Background: There has been an increasing number of arthroscopic surgeries performed in general orthopedic surgery practice, as well as a rapid evolution of arthroscopic techniques. The objective of this investigation was to assess the adequacy of arthroscopic training in U.S. orthopedic residency programs from a resident and program director perspective. Materials and Methods: The study was performed with a mail-in survey to orthopaedic surgery residents and program directors. Out of 151 programs contacted, we received responses from 24 program directors (15.9%) and 272 residents (11.1% of 2447 possible residents in years 2 through 5 in 2006). Program demographics and resident and program director assessments of arthroscopic surgical training was obtained from the questionnaire. Assessment of open surgical techniques was used as a control. The responses from fifth-year residents (83 of a possible 612 in 2006 (13.6%)) and program directors were used for detailed analysis. Results: Only 32% (27/83) of ffth-year residents felt there was adequate time dedicated to arthroscopic training, compared to 66% (16/24) of program directors (p < 0.01). Thirty-four percent (28/83) of ffth-year residents felt as prepared in arthroscopy as open techniques, in contrast to 58% (14/24) of program directors, who felt ffth-year residents were appropriately prepared in arthroscopic techniques (p = 0.03). The amount of surgery that residents are allowed to perform correlated signifcantly (p < 0.01) with confidence levels. Conclusions: Fifth-year residents who were surveyed felt less prepared in arthroscopic training, compared to open surgical procedures. Program directors surveyed over estimated confdence levels in ffth-year residents performing arthroscopic procedures. To ensure that graduating residents are appropriately prepared for the current demands of a clinical setting, it may be necessary to reexamine residency requirements to ensure adequate practice in developing arthroscopic surgical skills.

Background: The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose, a metal-on-metal prosthesis with improved tribology was developed. Our early results using this implant are presented. Materials and Methods: A prospective analysis was performed for 56 Metasul hip arthroplasties between 1997 and 2001. There were 39 patients (43 hips) available for both clinical and radiographic evaluation at an average follow-up period of 42 months. Outcomes were measured using the Harris hip score. Discussion: The average Harris hip score increased from 40.7 to 81.1. Subjectively, 87% of the primary cases were satisfied. The majority of patients had pain-free range of motion and had returned to improved daily functions. One technical intraoperative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring, due to a femoral crack. There were two cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intraoperative culture was successfully treated with intravenous antibiotics. Two patients required revision to a cemented acetabular prosthesis, one due to cup loosening and the other due to a painful hip with a suspected infection. Radiolucent lines were seen in the acetabulum in one case, which underwent revision. No femoral or pelvic radiolucent lines were found. Conclusions: We have had relatively satisfactory results in the early follow-up period. It remains premature to draw conclusions as to the superiority of this system over a conventional metal-on-polyethylene bearing prosthesis. Long-term follow-up studies are needed.

Background: Proximal femur fractures are one of the most common injuries necessitating operative treatment. The aim of this prospective study was to evaluate and compare the possible effects of the preoperative application of a skin traction device, with or without weights, on pain relief in patients with acute proximal femur fracture. Materials and Methods: This study included 108 pre-operative patients with hip fractures. The subjects were randomly divided into three groups, and the following treatments were administered: Group 1, skin traction with 2 kg of weights; Group 2, skin traction without weights; and Group 3, pillow placement under the affected limb. Results: Pain was assessed using the visual analog scale (VAS). No significant differences were observed in the scores of the three groups before the pain relief treatment. All three modes of treatment resulted in significant pain reduction in subjects. Patients treated without a weight-loaded skin traction kit had better pain relief compared to the other two groups; this outcome was statistically significant. Conclusion: This study indicates that pillow placement under an injured limb can be safely used instead of traction, which has no significant benefit. However, an external device, such as a skin traction kit without weight, may be used in patients with persistent pain; this external device may have an additive placebo effect, as was proven in this study.

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of “hardware” and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may beneft by subspecialty review of the current practice of sending internal fxation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confrm the removal of internal fxation hardware in lieu of pathologic evaluation.

Tricyclic antidepressants have not been explicitly studied in the conservative treatment of lumbar spinal stenosis. A retrospective chart review was conducted in a subset of patients with chronic low back pain and lumbar spinal stenosis managed with low dose tricyclic antidepressants. Of 26 patients, 20 reported improvement in back pain. The majority of patients reported improvement with an initial dose of 10 mg of either amitriptyline or nortriptyline and remained on this dose. Patients with both leg and back pain reported improvement in greater proportion than patients with back pain alone. According to this study tricyclic antidepressants appear to be effective in controlling lumbar spinal stenosis symptoms in this patient population. Tricyclic antidepressants need to be further analyzed in randomized controlled studies as a means to conservatively manage lumbar spinal stenosis with stratifcation based on location of pain.

Background: The addition of a lateral suture anchor fixation row to rotator cuff repairs has been shown to improve initial cuff reattachment strength and footprint area. This study evaluated the mechanical function of this lateral row by measuring suture tensions at the individual anchor sites. Materials and Methods: Eight cadaveric shoulders underwent simulated rotator cuff repairs, using either double row or suture-bridge repair techniques. Suture tensions at each anchor were measured for several static, simulated shoulder positions relevant to postoperative patient management by specially designed instrumented anchors. Results: Signifcantly greater suture tensions were measured at the medial anchor sites than at the lateral sites for the double-row (p < 0.001), as well as the suture-bridge constructs (p < 0.016). In the double-row technique, the lateral row sustained 21% (range, 6 to 31) of the total anchor load; whereas, in the suture-bridge technique, the lateral row sustained 33% (range, 8 to 42). Shoulder abduction from 45° to 60° had little effect on anchor tensions; 20° internal and external rotation signifcantly (p = 0.032) increased loads on the anterior and posterior anchors. Conclusions: Forces are transmitted through the entire body of the tendon at its humeral fxation, loading the lateral anchors, as well as the medial row, for the two fxation techniques studied. These fndings explain the higher laboratory-obtained fxation strengths of double-row techniques. The magnitude and distribution of anchor suture tensions could have important implications for postoperative positioning and activity

This study compared the sliding characteristics of three lag screw designs used with trochanteric nails and determined the effects of lubrication on sliding. They were tested by an established method to measure initiation and ease of lag screw sliding. These tests were then repeated with calf serum lubrication. There were signifcant differences (p < 0.05) between the loads required to initiate lag screw sliding that appeared to be related to design. Screw sliding was similar for all three designs; however, the presence of lag screw locking slots affected sliding in that region. Lubrication did not affect either parameter. Lag screw design aspects, such as diameter and, particularly, surface fnish, affect sliding. Due to the small contact area between the lag screw and nail creating high interface stresses, lubrication had no effect on lag screw sliding.

Coracoid fractures are uncommon injuries, in isolation or in association with other osseoligamentous injuries about the shoulder girdle. We report a case of successful operative management of symptomatic ipsilateral nonunions of a type I coracoid base fracture and a lateral one-third clavicular fracture, which developed following nonoperative treatment of this exceedingly rare injury pattern. Following open distal clavicle excision and reduction of the coracoclavicular interval with screw fxation, radiographic union and excellent clinical outcome were achieved. This rare and potentially troublesome injury pattern is discussed, and the literature regarding ipsilateral coracoid and osseoligamentous injuries about the shoulder is reviewed.

A 4-month-old female infant was brought to our offce by her parents, who had noticed a lump on the child’s right elbow. Examination revealed a hard, painless lump in the antero-external region that was not reducible in fexion-extension or in pronation-supination. Neither palpation nor passive motion produced pain. Preoperative radiographs revealed a bony mass in the anteroexternal region of the proximal ulnar metaphysic (solitary osteochondroma), which was displacing the radial head into anteroexternal dislocation. No physiological bowing of the proximal metaphysis of the ulna was present. The infant underwent surgery at 6 months of age. No remains of the annular ligament were found. A complete resection of the tumour mass was performed, after which it was possible to reduce the radial head, together with the humeral condyle. Trans-radiocapitellar fixation was applied, with immobilization for 6 weeks. Subsequent radiological study revealed a congruent reduction of the radial head, with a progressive periosteal reaction of the posterior cortex of the ulna that evolved towards remodeling of the physiological bowing. Eight years after the surgery, the child remains asymptomatic, with complete range of motion and symmetric carrying angles. There were no relapses of osteochondroma, the deformity, or radioulnar synostosis.

Stress fractures of the pubic rami are rare occurrences and most frequently occur in association with total hip arthroplasty (THA). Reported historically with both cemented and noncemented THA components, postoperative stress fractures likely occur secondary to a rapid postoperative increase in patient activity following years of disability. Though stress fractures of the pubic rami should be considered in the differential diagnosis of groin pain following THA, they require a high degree of suspicion. Diagnosis may be achieved via bone scan after ruling out alternative causes of postoperative groin pain and after accounting for associated medical conditions. Treatment is minimally invasive, requiring a limited period of weightbearing and activity modifcation, often with full resolution of groin pain and a return to postoperative activity levels.

While hospitalized with polymyositis, a medically complex 56-year-old male experienced an acute exacerbation of gout. Both ultrasound and magnetic resonance imaging cross-sectional modalities were used to detect, localize, and characterize a soft tissue mass. The tumor was ultimately found to be secondary to gouty infammation of the pes anserine bursa, a previously unrecognized manifestation of acute gout.

Infection around the shoulder joint is rare. Clinical suspicion and diagnostic imaging are required for accurate diagnosis. We present three cases that emphasise particular diagnostic challenges when dealing with infection around the shoulder joint. Discussion includes the role of ultrasound as a screening tool and the importance of magnetic resonance imaging (MRI) in the accurate diagnosis and localisation of infections around the shoulder.

Osteoblastoma is an extremely rare entity that represents less than 1% of all bone tumors, and affects twice as many males as females with peak incidence between 15 and 20 years. Osteoblastomas commonly affect axial bones, long bones, bones of the foot and hand, and less commonly the pelvis, scapula, ribs, and clavicle. Osteoblastoma does not have a classic presentation, but can vary with the location and size of the tumor. The main complaint is often progressive pain localized at the tumor site. Osteoblastoma is a benign tumor with an aggressive behavior. The treatment is wide surgical resection, otherwise it continues to enlarge and destroy the bone and surrounding structures. We report a 32-year-old male with an osteoblastoma of this sternum who was treated with an en-bloc resection and reconstruction with Marlex® and a methylmethacrylate plate.

Vertebral dislocations are high energy injuries that rarely occur in the low back, but are found more frequently at the level of the thoracolumbar and sacrolumbar junctions. Dislocations of the mid-lumbar vertebrae are exceptional, with only 16 cases found in the literature. All previously reported cases were treated surgically. In four of these cases, the patients had no initial neurological lesions, and most of those who did have a neurological defcit exhibited some degree of recovery. We present the case report of an L3-L4 dislocation, without neurological lesions, resulting from an airplane crash. The anatomopathological mechanism of injury is discussed, together with treatment, which consisted of an initial closed reduction using a halo-bifemoral system, followed by pedicle instrumentation and arthrodesis from L2 to L5.

Background: There has been an increasing number of arthroscopic surgeries performed in general orthopedic surgery practice, as well as a rapid evolution of arthroscopic techniques. The objective of this investigation was to assess the adequacy of arthroscopic training in U.S. orthopedic residency programs from a resident and program director perspective. Materials and Methods: The study was performed with a mail-in survey to orthopaedic surgery residents and program directors. Out of 151 programs contacted, we received responses from 24 program directors (15.9%) and 272 residents (11.1% of 2447 possible residents in years 2 through 5 in 2006). Program demographics and resident and program director assessments of arthroscopic surgical training was obtained from the questionnaire. Assessment of open surgical techniques was used as a control. The responses from fifth-year residents (83 of a possible 612 in 2006 (13.6%)) and program directors were used for detailed analysis. Results: Only 32% (27/83) of ffth-year residents felt there was adequate time dedicated to arthroscopic training, compared to 66% (16/24) of program directors (p < 0.01). Thirty-four percent (28/83) of ffth-year residents felt as prepared in arthroscopy as open techniques, in contrast to 58% (14/24) of program directors, who felt ffth-year residents were appropriately prepared in arthroscopic techniques (p = 0.03). The amount of surgery that residents are allowed to perform correlated signifcantly (p < 0.01) with confidence levels. Conclusions: Fifth-year residents who were surveyed felt less prepared in arthroscopic training, compared to open surgical procedures. Program directors surveyed over estimated confdence levels in ffth-year residents performing arthroscopic procedures. To ensure that graduating residents are appropriately prepared for the current demands of a clinical setting, it may be necessary to reexamine residency requirements to ensure adequate practice in developing arthroscopic surgical skills.

Background: The need for better durability and longevity in total hip arthroplasty in high demand patients is a constant challenge. For this purpose, a metal-on-metal prosthesis with improved tribology was developed. Our early results using this implant are presented. Materials and Methods: A prospective analysis was performed for 56 Metasul hip arthroplasties between 1997 and 2001. There were 39 patients (43 hips) available for both clinical and radiographic evaluation at an average follow-up period of 42 months. Outcomes were measured using the Harris hip score. Discussion: The average Harris hip score increased from 40.7 to 81.1. Subjectively, 87% of the primary cases were satisfied. The majority of patients had pain-free range of motion and had returned to improved daily functions. One technical intraoperative complication (false route) was resolved with immediate revision. Two patients required cerclage wiring, due to a femoral crack. There were two cases of persistent distal peroneal nerve palsy. Three cases of anterior dislocations were reduced and did not recur. A case of positive intraoperative culture was successfully treated with intravenous antibiotics. Two patients required revision to a cemented acetabular prosthesis, one due to cup loosening and the other due to a painful hip with a suspected infection. Radiolucent lines were seen in the acetabulum in one case, which underwent revision. No femoral or pelvic radiolucent lines were found. Conclusions: We have had relatively satisfactory results in the early follow-up period. It remains premature to draw conclusions as to the superiority of this system over a conventional metal-on-polyethylene bearing prosthesis. Long-term follow-up studies are needed.

Background: Proximal femur fractures are one of the most common injuries necessitating operative treatment. The aim of this prospective study was to evaluate and compare the possible effects of the preoperative application of a skin traction device, with or without weights, on pain relief in patients with acute proximal femur fracture. Materials and Methods: This study included 108 pre-operative patients with hip fractures. The subjects were randomly divided into three groups, and the following treatments were administered: Group 1, skin traction with 2 kg of weights; Group 2, skin traction without weights; and Group 3, pillow placement under the affected limb. Results: Pain was assessed using the visual analog scale (VAS). No significant differences were observed in the scores of the three groups before the pain relief treatment. All three modes of treatment resulted in significant pain reduction in subjects. Patients treated without a weight-loaded skin traction kit had better pain relief compared to the other two groups; this outcome was statistically significant. Conclusion: This study indicates that pillow placement under an injured limb can be safely used instead of traction, which has no significant benefit. However, an external device, such as a skin traction kit without weight, may be used in patients with persistent pain; this external device may have an additive placebo effect, as was proven in this study.

This report questions the cost and effectiveness of routinely sending explanted hardware to pathology for evaluation. Forty-six consecutive patients who had symptomatic hardware removed were enrolled in this study. Pathology reports following hardware removal were obtained, and charts were reviewed for these patients. The pathology department was contacted for related departmental procedure codes, and hospital billing records were obtained regarding the cost of the procedure. In all cases, the pathology reports gave the gross diagnosis of “hardware” and the gross description included the measurements of the internal fixation hardware removed. In no case did the report alter the plan of the attending physician. The healthcare system may beneft by subspecialty review of the current practice of sending internal fxation devices to pathology for evaluation. We recommend a single radiographic view along with proper documentation in the postoperative report to confrm the removal of internal fxation hardware in lieu of pathologic evaluation.

Tricyclic antidepressants have not been explicitly studied in the conservative treatment of lumbar spinal stenosis. A retrospective chart review was conducted in a subset of patients with chronic low back pain and lumbar spinal stenosis managed with low dose tricyclic antidepressants. Of 26 patients, 20 reported improvement in back pain. The majority of patients reported improvement with an initial dose of 10 mg of either amitriptyline or nortriptyline and remained on this dose. Patients with both leg and back pain reported improvement in greater proportion than patients with back pain alone. According to this study tricyclic antidepressants appear to be effective in controlling lumbar spinal stenosis symptoms in this patient population. Tricyclic antidepressants need to be further analyzed in randomized controlled studies as a means to conservatively manage lumbar spinal stenosis with stratifcation based on location of pain.

Background: The addition of a lateral suture anchor fixation row to rotator cuff repairs has been shown to improve initial cuff reattachment strength and footprint area. This study evaluated the mechanical function of this lateral row by measuring suture tensions at the individual anchor sites. Materials and Methods: Eight cadaveric shoulders underwent simulated rotator cuff repairs, using either double row or suture-bridge repair techniques. Suture tensions at each anchor were measured for several static, simulated shoulder positions relevant to postoperative patient management by specially designed instrumented anchors. Results: Signifcantly greater suture tensions were measured at the medial anchor sites than at the lateral sites for the double-row (p < 0.001), as well as the suture-bridge constructs (p < 0.016). In the double-row technique, the lateral row sustained 21% (range, 6 to 31) of the total anchor load; whereas, in the suture-bridge technique, the lateral row sustained 33% (range, 8 to 42). Shoulder abduction from 45° to 60° had little effect on anchor tensions; 20° internal and external rotation signifcantly (p = 0.032) increased loads on the anterior and posterior anchors. Conclusions: Forces are transmitted through the entire body of the tendon at its humeral fxation, loading the lateral anchors, as well as the medial row, for the two fxation techniques studied. These fndings explain the higher laboratory-obtained fxation strengths of double-row techniques. The magnitude and distribution of anchor suture tensions could have important implications for postoperative positioning and activity

This study compared the sliding characteristics of three lag screw designs used with trochanteric nails and determined the effects of lubrication on sliding. They were tested by an established method to measure initiation and ease of lag screw sliding. These tests were then repeated with calf serum lubrication. There were signifcant differences (p < 0.05) between the loads required to initiate lag screw sliding that appeared to be related to design. Screw sliding was similar for all three designs; however, the presence of lag screw locking slots affected sliding in that region. Lubrication did not affect either parameter. Lag screw design aspects, such as diameter and, particularly, surface fnish, affect sliding. Due to the small contact area between the lag screw and nail creating high interface stresses, lubrication had no effect on lag screw sliding.

Coracoid fractures are uncommon injuries, in isolation or in association with other osseoligamentous injuries about the shoulder girdle. We report a case of successful operative management of symptomatic ipsilateral nonunions of a type I coracoid base fracture and a lateral one-third clavicular fracture, which developed following nonoperative treatment of this exceedingly rare injury pattern. Following open distal clavicle excision and reduction of the coracoclavicular interval with screw fxation, radiographic union and excellent clinical outcome were achieved. This rare and potentially troublesome injury pattern is discussed, and the literature regarding ipsilateral coracoid and osseoligamentous injuries about the shoulder is reviewed.

A 4-month-old female infant was brought to our offce by her parents, who had noticed a lump on the child’s right elbow. Examination revealed a hard, painless lump in the antero-external region that was not reducible in fexion-extension or in pronation-supination. Neither palpation nor passive motion produced pain. Preoperative radiographs revealed a bony mass in the anteroexternal region of the proximal ulnar metaphysic (solitary osteochondroma), which was displacing the radial head into anteroexternal dislocation. No physiological bowing of the proximal metaphysis of the ulna was present. The infant underwent surgery at 6 months of age. No remains of the annular ligament were found. A complete resection of the tumour mass was performed, after which it was possible to reduce the radial head, together with the humeral condyle. Trans-radiocapitellar fixation was applied, with immobilization for 6 weeks. Subsequent radiological study revealed a congruent reduction of the radial head, with a progressive periosteal reaction of the posterior cortex of the ulna that evolved towards remodeling of the physiological bowing. Eight years after the surgery, the child remains asymptomatic, with complete range of motion and symmetric carrying angles. There were no relapses of osteochondroma, the deformity, or radioulnar synostosis.

Stress fractures of the pubic rami are rare occurrences and most frequently occur in association with total hip arthroplasty (THA). Reported historically with both cemented and noncemented THA components, postoperative stress fractures likely occur secondary to a rapid postoperative increase in patient activity following years of disability. Though stress fractures of the pubic rami should be considered in the differential diagnosis of groin pain following THA, they require a high degree of suspicion. Diagnosis may be achieved via bone scan after ruling out alternative causes of postoperative groin pain and after accounting for associated medical conditions. Treatment is minimally invasive, requiring a limited period of weightbearing and activity modifcation, often with full resolution of groin pain and a return to postoperative activity levels.

While hospitalized with polymyositis, a medically complex 56-year-old male experienced an acute exacerbation of gout. Both ultrasound and magnetic resonance imaging cross-sectional modalities were used to detect, localize, and characterize a soft tissue mass. The tumor was ultimately found to be secondary to gouty infammation of the pes anserine bursa, a previously unrecognized manifestation of acute gout.

Infection around the shoulder joint is rare. Clinical suspicion and diagnostic imaging are required for accurate diagnosis. We present three cases that emphasise particular diagnostic challenges when dealing with infection around the shoulder joint. Discussion includes the role of ultrasound as a screening tool and the importance of magnetic resonance imaging (MRI) in the accurate diagnosis and localisation of infections around the shoulder.

Osteoblastoma is an extremely rare entity that represents less than 1% of all bone tumors, and affects twice as many males as females with peak incidence between 15 and 20 years. Osteoblastomas commonly affect axial bones, long bones, bones of the foot and hand, and less commonly the pelvis, scapula, ribs, and clavicle. Osteoblastoma does not have a classic presentation, but can vary with the location and size of the tumor. The main complaint is often progressive pain localized at the tumor site. Osteoblastoma is a benign tumor with an aggressive behavior. The treatment is wide surgical resection, otherwise it continues to enlarge and destroy the bone and surrounding structures. We report a 32-year-old male with an osteoblastoma of this sternum who was treated with an en-bloc resection and reconstruction with Marlex® and a methylmethacrylate plate.

Vertebral dislocations are high energy injuries that rarely occur in the low back, but are found more frequently at the level of the thoracolumbar and sacrolumbar junctions. Dislocations of the mid-lumbar vertebrae are exceptional, with only 16 cases found in the literature. All previously reported cases were treated surgically. In four of these cases, the patients had no initial neurological lesions, and most of those who did have a neurological defcit exhibited some degree of recovery. We present the case report of an L3-L4 dislocation, without neurological lesions, resulting from an airplane crash. The anatomopathological mechanism of injury is discussed, together with treatment, which consisted of an initial closed reduction using a halo-bifemoral system, followed by pedicle instrumentation and arthrodesis from L2 to L5.