Comprehensive Review of Rock Climbing Injuries.

Increasing numbers of people are participating in the sport of rock climbing, and its growth is expected to continue with the sport's Olympic debut in 2020. Extreme loading of the upper extremities, contorted positioning of the lower extremities, rockfall, and falling from height create an elevated and diverse injury potential that is affected by experience level and quantity of participation. Injuries vary from acute traumatic injuries to chronic overuse injuries. Unique sport-specific injuries to the flexor tendon pulley system exist, but the remaining musculoskeletal system is not exempt from injury. Orthopaedic evaluation and surgery is frequently required. Understanding the sport of rock climbing and its injury patterns, treatments, and prevention is necessary to diagnose, manage, and counsel the rock-climbing athlete.

Advances in Wound Management.

Wound management is a notable healthcare and financial burden, accounting for >$10 billion in annual healthcare spending in the United States. A multidisciplinary approach involving orthopaedic and plastic surgeons, wound care nursing, and medical and support staff is often necessary to improve outcomes. Orthopaedic surgeons must be familiar with the fundamental principles and evidenced-based concepts for the management of acute and chronic wounds. Knowledge of surgical dressings, negative pressure wound therapy, tissue expanders, dermal apposition, biologics, and extracellular matrices can aide practitioners in optimizing wound care.

Tissue expanders with a focus on extremity reconstruction.

INTRODUCTION: Acute traumatic or surgical wounds that cannot be primarily closed often cause substantial morbidity and mortality. This often leads to increased costs from higher material expenses, more involved nursing care, and longer hospital stays. Advancements in soft tissue expansion has made it a popular alternative to facilitate early closure without the need for more complicated plastic surgical procedures. AREAS COVERED: In this review, we briefly elaborate on the history and biomechanics of tissue expansion and provide comprehensive descriptions of traditional internal tissue expanders and a variety of contemporary external tissue expanders. We describe their uses, advantages, disadvantages, and clinical outcomes. The majority of articles reviewed include case series with level IV evidence. Outcome data was collected for studies after 1990 using PubMed database. EXPERT COMMENTARY: An overall reduction in cost, time-to-wound closure, hospital length-of-stay, and infection rate may be expected with most tissue expanders. However, further studies comparing outcomes and cost-effectiveness of various expanders may be beneficial. Surgeons should be aware of the wide array of tissue expanders that are commercially available to individualize treatment based on thorough understanding of their advantages and disadvantages to optimize outcomes. We predict the use of external expanders to increase in the future and the need for more invasive procedures such as flaps to decrease.

Fifteen to twenty-five year functional outcomes of twenty-two patients treated with posterior Cotrel-Dubousset type instrumentation: a limited but detailed review of outcomes.

BACKGROUND: Long-term outcomes of patients undergoing extensive fusions for adolescent idiopathic scoliosis (AIS) have conflicting results. Moskowitz found uninstrumented scoliosis fusion patients had similar back pain as a normal age matched population. Recently, long-term outcomes of patients with Harrington rod instrumentation were reviewed and found similar functional outcome scores to non-scoliosis patients, with trending toward worse outcomes when fusions extended to L4. Our study examined long-term functional outcomes of patients treated with Cotrel-Dubousset (CD) instrumentation and determined whether distal level of instrumented fusion (L4 and L5) correlate with increased back pain or lower functional level. METHODS: Retrospective review of AIS surgeries from 1986 to 1996 was undertaken. Patient demographics and surgical data were collected via case-note audit. Patients were contacted and asked to complete a series of functional outcome questionnaires including visual analog scales (VAS) for pain, Short-Form 36 (SF-36), Scoliosis Research Society 22 (SRS-22) and Oswestry Disability Index (ODI) for function. ANOVA technique categorically compared outcome scores to most distal levels of fusion. Linear regression compared patient reported outcomes to time elapsed since surgery. Statistical significance was p < 0.05. RESULTS: One hundred twelve patients were identified, 50 patients were contacted, and 22 agreed to participation and completed a full assessment. Follow-up time since surgery ranged from 15 to 26 years and age ranged from 30 to 43 years. Six patients reported daily VAS back pain of ≥5; with a mean of 2.5. Back pain was not associated with level of distal fusion (p = 0.92). ODI was 15.36, with six patients' ODI >20. No relationship was shown between ODI and distal level of fusion (p = 0.72). SF-36 and SRS 22 values were also not related to distal level of instrumentation. Patient reported VAS back pain scores (r(2) = 0.18, p = 0.05), ODI (r(2) = 0.09, p = 0.17), and SF-36 and SRS-22 were not worse in patients with longer follow-up over time. Back pain and certain functional score subcategories of the SF-36 and SRS-22 trended toward improved results over time. CONCLUSIONS: Most patients who underwent multi-segment spinal fixation appeared to do well long-term, with minimal back pain. Lowest instrumented segment did not appear to be associated with increased back pain after 15 to 25 years follow-up.

Social and Cultural Barriers: Understanding Musculoskeletal Health Literacy: AOA Critical Issues.

The Institute of Medicine considers limited health literacy a "silent epidemic," as approximately half of Americans lack the competencies necessary for making informed decisions regarding their health. Limited health literacy substantially impedes the effective dissemination and comprehension of relevant health information, and also complicates communication, compromises care, and leads to worse patient outcomes. Poor health, early death, and worse control of chronic conditions have also been associated with limited health literacy. Unfortunately, physicians often struggle to identify those with limited health literacy, which can have adverse effects on the physician-patient relationship. In this article, we discuss the meaning of health literacy,the risk factors for and consequences of limited health literacy, orthopaedic-specific implications and investigations, and the strategies orthopaedic surgeons can utilize to improve health literacy and communication.

Orthopaedic Considerations for the Adult With Osteogenesis Imperfecta.

Osteogenesis imperfecta is a heritable group of collagen-related disorders that affects up to 50,000 people in the United States. Although the disease is most symptomatic in childhood, adults with osteogenesis imperfecta also are affected by the sequelae of the disease. Orthopaedic manifestations include posttraumatic and accelerated degenerative joint disease, kyphoscoliosis, and spondylolisthesis. Other manifestations of abnormal collagen include brittle dentition, hearing loss, cardiac valve abnormalities, and basilar invagination. In general, nonsurgical treatment is preferred for management of acute fractures. High rates of malunion, nonunion, and subsequent deformity have been reported with both closed and open treatment. When surgery is necessary, surgeons should opt for load-sharing intramedullary devices that span the entire length of the bone; locking plates and excessively rigid fixation generally should be avoided. Arthroplasty may be considered for active patients, but the procedure frequently is associated with complications in this patient population. Underlying deformities, such as malunion, bowing, rotational malalignment, coxa vara, and acetabular protrusio, pose specific surgical challenges and underscore the importance of preoperative planning.

Health Literacy in Patients Seeking Orthopaedic Care: Results of the Literacy in Musculoskeletal Problems (LIMP) Project.

BACKGROUND: Health literacy is the most important predictor of an individual's health status, with more frequent hospitalizations, worse control of chronic conditions, and suboptimal treatment outcomes associated with limited literacy. Despite this, little is known about musculoskeletal health literacy. As such, this study utilized a musculoskeletal specific literacy survey (the LiMP questionnaire) to evaluate the level of comprehension in patients presenting to the emergency department with musculoskeletal complaints, with an emphasis on their understanding of anatomy, terminology, diagnosis and treatment of musculoskeletal conditions. The relationship between musculoskeletal specific and general health literacy was also assessed, in addition to the risk factors for limited musculoskeletal comprehension. METHODS: In this cross-sectional study, each of the 248 participants completed a demographic survey, the LiMP questionnaire, and the Newest Vital Sign (NVS), a general health literacy assessment tool. A x(2) analysis was used to compare results from the LiMP questionnaire and NVS, and to evaluate the relationship between musculoskeletal health literacy and demographic parameters. RESULTS: The mean LiMP score was 4.68 ± 1.78 out of a possible nine points. Questions regarding musculoskeletal conditions were answered correctly by 47.4% of respondents. Questions regarding diagnosis and treatment were answered correctly by 31.2% of respondents. Questions regarding anatomy and terminology were answered correctly by 65.3% of respondents. Limited musculoskeletal literacy, defined as LiMP questionnaire scores of <6, was observed in 69% of subjects. Inadequate general health literacy, defined as NVS scores <4, was observed in 48% of subjects. This difference was statistically significant (p<0.001). Those who identified themselves as Caucasian and having an education level of ≥ college were significantly more likely to have adequate musculoskeletal literacy (p=0.001, p<0.001, respectively). CONCLUSIONS: The prevalence of limited musculoskeletal literacy is greater than that of limited general health literacy, with minorities and those with lower education levels most at risk. These findings are consistent with other disease and specialty specific literacy studies. Although such insight will assist providers in accurately targeting education and outreach campaigns, it remains imperative that additional research be performed to determine if limited literacy correlates with increased complications and worse outcomes in those with musculoskeletal conditions. LEVEL OF EVIDENCE: Level IV. The authors have no relevant financial disclosures or conflicts of interest with regard to this manuscript. No funding was received.

MRI for the evaluation of knee pain: comparison of ordering practices of primary care physicians and orthopaedic surgeons.

BACKGROUND: Knee pain is one of the most common reasons for outpatient visits in the U.S. The great majority of such cases can be effectively evaluated through physical examination and judicious use of radiography. Despite this, an increasing number of magnetic resonance images (MRIs) of the knee are being ordered for patients with incomplete work-ups or for inappropriate indications. We hypothesized that MRIs ordered by orthopaedic providers were more likely to result in changes in diagnoses and/or plans for care than those ordered by non-orthopaedic providers. METHODS: We reviewed the charts of all consecutive new patients seen at our orthopaedic outpatient office between January 1, 2010, and December 31, 2011, with International Classification of Diseases, Ninth Revision (ICD-9) codes for meniscal or unspecific sprains and strains of the knee. A total of 1592 patients met our inclusion criteria and were divided into two groups: those initially evaluated and referred by their primary care physician (PCP) (n = 747) and those initially evaluated by one of our staff orthopaedic surgeons (n = 845). RESULTS: MRI-ordering rates were nearly identical between orthopaedic surgeons and PCPs (25.0% versus 24.8%; p = 0.945). MRIs ordered by orthopaedic surgeons, however, resulted in significantly more arthroscopic interventions than those ordered by PCPs (41.2% versus 31.4%; p = 0.042). Orthopaedic surgeons ordered MRIs for patients who were more likely to benefit from arthroscopic intervention, including patients who were younger (mean age, 45.1 years versus 56.5 years for those with PCP-ordered MRIs; p < 0.001), patients with acute symptoms (39.3% versus 22.2%; p < 0.001), and patients with a history of trauma (49.3% versus 36.2%; p = 0.019). Finally, orthopaedic surgeons were less likely than PCPs to order MRIs for patients with substantial osteoarthritis who subsequently underwent total knee arthroplasty (4.3% versus 9.2%; p = 0.048). CONCLUSIONS: MRI utilization by orthopaedic surgeons results in more appropriate interventions for patients with symptoms and findings most amenable to surgical intervention.

Dedicated orthopaedic operating rooms: beneficial to patients and providers alike.

OBJECTIVE: Dedicated orthopaedic operating rooms (DOORs) are increasingly popular solutions to reducing after-hours procedures, physician fatigue, and elective schedule disruptions. Although the benefits to surgeons are well understood, there are comparatively few studies that explore the effects of DOORs on patient care. We compared treatments and outcomes for all consecutive patients with femoral neck fractures, 4 years before and 4 years after implementation of a DOOR-based schedule. DESIGN: Retrospective case-control study. SETTING: Level 1 academic trauma center. PATIENTS: A total of 111 consecutive trauma patients undergoing surgical management of isolated OTA group 31-B femoral neck fractures. INTERVENTION: Based on individual patient factors and fracture characteristics, patients were managed with either hemiarthroplasty or open reduction internal fixation (ORIF). MAIN OUTCOME MEASURES: Surgical timing, intervention type, perioperative complications, and postoperative length of stay. RESULTS: Retrospective analysis revealed a significant decrease in after-hour surgery (4 PM-7:30 AM) for all femoral neck fractures (66.7%-19.3%; P < 0.001). No significant differences were found between the rates of arthroplasty versus those of open reduction internal fixation. Patients undergoing surgical treatment for femoral neck fractures after DOOR suffered significantly fewer morbidities, including significantly decreased rates of postoperative intensive care unit admissions, stroke, infections, and myocardial infarction or congestive heart failure exacerbations. We also observed a significant decrease in postoperative mortality (5.6% pre-DOOR vs. 0% post-DOOR; P = 0.04). Patients undergoing hemiarthroplasty experienced a significant shorter hospitalization (14.5 days pre-DOOR vs. 9.9 days post-DOOR; P = 0.04). CONCLUSIONS: In our experience, a weekday DOOR is closely associated with improvements in both patient safety and outcomes. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minor traumatic brain injury: a primer for the orthopaedic surgeon.

Minor traumatic brain injury (mTBI) is a major public health problem. The Centers for Disease Control and Prevention and the National Center for Injury Prevention and Control label it a "silent epidemic." Subtle signs and symptoms of mTBI, including headache, fatigue, and memory loss, are often seen in conjunction with musculoskeletal trauma. Although sometimes evident immediately, mTBI may not manifest until patients return to work and their personal lives. In the patient with acute concurrent mTBI, skeletal management must be based on either a period of observation to rule out evolving neurologic symptoms or, when warranted, the recommendations of a neurosurgeon. Such input is particularly important when mTBI is associated with a prolonged loss of consciousness or posttraumatic amnesia. In the outpatient setting, when concern for mTBI exists weeks after an injury, familiarity with and referral to locally available mTBI specialists and programs can facilitate proper care. Armed with this knowledge, the orthopaedic surgeon has an opportunity to positively influence outcomes and help provide crucial care that extends beyond the management of musculoskeletal injuries.

Elementary Implantable Force Sensor: For Smart Orthopaedic Implants.

Implementing implantable sensors which are robust enough to maintain long term functionality inside the body remains a significant challenge. The ideal implantable sensing system is one which is simple and robust; free from batteries, telemetry, and complex electronics. We have developed an elementary implantable sensor for orthopaedic smart implants. The sensor requires no telemetry and no batteries to communicate wirelessly. It has no on-board signal conditioning electronics. The sensor itself has no electrical connections and thus does not require a hermetic package. The sensor is an elementary L-C resonator which can function as a simple force transducer by using a solid dielectric material of known stiffness between two parallel Archimedean coils. The operating characteristics of the sensors are predicted using a simplified, lumped circuit model. We have demonstrated sensor functionality both in air and in saline. Our preliminary data indicate that the sensor can be reasonably well modeled as a lumped circuit to predict its response to loading.

Catastrophic fracture of a stable metal acetabular component.

Various modes of failure of primary and revision total hip arthroplasty have been well documented in the literature over the past 30 years. Concerns over polyethylene wear, osteolysis, and hypersensitivity reactions leading to component loosening and early revision have been evaluated and reported in the literature. Routine follow-up is important to monitor for postoperative issues that might lead to the subsequent need for revision.This article describes a case of a 64-year-old man who initially presented 11 years prior with an intertrochanteric fracture, which failed secondary to varus alignment and femoral head osteonecrosis. The fixation was converted to a total hip replacement using the S-ROM system (DePuy, Warsaw, Indiana). Subsequently, the patient was lost to follow-up after primary total hip arthroplasty and presented with a catastrophic fracture of the metal acetabular cup system. The failure was suggested by clinical presentation and confirmed by imaging studies showing a fractured acetabular shell with femoral head prosthesis resting in the superolateral ileum. The contributing factors that resulted in mechanical failure were polyethylene wear and component fracture. The acetabular component was revised with an in-growth cementless trabecular metal multihole cup (Zimmer, Warsaw, Indiana) with bone grafting of acetabular defects.Routine assessments help educate patients and allow careful monitoring by physicians while establishing a radiographic timeline for the identification, progression, or lack of postoperative complications.

Proximal interphalangeal joint arthrodesis using the tension band technique.

Arthritis and instability of the proximal interphalangeal (PIP) joints of the hand leads to chronic pain and decreased hand function. Proximal interphalangeal joint arthrodesis is an effective means of restoring hand function. The tension band technique is a reliable and cost-effective means of stabilizing the arthrodesis while allowing early hand motion. The dorsal tension band causes compression at the arthrodesis site during active motion, further facilitating healing. The technique is cost effective, using inexpensive pins and a wire. Complications include delayed union, pin protrusion from the bone, and painful hardware.

Vancouver type-B2 periprosthetic femoral fracture.

Effective treatment of a periprosthetic fracture requires a treatment strategy that is based on careful evaluation of the fracture pattern.

Spacer endoprosthesis for the treatment of infected total hip arthroplasty.

We reviewed the treatment of infected total hip arthroplasty with a temporary spacer endoprosthesis. To fabricate the spacer, antibiotic-loaded cement was inserted into a specially designed mold. A central rod pin was superficially imbedded as an endoskeleton once the cement reached a doughy state. After polymerization, the final product was removed from the mold and inserted as an articulating spacer. Twenty patients were followed for an average of 38 months (range, 26-67 months). There were no recurrent or persistent infections. Eighteen patients underwent a successful 2-stage exchange. Two patients retained the spacer as a definitive treatment method. Complications with the spacer included 2 fractures and 2 dislocations. Overall, this cost-effective technique provided efficient local antibiotic delivery, early mobilization, facilitation of reimplantation, and improved patient satisfaction.

Antibiotic-loaded articulating cement spacer in the 2-stage exchange of infected total knee arthroplasty.

An antibiotic-loaded articulating cement spacer (ALACS) was used in the 2-stage exchange of infected total knee arthroplasty. Specially designed molds produced articulating femoral and tibial spacer components. Twenty-four consecutive patients were followed for an average of 33 months (range, 28-51 months). Two patients (8%) had a persistent infection after the first stage. Twenty-two patients (92%) underwent a successful 2-stage exchange. Minimal soft-tissue contracture and minimal bone loss were encountered during reimplantation. None of these patients developed a recurrent or persistent infection. The average postoperative knee flexion was 104 degrees (range, 89 degrees-122 degrees). The average Hospital for Special Surgery score was 82 (range, 63-96). The ALACS spacer preserved knee function between stages, resulting in effective treatment of infection, facilitation of reimplantation, and improved patient satisfaction.

Complications of thermal ablation in wrist arthroscopy.

Wrist arthroscopy is a valuable diagnostic and therapeutic tool. Thermal ablation can be used concomitantly to treat partial ligamentous tears, triangular fibrocartilage cartilage complex tears, and to perform partial synovectomy. We reviewed 47 consecutive patients who underwent wrist arthroscopy with concomitant thermal ablation between 1997 and 2001. Three patients sustained serious complications. The serious complications included, in all three patients, tendon ruptures and in one case, a 5 x 10-mm full-thickness skin burn. Thermal treatment of collagenous tissues has recently gained popularity in the orthopedic literature, but there is little information on the potential complications. The arthroscopist of large and small joints must be aware of the risks involved when using thermal ablation.