The duration of symptoms does not correlate with rotator cuff tear severity or other patient-related features: a cross-sectional study of patients with atraumatic, full-thickness rotator cuff tears.

HYPOTHESIS: The purpose of this cross-sectional study is to determine whether the duration of symptoms influences the features seen in patients with atraumatic, full-thickness rotator cuff tears. Our hypothesis is that an increasing duration of symptoms will correlate with more advanced findings of rotator cuff tear severity on magnetic resonance imaging, worse shoulder outcome scores, more pain, decreased range of motion, and less strength. METHODS: We enrolled 450 patients with full-thickness rotator cuff tears in a prospective cohort study to assess the effectiveness of nonoperative treatment and factors predictive of success. The duration of patient symptoms was divided into 4 groups: 3 months or less, 4 to 6 months, 7 to 12 months, and greater than 12 months. Data collected at patient entry into the study included (1) demographic data, (2) history and physical examination data, (3) radiographic imaging data, and (4) validated patient-reported measures of shoulder status. Statistical analysis included a univariate analysis with the Kruskal-Wallis test and Pearson test to identify statistically significant differences in these features for different durations of symptoms. RESULTS: A longer duration of symptoms does not correlate with more severe rotator cuff disease. The duration of symptoms was not related to weakness, limited range of motion, tear size, fatty atrophy, or validated patient-reported outcome measures. CONCLUSIONS: There is only a weak relationship between the duration of symptoms and features associated with rotator cuff disease.

Patient understanding of the role of the orthopedic resident.

INTRODUCTION: Patients have identified the knowledge of a physician's level of training as important. Previous studies show equally poor patient's understanding of the medical education hierarchy. Given the importance to the patient and the possible effect on patient satisfaction, it is critical to evaluate patient's understanding of the orthopedic educational hierarchy. The specific aim of this study is to evaluate patient's understanding of the role of an orthopedic resident as it pertains to their orthopedic care. METHODS: Adult, English-speaking patients presenting to an outpatient academic orthopedic practice completed surveys similar to those utilized in prior research on this topic. Each questionnaire compiled demographics, questions assessing knowledge of the role of the resident in patient care, and questions to assess the patient's preferences regarding resident physician's role in their care. The knowledge section of the questionnaire was scored with 1 point given to each correct answer. The individual questions with the worst scores from the entire patient population were further evaluated to find demographic predictors of success. In addition to percent correct responses for the entire population, a linear regression model was used to evaluate the effect of age, gender, level of education, ethnicity, and number of academic visits on the knowledge section score. RESULTS: One hundred seventy-four (n = 174) patients completed the survey. Among them, 40% were male, 27% had a high school education or less, 82% were Caucasian, and for 18% it was their first visit to an academic hospital. The average score for the knowledge section was 10.2 (standard deviation±4.0) out of a possible of 16. Linear regression controlling for noted demographic variables revealed higher level of education to be predictive of a better score (coefficient 3.2; 95% confidence interval 1.9-4.7). The 3 worst scoring questions were regarding knowledge of (1) residents having completed medical school, (2) residents performing surgery with attending supervision, and (3) whether or not residents were actually doctors. For these questions higher level of education correlated with more correct answers (p = 0.005, p = 0.001, p = 0.000, respectively). Among the patients, 90% agreed that it was important for them to know the level of training of their physicians and 76% felt it was okay for residents to "learn" on them as long as they were supervised. CLINICAL SIGNIFICANCE: Patient's knowledge of the role the resident physician provides, in their care, is variable. Higher levels of education appear predictive of better understanding. Patients have difficulty discerning where residents fit in the medical hierarchy. Despite this misunderstanding, patients find it very important that they know the physician's level of training. Given the patient's high priority of knowing the level of training of the doctors who care for them and their frequent misunderstanding of the medical hierarchy, steps should be taken to better educate patients as to who is caring for them. Besides being important for patient's informed consent, it may improve patient satisfaction.

Management of knee arthropathy in patients with vascular malformations.

OBJECTIVE: To describe our experience with surgical intervention for symptomatic intraarticular vascular malformations of the knee in patients with peripheral vascular malformations including Klippel-Trénaunay syndrome (KTS). METHODS: Eleven patients underwent surgical intervention for symptomatic intraarticular vascular malformations of the knee between 1987 and 2008. Seven patients had KTS, and 4 patients had venous malformations. Surgical indications, imaging studies, clinical course, surgical procedures, complications, and follow-up visits were reviewed and recorded. RESULTS: A total of 11 patients (8 males; 3 females; mean age, 11.7 years; range, 2.5-23 years) underwent 12 surgical procedures. Five patients had an amputation, and 6 patients had knee synovectomies. One patient had bilateral knee synovectomies. Surgical indications included pain, swelling, limited mobility, and/or loss of knee motion. The average time of follow-up was 54 months (range, 7-109 months). Patient-reported pain scores decreased significantly from a mean of 2.9 +/- 1.4 preoperatively to 1.3 +/- 0.9 postoperatively (P = 0.01). CONCLUSIONS: When necessary, surgical intervention for intraarticular vascular malformations of the knee (amputation or synovectomy) may be effective in decreasing pain and improving mobility in patients with peripheral vascular malformations. It is possible that early synovectomy may slow or prevent the rapid destructive arthritis that occurs in these knees. Surgeons and patients should anticipate complications related to bleeding from vascular malformations. We recommend a multidisciplinary approach to the patient with KTS, particularly when surgical intervention is indicated.

Anatomical variations of the iliolumbar vein with application to the anterior retroperitoneal approach to the lumbar spine: a cadaver study.

Objectives of this study include identification of lumbosacral venous variations, designation of a critical area of dissection for surgical exposure, and comparison between both male/female and right/left-sided anatomy. Attempts were made to provide anatomic nomenclature that accurately describes these structures. Thirty-eight iliolumbar venous systems in 20 cadavers (11 females/9 males) were dissected. Each system was identified as one of three patterns of variation: common venous trunk (combining ascending lumbar and iliolumbar venous systems) with distal veins, common venous trunk without distal veins, and venous systems without a common venous trunk. Dimensions including distances to the inferior vena cava (IVC) confluence, the obturator nerve, and the lumbosacral trunk, and venous stem length were obtained to aid surgical dissection. Differences between males and females and those between right and left sides were compared. Anterior lumbosacral venous variations could be organized into three groups. A Type 1 venous system (common venous trunk with distal veins) was most common (53% of systems). The anatomical name "lateral lumbosacral veins" adequately describes the anatomical location of these veins and does not assume a direction of venous flow or the lack of individual distal veins. A critical area bordered by the obturator nerve anteriorly, the psoas muscle laterally, the spinal column medially, and sacrum posteriorly within 8.2 cm of the IVC confluence should be defined to adequately dissect the lateral lumbosacral veins. Differences in male and female lateral lumbosacral venous anatomy do not alter surgeon's approach to the anterior lumbar spine.

Magnetic resonance imaging of surgically confirmed anterior cruciate ligament graft disruption.

OBJECTIVE: To evaluate previously described primary and secondary MRI signs of disruption to anterior cruciate ligament (ACL) grafts in surgically proven cases. MATERIALS AND METHODS: We retrospectively analyzed MR images of 48 patients (mean age 29 years) with clinically suspected ACL graft disruption. All patients had surgical confirmation of the MRI findings. The reviewers analyzed the cases blinded to the surgical results and assessed each of the primary and secondary MRI signs of graft disruption individually. Subsequently, a final impression of the graft integrity based on a comprehensive assessment of all of the primary and secondary findings was made. RESULTS: Utilizing a comprehensive assessment of previously described primary and secondary MR findings of ACL graft disruption, the blinded reviewers were able to identify correctly full-thickness graft tears with test accuracy of 85%, sensitivity of 72%, and specificity of 100%. Individual assessment of the primary finding of graft fiber discontinuity had sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 72%, 100%, 100%, 77% and 85%, respectively, for full-thickness tears. Other individual primary and secondary findings were less reliable; however, the primary findings of marked segmental thinning of the graft and markedly abnormal graft orientation, and the secondary findings of bone contusions in the lateral compartment and large joint effusion, had high specificity and positive predictive value. Of the four missed cases, two had associated arthrofibrosis. CONCLUSION: The comprehensive assessment of previously described primary and secondary MRI findings of ACL graft disruption has high test specificity and moderately high test accuracy. The presence of graft fiber discontinuity is the most reliable primary or secondary finding when assessed individually. Marked segmental thinning of the graft and abnormal fiber orientation, and the presence of bone contusions in the lateral compartment and large joint effusion, are less reliable overall but are highly suggestive of full-thickness graft tear when present.

An explorative learning approach to teaching clinical anatomy using student generated content.

Translating basic sciences into a clinical framework has been approached through the implementation of various teaching techniques aimed at using a patient case scenario to facilitate learning. These techniques present students with a specific patient case and lead the students to discuss physiological processes through analysis of provided data supported by independent learning and research. However, no literature exists that describes a reverse teaching methodology in which students are given disease diagnosis and then asked to construct a patient case. This article discusses an explorative learning approach introduced in the gross anatomy course in which students were asked to use clinical skills and reasoning to create a patient case. The online knowledge-sharing portal utilizing MediaWiki provided a necessary base for students in completing their task. Teams were given 4 weeks to complete their written online project with weekly feedback provided by 3rd year teaching assistants using the Wiki discussion page. A survey was performed to assess competence regarding a patient write up and oral presentation. Skills that the teams acquired through the completion of this project will benefit future patient interactions. This project also emphasized and reinforced the importance of effective communication, leadership, and teamwork. This study shows that a clinical anatomy project that incorporates explorative learning can be an effective way of introducing students to the skills needed for patient write ups and oral presentations. Furthermore this approach to learning allows students to excel during their clinical years and to correlate anatomy to clinical diagnoses.