Pilot Study Analysis of Serum Cytokines to Differentiate Pediatric Septic Arthritis and Transient Synovitis.

BACKGROUND: In pediatric patients, the presentation of the nontraumatic acutely painful joint/limb poses a diagnostic dilemma due to the similarity of presentations of the most likely diagnoses [septic arthritis (SA), transient synovitis (TS), osteomyelitis]. Current tools employed to differentiate these diagnoses rely on nonspecific inflammatory markers, radiologic imaging, and arthrocentesis. Diagnostic algorithms utilizing these clinical, radiographic, and biochemical parameters have produced conflicting results. The purpose of this study was to identify a serum-based inflammatory signature which can differentiate SA from TS in pediatric patients. METHODS: Serum samples were collected from 22 pediatric patients presenting with joint/extremity pain whose working diagnosis included SA or TS. Each sample was analyzed for serum abundance of 72 distinct biomarkers and cytokines using enzyme linked immunosorbent assay based arrays. Linear discriminant analysis was performed to identify a combinatorial biomarker panel to predict a diagnosis of SA or TS. Efficacy of the biomarker panel was compared with definitive diagnoses as based on laboratory tests, arthrocentesis results, and clinical scenario. RESULTS: At the time of presentation: (1) mean erythrocyte sedimentation rate in the SA group was 56.6 mm/h and 12.4 mm/h in the TS group (P<0.001), (2) mean C-reactive protein was 55.9 mg/dL in the SA group and 13.7 mg/dL in the TS group (P=0.12), and (3) mean white blood cell was 10.9 k/mm3 in the SA group and 11.0 k/mm3 in the TS group (P=0.95). A combined panel of 72 biomarkers was examined using discriminant analysis to identify a limited set of predictors which could accurately predict whether a patient was diagnosed with SA or TS. A diagnostic algorithm consisting of transforming growth factor alpha, interleukin (IL)-7, IL-33, and IL-28A serum concentration correctly classified 20 of the 22 cases with a sensitivity and specificity of 90.9% (95% confidence interval: 73.9%-100.0%). CONCLUSION: This study identifies a novel serum-based 4-cytokine panel that accurately differentiates SA from TS in pediatric patients with joint/limb pain. LEVEL OF EVIDENCE: Level II-diagnostic study.

Total shoulder arthroplasty in patients with a B2 glenoid addressed with corrective reaming.

BACKGROUND: This study describes the short-term functional and radiographic outcomes after total shoulder arthroplasty (TSA) in shoulders with a B2 glenoid deformity addressed with corrective reaming. METHODS: We conducted a retrospective series of consecutive patients who underwent TSA with a Walch B2 glenoid quantified by computed tomography scan. All glenoid deformities were addressed using partially corrective glenoid reaming. Radiographic and functional outcome measures, including scores on the visual analog scale for pain, American Shoulder and Elbow Standardized Shoulder Assessment, and Simple Shoulder Test were collected. RESULTS: Functional outcome scores were available for 59 of 92 eligible subjects (64%) at a mean of 50 months. The mean preoperative retroversion measured 18° (range, -1° to 36°), superior inclination was 8° (range, -11° to 27°), and posterior subluxation was 67% (range, 39%-91%). Mean visual analog scale improved from 7.4 to 1.4, the American Shoulder and Elbow Shoulder Standardized Assessment improved from 35.4 to 84.3, and the SST improved from 4.5 to 9.1. Radiographs were evaluated at a mean of 31 months: 38 had no glenoid radiolucent lines, 13 glenoids had grade 1, 2 had grade 2, and 5 had grade 3 lucencies. There was no difference in the rate of progression of glenoid radiolucencies between shoulders with a preoperative glenoid version of ≤20° (27.8%) compared with glenoids with >20° of retroversion (22.7%, P = .670). No shoulders were revised due to glenoid loosening or instability. CONCLUSION: TSA with partial corrective glenoid reaming in selected shoulders with a B2 glenoid deformity resulted in excellent functional and radiographic outcomes at short-term follow-up, with a low risk of revision surgery.

Treatment of Acromioclavicular Joint Instability With a Tunnel-Free Reconstruction Technique.

Acromioclavicular joint injuries are a common shoulder injury encountered by orthopaedic surgeons. Many different surgical techniques have been described for the operative treatment of these injuries with no single, clear gold standard technique on which surgeons agree. Among the most common complications after surgical management of acromioclavicular injuries are loss of reduction, infection, fracture of clavicle or coracoid, and need for reoperation. We propose an arthroscopic-assisted, tunnel-free surgical technique using a tibialis anterior allograft combined with a FiberTape Cerclage (Arthrex, Naples, FL) to manage both acute and chronic acromioclavicular joint injuries. No bony tunnels are drilled and no hardware is implanted, which should obviate the risk for subsequent bony failure through a fracture, nor require subsequent hardware removal. In addition, the combination of suspensory and allograft fixation should impart sufficient stability to maintain an adequate reduction even in the face of failure of one of the fixation methods.

The Utility of the Hyperinlet View in Posterior Fixation of Pelvic Ring Injuries.

SUMMARY: Percutaneous pelvic fixation has evolved into a widely used, safe, and effective treatment option in the management of pelvic ring injuries. Proper preoperative and intraoperative radiographic evaluation of these injuries is critical to ensure safe placement of fixation of the pelvis. Traditional intraoperative views for posterior pelvic ring fixation include the pelvic inlet and outlet views. We propose that the intraoperative use of a hyperinlet view, which uses additional cranial tilt relative to the traditional inlet view, is helpful to better delineate the spinal canal and thereby better define the posterior limit of the osseous fixation pathway of the upper sacral segments. This study illustrates the use of this novel radiographic view and presents a patient cohort in which it was effectively used.

Total shoulder arthroplasty with an anterior-offset humeral head in patients with a B2 glenoid.

BACKGROUND: To address severe posterior subluxation associated with the Walch B2 glenoid deformity, the eccentricity of the prosthetic humeral head can be reversed, allowing the humerus to remain in a relatively posterior position while the prosthetic humeral head remains well-centered on the glenoid. This study describes the short-term outcomes after anatomic total shoulder arthroplasty (TSA) using this technique. METHODS: We retrospectively reviewed a consecutive series of patients with a B2 glenoid who underwent TSA with the prosthetic eccentric humeral head rotated anteriorly for excessive posterior subluxation noted intraoperatively. Medical records were reviewed for visual analog scale (VAS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Simple Shoulder Test (SST) scores. Final radiographs were analyzed for instability, lesser tuberosity osteotomy healing, and glenoid loosening. RESULTS: Twenty patients were included with outcome scores at a mean of 48 months. Mean VAS (P < .0001), ASES (P < .0001), and SST (P < .0001) scores improved significantly. Using the Lazarus classification for glenoid loosening, 5 patients had grade 1 lucency and 2 had grade 2 lucency at a mean of 24 months' follow-up. The remaining 13 patients had no glenoid lucencies. Radiographic decentering was reduced from a mean of 9.9% ± 5.7% preoperatively to 0.5% ± 3.0% postoperatively (P < .001). There were no cases of lesser tuberosity repair failures or revision surgery. CONCLUSION: TSA in patients with a B2 glenoid with a reversed, anterior-offset humeral head to address residual posterior subluxation resulted in excellent functional outcomes at short-term follow-up with improvement in humeral head centering. Early radiographic follow-up suggests low risks of progressive glenoid lucencies and component loosening.

Cross-Sectional Survey Results on Mental Health Among Orthopedic Surgery Residents Across North America.

OBJECTIVE: With recent increasing rates of medical student and physician suicide, there has been a focus on examining depression in medical providers and trainees, particularly surgical residents. However, there is a paucity of data specific to orthopedic surgery. Our goal was to evaluate the mental health status of current trainees across North America in order to determine whether or not there were specific demographic or program characteristics correlated with improved mental health scores. DESIGN: A cross-sectional survey was developed and administered to collect basic demographic information as well as residency program qualities. The Mental Health Inventory 5 (MHI-5) was used to assess depression and anxiety in study participants. We then evaluated the associations between various resident and program characteristics and depression scores with a p value set at <0.05 for significance. SETTING: Orthopedic Surgery residency programs across the United States and Canada. Surveys were distributed to 44 programs and responses were received from 41 of those programs. PARTICIPANTS: An anonymous survey was distributed to Orthopedic Surgery residents across the United States and Canada; participation in the survey was voluntary and free of coercion. We received a total of 279 responses from 41 institutions across North America. RESULTS: The mean MHI-5 score of all respondents was 71.5 (range 8.0-100). Women, PGY2 and PGY3 residents and those working >80 hours per week were found to have significantly lower MHI-5 scores. Greater MHI-5 scores were seen in respondents who felt their program offered them an adequate level of surgical independence, case volume/variety, mentorship, and educational opportunities as well as adequate resources to deal with personal or work-related issues. CONCLUSIONS: This study illustrates the prevalence of low-level depression in United States and Canadian orthopedic surgery residents. Additionally, we identified several characteristics that residency programs may focus on to help prevent burnout and depression in trainees.

The Arterial Anatomy of the Lateral Ligament Complex of the Ankle: A Cadaveric Study.

BACKGROUND: Ankle sprains are the most common musculoskeletal injury in the United States. Chronic lateral ankle instability can ultimately require operative intervention to decrease pain and restore stability to the ankle joint. There are no anatomic studies investigating the vascular supply to the lateral ankle ligamentous complex. PURPOSE: To define the vascular anatomy of the lateral ligament complex of the ankle. STUDY DESIGN: Descriptive laboratory study. METHODS: Thirty pairs of cadaveric specimens (60 total legs) were amputated below the knee. India ink, followed by Ward blue latex, was injected into the peroneal, anterior tibial, and posterior tibial arteries to identify the vascular supply of the lateral ligaments of the ankle. Chemical debridement was performed with 8.0% sodium hypochlorite to remove the soft tissues, leaving casts of the vascular anatomy intact. The vascular supply to the lateral ligament complex was then evaluated and recorded. RESULTS: The vascular supply to the lateral ankle ligaments was characterized in 56 specimens: 52 (92.9%) had arterial supply with an origin from the perforating anterior branch of the peroneal artery; 51 (91.1%), from the posterior branch of the peroneal artery; 29 (51.8%), from the lateral tarsal branch of the dorsalis pedis; and 12 (21.4%), from the posterior tibial artery. The anterior branch of the peroneal artery was the dominant vascular supply in 39 specimens (69.6%). CONCLUSION: There are 4 separate sources of extraosseous blood supply to the lateral ligaments of the ankle. In all specimens, the anterior talofibular ligament was supplied by the anterior branch of the peroneal artery and/or the lateral tarsal artery of the dorsalis pedis, while the posterior talofibular ligament was supplied by the posterior branch of the peroneal artery and/or the posterior tibial artery. The calcaneofibular ligament received variable contributions from the anterior and posterior branches of the peroneal artery, with few specimens receiving a contribution from the lateral tarsal or posterior tibial arteries. CLINICAL RELEVANCE: Understanding the vascular anatomy of the lateral ligament complex is beneficial when considering surgical management and may provide insight into factors that lead to chronic instability.

Patient Preferences for the Treatment of Shoulder and Proximal Biceps Disorders Are Associated With Patient Age, Race, Sex, and Activity Level.

BACKGROUND: Patient preference information has become increasingly more important in clinical decision making. PURPOSE: To assess patient preferences when making treatment decisions in the shoulder to determine which features are more important according to patient age, race, activity level, and sex. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Study participants aged ≥18 years were surveyed as to their preferences regarding surgical treatment for shoulder and proximal biceps abnormalities. Survey features included time to return to unrestricted activities, time to return to work, size and appearance of scars, the potential for persistent pain in the upper arm or shoulder, fatigue in the biceps with repetitive lifting, potential for muscle cramping, and deformity in the proximal biceps. Participants also completed a validated shoulder activity scale, and demographic data regarding age, race, and sex were collected. RESULTS: A total of 349 participants (166 female, 183 male) with a mean age of 45 years (range, 18-81 years) completed the survey. Overall, time to return to unrestricted activities and residual pain were considered very important to the majority of the respondents, while the size and appearance of surgical scars were of little importance. Prior shoulder pain (ρ = -0.17; P = .01) and prior shoulder surgery (ρ = -0.16; P = .03) correlated to concern about time to return to unrestricted activities. Younger age (ρ = -0.11; P = .04) and a higher level of education (ρ = 0.14; P = .03) correlated with greater concern for time to return to work. Women and African Americans were more concerned about the size and appearance of surgical scars (ρ = -0.28; P < .0001 and ρ = -0.20; P = .0002, respectively) and biceps deformity. Respondents with a higher activity level (ρ = 0.20; P = .0002) and men (ρ = 0.11; P = .04) were more concerned about fatigue. CONCLUSION: Concerns about residual pain, time to return to unrestricted activities, and time away from work are important to patients when considering the treatment for shoulder lesions. Patient preferences are associated with age, sex, race, and shoulder activity level. These features should be considered when discussing treatment options for shoulder and proximal biceps tendon disorders.

The Arterial Anatomy of the Deltoid Ligament: A Cadaveric Study.

BACKGROUND: There is an increasing interest in the operative treatment of deltoid ligament disruption in the setting of chronic ankle instability. Understanding the vascular anatomy of the deltoid complex is beneficial when considering operative procedures on the medial ankle and may provide insight into factors that lead to chronic deltoid insufficiency and ankle instability. METHODS: Thirty-two pairs of cadaveric specimens (64 total legs) were amputated below the knee, and the tibialis anterior, tibialis posterior, and peroneal arteries were injected with India ink and Ward's blue latex. Specimens then underwent chemical debridement to identify the vascular supply to the deltoid ligament. A subset of specimens also underwent intraosseous debridement using the modified Spalteholz technique. RESULTS: The vascular supply to the deltoid ligament was clearly visualized in 60 (93.8%) specimens. Fifty-eight specimens (96.7%) had arterial supply with an origin from the medial tarsal artery, 57 specimens (95%) had supply from the tibialis posterior artery, and 23 (38.3%) specimens had supply from the tibialis anterior artery. All specimens had at least 1 location of intraosseous vascular supply, either at the medial malleolus or medial talus. CONCLUSION: There were 3 separate extraosseous sources and 2 intraosseous sources of vascular supply to the deltoid ligament. CLINICAL RELEVANCE: Knowledge of the vascular supply may aid in identifying factors that predispose a subset of patients with medial ankle sprains to failure of conservative treatment, as well as provide useful anatomic information when considering operative treatment for chronic ankle instability.

Quality of internet health information on thumb carpometacarpal joint arthritis.

INTRODUCTION: The Internet has become a heavily used source of health information. No data currently exists on the quality and characteristics of Internet information regarding carpometacarpal (CMC) arthritis. METHODS: The search terms "cmc arthritis," "basal joint arthritis," and "thumb arthritis" were searched using Google and Bing. Search results were evaluated independently by four reviewers. Classification and content specific review was performed utilizing a weighted 100-point information quality scale. RESULTS: Of the 60 websites reviewed, 27 were unique pages with 6 categorized as academic and 21 as non- academic. Average score on content specific review of academic websites was 56.8 and for non-academic was 42.7 (p=0.054). Average Flesch-Kincaid Grade Level for academic websites was 12.4, and for non-academic was 9.9 (p=0.015). CONCLUSION: Internet health information regarding thumb CMC arthritis is primarily non-academic in nature, of generally poor quality, and at a reading level far above the U.S. average reading level of 6th grade. Higher-quality websites with more complete content and appropriate readability are needed. CLINICAL RELEVANCE: The quality of Internet health information regarding thumb CMC arthritis is suboptimal.

Evaluation of the content and accessibility of web sites for accredited orthopaedic sports medicine fellowships.

BACKGROUND: The Internet is a common source of information for orthopaedic residents applying for sports medicine fellowships, with the web sites of the American Orthopaedic Society for Sports Medicine (AOSSM) and the San Francisco Match serving as central databases. We sought to evaluate the web sites for accredited orthopaedic sports medicine fellowships with regard to content and accessibility. METHODS: We reviewed the existing web sites of the ninety-five accredited orthopaedic sports medicine fellowships included in the AOSSM and San Francisco Match databases from February to March 2012. A Google search was performed to determine the overall accessibility of program web sites and to supplement information obtained from the AOSSM and San Francisco Match web sites. The study sample consisted of the eighty-seven programs whose web sites connected to information about the fellowship. Each web site was evaluated for its informational value. RESULTS: Of the ninety-five programs, fifty-one (54%) had links listed in the AOSSM database. Three (3%) of all accredited programs had web sites that were linked directly to information about the fellowship. Eighty-eight (93%) had links listed in the San Francisco Match database; however, only five (5%) had links that connected directly to information about the fellowship. Of the eighty-seven programs analyzed in our study, all eighty-seven web sites (100%) provided a description of the program and seventy-six web sites (87%) included information about the application process. Twenty-one web sites (24%) included a list of current fellows. Fifty-six web sites (64%) described the didactic instruction, seventy (80%) described team coverage responsibilities, forty-seven (54%) included a description of cases routinely performed by fellows, forty-one (47%) described the role of the fellow in seeing patients in the office, eleven (13%) included call responsibilities, and seventeen (20%) described a rotation schedule. Two Google searches identified direct links for 67% to 71% of all accredited programs. CONCLUSIONS: Most accredited orthopaedic sports medicine fellowships lack easily accessible or complete web sites in the AOSSM or San Francisco Match databases. CLINICAL RELEVANCE: Improvement in the accessibility and quality of information on orthopaedic sports medicine fellowship web sites would facilitate the ability of applicants to obtain useful information.

Examining Internet resources on gender differences in ACL injuries: what patients are reading.

BACKGROUND: The Internet is a popular and powerful resource used by both clinicians and patients. However, medical information on the Internet is often unregulated, biased, and of poor quality. Given the frequency of ACL injuries in young women, this topic was used as a case study to examine the information available to patients on the Internet. METHODS: An Internet search was performed using the top three general search engines for four different search phrases related to ACL injuries in females. The top ten sites from each search were analyzed on the basis of both website interface and a specific content scoring guide. RESULTS: A total of 35 unique websites were analyzed. The majority of websites were authored by a layperson or had an unidentified author. Readability data indicated that many sites were written at literacy levels that were too difficult for the average reader. Finally, the average content analysis score for all sites was 41.6 out of a possible 100 points (range 10-87.5); only one-third of the websites cited references for the information provided. CONCLUSIONS: We found the Internet information on ACL injuries in women to be largely unsupported, outdated and too difficult for the average reader to comprehend. The average site covered less than half of the topics that we considered relevant to ACL injuries in females indicating that information available on the Internet is largely incomplete. CLINICAL RELEVANCE: Clinicians should be aware of the deficiencies in Internet information in order to appropriately address these issues with patients.