Arthroscopic assessment of syndesmotic instability: Are we pulling correctly in the coronal plane?

BACKGROUND: While the lateral hook test (LHT) has been widely used to arthroscopically evaluate syndesmotic instability in the coronal plane, it is unclear whether the angulation of the applied force has any impact on the degree of instability. We aimed to determine if changing the direction of the force applied while performing the LHT impacts the amount of coronal diastasis observed in subtle syndesmotic injuries. METHODS: In 10 cadaveric specimens, arthroscopic evaluation of the syndesmotic joint was performed by measuring anterior and posterior-third coronal plane diastasis in the intact state, and repeated after sequential transection of the 1) anterior inferior tibiofibular ligament (AITFL), 2) interosseous ligament (IOL), and 3) posterior inferior tibiofibular ligament (PITFL). In all scenarios, LHT was performed under 100 N of laterally directed force. Additionally, LHT was also performed under: 1) anterior inclination of 15 degrees and 2) posterior inclination of 15 degrees in intact and AITFL+IOL deficient state. RESULTS: Compared to the intact state, the syndesmosis became unstable after AITFL +IOL transection under laterally directed force with no angulation (p = 0.029 and 0.025 for anterior and posterior-third diastasis, respectively), which worsened with subsequent PITFL transection (p = <0.001). Moreover, there was no statistical difference in anterior and posterior-third coronal diastasis in both intact and AITFL+IOL deficient states under neutral, anterior, and posteriorly directed force (p-values ranging from 0.816 to 0.993 and 0.396-0.80, respectively). However, in AITFL+IOL transected state, posteriorly directed forces resulted in greater diastasis than neutral or anteriorly directed forces. CONCLUSIONS: Angulation of the applied force ranging from 15 degrees anteriorly to 15 degrees posteriorly during intraoperative LHT has no effect on coronal plane measurements in patients with subtle syndesmotic instability. On the other hand, posteriorly directed forces result in more sizable diastasis, potentially increasing their sensitivity. CLINICAL RELEVANCE: When arthroscopically evaluating subtle syndesmotic instability, clinicians should assess coronal diastasis with the hook angled 15 degrees posteriorly.

Utility of Diagnostic Ultrasound in the Assessment of Patellar Instability.

Background: The use of imaging to diagnose patellofemoral instability is often limited by the inability to dynamically load the joint during assessment. Therefore, the diagnosis is typically based on physical examination using the glide test to assess and quantify lateral patellar translation. However, precise quantification with this technique remains difficult. Purpose: To quantify patellar position using ultrasound imaging under dynamic loading conditions to distinguish between knees with and without medial patellofemoral complex (MPFC) injury. Study Design: Controlled laboratory study. Methods: In 10 cadaveric knees, the medial patellofemoral distance was measured to quantify patellar position from 0° to 40° of knee flexion at 10° increments. Knees were evaluated at each flexion angle under unloaded conditions and with 20 N of laterally directed force on the patella to mimic the glide test. Patellar position measurements were made on ultrasound images obtained before and after MPFC transection and compared for significant differences. To determine the ability of medial patellofemoral measurements to differentiate between MPFC-intact and MPFC-deficient states, area under the receiver operating characteristic (ROC) curve analysis and the Delong test were used. The optimal cutoff value to distinguish between the deficient and intact states was determined using the Youden J statistic. Results: A significant increase in medial patellofemoral distance was observed in the MPFC-deficient state as compared with the intact state at all flexion angles (P = .005 to P < .001). When compared with the intact state, MPFC deficiency increased medial patellofemoral distance by 32.8% (6 mm) at 20° of knee flexion under 20-N load. Based on ROC analysis and the J statistic, the optimal threshold for identifying MPFC injury was 19.2 mm of medial patellofemoral distance at 20° of flexion under dynamic loading conditions (area under the ROC curve = 0.93, sensitivity = 77.8%, specificity = 100%, accuracy = 88.9%). Conclusion: Using dynamic ultrasound assessment, we found that medial patellofemoral distance significantly increases with disruption of the MPFC. Clinical Relevance: Dynamic ultrasound measurements can be used to accurately detect the presence of complete MPFC injury.

The arthroscopic syndesmotic assessment tool can differentiate between stable and unstable ankle syndesmoses.

PURPOSE: Patients with stable isolated injuries of the ankle syndesmosis can be treated conservatively, while unstable injuries require surgical stabilisation. Although evaluating syndesmotic injuries using ankle arthroscopy is becoming more popular, differentiating between stable and unstable syndesmoses remains a topic of on-going debate in the current literature. The purpose of this study was to quantify the degree of displacement of the ankle syndesmosis using arthroscopic measurements. The hypothesis was that ankle arthroscopy by measuring multiplanar fibular motion can determine syndesmotic instability. METHODS: Arthroscopic assessment of the ankle syndesmosis was performed on 22 fresh above knee cadaveric specimens, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament, the interosseous ligament, the posterior inferior tibiofibular ligament, and deltoid ligaments. In all scenarios, four loading conditions were considered under 100N of direct force: (1) unstressed, (2) a lateral hook test, (3) anterior to posterior (AP) translation test, and (4) posterior to anterior (PA) translation test. Anterior and posterior coronal plane tibiofibular translation, as well as AP and PA sagittal plane translation, were arthroscopically measured. RESULTS: As additional ligaments of the syndesmosis were transected, all arthroscopic multiplanar translation measurements increased (p values ranging from p < 0.001 to p = 0.007). The following equation of multiplanar fibular motion relative to the tibia measured in millimeters: 0.76*AP sagittal translation + 0.82*PA sagittal translation + 1.17*anterior third coronal plane translation-0.20*posterior third coronal plane translation, referred to as the Arthroscopic Syndesmotic Assessment tool, was generated from our data. According to our results, an Arthroscopic Syndesmotic Assessment value equal or greater than 3.1 mm indicated an unstable syndesmosis. CONCLUSIONS: This tool provides a more reliable opportunity in determining the presence of syndesmotic instability and can help providers decide whether syndesmosis injuries should be treated conservatively or operatively stabilized. The long-term usefulness of the tool will rest on whether an unstable syndesmosis correlates with acute or chronic clinical symptoms.

Arthroscopic Assessment of Syndesmotic Instability in the Sagittal Plane in a Cadaveric Model.

BACKGROUND: Syndesmotic instability is multidirectional, occurring in the coronal, sagittal, and rotational planes. Despite the multitude of studies examining such instability in the coronal plane, other studies have highlighted that syndesmotic instability may instead be more evident in the sagittal plane. The aim of this study was to arthroscopically assess the degree of syndesmotic ligamentous injury necessary to precipitate fibular translation in the sagittal plane. METHODS: Twenty-one above-knee cadaveric specimens underwent arthroscopic evaluation of the syndesmosis, first with all syndesmotic and ankle ligaments intact and subsequently with sequential sectioning of the anterior inferior tibiofibular ligament (AITFL), the interosseous ligament (IOL), the posterior inferior tibiofibular ligament (PITFL), and deltoid ligament (DL). In all scenarios, an anterior to posterior (AP) and a posterior to anterior (PA) fibular translation test were performed under a 100-N applied force. AP and PA sagittal plane translation of the distal fibula relative to the fixed tibial incisura was arthroscopically measured. RESULTS: Compared with the intact ligamentous state, there was no difference in sagittal fibular translation when only 1 or 2 ligaments were transected. After transection of all the syndesmotic ligaments (AITFL, IOL, and PITFL) or after partial transection of the syndesmotic ligaments (AITFL, IOL) alongside the DL, fibular translation in the sagittal plane significantly increased as compared with the intact state (P values ranging from .041 to <.001). The optimal cutoff point to distinguish stable from unstable injuries was equal to 2 mm of fibular translation for the total sum of AP and PA translation (sensitivity 77.5%; specificity 88.9%). CONCLUSION: Syndesmotic instability appears in the sagittal plane after injury to all 3 syndesmotic ligaments or after partial syndesmotic injury with concomitant deltoid ligament injury in this cadaveric model. The optimal cutoff point to arthroscopically distinguish stable from unstable injuries was 2 mm of total fibular translation. CLINICAL RELEVANCE: These data can help surgeons arthroscopically distinguish between stable syndesmotic injuries and unstable ones that require syndesmotic stabilization.

The Mini C-Arm Sock: A Novel and Simple Technique for Draping to Prevent Contamination and Penetration.

The mini C-arm is frequently used in foot and ankle surgery. However, its continuous manipulation introduces potential means of contaminating the sterile surgical field. A simple and effective draping technique of the mini C-arm is described to minimize risk of contamination and sharps penetration that can damage the C-arm. Levels of Evidence: Level V.

Morbidity and Mortality Associated with Geriatric Ankle Fractures: A Medicare Part A Claims Database Analysis.

BACKGROUND: The purpose of this study was to examine the incidence of adverse events in elderly patients who required inpatient admission after sustaining an ankle fracture and to consider these data in relation to geriatric hip fracture and other geriatric patient admissions. METHODS: A retrospective cohort study of patients admitted with an ankle fracture, a hip fracture, or any other diagnosis was performed with the Medicare Part A database for 2008. The primary outcome measure was the one-year mortality rate, examined with multivariate analysis factoring for both patient age and preexisting comorbidity. Secondary outcome measures analyzed additional morbidity as reflected by length of stay, discharge disposition, readmissions, and medical complications. RESULTS: There were 19,648 patients with ankle fractures, 193,980 patients with hip fractures, and 5,801,831 patients with other admitting diagnoses. Significant differences (p < 0.001) were noted in both age and comorbidity status between the group with ankle fractures and the group with hip fractures. The one-year mortality after admission was 11.9% for patients with ankle fracture, 28.2% for patients with hip fracture, and 21.5% for patients with any other admission. Upon using multivariate analysis to account for both age and comorbidity, the hazard ratio for one-year mortality associated with fracture was 1.088 for patients with hip fracture and 0.557 for patients with ankle fracture. CONCLUSIONS: Even after selecting for admitted patients and accounting for both age and comorbidity, geriatric patients with ankle fractures were found to have a lower one-year morbidity compared with geriatric patients who had sustained a hip fracture or alternative admitting diagnoses. Geriatric patients with ankle fractures are likely healthier and more active in ways that are not captured by simply accounting for age and comorbidity. These findings may support more aggressive definitive management of such injuries in this population. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Operative versus nonoperative treatment of geriatric ankle fractures: a Medicare Part A claims database analysis.

BACKGROUND: The incidence of ankle fractures is increasing in the geriatric population, and several studies suggest them to be the third most common extremity fracture in this age group. Previous work has reflected relatively low complication rates during operative treatment. Little is known, however, about the association between these injuries and overall mortality, nor whether operative intervention has any effect on mortality. We hypothesized that geriatric ankle fractures would be correlated with an elevated mortality rate and that operative intervention would be associated with a reduced mortality when compared to nonoperative management. METHODS: Following Institutional Review Board approval we retrospectively assessed all relevant 2008 part A inpatient claims from the Medicare database. We queried diagnosis codes for ankle fractures, and then excluded any patients whose age was less then 65 or had an admission related to an ankle fracture during the previous year. Operative patients were then identified by their ICD-9 procedure codes occurring within 30 days of their initial diagnosis code; all other patients were presumed to be treated without operative intervention, thereby creating 2 groups for comparison. We then analyzed this database for specific variables including overall mortality, length of stay, age distribution, and other demographical characteristics. Groups were compared with Elixhauser and Deyo-Charlson scores to determine the level of comorbidities in each group. Multivariate logistic regression analysis was used to determine if operative intervention had a protective effect. RESULTS: In all, 19 648 patients with an ankle fracture were identified. Of those, 15 193 underwent operative intervention (77.3% ) and 4455 were treated nonoperatively (22.7% ). The mean ages for nonoperative and operative intervention were 80.9 and 76.5, respectively (P < .0001). The average length of stay for nonoperative management was 4.5 days, while operative intervention resulted in a length of stay of 4.6 days (P = .43). One-year mortality was 21.5% for the nonoperative group and 9.1% for the operative group (P < .0001). The mean Elixhauser score for the nonoperative group was 2.5 and 2.2 for the operative group (P < .0001). The mean Deyo-Charlson score was 1.3 and 1.0 for the nonoperative and operative groups, respectively (P < .0001). Multivariate logistic regression analysis demonstrated an odds ratio of 0.534 of death within 1 year for patients undergoing operative intervention as compared to nonoperative intervention (95% CI 0.483-0.591, P < .0001). CONCLUSION: The incidence of geriatric ankle fractures continue to increase as our population continues to grow older. A significantly larger number of those patients were treated with operative intervention, at a ratio of approximately 3:1 versus nonoperative management. Despite a relatively low overall reported complication rate with treatment of these injuries, they are associated with substantially increased 1-year mortality in both patient groups. Compared to the operative group, the nonoperative cohort demonstrated a 2-fold elevated mortality rate, although this may be related to them being an arguably more frail population as suggested by both comorbidity indexes. In spite of the difference in comorbidities, logistic regression analysis demonstrated operative intervention to have a protective effect. LEVEL OF EVIDENCE: Level III, comparative series.

International health electives in orthopaedic surgery residency training.

BACKGROUND: Residents in surgical training programs today demonstrate an increasingly strong interest in global health. Given the considerable need for specialists in underserved areas, some surgical residency programs offer international health electives in resource-poor settings to augment resident training. This study aims to quantify and to characterize international health elective opportunities among orthopaedic surgery residency programs across the United States. METHODS: A web-based survey was distributed to program directors and program coordinators of the 154 U.S. orthopaedic surgery residency programs accredited by the Accreditation Council for Graduate Medical Education. Questions assessed the availability and characteristics of international health electives, the barriers to offering opportunities, and the opinions of program directors regarding the value of international health electives in orthopaedic surgery training. RESULTS: Seventy-three orthopaedic surgery residency programs (47.4% response rate) responded to the survey, with twenty-four responses from program directors and forty-nine responses from program coordinators. Nineteen programs (26.0%) offer international elective training opportunities. Fifty programs had notable barriers to offering international electives. These barriers included lack of training time (thirty-seven programs [74%]), lack of funding (thirty-five programs [70%]), and lack of an international partner to facilitate an international health elective (seventeen programs [34%]). Directors of programs that offer international health electives compared with directors of programs that do not offer these electives felt more strongly that international health electives are important in residency training (mean Likert scale score of 4.2 compared with 2.65; p = 0.00195), that international health electives are valuable for residents (mean Likert scale score of 4.6 compared with 3.53; p = 0.0265), and that exposure to international health care should be required during residency training (mean Likert scale score of 3.0 compared with 1.65; p = 0.0194). CONCLUSIONS: A minority of the orthopaedic surgery residency programs that participated in this study offers international health elective opportunities to trainees. Barriers such as time parameters and funding limit their availability. Our results characterize international health electives and highlight potential areas of intervention that could increase their availability to a greater number of residents.

Prospective analysis of a novel orthopedic residency advocacy education program.

INTRODUCTION: Future physician leaders must be able to critically assess health care policy and patient advocacy issues. Currently, no nationally accepted, standardized curriculum to provide advocacy education during orthopedic residency training exists. We therefore developed an "Advocacy" curriculum for our orthopedic residents designed to direct particular attention to patient advocacy, specialty advocacy, and healthcare policy. METHODS: Residents were given pre- and post-curriculum questionnaires to gauge their perception of the importance, strengths, and weaknesses of this curriculum. A paired t-test was used to compare pre- and post-curriculum responses. RESULTS: Twenty-one of 24 orthopedic residents completed the pre-curriculum and post-curriculum questionnaire regarding the importance of advocacy education (87.5% response rate). Overall, 85.7% (18/21) of responders ranked the curriculum on orthopedic advocacy as good or excellent. Prior to the advocacy curriculum, 33.3% (7/21) of residents felt that learning about orthopedic advocacy was important to their education, while following the curriculum 100% (21/21) felt so (p<0.05). The percentage of residents who considered health policy to be important increased from 71.4% (15/21) to 95.2% (20/21) following the curriculum(p<0.05). Following the advocacy curriculum, 90.5% (19/21) of responders would be interested in getting involved in orthopedic advocacy. DISCUSSION: This curriculum significantly increased residents' belief in the importance of advocacy issues. Following the curriculum, 100% of responding residents considered orthopedic advocacy education as important. An advocacy curriculum may serve as an integral preparatory educational core component to residency training.

ACGME Accreditation of Orthopaedic Surgery Subspecialty Fellowship Training Programs.

BACKGROUND: Orthopaedic surgery training in the United States consists of a five-year-minimum orthopaedic surgery residency program, followed by optional subspecialty fellowship training. There is an increasing trend for trainees to complete at least one fellowship program following residency training, with approximately 90% of current trainees planning to complete a fellowship. The purpose of this investigation was to assess the overall variability of orthopaedic subspecialty fellowships in terms of characteristics, match process, and the tendency to be accredited by the Accreditation Council for Graduate Medical Education. METHODS: Nine orthopaedic surgery subspecialties were assessed for their fellowship match program, their number of fellowship programs and positions in the match, and the number of programs and positions accredited by the Accreditation Council for Graduate Medical Education. Programs with a Subspecialty Certificate offered by the American Board of Orthopaedic Surgery were compared with programs without a Subspecialty Certificate. Comparative statistics utilizing an unpaired t test with a statistical cutoff of p < 0.05 were performed. RESULTS: Three separate matching programs are used by the nine subspecialties. Hand surgery utilizes the National Residents Matching Program, shoulder and elbow surgery utilizes the American Shoulder and Elbow Surgeons Fellowship Match, and the other seven subspecialties utilize the San Francisco Matching Program. In total, 478 fellowship programs were identified, representing 897 fellowship positions. The highest percentage of fellowship programs that are accredited by the Accreditation Council for Graduate Medical Education was in orthopaedic sports medicine (93.1%), compared with the lowest percentage in foot and ankle orthopaedics (16.3%). A significantly higher percentage (p < 0.05) of fellowship programs accredited by the Accreditation Council for Graduate Medical Education were found for subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates (hand and sports) (87.9%) compared with subspecialties without Subspecialty Certificates (34.3%). CONCLUSIONS: There are more orthopaedic subspecialty fellowship positions available annually than there are graduating orthopaedic surgery residents. Three independent matching programs are currently being used by the nine orthopaedic subspecialties. Subspecialties vary in the proportion of programs with Accreditation Council for Graduate Medical Education accreditation. Subspecialties with American Board of Orthopaedic Surgery Subspecialty Certificates have a significantly greater proportion of fellowship programs accredited by the Accreditation Council for Graduate Medical Education compared with those without Subspecialty Certificates. CLINICAL RELEVANCE: Orthopaedic subspecialty fellowship programs are rapidly becoming a perceived necessity as part of orthopaedic surgery training. Fellowships continue to vary in matching system and their accreditation characteristics.

Establishing the relationship between clinical outcome and extent of osseous bridging between computed tomography assessment in isolated hindfoot and ankle fusions.

BACKGROUND: Determining the success of joint fusion operations is often a diagnostic dilemma, and many factors may be considered. Most would agree that the broad categories of clinical success and radiographic success are likely most useful to determine the overall success of a joint fusion operation. Very little evidence exists to assist the surgeon in determining what constitutes a successful radiographic fusion. The aim of this study was to determine the extent of osseous bridging as measured by computed tomography (CT) that was associated with a good clinical outcome as measured by the 12-Item Short Form (SF-12), Foot Function Index (FFI), and American Orthopaedic Foot & Ankle Society (AOFAS) clinical outcomes questionnaires at 24 weeks. METHODS: Patients who had isolated joint fusions were evaluated (n = 275) to determine the correlation of extent of osseous bridging with clinical outcome. The extent of osseous bridging across the joint in question was categorized as absent (0%-24%), minimal (25%-49%) moderate (50%-74%), or complete (75%-100%). Clinical outcome scores included the SF-12, FFI, and AOFAS outcomes score. RESULTS: Patients evaluated to have at least minimal osseous bridging at fusion sites (25%-49%) on CT reported a clinically important improvement in SF-12, FFI, and AOFAS, whereas those with "absent" osseous bridging (0%-24%) did not report a clinically important improvement in outcome scores. CONCLUSION: This study suggests that osseous bridging of greater than 25% to 49% at the fusion site measured by CT may be necessary to consider a hindfoot or ankle fusion clinically successful. LEVEL OF EVIDENCE: Level IV, case series.

Critical analysis of a trauma fellowship-modeled, six-year orthopaedic surgery training program.

BACKGROUND: Work-hour restrictions and increased supervision requirements have altered the clinical experience of orthopaedic surgery residents, while the specialty's body of knowledge and requisite skill set continue to expand. This dilemma means that the duration and practice experience of the traditional orthopaedic residency may not meet the needs of today's trainees. For the past eighteen years, however, residency training in the Department of Orthopaedic Surgery at Brown University has included a mandatory postgraduate year six (PGY6) trauma fellowship-modeled year, during which trainees are conferred full staff admitting and operating privileges, with time allotted for completing research. They are supervised by senior attending staff, with increasing autonomy as the year progresses. A formal, critical analysis of this transition-to-practice training model in orthopaedics has not previously been described. METHODS: An anonymous thirty-one-item questionnaire was distributed to all practicing graduates of the six-year Brown University Orthopaedic Surgery training program (n = 69). A 5-point Likert scale was used to assess attitudinal questions. An independent-sample t test was used to compare the responses of pre-duty-hour trainees with those of post-duty-hour trainees, with a p value of <0.05 utilized for significance. RESULTS: All sixty-nine practicing graduates of the Brown University PGY6 trauma fellowship completed the survey (100% response rate). Most graduates (78.2%) would choose to complete the PGY6 year if they had to do residency again, and 72.4% would recommend trauma fellowship-modeled training to residents beginning their training. Trainees who completed residency during or after the imposed 2003 Accreditation Council for Graduate Medical Education duty-hour restrictions (79.3%) were significantly more likely (p = 0.014) to rank the PGY6 year as their most valuable training year compared with trainees who completed residency prior to duty-hour restrictions (50.0%). Nearly half of the graduates (46.4%) thought that the PGY6 fellowship year was financially burdensome. CONCLUSIONS: The unique trauma fellowship-modeled sixth year of orthopaedic surgery training at Brown University was thought to be a valuable training experience by a large majority of graduates, although nearly half thought that the year was financially burdensome. These data suggest that a trauma fellowship-based sixth year of independent yet structured training has the potential to enhance orthopaedic education and could become an alternative standard given the current requirements imposed upon surgical residency training. These results may help guide further discussion among orthopaedic training programs to determine the optimal model for orthopaedic residency education in the twenty-first century.

Foot and ankle fellowship training: a national survey of past, present, and prospective fellows.

BACKGROUND: Surgical specialties have become increasingly subspecialized. An expanding demand for foot and ankle care administered by trained specialists has driven the need for foot and ankle-trained orthopaedic surgeons. This survey was designed to elucidate the reasons why residents choose a career in foot and ankle surgery. METHODS: We conducted a national, anonymous, 11-question survey of past, present, and prospective foot and ankle fellows (156 mailed). The questions focused on trying to understand the decision-making process in pursuing a foot and ankle fellowship, and assessing the overall satisfaction of this career choice. Questionnaires were returned within one month of their mailing. RESULTS: We achieved a 40% overall response rate. The fellow's relationship with their residency program's foot and ankle specialist was the primary catalyst for pursuing foot and ankle as a career. Nearly all respondents were satisfied with their decision to do a foot and ankle fellowship, though some were disappointed early in practice with remuneration, practice competition, and patient dissatisfaction. American Orthopaedic Foot and Ankle Society (AOFAS) membership was nearly unanimous. CONCLUSION: The relationship established between a resident and his or her foot and ankle mentor while in training appears to have the greatest impact on pursuing foot and ankle surgery as a career. Once in practice, few trained fellows regret their decision, and few report disappointments not similarly voiced by other orthopaedic subspecialties. Based on this data, the importance of a foot and ankle rotation elective during orthopaedic residency and the impact subspecialty service attending have on resident interests and career choices seem clear.

Patient compliance in avoiding wrong-site surgery.

BACKGROUND: Wrong-site orthopaedic surgery is an uncommon, devastating, and preventable complication. The sole responsibility for avoiding this inadvertent event has historically been placed on physicians, nurses, and ancillary health-care personnel. Very little attention has been focused on the role of the patient. The successful outcome of any surgical or medical intervention requires an interactive doctor-patient relationship. The hypothesis of this study was that a substantial number of patients who undergo elective orthopaedic surgery do not comply with instructions designed specifically to prevent wrong-site surgery. METHODS: We prospectively evaluated the frequency with which 100 consecutive patients in a private foot-and-ankle practice followed the explicit preoperative instruction, before they underwent elective orthopaedic surgery, to mark "NO" on the extremity that was not to be operated on. Full compliance was defined as a mark on the correct extremity consistent with the instructions. Partial compliance was defined as a mark that was different from that requested by the specific preoperative instructions, and noncompliance was defined as the absence of any mark. Specific demographic and surgical factors were recorded from medical charts and compared between compliant and noncompliant patients. RESULTS: Fifty-nine of the 100 patients marked the extremity correctly, thirty-seven made no mark, and four were considered partially compliant. Of the ten patients with a Workers' Compensation claim, seven were noncompliant compared with thirty (33%) of the ninety patients who had not made a Workers' Compensation claim (p = 0.023). Patients who had had a previous related surgical procedure also had a significantly higher rate of noncompliance (51%; nineteen of thirty-seven) compared with those with no previous surgery (29%; eighteen of sixty-three; p = 0.023). CONCLUSIONS: A surprisingly high number of patients do not comply with explicit preoperative instructions created specifically to prevent wrong-site surgery. This behavior suggests that patients expect the system to "take care of everything," despite solicitation of their active participation to avoid such adverse events. Although physicians and related health-care personnel certainly have the greatest responsibility to provide the highest possible quality of care, patients undergoing surgery must be encouraged to take a more active role in their health care in order to optimize outcome and minimize risk.