciate ligament reconstruction: Part 2. Four tibial devices.

We conducted a study to biomechanically compare 4 tibial hamstring tendon fixation devices commonly used in anterior cruciate ligament reconstruction. Quadrupled human semitendinosus-gracilis tendon grafts were fixed into porcine tibias using 4 separate fixation devices. For each device, 10 specimens were tested (1500-cycle loading test at 50-200 N). Specimens surviving the cyclic loading then underwent a single load-to-failure test. Failure mode, stiffness, ultimate load, and residual displacement were recorded. Eight of 10 Delta screw (Arthrex), 2 of 10 Retroscrew (Arthrex), 10 of 10 WasherLoc (Arthrotek), and 10 of 10 Intrafix (Depuy Mitek) devices completed the 1500-cycle loading test. Residual displacement was significantly (P < .001) lower for Intrafix (2.9 mm), WasherLoc (5.6 mm), and Delta (6.4 mm) than for Retroscrew (25.5 mm). Mean stiffness was significantly (P < .05) higher for Intrafix (129 N/mm) than for the other devices. Mean load to failure was highest for Intrafix (656 N), then WasherLoc (630 N), Delta (430 N), and Retroscrew (285 N). The Intrafix device demonstrated superior strength in the fixation of hamstring grafts in the tibia. WasherLoc was close behind.

Biomechanical comparison of hamstring tendon fixation devices for anterior cruciate ligament reconstruction: part 1. Five femoral devices.

We conducted a study to biomechanically compare 5 femoral hamstring tendon fixation devices commonly used in anterior cruciate ligament reconstruction. Quadrupled human semitendinosus-gracilis tendon grafts were fixed into porcine femurs using 5 separate fixation devices. For each device, 10 specimens were tested (1500-cycle loading test at 50-200 N). Specimens surviving the cyclic loading then underwent a single load-to-failure (LTF) test. Failure mode, stiffness, ultimate load, and rigidity were recorded. Two of 10 Delta screw (Arthrex), 10 of 10 Bio-TransFix (Arthrex), 10 of 10 Bone Mulch screw (Arthrotek), 10 of 10 EZLoc (Arthrotek), and 10 of 10 Zip Loop (Arthrotek) devices completed the 1500-cycle loading test. Residual displacement was lowest for Bio-TransFix (4.1 mm) followed by Bone Mulch (5.2 mm), EZLoc (6.4 mm), Zip Loop (6.8 mm), and Delta (8.2 mm). Mean stiffness was significantly (P < .001) higher for Bone Mulch (218 N/mm) than for Bio-TransFix (171 N/mm), EZLoc (122 N/mm), Zip Loop (105 N/mm), or Delta (84 N/mm). Mean LTF was significantly ( P < .001) higher for Bone Mulch (867 N) than for Zip Loop (615 N), Bio-TransFix (552 N), EZLoc (476 N), or Delta (410 N). The Bone Mulch screw demonstrated superior strength in the fixation of hamstring grafts in the femur. Bio-TransFix was close behind. The Delta screw demonstrated poor displacement, stiffness, and LTF. When used as the sole femoral fixation device, a device with low LTF, decreased stiffness, and high residual displacement should be used cautiously in patients undergoing aggressive rehabilitation.