Web-Based Education Prior to Knee Arthroscopy Enhances Informed Consent and Patient Knowledge Recall: A Prospective, Randomized Controlled Study.

BACKGROUND: Preoperative patient education is an important part of the informed consent process, and a perceived lack of information can lower patient satisfaction. We sought to evaluate the effect of a web-based multimedia patient education tool on the perioperative experience of patients undergoing first-time knee arthroscopy for a meniscal tear. METHODS: Adult patients undergoing knee arthroscopy for the first time for a primary diagnosis of a meniscal tear were consecutively enrolled into the study from January 2014 through June 2014. Patients were equally randomized to a control group, who received standard preoperative counseling, or the intervention group, who completed a twenty-minute web-based multimedia tutorial in addition to standard counseling. The web-based tutorial covered relevant anatomy, pathology, and general perioperative instructions, and it was completed prior to the preoperative visit. Patients completed surveys that evaluated their preparedness for surgery and knowledge recall at the preoperative visit, on the day of surgery, and after the first postoperative visit. RESULTS: Sixty-four patients were enrolled, and fifty-five patients (86%; twenty-nine in the control group and twenty-six in the intervention group) with complete data sets were included in the analysis. Preoperatively, the intervention group felt significantly more informed about the surgery and more clearly understood the risks and benefits of, and alternatives to, the surgery (all p < 0.001). Postoperatively, the intervention group reported being significantly more satisfied with the perioperative education that they had received and felt more informed about their surgery and rehabilitation (p ≤ 0.05). Patients in the intervention group were significantly more likely to correctly answer questions regarding their surgical details at the first postoperative visit (p ≤ 0.03). CONCLUSIONS: Patients who completed the web-based tutorial had improved preoperative knowledge and preparedness as well as enhanced postoperative knowledge recall regarding their surgical procedure. The tutorial received high user satisfaction scores with low user burden scores and was an effective tool for enhancing the patients' perioperative experience.

Impact of fellowship training on clinical practice of orthopaedic sports medicine.

BACKGROUND: Approximately 90% of current orthopaedic graduates are engaging in fellowship training, with sports medicine being the most commonly chosen specialty. The purpose of this study was to evaluate the impact of fellowship training on clinical decision-making by fellowship-trained sports medicine surgeons. METHODS: A survey was designed to assess the importance of fellowship on common clinical decisions made in the nonoperative and surgical treatment of knee, shoulder, and elbow disorders. The survey also included questions for the respondents on their comfort level with a variety of routine and complex surgical procedures. The survey was sent to alumni of 113 orthopaedic sports medicine programs across the United States. RESULTS: Completed surveys were returned by 310 surgeons who had been in practice for an average of 9.0 years. They represented alumni of twenty-nine orthopaedic sports medicine fellowship programs across sixteen states. Fellowship was considered very important for surgical decision-making in the knee and shoulder. For nonoperative treatment, fellowship had a greater impact on shoulder disorders than on knee or elbow disorders. Fellowship was significantly more important than residency (p < 0.001) for determining preferred surgical equipment, implants, and braces. Among the surgical procedures assessed, respondents were least comfortable with the treatment of multi-ligamentous knee injuries, posterior cruciate ligament injuries, and shoulder instability with bone loss. CONCLUSIONS: Fellowship has a significantly higher impact than residency on industry-related decision-making. Fellowship-trained sports surgeons should consider seeking additional training in the treatment of multi-ligamentous knee injuries, posterior cruciate ligament injuries, shoulder instability with bone loss, and elbow disorders. The current findings were limited by the relatively small respondent pool, which represented only 26% of sports medicine fellowship programs in the United States.

How does external rotation bracing influence motion and functional scores after arthroscopic shoulder stabilization?

BACKGROUND: After arthroscopic shoulder stabilization, the loss of motion or delayed recovery of motion remains a clinical problem and may lead to poor patient satisfaction. There remains no consensus regarding the optimal position for postoperative immobilization and it is not known whether the position for shoulder immobilization has an effect on motion and functional recovery. QUESTIONS/PURPOSES: We asked: (1) Do patients treated with external rotation (ER) bracing after arthroscopic anterior shoulder stabilization reliably regain ROM and shoulder function? And (2) what is the frequency of recurrent instability and brace-related complications associated with the use of ER bracing? METHODS: Forty consecutive patients with a primary diagnosis of anterior shoulder instability underwent arthroscopic stabilization and received postoperative ER bracing; 33 patients (83%; mean age, 23 years; range, 13-44 years) were followed for at least 1 year postoperatively and seven patients were lost to followup. Shoulder ROM and functional scores were recorded preoperatively and at 2 weeks, 12 weeks, 6 months, and greater than 1 year (mean, 16 months) after surgery. RESULTS: All patients recovered their preoperative ROM and most patients achieved normal ROM by 3 months after surgery. Significant improvements in American Shoulder and Elbow Surgeons (ASES) and Western Ontario Shoulder Instability (WOSI) scores were observed at each postoperative time point. The mean (± SD) final scores were 95 ± 9 for the ASES and 87% ± 17% for the WOSI (p < 0.001 compared to preoperative scores). One patient (3%) developed recurrent instability. No patients underwent reoperation for the injured shoulder for any reason during the followup period. CONCLUSIONS: ER bracing after arthroscopic shoulder stabilization is associated with a predictable recovery of ROM and functional score improvement. Future studies comparing ER bracing to traditional sling use should be conducted to determine the optimal method of postoperative immobilization. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Proximal humerus and humeral shaft nonunions.

The rate of nonunion is estimated to be 1.1% to 10% following closed treatment of proximal humerus fracture and 5.5% following closed treatment of humeral shaft fracture. Surgical management should be considered for fractures that demonstrate no evidence of progressive healing on consecutive radiographs taken at least 6 to 8 weeks apart during the course of closed treatment. In the case of proximal humerus nonunion, recent series have demonstrated union in >90% of patients treated with reconstruction using locking plates and autogenous bone graft. Shoulder arthroplasty is reserved as a salvage option in cases in which the humeral head is not viable or the proximal fragment will not support osteosynthesis. For humeral shaft nonunions, open reduction and internal fixation with compression plating and bone graft remains the standard of care, with a >90% rate of union and good functional outcomes. Recent studies support the use of locked compression plates, dual plating, and cortical allograft struts in patients with osteopenic bone.

Investigation of the preservation of the fluid seal effect in the repaired, partially resected, and reconstructed acetabular labrum in a cadaveric hip model.

BACKGROUND: Debate exists on whether hip labral tears should be surgically repaired, partially resected, or reconstructed. Furthermore, limited data exist regarding the fluid seal properties of hip labrum repair and/or reconstruction with iliotibial band autograft when compared with the labrum-intact condition. Hypothesis/ PURPOSE: The purpose of this study was to investigate the fluid seal properties of hip labral repair and reconstruction techniques. We hypothesized that hip labral repair preserves the acetabular labral fluid seal greater than labral tear, partial-resection, and reconstruction conditions. STUDY DESIGN: Controlled laboratory study. METHODS: Six human cadaveric hemipelvises were dissected of all soft tissue, leaving the hip capsule intact. Fluid efflux was measured under 5 conditions using a custom fluid infusion device: (1) hip labrum intact, (2) labral tear, (3) labral repair with suture anchors, (4) partial labral resection, and (5) labral reconstruction using ipsilateral iliotibial band autograft. Joint fluid expression was measured as flow rate under 3 different pressure settings (2, 3, and 4 psi). Statistical differences between conditions were assessed using 2-way, repeated-measures analysis of variance. The Student-Newman-Keuls (SNK) multiple comparison test was used to determine differences between levels. RESULTS: There was a significant increase in fluid efflux with a simulated labral tear (0.54 ± 0.3 mL/sec) when compared with the intact hip labrum condition (0.006 ± 0.008 mL/sec, P < .05). The labrum-repaired condition (0.21 ± 0.2 mL/sec) demonstrated significantly less fluid efflux when compared with the labral-tear condition. Hip labral repair significantly prevented greater fluid efflux when compared with partial labral resection (0.60 ± 0.4 mL/sec) and reconstruction with iliotibial band autograft (0.54 ± 0.3 mL/sec; P < .05). Labral repair did not preserve fluid efflux as effectively as in the labrum-intact condition (0.21 ± 0.2 > 0.006 ± 0.008 mL/sec; P < .05). There was no difference observed in fluid efflux between the labral reconstruction, tear, or resection conditions (P > .05). CONCLUSION: In this human cadaveric model, hip labral repair outperforms partial labral resection and reconstruction in preserving the joint fluid seal; however labral repair does not restore fluid seal characteristics as effectively as in the labrum-intact condition. CLINICAL RELEVANCE: Further prospective studies are needed to determine whether hip labral repair outperforms partial labral resection and/or reconstruction in clinical practice.

Operative treatment of isolated greater tuberosity fractures: retrospective review of clinical and functional outcomes.

Displaced isolated greater tuberosity fractures are rare injuries that require operative treatment to optimize rotator cuff function and prevent painful subacromial impingement. A lack of consensus exists regarding ideal management of these injuries because of the paucity of literature on the subject.The outcomes of 17 patients treated with open (n=15) or arthroscopic (n=2) fixation at the authors' institution between 2001 and 2009 were retrospectively reviewed. Postoperative range of motion, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score, and overall patient satisfaction were recorded at final follow-up. At a mean of 5.2 years (range 1.5-9.7 years), average postoperative active forward elevation was 150.3° (range, 60°-180°), ASES score was 82.9 (range, 46.7-100), and VAS score was 1.4 (range, 0-5). According to Neer's criteria, the overall outcome was excellent in 11 (65%) patients, satisfactory in 5 (29%) patients, and unsatisfactory in 1 (6%) patient. Final postoperative radiographs were available for 15 patients at a mean of 6.64 months. Radiographic union with near-anatomic position of the greater tuberosity was achieved in 13 (87%) of 15 patients. The presence of rotator cuff and rotator interval tears requiring repair, history of dislocation, age 60 years or older, and delayed time to surgery ≥ 10 days did not significantly (P>.05) influence the patients' final active forward elevation and ASES scores.Favorable patient outcomes can be achieved when fractures with >5 mm of displacement are treated with anatomic reduction and secure fixation. For a specific injury, the ideal surgical approach and method of fixation is dictated by patient characteristics and fracture pattern.

Simultaneous use of 2 C-arm devices facilitates percutaneous treatment of proximal humerus fractures.

Percutaneous treatment of proximal humerus fractures is a technically challenging procedure because percutaneous implants must be placed in a specific configuration to obtain optimal fixation while avoiding joint penetration. Using 2 C-arm devices can expedite this procedure by providing simultaneous visualization of the fracture and implants in 2 planes. Simultaneous orthogonal imaging during pin insertion decreases the number of passes needed to obtain optimal pin placement. Dual fluoroscopy also avoids excess exposures and inadvertent sterile field contamination, which can occur with repeated C-arm repositioning.

Arthroscopic alphabet soup: recognition of normal, normal variants, and pathology.

The capsule, labrum, glenohumeral ligaments, and rotator cuff represent the static and dynamic stabilizers of the glenohumeral joint. Various injuries can occur to one or more of these structures during traumatic shoulder dislocation, predisposing the patient to recurrent instability. Improved understanding of shoulder anatomy and biomechanics, and advancements in arthroscopic technique led to the recognition of various pathologic lesions that may contribute to instability. The ability to identify and address these lesions during arthroscopy will allow the surgeon to more fully tailor operative treatments for each individual patient suffering from shoulder instability. Furthermore, the ability to differentiate pathologic lesions from normal anatomic variants is critical to avoid inadvertent repair that will lead to loss of normal function and worsening symptoms.

Mutant p53 gain of function in two mouse models of Li-Fraumeni syndrome.

The p53 tumor suppressor gene is commonly altered in human tumors, predominantly through missense mutations that result in accumulation of mutant p53 protein. These mutations may confer dominant-negative or gain-of-function properties to p53. To ascertain the physiological effects of p53 point mutation, the structural mutant p53R172H and the contact mutant p53R270H (codons 175 and 273 in humans) were engineered into the endogenous p53 locus in mice. p53R270H/+ and p53R172H/+ mice are models of Li-Fraumeni Syndrome; they developed allele-specific tumor spectra distinct from p53+/- mice. In addition, p53R270H/- and p53R172H/- mice developed novel tumors compared to p53-/- mice, including a variety of carcinomas and more frequent endothelial tumors. Dominant effects that varied by allele and function were observed in primary cells derived from p53R270H/+ and p53R172H/+ mice. These results demonstrate that point mutant p53 alleles expressed under physiological control have enhanced oncogenic potential beyond the simple loss of p53 function.