The Acceptability of Remotely Delivered Cognitive Adaptation Training.

Cognitive Adaptation Training (CAT) is a psychosocial treatment using environmental supports such as signs, checklists, technology, and the organization of belongings to bypass cognitive and motivational impairments for those with serious behavioral health problems. We conducted a survey of 204 members of managed Medicaid in Texas to examine the acceptability of, opinions about and preferences for CAT delivered in-person (CAT) or remotely (R-CAT) where supplies would be mailed and visits would occur via videoconferencing. The telephone survey presented descriptions of CAT and R-CAT in counterbalanced order eliciting general opinions about the treatments, such as (1) whether they would accept the treatments if they were offered the day of the survey at no cost, (2) which treatment was preferred, and (3) the extent to which they agreed or disagreed with a number of statements about components of the treatments. Results indicated that both R-CAT and CAT were acceptable to respondents with overall acceptance rates significantly higher for R-CAT 87% than for CAT (78%). With respect to preferences, 27% and 28% of respondents preferred CAT and R-CAT, respectively, and 41% of respondents preferred both equally. Black respondents more often preferred in-person CAT to other alternatives. Respondents agreed that they needed help, that they were comfortable with technology, and that they believed the programs would help them. The vast majority of qualitative comments about the treatments were positive. Results suggest that it will be important to assess the efficacy and effectiveness of CAT delivered remotely in randomized trials.

Systematic review on cadaveric studies of anatomic anterior cruciate ligament reconstruction.

PURPOSE: One of the templates in the development of "anatomic" anterior cruciate ligament (ACL) reconstruction has been basic science studies focusing on comparing various aspects of ACL reconstruction in order to optimize surgical technique. However, often such papers lack necessary data in the methods section to ascertain the proposed surgical technique as anatomic. The goal of this systematic review was to evaluate basic science studies on anatomic ACL reconstruction. METHODS: A systematic electronic search was performed using the MEDLINE and EMBASE databases. Studies that were published from January 1995 to April 2009 were included. Only basic science studies on human cadavers that reported "anatomic" ACL reconstruction and written in English were included. Variation in surgical technique and reporting of surgical description were assessed. RESULTS: Eighteen studies were included in this systematic review. Only the fixation method, graft type and tension pattern were reported in the majority studies. Notchplasty and radiographic documentation were grossly underreported. Other surgical data were reported at best in two-thirds of the studies. There was a large variation in the reported surgical techniques among the included studies. Due to the aforementioned, it was not deemed possible to pool data of the included studies. CONCLUSION: For most variables in the surgical technique description, there was sizeable underreporting resulting in an inability to pool the outcomes. To provide literature that holds up to the current high level of medical research, authors are encouraged to report their surgical technique in a thorough manner, similar to high-level clinical trials.

Increased medial tibial slope in teenage pediatric population with open physes and anterior cruciate ligament injuries.

PURPOSE: Variations in bony morphology have been associated with anterior cruciate ligament (ACL) injury risk. The primary aim of this study was to compare the tibial slope in the teenage pediatric population with open physes, with and without ACL injury. The secondary aims were to compare the notch width index (NWI) and determine the influence of gender and age on tibial slope and NWI. METHODS: Thirty-nine teenage pediatric subjects were included in this study, 16 with and 23 without ACL injury. Medial tibial slope and lateral tibial slope and NWI as measured on plain radiographs were compared between the groups using an independent t-test. Comparison of tibial slope and NWI was also performed between male and female subjects. Pearson correlation coefficient between age and tibial slope and NWI was calculated. RESULTS: The medial tibial slope averaged 10.2 (±3.9) degrees, the lateral tibial slope 11.5 (±3.9) degrees, and the NWI 0.26. There was a significant difference in medial tibial slope between the ACL-injured (12.1 degrees) subjects and the controls (8.9 degrees) (P = 0.009). There was no significant difference in lateral tibial slope or NWI between the groups. There was no significant difference in the medial tibial slope and lateral tibial slope and NWI between the male and female subjects. Subject age was not correlated with medial tibial slope and lateral tibial slope or NWI. CONCLUSION: There was an increased medial tibial slope in ACL-injured teenagers with open physes, when compared to a control group of teenager with open physes without ACL injury.

Flexion-type fractures of the proximal tibial physis: a report of five cases and review of the literature.

This study describes five patients who had sustained a rare flexion-type fracture separation of the proximal tibial epiphysis and reviews the previous reports of this injury in the literature. The average age of our patients at injury was 15 years. All were male. The left side was involved in four patients; the right in one patient. Four of the injuries occurred during sports activities. All five of these fractures healed in satisfactory alignment after 6 weeks of immobilization without complication. We conclude that these injuries can be safely managed by closed reduction and cast immobilization in a position of full knee extension.

The role of the first metarsocuneiform joint in juvenile hallux valgus.

Juvenile hallux valgus (JHV) is a relatively common condition in the female adolescent. The etiology of the condition has been attributed to various deformities in the forefoot, ranging from the first metatarsophalangeal joint, the morphology of the distal metatarsal, and the intermetatarsal angle (IMA). There have been very few studies evaluating the first metarsocuneiform (MTC) joint, and the results available vary. The purpose of this study is to more critically evaluate the MTC joint with novel angular measurements as a contributor to JHV. A cohort of 46 feet from 29 patients (average age 14.2 years) with hallux valgus as defined as IMA of greater than 10 degrees were evaluated. The hallux valgus angle, IMA, base of first metatarsal to articular surface of medial cuneiform angle, first metatarsal to cuneiform (1MCA), second metatarsal to cuneiform (2MCA), intrinsic medial cuneiform obliquity angle (COA), distal metatarsal articular angle, and ratio of first cuneiform to second cuneiform length were measured. The same was done for an age-matched control group of 36 normal feet from 25 patients (average age 13.2 years). The two groups were statistically compared. There were several statistically significant differences between the study and control groups. Naturally, the hallux valgus angle and IMA were statistically greater by definition. In addition, the distal metatarsal articular angle and 1MCA were significantly larger in the study group. The magnitude of the 2MCA was found to positively correlate with the magnitude of the IMA. The COA angle was not found to be statistically different. In conclusion, the role of the MTC joint in JHV has been evaluated earlier with varying results. The objective of this study is to critically evaluate the MTC joint with novel angular measurements to delineate its contribution to JHV. One such novel measurement is the 1MCA. The statistically significant increase in 1MCA suggests that a property intrinsic to the articulation between the medial cuneiform and the first metatarsal may be involved in JHV. Another angle, the 2MCA was found to positively correlated with increased IMA, further implicating the MTC joint as a contributor to increased IMA and thus, JHV. Third, the COA was used to define the intrinsic obliquity of the medial cuneiform articular angle. This angle was not found to be statistically different between the study and control groups, suggesting that the morphology of the cuneiform is not involved in JHV.

Femoral intercondylar notch shape and dimensions in ACL-injured patients.

The femoral intercondylar notch has been an anatomic site of interest as it houses the anterior cruciate ligament (ACL). The objective of this study was to arthroscopically evaluate the femoral notch in patients with known ACL injury. This evaluation included establishing a classification for notch shapes, identifying the shape frequency, measuring notch dimensions, and determining correlation between notch shape, notch dimensions, and demographic patient data. In this clinical cohort study, 102 consecutive patients underwent diagnostic arthroscopic evaluation of the notch. Several intra-operative photos, videos, and measurements were taken of the notch. Demographic data for each patient were recorded including age, gender, height, weight, and BMI. Three categories of notch shape were established: 1. A-shaped; 2. U-shaped; and 3. W-shaped. Two blinded independent orthopedic surgeons were asked to categorize the recorded notches. Notch shape, dimensions, and demographic factors were correlated. Of the 102 notches evaluated, 55 notches were found to be "A-shaped," 42 "U-shaped," and 5 "W-shaped." "A-shaped" notches were narrower in all width dimensions than "U-shaped" notches. Only patient height was found to influence notch shape with a positive association between taller patients and "U-shaped" and "W-shaped" notches (P = 0.011). Women had a smaller notch width at the base and middle of the notch. With this data, surgeons who enter the knee and appreciate an "A-shaped" notch should consider placing the arthroscope in the anteromedial portal and drill the femoral tunnel through an accessory medial portal to improve visualization and accuracy in anatomic femoral tunnel creation.

Cost-effectiveness analysis of core decompression.

Core decompression is widely used to treat the early stages of osteonecrosis of the hip. The purpose of this analysis is to assist orthopedic surgeons in judging whether currently available data support the use of core decompression as cost-effective. A decision model was created for the treatment of osteonecrosis of the femoral head. Literature review was used to identify possible outcomes and their probability after initial treatment with either observation or core decompression. This model demonstrates core decompression must delay the need for total hip arthroplasty for a minimum of 5 years to maintain an incremental cost-effectiveness ratio lower than 50,000 dollars per quality-adjusted life year gained. Treatment options with ratios higher than 50,000 dollars per quality-adjusted life year are generally considered to have limited cost-effectiveness. This study demonstrates that core decompression has the potential to be a highly cost-effective alternative if it is leads to a delay in the need for total hip arthroplasty of 5 years or longer.