Hospital outcome after emergent vs elective revision total hip arthroplasty.

This is a retrospective review of inpatient outcomes, based upon emergent or elective admission for revision total hip arthroplasty (THA) procedures performed between 2000 and 2006. Three hundred forty-two revision THA procedures (291 elective, 51 emergent) were identified. Emergent revisions were more likely to be older (69.9 vs 62.7; P = .003), women (72% vs 54%), require longer hospitalization (8.3 vs 3.8 days), and require a skilled care facility at discharge. No significant difference was observed in mortality. We identified 2 basic outcome measures suggesting that patients undergoing emergent revision will have a more complex hospitalization and require more assistance at discharge. Clarifying emergent vs elective THA at admission may assist in better planning and assessment of patient needs regarding rehabilitation, hospital management, and discharge planning.

Reconstruction of swan neck deformities after proximal interphalangeal joint arthroplasty.

BACKGROUND: The authors report the use of a single slip of the flexor digitorum superficialis (FDS) as a hemitenodesis through the A2 pulley in treating swan neck deformities after previous unconstrained proximal interphalangeal joint (PIP) arthroplasty. METHODS: A retrospective chart review was undertaken to identify non-constrained PIP joint arthroplasties that underwent a subsequent soft tissue hemitenodesis for swan neck deformities. The range of motion (ROM), implant design, preoperative diagnosis, and surgical approach were collected. The Michigan Hand Outcomes Questionnaire and patient satisfaction questionnaire were collected. RESULTS: There were 12 patients with 14 procedures reviewed. There were seven surface replacement arthroplasties (SRA) (cobalt chrome on polyethylene) and eight pyrocarbon prostheses. The primary diagnosis for the initial joint arthroplasty was osteoarthritis (8), post-traumatic (2), and rheumatoid arthritis (5). The primary dorsal approach was a longitudinal split in eleven cases, Chamay in two, and unknown in one case. Nine of the 14 revision procedures had a concomitant dorsal approach to the joint. The average final position intraoperatively was 24.2° of flexion (range 15°-40°). Final ROM was 39° with average follow-up of 30 months. The average postoperative radiographic position was 20.3° flexion with an average of 24.8° hyperextension preoperatively. There was one failure secondary to implant loosening requiring fusion. DISCUSSION: For patients with a swan neck deformity after PIP arthroplasty, a FDS hemitenodesis provides a treatment option with a low revision rate, retained motion, and maintenance of the original implant with no shortening of the digit.

Factors influencing resident participation in the AAOS Political Action Committee.

Resident participation in the political action committee (PAC) is important for professional advocacy and for ensuring access to quality musculoskeletal care. The following questions were asked: Would faculty contribution-matching increase donation rates and amounts among orthopedic surgery residents at a single institution? What barriers do residents self-identify that prevent or delay PAC participation? How do residents perceive a faculty contribution-matching program? Residents at 1 institution were encouraged to participate in the PAC before and after the introduction of a faculty contribution-matching program. In addition, telephone follow-up was performed and resident perceptions were assessed regarding the program and barriers to participation. Rates of participation, amounts donated, and perceptions are reported. Resident participation in the PAC increased from 10% to 95% following the introduction of a faculty contribution-matching program. The second group of residents contributed 67 cents for every dollar given by the first group. Significant barriers identified included time constraints and an inability to access the PAC Web portal. Ninety-four percent of the initial nonresponders said that they made joining the PAC a priority after learning about the faculty contribution-matching program. They specifically cite giving greater attention to an issue that the faculty value. Four months after the initial e-mail, 100% of residents had contributed. Residents believe that professional activism is important but ascribe it a lower priority than other professional duties. Residency programs might facilitate resident involvement in the PAC by instituting faculty contribution-matching and by assisting junior residents with their American Association of Orthopaedic Surgeons login information.

Effect of health insurance type on access to care.

Growing orthopedic and nonorthopedic literature illustrates the point that having health insurance does not equal having access to care. The goal of this study was to evaluate the burden placed on patients to gain access to outpatient orthopedic care. For this study, burden was quantified as the distance traveled by the patient to be seen in clinic. This study was a retrospective review of all new patient encounters at an adult orthopedic outpatient clinic in an academic tertiary referral center over 1 calendar year. All patients were stratified into 4 categories: commercial/private insurance, Medic-aid, Medicare, and uninsured/private pay. The average distance traveled by each patient to the center was then calculated based on the patient's billing zip code. Patient visits were further stratified based on whether the patients were seen by 1 of 3 different categories of providers: general orthopedics/adult reconstruction, spine, and sports/upper extremity. The study group comprised 774 (31.1%) Medicaid patients, 653 (26.2%) Medicare patients, 917 (36.8%) commercial/private insurance patients, and 146 (5.9%) uninsured/private pay patients. The average 1-way distance traveled was 36.2 miles for Medicaid patients, 21.3 miles for Medicare patients, 24.1 miles for commercial/private insurance patients, and 25.3 miles for uninsured/private pay patients (P<.00). Subgroup analysis noted a statistical difference in distance traveled for the general orthopedics/adult reconstruction and sports/upper extremity groups. The study's findings suggest that having insurance does not equal access to outpatient orthopedic care at a single institution. The specific burdens that each group faces to gain access to care are unclear.

Bilateral extensor digitorum brevis manus.

Dorsal wrist pain and swelling is commonly attributed to a dorsal wrist ganglion. However, based on the authors' experience, a cautious surgeon should keep the uncommonly symptomatic diagnosis of an extensor digitorum brevis manus in their differential despite classic ganglion presentation and suggestive advanced imaging. This article describes a case of a young patient who presented with bilateral symptomatic extensor digitorum brevis manus anomalies that required surgical intervention. An extensor digitorum brevis manus is present in 3% of the population in a classic anatomy study from Japan and is most commonly symptomatic with heavy activity and extremes of wrist extension. Anatomically, the extensor digitorum brevis manus is located in the fourth wrist compartment and most commonly inserts on the index finger extensor mechanism. Examination often reveals a spindle-shaped mass that is palpable distal to the extensor mechanism and moves with extensor tendon motion. Magnetic resonance imaging shows a typical dorsal mass distal to the common extensors with a similar signal as muscle with all image sequencing. Treatment includes activity alterations to relieve symptoms or surgical excision of the muscle belly for refractory cases with care taken to preserve the index extensor mechanism.

Surgical simulators and hip fractures: a role in residency training?

BACKGROUND: Orthopedic surgery residency training requires intellectual and motor skill development. In this study, we utilized a computer-based haptic simulator to examine a potential model for evaluation of resident proficiency and efficiency in the placement of a center guide wire during fixation of an intertrochanteric proximal femur fracture. We hypothesize the junior residents will utilize more fluoroscopy and require more time to complete the task. METHODS: Postgraduate year (PGY) 1-5 residents completed the same task of placing a single central guide pin into a femoral head for a dynamic hip screw construct utilizing a haptic surgical simulator. Residents were divided into 2 groups (PGY 1-2 and PGY 3-5) and then evaluated based on final tip-apex distance (TAD), fluoroscopy time, time to complete the task, total number of distinct attempts at pin placement for each femur construct, as well as final 3-dimensional location of the pin from the isometric center of the femoral head. RESULTS: No statistically significant differences were noted between the 2 groups in total time or for tip-apex distance, anterior/posterior medial/lateral position, anterior/posterior superior/inferior, and lateral x-ray medial/lateral positioning measurements. Significant differences between Groups I and II were observed in anterior/posterior final position on the lateral view (p = 0.01), unique attempts (0.77 and 1.5, p = 0.03), and total fluoroscopic time (18.4 seconds and 12.9 seconds, p = 0.05). CONCLUSIONS: In this study, we displayed that based on our simulator model there was no statistical difference between Group I and II in time to completion, final placement on anterior/posterior (A/P) view, and tip-apex distance. There was a statistically significant difference in the anterior/posterior placement of the wire in lateral view between the 2 groups, fluoroscopy time, and number of attempts per trial. Our findings suggest a computer-based surgical simulator can identify measurable differences in surgical proficiency between junior and senior orthopedic surgery residents and may play an expanding role in resident education.

Bilateral gluteal compartment syndrome following robotic-assisted prostatectomy.

Bilateral gluteal compartment syndrome is a rare condition. Only 6 previous cases have been reported in the literature. Two previous cases involved positioning for urological procedures, while the other cited causes of bilateral gluteal compartment syndrome include exercise-induced, trauma, and prolonged immobilization from substance abuse. The 2 previously published reports of bilateral gluteal compartment syndrome associated with urologic positioning were treated conservatively due to late presentation and onset of rhabdomyolysis. This article presents a case of a 61-year-old man who developed bilateral gluteal compartment syndrome following prolonged urologic surgery in a dorsal lithotomy position. Orthopedic evaluation revealed physical examination findings and intracompartment pressures consistent with bilateral gluteal compartment syndrome. He underwent bilateral gluteal compartment fasciotomies. An expansile-type Kocher Langenbach incision was made, extending from lateral to the posterior superior iliac spine inferior to the level of the greater trochanter. The 3 compartments were decompressed bilaterally. At completion, the compartments showed definite objective softening. He was treated with delayed closure of his fasciotomy wounds. He was discharged home on sixth postoperative day 6. His wounds healed without difficulty and he regained normal strength and sensation in his lower extremities. Gluteal compartment syndrome following surgery is a preventable condition. Prevention should center on intraoperative padding and positioning, intraoperative repositioning, and restricting the length of the procedure. Once it is identified, early diagnosis and treatment can prevent long term complications.

Symptomatic loose bodies of the knee located in a popliteal cyst.

Locating loose bodies in a knee arthroscopically can be challenging. Common locations for loose bodies to hide include the lateral and medial gutters as well as under the menisci. In 1986, Fergusson and Burge reported a single case of a loose body intermittently traveling between the intracapsular space and an extracapsular popliteal cyst. This article describes a similar event involving a 22-year-old man. Our patient experienced recurrent symptomatic loose bodies in the knee requiring previous knee arthroscopies. Most recently the patient had a radiographically documented and clinically symptomatic intra-articular knee loose body prior to surgery. Initial basic diagnostic knee arthroscopy did not reveal the loose body. On further arthroscopic evaluation of the posteromedial compartment of the knee, a capsular opening to a popliteal cyst was discovered. An accessory posteromedial portal was then used to directly visualize the contents of the cyst. Three loose bodies capable of traveling between the cyst and the joint were discovered. Transillumination allowed for safe localization of the cyst and subsequent percutaneous removal of the loose bodies under direct arthroscopic visualization.We recommend direct arthroscopic visualization of the posteromedial and posterolateral compartments of the knee when a known loose body cannot be located during basic diagnostic knee arthroscopy.