Business and Practice Management Knowledge Deficiencies in Graduating Orthopedic Residents.

We conducted a study to determine the general level of knowledge that orthopedic residents have on business and practice management topics at graduation and to evaluate the level of knowledge that practicing orthopedic surgeons need in order to function effectively in a medical practice. Residency graduates from a single training program were asked to complete a survey that gathered demographic information and had surgeons rate their understanding of 9 general business and practice management skills and the importance of these skills in their current practice situation. The amount of necessary business knowledge they lacked at graduation was defined as a functional knowledge deficiency (FKD) and was calculated as the difference between the reported importance of a topic in current practice and the level of understanding of that topic at graduation (larger FKD indicates greater deficiency). Those in physician-managed practices reported significantly higher levels of understanding of economic analytical tools than those in nonphysician-managed practices. There were no other statistically significant differences among groups. Hospital-employed physicians had the lowest overall FKD (4.0), followed by those in academic practices (5.1) and private practices (5.9). Graduating orthopedic surgeons appear to be inadequately prepared to effectively manage business issues in their practices, as evidenced by the low overall knowledge levels and high FKDs.

Obesity, orthopaedics, and outcomes.

Obesity, one of the most common health conditions, affects an ever-increasing percentage of orthopaedic patients. Obesity is also associated with other medical conditions, including diabetes, cardiovascular disease, pulmonary disease, metabolic syndrome, and obstructive sleep apnea. These comorbidities require specific preoperative and postoperative measures to improve outcomes in this patient population. Patients who are obese are at risk for increased perioperative complications; however, orthopaedic procedures may still offer notable pain relief and improved quality of life.

Platelet-rich plasma in orthopaedic applications: evidence-based recommendations for treatment.

Autologous platelet-rich plasma (PRP) therapies have seen a dramatic increase in breadth and frequency of use for orthopaedic conditions in the past 5 years. Rich in many growth factors that have important implications in healing, PRP can potentially regenerate tissue via multiple mechanisms. Proposed clinical and surgical applications include spinal fusion, chondropathy, knee osteoarthritis, tendinopathy, acute and chronic soft-tissue injuries, enhancement of healing after ligament reconstruction, and muscle strains. However, for many conditions, there is limited reliable clinical evidence to guide the use of PRP. Furthermore, classification systems and identification of differences among products are needed to understand the implications of variability.

Tibial tuberosity fractures in adolescents: is a posterior metaphyseal fracture component a predictor of complications?

BACKGROUND: Tibial tuberosity fractures have been described as uncommon injuries, but their frequency appears to be increasing. Because of the relatively few cases reported in the literature, little is known regarding risk factors for complications. In a large group of adolescents with tibial tuberosity fractures, we noted more frequent complications in patients who had posterior metaphyseal fractures in addition to tibial tuberosity avulsion fractures. The purpose of this study was to examine the outcomes associated with this fracture pattern and compare them with tibial tuberosity fractures without the posterior component. METHODS: All patients who had closed or open reduction and internal fixation of a tibial tuberosity fracture between January 2003 and December 2010 were identified. All radiographs and medical records were reviewed. RESULTS: Fifty-three tibial tuberosity fractures had radiographs available for review; 15 (28%) fractures had a posterior component identified by either radiograph or computed tomography scan. Four of these combined injuries had an adverse event: 1 patient had compartment syndrome affecting all 4 compartments and 3 patients had refractures after closed reduction and casting. None of the 38 tibial tuberosity fractures without a posterior metaphyseal component had these complications. All patients had complete fracture healing and had returned to full activity at last follow-up. CONCLUSIONS: In this study, a posterior metaphyseal fracture associated with a tibial tuberosity fracture was a marker for potential complications. If radiographs suggest that a fracture line extends through the posterior metaphysis, computed tomography imaging is recommended to confirm the fracture pattern. Open reduction and internal fixation that includes both the anterior and posterior fragments is recommended for all fractures with these combined components, including nondisplaced fractures, because of an increased risk of refracture. LEVEL OF EVIDENCE: Level IV (case study).

Emergency room visits by pediatric fracture patients treated with cast immobilization.

BACKGROUND: The purpose of this review was to determine when and why pediatric patients with cast complaints return to the emergency room (ER). If this could be determined, educational and treatment strategies may help decrease the number of these visits and the cost of care. METHODS: Retrospective chart review of patients initially seen in a busy urban pediatric orthopaedic clinic identified those who had an ER visit because of a cast-related problem over a 5-year period. Patients were included only if they were seen for their initial visit and cast application in our fracture clinic. RESULTS: Of 168 ER visits made by 155 children treated with cast immobilization, 29% were because of a wet cast; 10%, a damaged cast; 23%, a tight cast; 13%, a loose cast; and 10%, pain. In addition to wet and damaged casts, compliance issues included a missed clinic appointment (5%) and being told by medical personnel to return to the ER for a cast check (8%). Several groups with a high risk for return to the ER were identified: the younger the patient, the more likely that the cast was too loose or wet, and the older the patient, the more likely the cast was too tight. Cast type also played a role: a significantly higher rate of return to the ER was found with long arm, long leg, and hand casts. There were no major complications and no child required hospitalization. CONCLUSIONS: All 168 ER visits required only a cast change or reassurance, which could have been done during regular fracture clinic hours; no child required hospitalization or surgery. From these results, a program has been instituted that includes patient education, triage, and follow-up in our fracture clinics to not only improve the quality of patient care but to decrease the financial burden on physicians and the healthcare system. LEVEL OF EVIDENCE: Economic and decision analysis, Level III.

Heterotopic ossification of the hip after non-accidental injury in a child: case report.

Heterotopic ossification is bone formation that occurs in an abnormal soft tissue location, most commonly after trauma, head injury, and surgical procedures such as joint arthroplasty. We report a rare case of severe heterotopic ossification caused by nonaccidental injury in a 3-year-old child. To our knowledge, heterotopic ossification as a result of nonaccidental injury in children has been reported in only 2 other patients. Physicians should be aware of this rare presentation of nonaccidental injury, and nonaccidental injury should be considered in the differential diagnosis in children who present with heterotopic ossification.

Medical errors in orthopaedics. Results of an AAOS member survey.

BACKGROUND: There has been widespread interest in medical errors since the publication of To Err Is Human: Building a Safer Health System by the Institute of Medicine in 2000. The Patient Safety Committee of the American Academy of Orthopaedic Surgeons has compiled the results of a member survey to identify trends in orthopaedic errors that would help to direct quality assurance efforts. METHODS: Surveys were sent to 5540 Academy fellows, and 917 were returned (a response rate of 16.6%), with 53% (483) reporting an observed medical error in the previous six months. RESULTS: A general classification of errors showed equipment (29%) and communication (24.7%) errors with the highest frequency. Medication errors (9.7%) and wrong-site surgery (5.6%) represented serious potential patient harm. Two deaths were reported, and both involved narcotic administration errors. By location, 78% of errors occurred in the hospital (54% in the surgery suite and 10% in the patient room or floor). The reporting orthopaedic surgeon was involved in 60% of the errors; a nurse, in 37%; another orthopaedic surgeon, in 19%; other physicians, in 16%; and house staff, in 13%. Wrong-site surgeries involved the wrong side (59%); another wrong site, e.g., the wrong digit on the correct side (23%); the wrong procedure (14%); or the wrong patient (5% of the time). The most frequent anatomic locations were the knee and the fingers and/or hand (35% for each), the foot and/or ankle (15%), followed by the distal end of the femur (10%) and the spine (5%). CONCLUSIONS: Medical errors continue to occur and therefore represent a threat to patient safety. Quality assurance efforts and more refined research can be addressed toward areas with higher error occurrence (equipment and communication) and high risk (medication and wrong-site surgery).

Quantitative trait loci, genes, and polymorphisms that regulate bone mineral density in mouse.

This is an in silico analysis of data available from genome-wide scans. Through analysis of QTL, genes and polymorphisms that regulate BMD, we identified 82 BMD QTL, 191 BMD-associated (BMDA) genes, and 83 genes containing known BMD-associated polymorphisms (BMDAP). The catalogue of all BMDA/BMDAP genes and relevant literatures are provided. In total, there are substantially more BMDA/BMDAP genes in regions of the genome where QTL have been identified than in non-QTL regions. Among 191 BMDA genes and 83 BMDAP genes, 133 and 58 are localized in QTL regions, respectively. The difference was still noticeable for the chromosome distribution of these genes between QTL and non-QTL regions. These results have allowed us to generate an integrative profile of QTL, genes, polymorphisms that determine BMD. These data could facilitate more rapid and comprehensive identification of causal genes underlying the determination of BMD in mouse and provide new insights into how BMD is regulated in humans.

The complexity in hunting for candidate genes within QTL that determine susceptibility to arthritis in rats.

Quantitative trait loci (QTL) often span large genomic regions that contain from dozens to hundreds of genes. Over the last decade, a large number of QTL that regulate arthritis have been identified using rodent models of inflammatory arthritis. To examine the relationship between genes in those QTL and arthritis, we conducted a literature search using the key words arthritis and QTL in PubMed for publications up to January 2007 and obtained 60 QTL identified from experimental arthritis in rats. We then ascertained the identity of genes within those QTL regions based on data from the Ensembl database. We found a potential total of 17,012 genes within 60 arthritis QTL covering 1,607,804,390 base pairs of genomic sequences. The potential of every gene to be involved in arthritis was evaluated using all available reports from Online Mendelian Inheritance in Man (OMIM) and PubMed. On the basis of this analysis, 162 genes were identified as candidate genes of arthritis QTL. Importantly, associations between polymorphisms of some of these candidate genes and human arthritis have been reported in previous studies. These data suggest that the relationship between the candidate genes that we identified and arthritis QTL should be investigated in more detail. This comprehensive search should provide assistance in the identification of causative genes underlying arthritis QTL.

Transphyseal anterior cruciate ligament reconstruction using mesenchymal stem cells.

BACKGROUND: Conventional techniques for reconstruction of the anterior cruciate ligament in skeletally immature patients risk potential iatrogenic growth disturbance because of drilling across the physis. Animal models have demonstrated mixed results regarding growth disturbances from soft tissue grafts across the physis. HYPOTHESIS: Mesenchymal stem cells derived from bone marrow may be effective in preventing growth arrest after intra-articular anterior cruciate ligament reconstruction. STUDY DESIGN: Controlled laboratory study. MATERIAL AND METHODS: The anterior cruciate ligament was removed from 15 skeletally immature rabbits, which were divided into 3 groups: 5 rabbits (group 1) had only drilling of tunnels through the distal femoral and proximal tibial physes 5 (group 2) underwent drilling of the tunnels and reconstruction with an extensor digitorum communis autograft; and 5 (group 3) had drilling and reconstruction with an extensor digitorum communis autograft that had been seeded with mesenchymal stem cells. Radiographs were obtained every 3 weeks, and the animals were sacrificed 3 to 20 weeks after surgery. The surgically treated and contralateral control knees were salvaged, and each knee was examined grossly, radiographically, and histologically. RESULTS: A bone bridge spanned the physis in all nongrafted knees (group 1) by 3 weeks after surgery. In group 2, the extensor digitorum communis autograft seemed to slow but not prevent the development of bony bridges and angular deformities. In contrast, the mesenchymal stem cell-seeded grafts (group 3) appeared to provide a marked protective effect against growth arrest and angular deformity. CONCLUSION: The results of this study suggest that angular deformity and growth arrest that occur after drilling across the physis during anterior cruciate ligament reconstruction can be prevented or minimized by implanting mesenchymal stem cells onto the transphyseal soft tissue graft. CLINICAL RELEVANCE: These results may facilitate the development of strategies to prevent growth disturbances of the physis with intra-articular reconstructive procedures in pediatric patients.