Search

The Press Ganey survey is the most widely used instrument for measuring patient satisfaction. Understanding the factors that influence these surveys may permit better use of survey results and may direct interventions to increase patient satisfaction. Press Ganey Clinician and Group Consumer Assessment of Healthcare Providers and Systems surveys administered to ambulatory spine surgery clinic patients within a large tertiary care network from May 2016 to September 2017 were retrospectively reviewed. Mean comparison testing was performed to measure associations between patient demographics and responses to "overall provider rating" and "recommend this provider's office" survey questions. Mean difference to achieve significance was set at α<0.05. A multivariate analysis was performed to determine independent factors. A total of 1400 survey responses from the offices of 11 orthopedic spine surgeons were included. Patients 18 to 34 years old had significantly lower responses to the overall provider rating question than older patients (P<.001), and increasing patient age was correlated with improved ratings. Highest education level was inversely correlated with satisfaction scores, with patients who had attained graduate level education having the lowest satisfaction scores (P=.001). Those with commercial insurance had significantly lower ratings for recommend this provider's office (P=.042) and overall provider rating (P=.022) questions than those with other insurance types. Patients administered the survey on paper had significantly lower ratings than those administered the survey online (P=.006). Provider ratings were significantly higher when the sex and ethnicity of the patient were concordant with the provider (P=.021). This study showed that independent, nonmodifiable factors such as age, education level, and survey mode were significantly associated with the satisfaction of ambulatory spine surgery clinic patients. [Orthopedics. 2019; 42(3):143-148.]., (Copyright 2019, SLACK Incorporated.)

The surgical management of benign and benign aggressive bone tumors typically involves intralesional curettage and reconstruction of the resulting defect with cement or bone graft material. At the authors' institution, an injectable synthetic calcium sulfate-calcium phosphate composite is now the standard graft material for these cases. This study reports the long-term follow-up, specifically the stability of bone regeneration, for the use of the synthetic graft material for oncologic reconstruction. Fourteen patients who underwent intralesional curettage of a primary bone tumor followed by cavitary reconstruction with synthetic graft material who had at least 4-year follow-up were identified from an institutional orthopedic oncology database. Clinical outcome data, focusing on long-term clinical and radiographic features of the reconstruction, were extracted from electronic and paper medical records. Seven females and 7 males were included (mean age at surgery, 28.1 years; range, 13-64 years). Follow-up ranged from 50 to 105 months (mean, 68 months). Most surgical reconstructions were done for the lower limb (n=11), and giant cell tumor of bone was the most common tumor treated. The mean amount of synthetic graft material used was 18.6 cm 3 . Complete radiographic resorption and new bone incorporation was observed within the first year, and bone remodeling was complete in all patients. Bone remodeling remained stable throughout the longer-term follow-up (ie, up to 9 years). The use of an injectable synthetic calcium sulfate-calcium phosphate composite is a viable option in the reconstruction of cavitary bone defects following intralesional curettage of primary benign bone tumors. This reconstruction technique was safe, with no long-term complications, and led to complete radiographic resorption and new bone incorporation with long-lasting stability. [Orthopedics. 2018; 41(6):e868-e875.]., (Copyright 2018, SLACK Incorporated.)

Despite significant research documenting the detrimental effects of tobacco, the orthopedic literature lacks evidence regarding how surgeons alter their management of elective surgery when patients use nicotine. To better understand how patients' use of nicotine influences orthopedic surgeons' pre- and postoperative management of elective surgery, a 9-question paper survey was distributed at the 2012 annual meeting of the American Academy of Orthopaedic Surgeons among attending US orthopedic surgeons, including general orthopedists and specialty-trained orthopedic surgeons. Survey questions focused on attitudes and practice management regarding patients who use nicotine. Using a chi-square test, no statistically significant variation was observed between subspecialists and general orthopedists or among different subspecialties. Ninety-eight percent of the orthopedic surgeons surveyed counseled tobacco users about the adverse effects of nicotine. However, approximately half of all of the respondents spent less than 5 minutes on perioperative nicotine counseling. Forty-one percent of all of the respondents never delayed elective surgery because of a patient's nicotine use, followed closely by 39% delaying surgery for less than 3 months. Subspecialty had little influence on how orthopedic surgeons managed nicotine users. The high rate of counseling on the adverse effects of nicotine suggested agreement regarding the detrimental effects of smoking. However, the study population infrequently delayed surgery or used smoking cessation measures. Studies are needed to determine why few surgeons frequently alter the management of nicotine users and what modifications in orthopedic practice could improve outcomes for these patients. [Orthopedics. 2017; 40(1):e90-e94.]., (Copyright 2016, SLACK Incorporated.)

Patient-reported outcome measures are helping clinicians to use evidence-based medicine in decision making. The use of computer-based questionnaires to gather such data may offer advantages over traditional paper-based methods. These advantages include consistent presentation, prompts for missed questions, reliable scoring, and simple and accurate transfer of information into databases without manual data entry. The authors enrolled 308 patients over a 16-month period from 3 orthopedic clinics: spine, upper extremity, and trauma. Patients were randomized to complete either electronic or paper validated outcome forms during their first visit, and they completed the opposite modality at their second visit, which was approximately 7 weeks later. For patients with upper-extremity injuries, the Penn Shoulder Score (PSS) was used. For patients with lower-extremity injuries, the Foot Function Index (FFI) was used. For patients with lumbar spine symptoms, the Oswestry Disability Index (ODI) was used. All patients also were asked to complete the 36-Item Short Form Health Survey (SF-36) Health Status Survey, version 1. The authors assessed patient satisfaction with each survey modality and determined potential advantages and disadvantages for each. No statistically significant differences were found between the paper and electronic versions for patient-reported outcome data. However, patients strongly preferred the electronic surveys. Additionally, the paper forms had significantly more missed questions for the FFI (P<.0001), ODI (P<.0001), and PSS (P=.008), and patents were significantly less likely to complete these forms (P<.0001). Future research should focus on limiting the burden on responders, individualizing forms and questions as much as possible, and offering alternative environments for completion (home or mobile platforms)., (Copyright 2016, SLACK Incorporated.)

As the population ages and medical care, along with a functional life style, continues to improve the health of this group, the number of joint replacement surgeries will continue to rise each year in the United States. This growing volume carries with it the risk of venous thromboembolism associated with joint replacement surgery. The American College of Chest Physicians and the American Academy of Orthopedic Surgery have provided guidelines for preventing this complication with the use of warfarin, low molecular weight heparins, pentasaccharides, and aspirin. These agents have had variable efficacy and safety preventing postoperative and out-of-hospital venous thromboembolism. New classes of oral agents, which inhibit Factor II or Factor X, have been shown to be an effective and safe class of anticoagulants that do not require monitoring or have food and drug interactions. This paper will review the current data on the new oral anticoagulants in joint replacement surgery., (Copyright 2010, SLACK Incorporated.)

The use of surgical navigation to aid in total joint replacement requires the bony fixation of reference marker arrays. In this context, a number of potential complications have been reported, including pin-site infection, soft tissue morbidity, and stress fracture. This study was performed to determine whether a femoral pinless, imageless navigation method for total hip arthroplasty (THA) is an accurate alternative method of measuring leg-length and offset change intraoperatively. Computer-assisted THA was simulated on a Sawbones bench test model including a femoral soft tissue model. Leg-length and offset changes were calculated by an imageless navigation system using the pinless measurement algorithm, in which the calculation of leg-length and offset changes is based on a specific realignment of the leg and then compared to corresponding measurements on a millimeter scale at the level of the femoral condyles. Mean difference in leg-length measurement (navigation versus millimeter paper) was 0.9 mm (95% confidence interval [CI]: 0.03-1.7 mm, P=.043), and the corresponding mean difference in offset was 1 mm (95% CI: 0.06-1.9 mm, P=.038). A noninvasive, pinless femoral system is a reliable tool for controlling leg length and offset during THA in an in-vitro setup. This system could lead to a reduction of potential risks associated with navigation techniques., (Copyright 2010, SLACK Incorporated.)

This article presents a case of a chronic, nonhealing thumb wound in a patient with diabetes mellitus. A 67-year-old right-hand-dominant man presented with progressive erythema and swelling of the right thumb several months after sustaining a paper cut along the eponychium. The patient had already completed an extensive laboratory evaluation, including bacterial and fungal cultures, as well as a punch biopsy that was inconclusive. In addition, the patient underwent several rounds of empiric antibiotic therapy without resolution of his symptoms. Despite these measures, the patient's thumb wound persisted and new lesions began to appear proximally along the forearm. Excisional biopsy of the lesions was ultimately required to obtain additional tissue for a pathologic analysis. Culture of the specimen on Saboraud dextrose agar revealed a definitive diagnosis of infection with Sporothrix schenkii. A subsequent course of oral antifungal therapy with itraconazole was well tolerated and resulted in disease regression. Early diagnosis of sporotrichosis is essential to prevent complications including septic arthritis, systemic infection, and death. This case illustrates the importance of maintaining a high index of suspicion for atypical infectious agents in patients with poor immune function., (Copyright 2010, SLACK Incorporated.)

The Internet has produced a truly phenomenal increase in access to information. This is really only helpful to patients if the information is filtered and appropriate to their specific needs. Too often patients access information about conditions they have self-diagnosed and bring it to the consultation with their physician, who then has to spend time disabusing the patients of the misinformation they have accumulated. Patients also return home from their initial consultation, access the Internet, and come up with all manner of promotional information from companies and even orthopedic practices that they want explained to them by their physician. It is the overwhelming conclusion of orthopedic specialists that this kind of Internet use is actually a burden for them in caring for patients and is not contributing to patient enlightenment. It does not have to be this way, if physicians will do just 2 things: first, create white papers for patients that address common current questions, such as surgical approach or bearing surfaces for implants and why we do what we do. This is a huge time saver and will preempt many questions. Second, develop their own website or select excellent nonprejudicial sites to which they can refer patients. To do less will invite a neverending parade of questions irrelevant to patient welfare.

The purpose of the levels of evidence system is to provide a framework for critical evaluation of orthopedic literature. This rating system is based on guidelines from the Oxford Centre for Evidence-Based Medicine and is currently in use in several orthopedic surgery journals. The purpose of this study was to investigate resident knowledge of the levels of evidence criteria used in classification of clinical articles. Thirty-eight residents from 5 orthopedic surgery training programs, from year-in-training 3 to 5, determined the levels of evidence rating of 10 blinded articles representing all levels of evidence types in the orthopedic literature. Residents were then provided with a levels of evidence information sheet and asked to re-rate each article. The mean percentage correct for the initial rating was 29.5% and for the post-education rating was 41.3%, with significant improvement after levels of evidence education (P<.001). The year-in-training-3 group had the highest mean percentage correct for the average of both tests (46.7%) compared to year-in-training-4 (34.2%) and year-in-training-5 (25.4%). Residents were significantly more accurate scoring therapeutic (41.1% correct pre-levels of evidence; 51.6% post-levels of evidence) than prognostic studies (6.6% correct pre-levels of evidence; 28.9% post-levels of evidence) (P<.001). Residents graded the level of evidence correctly in fewer than half the papers. These findings indicate that resident knowledge of levels of evidence criteria is limited and suggest a need for more education in this area.

There is no consensus on how to optimally reconstruct a posterior cruciate ligament (PCL). This paper introduces a new surgical technique that provides more secure fixation, better graft selection, and more anatomic graft passage. This study focused on the tibial backside fixation of a soft tissue graft using a rigidfix system (RIGIDfix system; Mitek, Johnson & Johnson, Raynham, Massachusetts) and anatomic graft passage anterior to the meniscofemoral ligament (MFL) of Wrisberg.

The purpose of this anatomical study was to explore the different circular arc radii of the distal volar radius and provide more detailed anatomic information that will further the understanding of volar plate osteosynthesis. The profiles of the volar distal radii of 100 cadaver specimens were measured with a common profile gauge. Profiles were copied onto paper and then matched to a best-fit circular arc template to determine the radius of curvature on the radial and ulnar sides of the distal volar radius. The mean circular arc radius of the distal volar surface was 2.6 cm (+/-1 cm, 1-6 cm) on the radial side and 2.3 cm (+/-1 cm, 1-6 cm) on the ulnar side. A significant difference (P<.01) was noted in the radii of curvature of the distal radius in 55% of the study population. In 37% of these cases, the circular arc radius flattens toward the ulnar side. In 63%, it flattens toward the radial side. This characteristic may lead to a false rotation position of the distal fracture fragment following volar plate osteosynthesis. In addition, suboptimal or incorrect plate position may result due to the discrepancy between the plate radius of curvature and the radius of curvature of either the radial or ulnar volar radius.

Tibial plateau fractures are complex injuries that can affect both knee function and stability. In the past, surgeons have relied on radiographs, viewboxes, tracing paper, and scaled acetate templates to formulate a preoperative plan. With the advent of digital radiography, viewboxes, and standard radiographs are no longer routinely available. The availability of a digital format for preoperative planning has helped to address this, but fragment manipulation and implant templating are not features of most digital radiography systems. Digital surgical planning software allows for these functions thereby enabling the surgeon to formulate a preoperative plan for fracture reduction and fixation. Concomitant use of 3-dimensional (3D) imaging software permits unlimited inspection of the fracture by allowing for oblique or special views through manipulation of the software image as opposed to potentially painful positioning of the injured limb by the patient or radiograph personnel. This case report illustrates the advantages of these new software tools.

The mechanisms of pain and pain management can be complex. Often while reading current research papers on the physiology of pain, it is easy to get lost in the minutia of the mechanisms being investigated. It is important that orthopedic surgeons have a general understanding of the mechanisms of pain, maintain a current understanding of the new areas of pain management, and continue to refine their treatment regimes.

Stem designs, which have different design features, may produce similar clinical survival curves. Alteratively, some designs that are considered to be similar in design produce different survival rates. In this paper, design aspects of cemented femoral total hip replacement stems, how they can be grouped to design philosophies, and how they may affect the failure process are discussed. In addition, explanations of unsuccessful designs are posed to learn from previous mistakes and improve understanding of design aspects that affect the longevity of cemented femoral stem designs.

Anterior cervical diskectomy and fusion is a widely accepted treatment for anterior management of degenerative or traumatic instability of the cervical spine. To reduce or eliminate complications such as implant migration and failure, imaging degradation, and fusion stress shielding that are occasionally associated with spinal instrumentation, attention has been given to the use of bioresorbable anterior cervical plating devices. This paper is a preliminary report of a retrospective series in which a resorbable mesh and screw system (OS Reconstructive Mesh, MacroPore Biosurgery Inc, San Diego, Calif) was used for graft containment in single-level anterior cervical diskectomy and fusion. A review of patient charts and imaging studies was conducted to determine functional outcome, fusion success, and potential soft-tissue reaction to implant resorption. Nine patients with a diagnosis of cervical degenerative disk disease or traumatic disk disruption were treated between October 2001 and March 2002. Follow-up averaged 206 days. Eight patients were found to have an excellent result, one patient had a good result, and no patients had a satisfactory or poor result. At the time of follow-up, 77% of patients (7/9) were found to have a radiographically solid fusion. The two patients without a solid fusion were only on average 8 months out from their fusion procedure and manifested no symptoms related to fusion nonhealing. No significant soft-tissue reaction was noted clinically or radiographically in any of the patients. The results of this preliminary study indicate that bioresorbable anterior cervical plating for single-level anterior cervical diskectomy and fusion is both safe and effective.

In this paper we have presented a 13-year-old boy whose unicameral bone cyst of the proximal humerus was, after sustaining a pathological fracture, obliterated with conservative management of the fracture. The literature is uncertain as to how many similar cases will go on to refracture union and cyst resolution. Therefore, we feel that invasive procedures should be delayed until the fracture heals. If healing of the cyst is not evident at six to eight weeks and if the cyst is small and monoloculated or adjacent to the growth plate, methylprednisolone acetate would be a recommended procedure. In cases of larger and/or multiloculated cysts or cysts that resist steroidal treatment, curettage and bone grafting is warranted.

This paper describes a surgical procedure which combines wrist arthrodesis and metacarpophalangeal joint arthroplasty into one operation. Its basic indication is the severely crippled rheumatoid patient who is faced with multiple reconstructive surgical procedures. In addition to the combined wrist fusion and metacarpophalangeal joint arthroplasty, other surgical procedures can sometimes be performed into same hand, thereby completing the entire reconstruction in one operation. Of the 19 patients who have undergone the combined procedure, only one failed to obtain a solid clinical arthrodesis. There were no infections, skin sluffs or other complications. Combining the two procedures did not jeopardize either wrist fusion or metacarpophalangeal joint arthroplasty. Specific contraindications for the procedure are fixed wrist flexion contracture or a complete dislocation requiring extensive exposure in order to align or reduce the radiocarpal joint.

In 1973 a workshop sponsored by the National Academy of Sciences recommended that "efforts to develop prescription criteria for use of the numerous variants of the BK prosthesis should be intensified." This paper provides a review of the important considerations in the prescription of a below-knee prosthesis. It is intended that this information would assist the physician to make better informed decisions regarding the specific type of prosthesis for a particular patient. No attempt has been made to describe all prosthetic options since a majority of amputees are fit with only a few prescriptions. Thus, socket design, suspension, shank type, and foot specification may be optimized for individual patients through mutual agreement of the prosthetist and the knowledgeable physician. This paper will present some of the more difficult prescription solutions to the various fitting problems that are representative of our nation's amputee population. This is done with the knowledge that there may be other and equally successful solutions to these problems. Several illustrative examples are provided.

This unusual case of trauma depicts a 17-year-old female who had a history of chronic synovitis of her left knee for several months. The patient demonstrated persistent knee effusion despite treatment of several physicians. Failure of the left knee to respond to several surgical procedures, as well as the finding of numerous foreign bodies not present previously, evoked a high index of suspicion leading to the diagnosis of factitial synovitis. The paper further defines the entity, describes the personalities involved and the numerous methods used to inflict trauma. Lastly, the treatment regime is given.