Total hip arthroplasty in patients with common pediatric hip orthopedic pathology.

Purpose: Literature regarding total hip arthroplasty for pediatric hip diseases is scarce. This review aims to portray the various orthopedic conditions of childhood that can lead to significant impairment of the hip joint and, ultimately, to total hip arthroplasty in adolescence and adulthood. Methods: In total, 61 out of 3666 articles were selected according to (1) the diagnosis of one of the 12 pediatric hip pathologies (Legg-Perthes-Calvé disease, developmental dysplasia of the hip, slipped capital femoral epiphysis, neuromuscular hip dysplasia, post-traumatic avascular necrosis of the proximal femur, juvenile rheumatoid arthritis, achondroplasia, spondyloepiphyseal dysplasia, mucopolysaccharidosis, mucolipidosis, hip infections, and tumors) that required total hip arthroplasty; (2) minimum follow-up of 16 months; (3) assessed outcome with a clinical or radiologic score; (4) Methodological Items for Non-Randomized Studies quality score of 9 or higher. The following information for each pathology was retrieved: mean age at total hip arthroplasty, reason for total hip arthroplasty, type of total hip arthroplasty, surgical technique, mean follow-up, and outcomes. Results: Overall, the mean age at total hip arthroplasty for pediatric hip disease is in the sixth and seventh decade, except for tumors and skeletal dysplasias. The reason for performing total hip arthroplasty is often osteoarthrosis and abnormal anatomy. Prosthesis types change based on patient's conditions and technological advances; custom-made implants are used for tumors, juvenile rheumatoid arthritis, and skeletal dysplasias; for other diseases, the most frequent are modular cementless implants. Outcomes are generally good, and all studies portray functional and pain improvements. Conclusion: Total hip arthroplasty is performed more frequently than in the past in patients with pediatric hip pathologies; it enhances patients' quality of life by reducing pain and improving function. However, revision rate in these patients is not negligible.

Bilateral Scaphoid Fractures: A Systematic Literature Review.

Bilateral scaphoid fractures are rare lesions, warranting a review to synthesize current knowledge, identify gaps, and suggest research directions. Two authors, adhering to PRISMA guidelines, in January 2024 identified 16 case reports (1976-2023). Data extraction included demographics, injury mechanisms, associated injuries, fracture sites, treatments, and outcomes. Among 121 initial outcomes, 16 articles met the criteria, predominantly affecting young people (93.75% males, mean age 22 years). High-energy traumas (75%) often caused associated wrist injuries (68.75%). Most fractures required surgical intervention (68.75%), primarily headless compression screws. Bilateral scaphoid fractures, which are rare but associated with high-energy traumas, commonly involve wrist injuries. Surgical management is often necessary, yielding better outcomes with fewer complications. Further research is essential to understand the epidemiology, optimal management, and long-term results. Early diagnosis and appropriate treatment are crucial for preventing complications and ensuring favorable patient outcomes.

Preoperative Risk Factors for Periprosthetic Joint Infection: A Narrative Review of the Literature.

Periprosthetic joint infection (PJI) poses a challenging complication for many patients undergoing arthroplasty, and the literature identifies numerous risk factors. A comprehensive understanding of the primary risk and protective factors for PJI is valuable for surgeons. This article aims to compile and summarize the key risk factors for PJI documented in the literature. Some risk factors are related to the nutritional status of patients, with obesity, weight loss, hypovitaminosis, and malnutrition being frequently reported. Pathologies affecting patients also contribute to PJI risk, including septic arthritis, hepatitis, diabetes, urinary tract infections, anemia, hypothyroidism, osteoporosis, and dental pathologies. Unhealthy habits, such as tobacco and drug abuse, are significant factors. Previous corticosteroid injections may also play a role in infection development. A few protective factors are also reported in the literature (use of statins, preoperative decolonization, and preadmission skin preparation). The identification of risk factors and the implementation of evidence-based preoperative protocols are essential steps in reducing the incidence of PJI.

Do Preoperative Corticosteroid Injections Increase the Risk of Infection after Shoulder Arthroscopy or Shoulder Arthroplasty? A Systematic Review.

INTRODUCTION: Corticosteroid injections have demonstrated short-term benefits for shoulder pain. This symptomatic treatment method is used in various inflammatory conditions that affect the shoulder joint. Corticosteroid joint injections are not without risks and complications. Adverse effects have been documented, including damage to the articular cartilage, tendon rupture, and attenuation of the subject's immune response. The aim of this study was to examine the timing of preoperative corticosteroid injections on infectious outcomes of shoulder arthroscopies and shoulder arthroplasty. MATERIALS AND METHODS: In accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the PubMed, Cochrane, and Science Direct databases were systematically reviewed by two independent authors in January 2024. After full-text reading and checking the reference lists, 11 article were included. RESULTS: Patients who received a shoulder injection within three months prior to undergoing shoulder arthroplasty exhibited a markedly elevated incidence of infection. In addition, a significantly increased risk of periprosthetic joint infection (PJI) at 90 days postoperatively in patients who received CSIs (corticosteroid injections) within 1 month prior to shoulder arthroplasty was found. Different authors consider CSI injections within the 2 weeks prior to shoulder arthroscopy surgery principally associated with an increased risk of postoperative infection. DISCUSSION: There is still no consensus on the correct timing of preoperative CSIs in both arthroscopic and arthroplasty procedures. The literature does not identify whether the number of preoperative injections could increase the risk of periprosthetic infection. Obesity, sex, and smoking did not have a significant effect on PJIs; alcohol abuse could be considered as a risk factor for PJIs with CSIs. Both in prosthetic surgeries and in arthroscopy procedures, modifiable and unmodifiable factors play secondary roles. The risk of postoperative infection is greater within 3 months, although it is almost comparable at one- and two-year follow-ups.

The Anterolateral Ligament of the Knee in Pediatric Patients: What Do We Know? A Scoping Review.

The knowledge on the anatomy, function and biomechanics and the role of surgical procedures on the anterolateral ligament (ALL) of the knee is still controversial. Only a few papers have examined the ALL in children. The aim of this review is to analyze all the available literature about ALL in the pediatric population. Following the PRISMA criteria, the literature was systematically reviewed, examining all the articles about ALL in pediatric patients. Eight articles were involved in this study. Five cadaveric studies, two diagnostic studies, and one cross-sectional study were found. The identification of the ALL is not always possible in diagnostic studies using magnetic resonance (MRI) or in dissecting specimens. A high variability in the presence of the ligament and in its origin and insertion were found among the studies. It is more difficult to identify the ligament in younger patients than in older children, suggesting that its presence may develop at some point during the growth. Further studies are needed for a detailed knowledge of the ALL.

Clinical and Radiographic Outcomes and Treatment Algorithm for Septic Arthritis in Children.

BACKGROUND: Septic arthritis (SA) in children is an acute inflammatory disease of the joints. If not treated promptly, it could become a surgical emergency. The incidence of the disease in children in Europe is approximately 2-7 per 100,000 children. The aim of this systematic review was to investigate which of these treatments-arthrocentesis, arthrotomy, and arthroscopy-provides better results in children and when to use them. METHODS: Three independent authors conducted a systematic review of PubMed, ScienceDirect, and MEDLINE databases to assess studies with any level of evidence that reported the surgical outcome of SA. Two senior investigators evaluated and approved each stage's findings. RESULTS: A total of 488 articles were found. After screening, we chose 24 articles that were suitable for full-text reading based on the inclusion and exclusion criteria. The results of our analysis showed that there are no numerically significant differences reported in the literature on clinical and radiographic outcomes by surgical technique. CONCLUSIONS: We developed an algorithm that could be used if septic arthritis is suspected. Based on our results, the surgical technique to be used will depend on the operator who will perform it.

Bosworth Fractures of the Ankle: A Systematic Literature Review.

Bosworth lesions are fracture-dislocations of the ankle and are characterized by entrapment of the proximal segment of the fibula behind the posterior tubercle of the distal tibia. Treatment is challenging, mainly due to failure of a closed reduction. The aim of this study was to review the literature concerning this type of injury. A total of 103 patients with Bosworth fractures were included in the study. The analyzed studies yielded a total of 103 cases, of which 68% (n = 70) were male and 32% (n = 33) were female. Bosworth fractures are mainly due to accidental trauma (58.2%), sports-related injuries (18.4%), and traffic accidents (18.4%). More than 76% of the patients presented a Danis-Weber B fracture, 8.7% a type C fracture, and only 0.97% presented a type A fracture. In 92.2% of the patients, the attempted closed reduction was unsuccessful. A definitive treatment with open reduction and internal fixation (ORIF) was used in 96 patients (93.2%). The most frequent complication was post-traumatic arthritis (10.7%). Bosworth fractures are challenging. The available literature lacks adequate information about this fracture, and an approved standardized algorithm for treating such fractures is not available.

A new robotically assisted technique can improve outcomes of total knee arthroplasty comparing to an imageless navigation system.

BACKGROUND: Robotic assisted total knee arthroplasty (RTKA) has shown improved knee alignment and reduced radiographic outliers. However, there remains debate on functional outcomes and patient-reported outcomes (PROMs). This study compares the 1-year clinical outcomes of a new imageless robotically assisted technique (ROSA Knee System, Zimmer Biomet, Warsaw, IN) with an imageless navigated procedure (NTKA, iAssist Knee, Zimmer, Warsaw, IN). METHODS: The study is a retrospective analysis of prospectively collected data that compared the functional outcomes and PROMs of 50 imageless RTKA with 47 imageless NTKA at 1-year follow-up. Baseline characteristics, intraoperative and postoperative information were collected including complications, revisions, Knee Society Score (KSS), Knee injury and Osteoarthritis Outcome Score (KOOS) score, and Forgotten Joint Score (FJS-12). Radiographic analysis of preoperative and postoperative images evaluating hip-knee-ankle (HKA) angle was performed. RESULTS: There was no difference regarding baseline characteristics between the groups. Mean operative time was significantly longer in the RTKA group (122 min vs. 97 min; p < 0.0001). Significant differences were reported for the "Pain" (85 [RTKA] vs 79.1 [NTKA]; p = 0.0283) subsection of the KOOS score. In addition, RTKA was associated with higher maximum range of motion (119.4° vs. 107.1°; p < 0.0001) and better mean improvement of the arc of motion by 11.67° (23.02° vs. 11.36°; p < 0.0001). No significant differences were noted for other subsections of KOOS, KSS, FJS-12, complications, or limb alignment at 1-year follow-up. CONCLUSIONS: Imageless RTKA was associated with longer surgical time, better pain perception and improved ROM at 12-month follow-up compared with NTKA. No significant differences were reported on other PROMs, complication rates and radiographic outcomes. LEVEL OF EVIDENCE: III.

Does age affect outcome in children with clavicle fracture treated conservatively? QuickDash and MRC evaluation of 131 consecutive cases.

BACKGROUND: Non-operative treatment with immobilization is the gold-standard for paediatric clavicular fractures. Purpose of this study is to evaluate functional outcomes and efficacy of non-operative treatment of clavicular fractures in a succession of 131 children. METHODS: Between 2006 and 2012, we treated non-surgically 131 children for a clavicular fracture. All fractures have been classified according to Robinson classification. Clavicle shortening, range of movements and muscular strength through the Medical Research Council (MRC) Scale were evaluated. To assess the outcomes, QuickDASH questionnaire, dividing the sample in 3 age-related group, was administered. RESULTS: The average follow-up was 26 months (8-84 months). Clavicle shortening at the time of injury occurred in 18 cases. All fractures reached union. Average time to union was 34 days. Mean time return to activity was 12.6 weeks. No cases of nonunion or delayed union were reported. Complications occurred in 21 cases. A shortening persisted in 2 cases. Only one patient had a slight functional restriction. Average QuickDASH Score was 6.2±1.1 (range 4.3-9.4). All patients recovered to an MRC Score of 5, except for one patient with a score of 4. Best QuickDASH Scores were observed in the group aged under 8 years and in non-comminuted and lateral third fractures of the clavicle. CONCLUSIONS: Observing results, clavicle fractures have a satisfactory clinical healing as shown by the good scores at QuickDASH and MRC Scale. Younger children under 8 years can achieve the best results with a conservative treatment in terms of bone healing and activity level.

Pain Education in the Management of Patients with Chronic Low Back Pain: A Systematic Review.

New prospective of chronic low back pain (CLBP) management based on the biopsychosocial model suggests the use of pain education, or neurophysiological pain education, to modify erroneous conceptions of disease and pain, often influenced by fear, anxiety and negative attitudes. The aim of the study is to highlight the evidence on the outcomes of a pain education-oriented approach for the management of CLBP. The search was conducted on the Pubmed, Scopus, Pedro and Cochrane Library databases, leading to 2673 results until September 2021. In total, 13 articles published in the last 10 years were selected as eligible. A total of 6 out of 13 studies support a significant reduction in symptoms in the medium term. Disability is investigated in only 11 of the selected studies, but 7 studies support a clear reduction in the medium-term disability index. It is difficult to assess the effectiveness of the treatments of pain education in patients affected by CLBP, due to the multimodality and heterogeneity of the treatments administered to the experimental group. In general, methods based on pain education or on cognitive-behavioral approaches, in association with physical therapy, appear to be superior to physiotherapeutic interventions alone in the medium term.

Mid-Long-Term Outcomes of Surgical Treatment of Legg-Calvè-Perthes Disease: A Systematic Review.

BACKGROUND: Legg-Calvè-Perthes disease (LCPD) is a common childhood disease that usually occurs in 4- to 12-year-old children. Surgical treatment consists of femoral, pelvic, or combined osteotomies. This comprehensive review aimed to investigate the mid- and long-term outcome of the surgical treatment. METHODS: A systematic review of PubMed, Science Direct, and MEDLINE databases was performed by two independent authors, using the keywords "outcome", "surgical treatment", "pelvic osteotomy", "femoral osteotomy", and "Legg-Calvè-Perthes disease" to evaluate studies of any level of evidence that reported the surgical outcome of LCPD. The result of every stage was reviewed and approved by two senior investigators. RESULTS: A total of 2153 articles were found. At the end of the screening, we selected 23 articles eligible for full-text reading according to the inclusion and exclusion criteria. Our analysis showed that the main prognostic factors for surgical outcome in patients with LCPD are the age at onset and the degree of initial disease severity. CONCLUSIONS: Surgical treatment in patients older than 6 years has excellent results in Herring B and B/C hips and poor results in Herring C hips, with a slight advantage for patients between 6 and 8 years old.

Diagnostic Tools in the Detection of Physical Child Abuse: A Systematic Review.

Child abuse is a critical social issue. The orthopedic surgeon's role is essential in noticing signs and symptoms of physical abuse. For this reason, several authors have proposed scoring systems to identify abuse early on and reduce undiagnosed cases. The aim of this systematic review is to overview the screening tools in the literature. In 2021, three independent authors performed a systematic review of two electronic medical databases using the following inclusion criteria: physical child abuse, questionnaire, survey, score, screening tool and predictive tool. Patients who had experienced sexual abuse or emotional abuse were excluded. The risk of bias evaluation of the articles was performed according to the Newcastle-Ottawa Quality Assessment Scale Cohort Studies. Any evidence-level study reporting clinical data and dealing with a physical child abuse diagnosis tool was considered. A total of 217 articles were found. After reading the full texts and checking the reference lists, n = 12 (71,035 patients) articles were selected. A total of seven screening tools were found. However, only some of the seven diagnostic tools included demonstrated a high rate of sensitivity and specificity. The main limits of the studies were the lack of heterogeneity of evidence and samples and the lack of common assessing tools. Despite the multiplicity of questionnaires aimed at detecting validated child abuse, there was not a single worldwide questionnaire for early diagnosis. A combination of more than one test might increase the validity of the investigation.

Comparison between Vascular and Non-Vascular Bone Grafting in Scaphoid Nonunion: A Systematic Review.

BACKGROUND: Scaphoid fractures correspond to 60% of all carpal fractures, with a risk of 10% to progress towards non-union. Furthermore, ~3% present avascular necrosis (AVN) of the proximal pole, which is one of the main complications related to the peculiar vascularization of the bone. Scaphoid non-union can be treated with vascularized and non-vascularized bone grafting. The aim of the study is to evaluate the rates of consolidation of scaphoid non-union treated using two types of grafts. METHODS: A systematic review of two electronic medical databases was carried out by two independent authors, using the following inclusion criteria: non-union of the proximal pole of the scaphoid bone, treated with vascular bone grafting (VBG) or non-vascular bone grafting (NVBG), with or without the use of internal fixation, patients aged ≥ 10 years old, and a minimum of 12 months follow-up. Research of any level of evidence that reports clinical results and regarding non-union scaphoid, either using vascularized or non-vascularized bone grafting, has been included. RESULTS: A total of 271 articles were identified. At the end of the first screening, 104 eligible articles were selected for the whole reading of the text. Finally, after reading the text and the control of the reference list, we selected 26 articles following the criteria described above. CONCLUSIONS: The choice of the VBG depends mainly on the defect of the scaphoid and on the surgeon's knowledge of the different techniques. Free vascular graft with medial femoral condyle (MFC) seems to be a promising alternative to local vascularized bone grafts in difficult cases.

The Etiology and Risk Factors of Osgood-Schlatter Disease: A Systematic Review.

The etiology and etiopathogenesis of Osgood-Schlatter Disease (OD) are not fully understood. The aim of this review is to systematically analyze the available literature about the etiology and risk factors of OD. The literature was systematically reviewed using the PRISMA criteria to evaluate all studies published in the last 25 years (between 1996 and 2021) dealing with the etiology of OD. A total of 16 articles were included. The etiology and risk factors of OD are controversial. The main articles focused on muscular factors (mainly tightness of the rectus femoris), alteration of the patellar tendon or extensor mechanism, mechanical factors (repetitive solicitation, trauma, sports), tibial anatomy (tibial slope or tibial torsion), and histological alteration. Associations with ankle kinematic and behavior disorders were also reported. Many theories about the etiology, risk factors, and associated factors of OD have been reported in the literature, but more studies are needed to fully understand the etiopathogenesis of this disorder.

Patellofemoral Pain Syndrome in Young Female Athletes: A Case-Control Study.

Background: Patellofemoral pain syndrome (PFPS) is the most common cause of anterior knee pain in children and adolescents, and it is characterized by highly limiting, recurrent, frontal pain. Objectives: The purpose of the study is to assess the incidence and onset of PFPS in the young female athletes and to compare it to healthy individuals. Methods: Between 2017 and 2019, 51 subjects were reviewed and divided in three groups: rhythmic gymnastics athletes (RG; 21 individuals, mean age: 13.8 ± 3.6 years), basketball athletes (BG; 17 individuals, mean age: 14.2 ± 3.1 years), and control group (CG; 13 individuals, mean age: 14.5 ± 4.3 years). All patients underwent physical examination including patellar glide, tilt, grind and apprehension tests, tiptoe and jack tests, Coleman block, and navicular drop tests. The clinical and functional outcomes of the subjects were assessed using the Kujala patellofemoral score (KPS). Results: In RG patients were recorded 66.7% of normal footprint (NF), 9.5% of cavus feet (FCF), and 23.8% of flatfeet (FFF); 14.8% patellar positive tests, KS = 98.6 ± 13.7. BG patients had 70.6% of NF, 11.8% FCF, and 17.6% of FFF; 23.5% patellar positive tests, KS = 98.3 ± 12.4. CG patients had 61.5% of NF, 7.7% of FCF and 30.8% of FFF; 15.4% patellar positive tests, KPS = 98,9 ± 15.3. No statistically significance was found between the three cohorts of patients. Conclusions: PFPS is a common pathology; muscular imbalance and overuse could exacerbate pain and discomfort in young female athletes. Our findings show high type and level of sport activity are not related to increase frequency of clinical symptoms related to PFPS.

The Importance of Staging Arthroscopy for Chondral Defects of the Knee.

This study aims to evaluate the role of staging arthroscopy in the diagnosis of knee chondral defects and subsequent surgical planning prior to autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA), and meniscus allograft transplantation (MAT). All patients who underwent staging arthroscopy prior to ACI, OCA, or MAT at our institution from 2005 to 2015 were identified. Medical records were reviewed to document the diagnosis and treatment plan based on symptoms, magnetic resonance imaging (MRI) findings and previous operative records. Operative records of the subsequent staging arthroscopy procedure were reviewed to document the proposed treatment plan after arthroscopy. All changes in treatment plan following staging arthroscopy were recorded. Univariate analyses were performed to identify any significant predictors for likelihood to change. A total of 98 patients were included in our analysis. A change in surgical plan was made following arthroscopy in 36 patients (36.7%). Fourteen patients (14.3%) were found to have additional defects that warranted cartilage restoration surgery. In 15 patients (15.3%), at least one defect that was originally thought to warrant cartilage restoration surgery was found to be amenable to debridement alone. The surgical plan was changed from ACI to OCA in four cases (4.1%) and OCA to ACI in one case (1%). A previously proposed MAT was deemed unwarranted in one case (1%), and a planned meniscal repair was changed to MAT in another (1%). Patient age, sex, and the affected knee compartment were not predictors for a change in surgical plan. Body mass index (BMI) was significantly higher in patients who had a change in surgical plan (29.5 kg/m2) compared with those who did not (26.5 kg/m2). A change in surgical plan was more likely to occur for trochlear lesions (46.4%) compared with other articular surface lesions (p = 0.008). The results of our study indicate that staging arthroscopy is an important step in determining the most appropriate treatment plan for chondral defects and meniscal deficiency, particularly those with trochlear cartilage lesions.

Results of the Italian Pediatric Orthopedics Society juvenile flexible flatfoot survey: diagnosis and treatment options.

The objectives of this study were to collect and analyze current diagnosis and treatment options of symptomatic flexible flatfoot (FFF), as well as to identify treatment expectations, among the members of the Italian Pediatric Orthopedics Society (SITOP). Diagnosis and treatment preferences were recorded according to a web-based survey. The survey was divided into six main sections: (1) general clinical parameters; (2) foot aspects; (3) X-ray angles (or lines); (4) expectations; (5) standard clinical assessment; (6) treatment options. One hundred and ten out of 248 SITOP members answered to the questionnaire. Age (85.5%), pain at the level of the plantar arch or fascia (61.8%), fatigue (59.1%) were the clinical parameters of crucial importance. Heel valgus (85.4%), flexibility (61.8%) and forefoot supination (47.3%) were identified as the most important foot aspects. Ninety-two responders (83.6%) identified the 'improved ability to walk longer without symptoms or discomfort' as the principal treatment expectation. Pain evaluated through the visual analog scale (VAS) was considered crucial in 31.8% of cases. All respondents confirmed they also treat patients with FFF surgically; in particular, 97.3% of SITOP affiliates declare to perform arthroereisis followed by lateral column lengthening (29.1%) and medializing calcaneal osteotomy (9.1%). Although in this survey heterogeneous findings for diagnosis and treatment of patients with symptomatic FFF within SITOP members were found, a large preference for age, heel valgus, flexibility as clinical aspects and parameters, as well as nonoperative treatment and arthroereisis, was reported.

The Accuracy of 3D Printed Carpal Bones Generated from Cadaveric Specimens.

BACKGROUND: Computer assisted three-dimensional (3D) printing of anatomic models using advanced imaging has wide applications within orthopaedics. The purpose of this study is to evaluate the 3D printing accuracy of carpal bones. METHODS: Seven cadaveric wrists underwent CT scanning, after which select carpal bones (scaphoid, capitate, lunate, and trapezium) were dissected in toto. Dimensions including length, circumference, and volume were measured directly from the cadaver bones. The CT images were converted into 3D printable stereolithography (STL) files. The STL files were converted into solid prints using a commercially available 3D printer. The 3D printed models' dimensions were measured and compared to those of the cadaver bones. A paired t-test was performed to determine if a statistically significant difference existed between the mean measurements of the cadavers and 3D printed models. The intraclass correlation coefficients (ICC) between the two groups were calculated to measure the degree of agreement. RESULTS: On average, the length and circumference of the 3D printed models were within 2.3 mm and 2.2 mm, respectively, of the cadaveric bones. There was a larger discrepancy in the volume measured, which on average was within 0.65 cc (15.9%) of the cadaveric bones. These differences were not statistically significant (P > 0.05). There was strong agreement between all measurements except the capitate's length and lunate's volume. CONCLUSION: 3D printing can add value to patient care and improve outcomes. This study demonstrates that 3D printing can both accurately and reproducibly fabricate boney models that closely resemble the corresponding cadaveric anatomy.

Post-operative Opioid, Benzodiazepine and Sedative Usage in Medicare versus Commercial Insurance Hand Surgery Patients.

BACKGROUND: Opioid usage has increased in recent years. The purpose of this study is to assess post-operative opioid, sedative, and benzodiazepine usage in a Medicare population. METHODS: Consecutive patients undergoing elbow, wrist, and hand surgery by hand surgeons at one academic outpatient surgical center were prospectively enrolled. Patients were excluded if they were minors or if they underwent more than one surgical procedure during the study period. There were 269 patients enrolled, and this group was divided by insurance type into younger commercial insurance (CI) and older Medicare (MC) groups. The Pennsylvania Physician Drug Monitoring Program website was used to document all prescriptions of controlled substances filled six months prior to and after the surgical procedure. RESULTS: The mean age in the CI group was 45.8 years (range: 16-88) and 69.2 years (range: 43-91) in the MC group. Postoperatively, the CI patients filled significantly less opioid prescriptions than the MC group, 1.10 vs. 1.79. Patients in the CI group were given an average of 0.3 benzodiazepine prescriptions before surgery and 0.2 after surgery. Patients in the MC group were given 0.6 prescriptions before and 0.5 prescriptions of benzodiazepines after surgery. The CI group was given an average of 0.1 sedative/hypnotic prescriptions before surgery and 0.1 after surgery. The MC group was given 0.7 prescriptions before and 0.4 prescriptions of sedative/hypnotics after surgery.There were 0.17 prescriptions per patient in the CI group and 0.75 per patient in the MC group (P <.05). Twenty-two of 208 (10.6%) of CI and 16/61 (26.2%) of MC patients filled a prescription between 3-8 months post-operatively. CONCLUSION: Prolonged use of opioid, benzodiazepine and sedative medications is common after upper extremity surgical procedures. Older patients are also at risk, and may be even more likely than younger patients to use these medications post-operatively.

An Evaluation of the Source and Content of Kienböck's Disease Information on the Internet.

Introduction The use of the internet for health-related information continues to increase. Because of its decentralized structure, information contained within the World Wide Web is not regulated. The purpose of the present study is to evaluate the type and quality of information on the internet regarding Kienböck's disease. We hypothesized that the information available on the World Wide Web would be of good informational value. Materials and Methods The search phrase "Kienböck's disease" was entered into the five most commonly used internet search engines. The top 49 nonsponsored Web sites identified by each search engine were collected. Each unique Web site was evaluated for authorship and content, and an informational score ranging from 0 to 100 points was assigned. Each site was reviewed by two fellowship-trained hand surgeons. Results The informational mean score for the sites was 45.5 out of a maximum of 100 points. Thirty-one (63%) of the Web sites evaluated were authored by an academic institution or a physician. Twelve (24%) of the sites were commercial sites or sold commercial products. The remaining 6 Web sites (12%) were noninformational, provided unconventional information, or had lay authorship. The average informational score on the academic or physician authored Web sites was 54 out of 100 points, compared with 38 out of 100 for the remainder of the sites. This difference was statistically significant. Conclusion While the majority of the Web sites evaluated were authored by academic institutions or physicians, the informational value contained within is of limited completeness. More than one quarter of the Web sites were commercial in nature. There remains significant room for improvement in the completeness of information available for common hand conditions in the internet.