Posterior Tibial Slope is Increased in Patients With Tibial Tubercle Fractures and Osgood-Schlatter Disease.

BACKGROUND: Osgood-Schlatter disease (OSD) and tibial tubercle fractures are pathologies that affect the tibial tubercle apophysis in preadolescents and adolescents. Anatomic alignment of the proximal tibia may explain why some children develop OSD or sustain tibial tubercle fractures and some do not. Recent data has shown an association between posterior tibial slope angle (PTSA) and both OSD and proximal tibia physeal fractures. In this study, we compare radiographic parameters between patients with non-OSD knee pain, knees with OSD, and knees with tibial tubercle fracture to elucidate a difference between these groups. METHODS: Patients treated for OSD, tibial tubercle fractures, and knee pain, from 2012 to 2018, were retrospectively reviewed. Radiographic parameters for each study group included PTSA, anatomic lateral distal femoral angle, anatomic medial proximal tibial angle, patellar articular height, and the distance from the inferior aspect of the patellar articular surface. Caton-Deschamps index was then calculated. Demographic data was collected including age, sex, and body mass index. Demographic and radiographic data was compared using analysis of variance tests, χ2 tests, 2-sample t tests, and multiple linear regression. RESULTS: Two hundred fifty-one knees in 229 patients met inclusion criteria for the study. In all, 76% were male and the average age of the overall cohort was 14 years old. In patients with tibial tubercle fractures, the majority of fractures were Ogden type 3b (65%). After controlling for demographic variability, average PTSA in the fracture cohort was significantly greater than that in the control cohort (ß=3.49, P<0.001). The OSD cohort had a significantly greater posterior slope (ß=3.14) than the control cohort (P<0.001). There was no statistically significant difference between the fracture and OSD cohorts. There was also no difference in Caton-Deschamps index between the 2 study groups when compared with the control group. CONCLUSION: This study demonstrates that patients with tibial tubercle fractures and patients with OSD have an increased PTSA when compared with the control group. This information adds to the body of evidence that increased tibial slope places the proximal tibial physis under abnormal stress which may contribute to the development of pathologic conditions of proximal tibia such as OSD and tibial tubercle fractures. LEVEL OF EVIDENCE: Level III; retrospective comparative study.

The Introduction of a Preoperative MRI Protocol Significantly Reduces Unplanned Return to the Operating Room in the Treatment of Pediatric Osteoarticular Infections.

BACKGROUND: Pediatric osteoarticular infection can cause severe morbidity. Some infectious loci may be difficult to identify clinically, and there may be more than one. There is little agreement regarding the appropriate use of preoperative magnetic resonance imaging (MRI) in this setting. After noting an unacceptably high rate of unplanned returns to the operating room for recurrent infection, clinicians at a tertiary care children's hospital noticed many patients had adjacent foci of infection on postoperative MRI. As a result, patients experienced prolonged treatment courses and multiple surgeries. An interdisciplinary team instituted practice guidelines whereby all patients with suspected osteoarticular infection underwent MRI for planned debridement during a reserved morning slot with a surgical suite on hold to proceed directly to surgery if indicated. Images were reviewed in real time to form the surgical plan. Young patients that required sedation for MRI were taken to surgery under the same anesthetic used for MRI without being awakened. The purpose of our retrospective study is to determine if implementing the practice guidelines for acute management of osteoarticular infection reduced unplanned returns to the operating room. METHODS: A total of 93 patients with osteoarticular infection were included in this study. A total of 40 cases, group A, were treated before implementing practice guidelines; 53 cases, group B, were treated after implementing practice guidelines. Our primary outcomes of interest were the identification of adjacent infections prior to surgery and need for repeat surgery, either planned or unplanned. RESULTS: Implementation of these guidelines reduced repeat surgery from 50% of patients to <27% (P=0.0099). Of patients requiring repeat surgery, 85% (n=17) were unplanned in group A versus 60% (n=9) in group B (P=0.0099). Adjacent infections were identified in 47.5% (n=19) of patients in group A, versus 60% (n=32) in group B. Adjacent infections were known before surgery in 32% (n=6) of patients in group A versus 72% (n=23) in group B. There were no statistically significant differences in initial patient characteristics or sites of infection. CONCLUSIONS: Implementing these guidelines reduced the need for repeat surgery in this population. It is difficult to predict with sufficient accuracy which patients need preoperative MRI. While resource intensive, preoperative MRI appears to offer substantial benefit in preoperative planning.

Femoroacetabular Impingement in Pediatric Patients.

Subacute, nontraumatic hip pain is often a diagnostic challenge. Femoroacetabular impingement (FAI) is a common cause of atraumatic hip pain that is poorly understood. FAI is a result of abnormal morphologic changes in either the femoral head or the acetabulum. FAI is more prevalent in people who perform activities requiring repetitive hip flexion, but it remains common in the general population. Evaluation begins with physical examination maneuvers to rule out additional hip pathology and provocation tests to reproduce hip pain. Diagnosis is often made by radiography or magnetic resonance imaging. Initial treatment is generally more conservative, featuring activity modification and physical therapy, whereas more aggressive treatment requires operative management.

Readability of Orthopaedic Patient-reported Outcome Measures: Is There a Fundamental Failure to Communicate?

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly used to quantify patients' perceptions of functional ability. The American Medical Association and NIH suggest patient materials be written at or below 6th to 8th grade reading levels, respectively, yet one recent study asserts that few PROMs comply with these recommendations, and suggests that the majority of PROMs are written at too high of a reading level for self-administered patient use. Notably, this study was limited in its use of only one readability algorithm, although there is no commonly accepted, standard readability algorithm for healthcare-related materials. Our study, using multiple readability equations and heeding equal weight to each, hopes to yield a broader, all-encompassing estimate of readability, thereby offering a more accurate assessment of the readability of orthopaedic PROMS. QUESTIONS/PURPOSES: (1) What proportion of orthopaedic-related PROMs and orthopaedic-related portions of the NIH Patient Reported Outcomes Measurement Information System (PROMIS®) are written at or below the 6th and 8th grade levels? (2) Is there a correlation between the number of questions in the PROM and reading level? (3) Using systematic edits based on guidelines from the Centers for Medicare and Medicaid Services, what proportion of PROMs achieved American Medical Association and NIH-recommended reading levels? METHODS: Eighty-six (86) independent, orthopaedic and general wellness PROMs, drawn from commonly referenced orthopaedic websites and prior studies, were chosen for analysis. Additionally, owing to their increasing use in orthopaedics, four relevant short forms, and 11 adult, physical health question banks from the PROMIS®, were included for analysis. All documents were analyzed for reading grade levels using 19 unique readability algorithms. Descriptive statistics were performed using SPSS Version 22.0. RESULTS: The majority of the independent PROMs (64 of 86; 74%) were written at or below the 6th grade level, with 81 of 86 (94%) written at or below the 8th grade level. All item banks (11 of 11) and short forms (four of four) of the PROMIS® were written below the 6th grade reading level. The median reading grade level of the 86 independent PROMs was 5.0 (interquartile range [IQR], 4.6-6.1). The PROMIS® question banks had a median reading grade level of 4.1 (IQR, 3.5-4.8); the Adult Short Forms had a median reading grade level of 4.2 (IQR, 4.2-4.3) There was no correlation appreciated between the median reading grade level and the number of questions contained in a PROM (r = -0.081; p = 0.460). For PROMs above NIH-recommended levels, following edits, all (five of five) achieved NIH reading level goals and three (three of five) achieved American Medical Association goals. Editing of these PROMs improved readability by 4.3 median grade level (before, 8.9 [IQR, 8.4-9.1], after 4.6 [IQR, 4.6-6.4], difference of medians, 4.3; p = 0.008). CONCLUSIONS: Patient literacy has great influence on healthcare outcomes, and readability is an important consideration in all patient-directed written materials. Our study found that more than 70% of PROMs commonly used in orthopaedics, and all orthopaedic-related portions of the PROMIS® are written at or below the most stringent recommendations (≤ 6th grade reading level), and more than 90% of independent PROMs and all PROMIS® materials are written at or below an 8th grade level. Additionally, the use of the Centers for Medicare and Medicaid Services guidelines for editing high reading level PROMs yields satisfactory results. CLINICAL RELEVANCE: Fears of widely incomprehensible PROMs may be unfounded. Future research to identify the most appropriate readability algorithm for use in the healthcare sector, and revalidation of PROMs after readability-improving edits is warranted.

Rotator cuff crepitus: could Codman really feel a cuff tear?

BACKGROUND: The objective of this study was to assess the accuracy of palpating crepitus to diagnose rotator cuff tears. METHODS: Seventy consecutive consenting patients who presented with shoulder pain and no previous imaging or surgery on the affected shoulder were prospectively enrolled during a 10-month period. A standardized patient history and examination, including the crepitus test, were recorded in addition to obtaining standard radiographs. Additional imaging after initial evaluation was performed with magnetic resonance imaging and interpreted by a musculoskeletal radiologist blinded to the examination findings. Statistical analysis was used to determine sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the crepitus test in the clinical diagnosis of a rotator cuff tear. RESULTS: Sixty-three patients had histories, examinations, and imaging studies available for analysis. The crepitus test had a sensitivity of 67%, specificity of 80%, PPV of 91%, and NPV of 43% for all types of rotator cuff tears. The sensitivity and specificity for full-thickness or high-grade partial tears was 82% and 73%, respectively; the PPV and NPV were 77% and 79%. Increasing age improved accuracy as the presence of crepitus in patients older than 55 years had a sensitivity of 76%, specificity of 100%, PPV of 100%, and NPV of 38%. CONCLUSION: The crepitus test has a favorable sensitivity, specificity, PPV, and NPV to assess the integrity of the rotator cuff and may be a useful examination in the clinical diagnosis of a rotator cuff tear.

A Comprehensive Review of Bone Health in a Child: From Birth to Adulthood.

Bone health is critical for growth and development during childhood. Although fractures are common in children, fractures occurring in the absence of trauma should prompt physicians to consider underlying bone health disorders. This article provides an overview of the current definition of osteoporosis in children, highlighting its limitations and the potential for underdiagnosis. It also discusses the timing of screening initiation and various techniques used to assess bone health, along with their respective benefits and limitations. In addition, this article identifies several causes of primary and secondary osteoporosis in children, shedding light on previously overlooked disorders that can contribute to poor bone quality. The article emphasizes the importance of a multidisciplinary approach to therapeutic management and aims to optimize patient outcomes and improve the overall care of pediatric bone health disorders.

Re-evaluation of pectoralis major height as an anatomic reference for humeral height in fracture hemiarthroplasty.

BACKGROUND: Shoulder replacement may be indicated for complex proximal humeral fractures. The primary reason for disappointing results is the nonanatomic position of the prosthesis because the normal anatomic landmarks are disrupted when fractured. An anatomic reference outside of the zone of injury may facilitate proper positioning of fracture arthroplasty reconstructions. It is unknown whether the measurement from the top of the pectoralis major tendon (PMT) to the top of the humeral head is related to patient height. MATERIALS AND METHODS: PMT measurements were performed on 21 pairs of cadaveric shoulders. A second group of PMT measurements was performed on 107 patients receiving a shoulder magnetic resonance imaging scan. A third PMT comparison group was included using historical measurements from 20 pairs of cadaveric shoulders. All heights, sexes, and ages were known. Statistical analysis used mixed-effects linear regression models. RESULTS: A consistent association between patient height and PMT was found, with a mean distance from the top of the PMT to the top of the humeral head of 58.9 mm in men and 55.2 mm in women. For every 10-mm increase in patient height over 1.7 m, there is a 1.7-mm increase in PMT (P = .01). Age was not associated with PMT distance (P > .5). CONCLUSIONS: A predictable measurement from the upper portion of the PMT to the top of the humeral head exists to guide implant height in fracture hemiarthroplasty and may be approximated by use of patient height and sex.

Radial Head Incarceration After Closed Reduction of a Pediatric Elbow Dislocation With a Radial Neck Fracture: A Case Report.

CASE: A 10-year-old girl sustained a radial neck fracture with a posterior elbow dislocation. She was treated with closed reduction of the elbow with subsequent intra-articular displacement of the radial head, which necessitated open reduction and pinning of the radial neck fracture. CONCLUSION: Displacement of the radial neck fracture from impingement of the capitellum on the anterior radial head during closed reduction of the elbow dislocation is a rare injury pattern. It is important to examine the radial neck in high-energy posterior elbow dislocations before attempted reduction. We present a case with imaging depicting the injury mechanism and successful management with subsequent open reduction and fixation of the radial neck fracture.

Use of Epidural Analgesia in Children With Neuromuscular Conditions Following Hip Reconstruction.

BACKGROUND: Neuromuscular conditions, such as cerebral palsy, are the most common motor disabilities in the pediatric population. Children with these conditions frequently have accompanying hip deformities that require pelvic and femur osteotomy to correct the spastic hip dislocations. However, postoperative pain management remains an elusive and challenging problem. The purpose of this study was to determine whether postoperative use of epidural analgesia in patients with neuromuscular conditions provided similar outcomes with regard to pain scores, length of stay, duration of foley placement, duration of pain control, and complications as compared to traditional pain management regimens. To our knowledge, this is the first study comparing the use of epidural analgesia to conventional pain relief modalities following hip reconstruction in patients with neuromuscular conditions. METHODS: A retrospective cohort study was performed using records of pediatric patients with neuromuscular conditions treated at our tertiary care center between January 2009 and December 2019. Patients with neuromuscular conditions treated with epidural or non-epidural analgesia for pain relief following unilateral or bilateral proximal femoral osteotomies, pelvic osteotomies, or open hip reduction were eligible for study inclusion. Multiple linear regression was used to determine differences in length of stay, pain score, pain modality, duration of Foley placement, and complications between the two cohorts. RESULTS: Seventy patients met the inclusion criteria for the study. In all, 58 patients underwent unilateral procedures, of which 30 (52%) received epidural analgesia, and 28 (48%) received non-epidural pain control modalities. Demographic and baseline characteristics were similar among the cohort, except for BMI, which varied slightly. Average pain scores and pain control duration were not statistically different between the pain control modalities. After controlling for demographics, procedure, and immobilization type, the epidural group experienced significantly increased length of stay (+3.18 days, P=0.032) and duration of Foley placement (+1.04 days, P=.013). Complication rates between the two groups were not statistically significant. CONCLUSIONS: The use of epidural analgesia in children with neuromuscular conditions was associated with comparable pain scores, despite the increased length of stay and duration of Foley placement. No statistically significant difference in complication rates was observed between patients receiving epidural anesthesia and those receiving traditional pain modalities.

Caffeine intake does not appear to impair tendon-to-bone healing strength in a rat rotator cuff repair model.

Background: Tendon-to-bone (TtB) healing is essential for successful rotator cuff repair (RCR). This study aimed to investigate if caffeine intake impaired TtB healing in a rat RCR model. Methods: Seventy-two rats were randomized into a caffeinated group or a noncaffeinated group. Specimens received one week of oral caffeine solution or normal saline before RCR. All rats then underwent bilateral RCR. Caffeination or saline gavages continued until rats were sacrificed at 2, 4, and 8 weeks postoperatively. Load-to-failure (primary outcomes measure), maximum stress, and stiffness of the TtB interface were measured for one shoulder of each specimen. Six random shoulders from each group underwent histological assessment of TtB healing. Results: Load-to-failure and maximum stress of RCR did not appear to differ between groups at any time point. No difference in RCR stiffness was found between groups at 2 and 4 weeks; however, stiffness in the caffeinated group did appear to lower at 8 weeks (P = .04). Conclusion: Perioperative caffeine intake did not appear to affect load-to-failure strength of RCR in an animal model. Although our secondary outcome measures of maximum stress and stiffness also did not appear to be influenced by perioperative caffeine intake, there did appear to be a trend toward decreased RCR stiffness at 8 weeks postoperatively in specimens that received caffeine.

A Symposium on the Clinic of the Future and Telehealth: Highlights and Future Directions.

Children's National Hospital held a virtual symposium on "The Clinic of the Future and Telehealth" in December 2020. The goal of the symposium was to explore future trends in these domains. We also discussed how the coronavirus disease 2019 (COVID-19) pandemic accelerated ongoing changes in healthcare. We explored what is on the horizon in these fields and how these changes might affect care delivery in the future. Specifically, we discussed the "Clinic of the Future" with clinical teams from genetics and metabolism, orthopedic surgery, and primary care while our telehealth discussion involved genetics and metabolism, psychiatry, and telerehabilitation. As one example, wearable technology could be adopted among primary care practices and drive a shift in outpatient care from center-based care to patient-based care. We also examined technological innovations in physical exam instruments, gait analysis, imaging integration, and cast technology that could modernize the orthopedic surgery clinic. Telemedicine has rapidly expanded among all fields of medicine, especially since the COVID-19 pandemic, and has spurred innovation to improve the effectiveness of virtual physician visits. The development of technology to improve the virtual physical exam, during a telemedicine visit, further increases the utility of online appointments and increases access to care in all specialties. The incorporation of photogrammetry technology, in genetics and metabolism dysmorphology exams, will offer standardized tracking of patients that could improve diagnosis and treatment. Psychiatry has found nearly equal efficacy in diagnosis and treatment with telehealth visits and the additional benefit of gaining insight in the setting of the patients' home. Robotics has become increasingly common in rehabilitation, which can now incorporate a gaming experience that can be remotely updated and increase engagement and adherence in pediatric patients. The continued exploration of new ideas promises to improve both in-person and virtual care options.

A Unique "Reverse" Crescent Fragment in an Anterior-Posterior Compression Fracture: A Case Report.

CASE: We describe a patient with an anterior-posterior compression type pelvic fracture sustained after a motorcycle crash, with pubic symphysis disruption and a "reverse" crescent fragment. The injury force ruptured the anterior sacroiliac ligaments and travelled posterior medially, creating a complete Denis zone 2 sacral fracture, rather than rupturing the posterior sacroiliac ligaments as would be expected. The patient underwent open reduction and internal fixation of the pubic symphysis and closed reduction and percutaneous pinning of the right sacroiliac joint. CONCLUSIONS: This case presents a unique "reverse" crescent fragment not previously described in the literature as an anterior-posterior compression type III variant.

Trends and Risk Factors in Orthopedic Lawsuits: Analysis of a National Legal Database.

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.].

The Effect of Arthroscopic Rotator Interval Closure on Glenohumeral Volume.

The role of rotator interval in shoulder pathology and the effect of its closure are not well understood. In addition, the effect of rotator interval closure on intra-articular glenohumeral volume (GHV) remains unknown. We conducted a study to quantify the GHV reduction obtained with an arthroscopic rotator interval closure and to determine whether medial and lateral interval closures resulted in different degrees of volume reduction. We dissected 8 fresh-frozen cadaveric shoulders (mean age, 64.4 years) to the level of the rotator cuff. Volumetric measurements were taken before and after medial and lateral rotator interval closure incorporating the superior glenohumeral ligament and the upper portion of the subscapularis. Arthroscopic closure of the rotator interval with 2 sutures reduced GHV by a mean of 45%. More volume reduction resulted with use of a single lateral interval closure stitch than with use of a single medial stitch (35% vs 24%; P < .02). Arthroscopic rotator interval closure with 2 plication stitches is a powerful tool in reducing intracapsular volume of the shoulder and may be a useful adjunct in restoring glenohumeral stability. If a single plication stitch is preferred, a lateral stitch (vs a medial stitch) can be used for a significantly larger reduction in shoulder volume.

Assessing the reading level of online sarcoma patient education materials.

Cancer patients rely on patient education materials (PEMs) to gather information regarding their disease. Patients who are better informed about their illness have better health outcomes. The National Institutes of Health (NIH) recommends that PEMs be written at a sixth- to seventh-grade reading level. The purpose of this study was to evaluate the readability of online PEMs of bone and soft-tissue sarcomas and related conditions. We identified relevant online PEMs from the following websites: American Academy of Orthopaedic Surgeons, academic training centers, sarcoma specialists, Google search hits, Bonetumor.org, Sarcoma Alliance, Sarcoma Foundation of America, and Medscape. We used 10 different readability instruments to evaluate the reading level of each website's PEMs. In assessing 72 websites and 774 articles, we found that none of the websites had a mean readability score at or below 7 (seventh grade). Collectively, all websites had a mean readability score of 11.4, and the range of scores was grade level 8.9 to 15.5. None of the PEMs in this study of bone and soft-tissue sarcomas and related conditions met the NIH recommendation for PEM reading levels. Concerted efforts to improve the reading level of orthopedic oncologic PEMs are necessary.

Improving the readability of online foot and ankle patient education materials.

BACKGROUND: Previous studies have shown the need for improving the readability of many patient education materials to increase patient comprehension. This study's purpose was to determine the readability of foot and ankle patient education materials and to determine the extent readability can be improved. We hypothesized that the reading levels would be above the recommended guidelines and that decreasing the sentence length would also decrease the reading level of these patient educational materials. METHODS: Patient education materials from online public sources were collected. The readability of these articles was assessed by a readability software program. The detailed instructions provided by the National Institutes of Health (NIH) were then used as a guideline for performing edits to help improve the readability of selected articles. The most quantitative guideline, lowering all sentences to less than 15 words, was chosen to show the effect of following the NIH recommendations. RESULTS: The reading levels of the sampled articles were above the sixth to seventh grade recommendations of the NIH. The MedlinePlus website, which is a part of the NIH website, had the lowest reading level (8.1). The articles edited had an average reduction of 1.41 grade levels, with the lowest reduction in the Medline articles of 0.65. CONCLUSION: Providing detailed instructions to the authors writing these patient education articles and implementing editing techniques based on previous recommendations could lead to an improvement in the readability of patient education materials. CLINICAL RELEVANCE: This study provides authors of patient education materials with simple editing techniques that will allow for the improvement in the readability of online patient educational materials. The improvement in readability will provide patients with more comprehendible education materials that can strengthen patient awareness of medical problems and treatments.

Telementoring: use of augmented reality in orthopaedic education: AAOS exhibit selection.

BACKGROUND: Virtual interactive presence (VIP) is a new technology that allows an individual to deliver real-time virtual assistance to another geographically remote individual via a standard Internet connection. The objectives of this pilot study were to evaluate the efficiency and performance of a VIP system implemented in an operating room setting, determine the potential utility of the system for guidance of surgical procedures, and assess the safety of the system. METHODS: Following institutional review board approval, fifteen patients underwent arthroscopic shoulder procedures. Two VIP stations were used, one in the operating room and the other in an adjoining dictation room. The attending surgeon proctored operating resident surgeons from the dictation room until his physical presence was required in the operating room. Following each procedure, the attending surgeon, resident surgeons, and three surgical staff members completed a Likert-scale questionnaire regarding the educational utility, efficiency of use, and safety of the system. The operative time was also compared with historical data. RESULTS: Both attending and resident surgeons assigned a favorable rating to the utility of the VIP to highlight anatomy and provide feedback to the resident (p > 0.05 for the difference). Both groups agreed that the system was easy to use and that safety was not compromised (p > 0.05). The majority of resident and attending surgeon responses indicated no perceptible lag between motions (95% and 100%, respectively; p > 0.99) and no interference of the VIP system with the surgical procedure (85% and 100%, respectively; p = 0.24). The mean operative times with and without VIP use did not differ significantly for rotator cuff repair (p = 0.90) or for treatment of instability (p = 0.57). CONCLUSIONS: This pilot study revealed that the VIP technology was efficient, safe, and effective as a teaching tool. The attending and resident surgeons agreed that training was enhanced, and this occurred without increasing operative times. Furthermore, the attending surgeon believed that this technology improved teaching effectiveness. These results are promising, and further objective quantification is warranted.

Social networking profiles and professionalism issues in residency applicants: an original study-cohort study.

OBJECTIVE: To determine the frequency of social networking, the degree of information publicly disclosed, and whether unprofessional content was identified in applicants from the 2010 Residency Match. BACKGROUND: Medical professionalism is an essential competency for physicians to learn, and information found on social networking sites may be hazardous to the doctor-patient relationship and an institution's public perception. No study has analyzed the social network content of applicants applying for residency. METHODS: Online review of social networking Facebook profiles of graduating medical students applying for a residency in orthopedic surgery. Evidence of unprofessional content was based upon Accreditation Council for Graduate Medical Education guidelines. Additional recorded applicant data included as follows: age, United States Medical Licensing Examination part I score, and residency composite score. Relationship between professionalism score and recorded data points was evaluated using an analysis of variance. RESULTS: Nearly half of all applicants, 46% (200/431), had a Facebook profile. The majority of profiles (85%) did not restrict online access to their profile. Unprofessional content was identified in 16% of resident applicant profiles. Variables associated with lower professionalism scores included unmarried relationship status and lower residency composite scores. CONCLUSION: It is critical for healthcare professionals to recognize both the benefits and risks present with electronic communication and to vigorously protect the content of material allowed to be publically accessed through the Internet.

A biomechanical analysis of controllable intraoperative variables affecting the strength of rotator cuff repairs at the suture-tendon interface.

BACKGROUND: The tissue-suture interface remains the weakest aspect of a rotator cuff repair, highlighting the importance of identifying techniques to improve stitch strength. Choice of suture-passing devices, size of the tissue bite, and stitch configuration are variables that may influence stitch strength and therefore repair stability. PURPOSE: To evaluate the effect that size of the tissue penetrator device and tissue bite size have upon the holding strength of commonly used stitches. STUDY DESIGN: Controlled laboratory study. METHODS: Three different-sized tissue-penetrating devices, small circular, midsized circular, and large rectangular, were used to place sutures in 192 infraspinatus tendon grafts of sheep. Tissue bite sizes of either 0.5 cm or 1.0 cm for 4 different stitches, a simple, mattress, modified Mason-Allen (MMA), and massive cuff (MAC) stitch, were tested. Grafts were cyclically loaded and then loaded to failure. Mixed multivariate regression analysis was used to test the effect of instrument, bite size, and stitch configuration on peak-to-peak displacement, cyclic elongation, and load to failure. RESULTS: The average ultimate load to failure with the smallest penetrating device was 112 N, significantly higher than with both the midsized (95 N) and large devices (91 N) (P < .001). The average load to failure was 31 N higher for a 1.0-cm bite size when compared with a 0.5-cm bite size (P < .001). The largest load-to-failure differences were found with the type of stitch placed: simple, 48 N; mattress, 69 N; MMA, 130 N; and MAC, 152 N (all P < .02). For simple and mattress stitches, each additional pass of the suture increased the load to failure by 21 N. In MMA and MAC stitches, an additional pass resulted in an increase in the load to failure by 50 N. Cyclic elongation did not differ by instrument type (all P > .5). The elongation of stitches with a 1.0-cm bite size was 0.14 mm higher than stitches with a 0.5-cm bite size (P < .001). No meaningful difference in peak-to-peak displacement was seen for bite size, instrument type, or stitch construct. CONCLUSION: The strength of rotator cuff stitches was significantly affected by the different-sized tissue-penetrating instruments and size of the bite. However, the greatest predictor of time-zero stitch strength is the type of stitch placed. CLINICAL RELEVANCE: This study highlights the importance of stitch configuration in the repair of rotator cuff tears.