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Background: Stereotypes may discourage women from going into the historically male-dominated field of Adult Reconstruction. Other factors such as interest, confidence, and a sense of belonging may influence subspecialty choice. The objective of this study was to survey orthopedic surgery residents regarding their perceptions about Adult Reconstruction., Methods: A validated survey evaluating social determinants of behavior was adapted to assess orthopedic surgery residents' perceptions of Adult Reconstruction. The survey was electronically distributed to residents from 16 United States and Canadian Accreditation Council for Graduate Medical Education-accredited residency programs. There were 93 respondents including 39 women (42%) and 54 men (58%). Study data were collected and managed using an electronic data capture tool. Descriptive statistics were reported for all continuous variables. Percentiles and sample sizes were reported for categorical variables., Results: Women and men reported similar interest in Adult Reconstruction (46% versus 41%, P = .60). Fewer women reported that they were encouraged to go into Adult Reconstruction by faculty (62% versus 85%, P = .001). Women and men reported similar confidence in their own ability to succeed in the subspecialty of Adult Reconstruction. However, when asked about the ability of other residents, both sexes rated men as having higher levels of confidence. Women and men perceived other residents and faculty felt "men are better Adult Reconstruction surgeons," but did not personally agree with this statement., Conclusion: Women and men residents expressed similar rates of interest and self-confidence in Adult Reconstruction, but there were social barriers including negative stereotypes that may prevent them from pursuing careers in Adult Reconstruction., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Many surgical interventions are used to treat osteonecrosis of the femoral head. The instance and distribution of these various procedures may give some insight into the practicing community's understanding of the efficacy of these treatments. We therefore sought to determine trends in the types and numbers of procedures performed for atraumatic osteonecrosis from 1992 through 2008 in the United States., Questions/purposes: (1) How has the overall incidence of surgical treatment for atraumatic osteonecrosis changed over this time period; and (2) how has the percentage of THA performed for osteonecrosis (compared with joint-preserving procedures) changed over this time period?, Methods: The Nationwide Inpatient Sample database was used to collect information for all patients who had an International Classification of Diseases, 9(th) Revision diagnosis of hip osteonecrosis between 1992 and 2008. Procedures were collated according to frequency, and trends were analyzed for joint-preserving and joint-replacing procedures., Results: The total number of procedures performed over this time period for osteonecrosis of the hip increased from 3570 procedures to 6400 procedures per year. In 1992, 75% (n = 2678) of the procedures performed to treat osteonecrosis of the hip were THA, which increased to 88% (n = 5632) in 2008. The percentage of joint-preserving procedures consequently decreased from 25% to 12% over this period., Conclusions: Previously, THA was believed to have poor survivorship and clinical results for the treatment of osteonecrosis of the hip, but reports since 1993 have suggested improved survivorship of these reconstructions. Our study suggests that surgeons have incorporated this into their practice patterns, in that an increasing percentage of patients with this diagnosis are treated with THA. Additionally, the total number of procedures performed for osteonecrosis has increased, which may reflect an improved awareness of this disease and more aggressive approaches to diagnosis and treatment.

Background and Purpose: Real-time tomographic reflection is a novel technique that uses a geometrically fixed arrangement of a conventional ultrasound transducer, a transducer-incorporated monitor, and a half-silvered mirror. This device, dubbed the Sonic Flashlight, generates a virtual anatomically scaled image, obviating the need for a separate monitor. It may therefore facilitate invasive procedures, such as percutaneous access to the kidney. This proof-of-concept study assesses the feasibility of this technique for renal imaging and concomitant needle puncture guidance., Materials and Methods: In a swine model with induced hydronephrosis, the Sonic Flashlight was used to visualize and guide needle access to the renal pelvis. Passage of a 7-inch, 18-gauge spinal needle was performed. Entry into the collecting system was confirmed by the aspiration of urine., Results: The anechoic renal pelvis and hyperechoic needle tip could be seen with the Sonic Flashlight device. Successful access to the collecting system was obtained twice without dificulty. The sonographic image, appearing to emanate from the tip of the transducer, makes visualization and manipulation more intuitive. Furthermore, by placing the operator's eyes and hands in the same field as the sonogram, image-guided procedures are potentially easier to learn., Conclusion: The relatively shallow depth of penetration of the current device limits its clinical usefulness. A new Sonic Flashlight with a greater depth of penetration is in development.

We present hand-assisted laparoscopic ureteroureterostomy (HALUU) with renal mobilization as a novel approach to the management of proximal ureteral injury after lumbar disk surgery. A 63-year-old female underwent L4-L5 diskectomy and facetectomy with cage placement for back and leg pain. Postoperatively, she developed fever, nausea, abdominal pain, ileus and leukocytosis. A computed tomography scan of the abdomen and pelvis with intravenous contrast and delayed imaging demonstrated a left proximal ureteral injury with contrast extravasation. Retrograde and antegrade ureteral stent placement was unsuccessful; a nephrostomy tube was placed. Antegrade and retrograde ureterograms revealed a 3-cm proximal ureteral defect. All treatment options were discussed, and the patient chose to undergo hand-assisted laparoscopic renal mobilization with ureteroureterostomy, which was completed successfully without complications. Operative time was 381 minutes; estimated blood loss was 50 mL. The patient was discharged after 2 days, her ureteral stent was removed in 8 weeks, and follow-up with furosemide-mercaptoacetyltriglycine (MAG-3) renal scan demonstrated 30% function without evidence of obstruction. Hand-assisted laparoscopic ureteroureterostomy with renal mobilization can be performed as definitive management of a medium-length proximal ureteral injury. This is the first case describing this management technique after lumbar disk surgery.

A total of 1,401 primary total knee arthroplasties (TKA) were reviewed; 44 (3.2%) had at least the patellar component revised. Nine of these knees (eight patients) had insufficient bone stock to allow reimplantation of another patellar component. Clinical data on the nine knees were obtained with recent follow-up evaluation, review of their medical records and radiographs. Evaluation included Hospital for Special Surgery (HSS) scores. Average follow-up was 4 years and 7 months, 2-year range (2 months to 8 years and 4 months). Common factors found in these nine knees included: thin patella after primary TKR status, osteoarthritis, good range of motion and patella alta. Results were good to excellent in seven knees and fair in two. The untoward associations with patellectomy such as quadriceps lag, extension weakness and anterior knee pain were not experienced. Resection of the patellar component, without reimplantation, is an acceptable alternative in revision TKA lacking adequate remaining bone stock.

Throughout history, medicine has witnessed paradigm shifts that significantly change patient treatment. Recently, the introduction and development of laparoscopic surgery has had a major impact on patient treatment. On the horizon is natural orifice translumenal endoscopic surgery (NOTES), which has tremendous potential. This review focuses on the history of natural orifice endoscopy in urology with the progression through therapeutic natural orifice endoscopy and resection to the development of upper tract natural orifice surgery. Further delineated is how technology has improved these procedures to set the stage for NOTES.

Background and Purpose: Patient safety and outcomes are paramount when using new technology. We report our initial experience of 100 patients with robot-assisted laparoscopic prostatectomy (RALP) with a focus on patient safety and outcomes., Materials and Methods: Data were prospectively collected from the first 100 consecutive patients who underwent RALP for localized prostate cancer from October 2004 to August 2007. To determine our learning curve, the cases were divided into quarters of 25 patients and stratified to identify trends., Results: Mean age was 59.4 years (range 44.5-72.6 yrs), body mass index was 28.4 (range 20.4-40.1), preoperative prostate-specific antigen (PSA) level was 5.7 ng/mL (range 0.4-15.0 ng/mL), and follow-up was 12.7 months (range 7 days-38 mos). Mean operative time was 5.9 hours (range 3.7-10.9 hr), and estimated blood loss (EBL) was 218 mL (range 25-600 mL). Thirty bilateral pelvic lymphadenectomies were performed. Twelve patients had pT(2a) disease, 3 had T(2b), 61 had T(2c), 22 had T(3a)N(0), and 1 had T(3b)N(1). Positive surgical margin rate was 23%. Overall complication rate was 26%. At last follow-up, 88% (76/86) of patients had undetectable PSA levels, and 80% (70/87) of patients were using no pads. Improvement in EBL and operative time was noted throughout the series, and changes in surgical technique and perioperative management were made to improve patient safety and outcomes., Conclusions: RALP perioperative parameters improved throughout the first 100 cases, while postoperative outcomes remained acceptable. Methods to improve patient safety and outcome occurred throughout the series. Even during the initial learning curve for this procedure, RALP appears to be another alternative for achieving prostate cancer control.

Total joint arthroplasty has been a successful operation for decades. Our current patients are younger and more active than those in the past. They place higher demands on themselves and have expectations commensurate with their lifestyles. Time-limited longevity with the large number of anticipated total joint replacement procedures and their potential burden to health care is a growing concern. In the past two decades, implant wear and osteolysis have been identified as major causes for the failure of otherwise well-functioning implants. Osteolysis can be divided into several categories: patient-specific, implant-specific, and the result of surgical factors. Although these categories are interrelated and not mutually exclusive, they enable us to build a framework in which to further advance our understanding of osteolysis and apply this information in a clinically relevant manner.

The objective of this study was to determine the effects of spaceflight on the structure of the tendon-bone junction (TBJ). Pregnant rats either flew in the space shuttle Atlantis (flight group; F) or were exposed to simulated launch and landing protocols (synchronous control group; SC) during days 9-19 of pregnancy. Following birth of their pups, maternal hindlimbs were studied using scanning electron and light microscopic histomophometric techniques. The tibial and calcaneal tuberosities, the fibular head, and the tibia-fibula junction were studied. Myofiber density and cross-sectional area of the quadratus femoris and soleus muscles and diameters of the calcaneal and patellar tendons were also evaluated. Cortical erosion was significantly greater at the tibial tuberosity and the fibular head in F animals compared to SC animals (P < 0.001). Sharpey fiber density was significantly less at the tibial tuberosity and fibular head in F animals compared to SC animals (P < 0.001). The myofiber area of both the soleus and quadratus femoris muscles and the diameters of both calcaneal and patellar tendons were significantly less in F compared to SC rats (P < 0.05). Our data illustrate that the TBJ morphology is affected by spaceflight at the attachment sites of the soleus and quadratus femoris muscles in pregnant animals, which could adversely affect their physical properties. These atrophic TBJ changes could have resulted from atrophy of the adjacent muscles and their tendons. Atrophic changes in the structure of the TBJ could predispose an animal to injury following spaceflight, when normal gravity conditions are reestablished.

Purpose: Written responses from American trained women in urological surgery were obtained to evaluate practice patterns, career choices and workplace satisfaction., Materials and Methods: A 3-page unblinded questionnaire was mailed in March 2003 to American trained women in urological surgery available through the databases of the Society of Women in Urology with subsequent statistical analysis., Results: The response rate was 60% but inclusive of all women in current academic practice in the United States. A total of 61% reported working 51 or more hours a week whereas 2% have left practice due to retirement or medical infirmity. There were 41% who had completed fellowships including 87% reporting active practice within their subspecialty, whereas 62% of fellowship trained surgeons remained in an academic practice. Among United States women in academic urological practice, academic progression has occurred in a third of this cohort., Conclusions: Threats to successful practice, consistent with other workplace surveys of physicians and professional women including gender based role limitation and inadequate mentoring, were commonly reported. These correctable workplace deficiencies represent an opportunity for American urology to enhance the professional workplace for all urologists regardless of gender.

We reviewed 44 consecutive patients treated for Legg-Calvé-Perthes disease who underwent serial technetium 99m diphosphonate bone scintigraphy. The average follow-up was 4.4 years. The bone-scintigraphy classification characterizes the A pathway by early lateral column formation not seen in the B pathway. Pathway A had 20 hips. The average age at presentation was 6.1 years. At last follow-up, this group had an average Mose classification of 1.2 and Catterall score of 2.4, without any patient having "head-at-risk" signs or requiring operative treatment. Pathway B had 20 hips. The average age at presentation was 5.8 years. At last follow-up, this group had an average Mose classification of 5.2, a Catterall score of 3.5, and 18 patients had head-at-risk signs, with 11 requiring operative treatment. Our bone-scintigraphy classification preceded the radiographic head-at-risk signs by an average of 3 months, allowing earlier treatment and correlated with subsequent femoral head involvement.

Rheumatoid arthritis is an autoimmune disease that causes inflammation mainly in synovial tissues. RA manifests as a chronic polyarthritis with intermittent acute inflammatory episodes. The inflammatory sites are characterized by infiltration of activated lymphocytes and macrophages into the synovial membrane, and the proliferation of synovial cells. The local production of a number of cytokines by proliferative synovial cells as well as by infiltrating cells appears to account for many of the pathological and clinical manifestations in rheumatoid arthritis. Tissues were collected from twelve RA patients undergoing joint replacement surgery. The synovium was collected and the cell types were identified, and markers for chronic and acute inflammatory mediators were measured. The cells types found in the synovium are capable of secreting cytokines which are capable of both acute inflammation (IL-1, IL-6, IL-8, MCP-1 and TNF), as well as chronic inflammation (IL-2, IL-10, and IL-4). The results obtained showed that the macrophages-derived acute inflammatory cytokines (IL-1, IL-6 and IL-8) were easily detected at levels of 22.6 +/- 12 pg/mg protein; 48.5 +/- 42 pg/mg protein, and 76 +/- 31 pg/mg protein; respectively. T-cell derived chronic inflammation cytokines (IL-2, IL-4 and IL-10) were rarely detected. Retrieved tissues that immunostained positive for IL-6, IL-1 and IL-8 also is suggestive of an acute inflammatory response. The results clearly demonstrate that the acute response may be responsible for the subsequent need for joint arthroplasties.

Cytokines are inflammatory mediators responsible for numerous clinical conditions, and are thought to lead to the resorption of bone. Understanding the nature of the cells producing these factors which control the resorption of bone will ultimately lead to a better understanding of why implants fail or integrate. In this study, synovial tissues and synovial fluids were processed for biochemical as well as histochemical and immunohistochemical determination cytokines responsible for bone resorption. The results from this study showed by both quantitative enzyme linked immunoassay (ELISA) and qualitatively by immunohistology a marked increase (twofold) in interleukin-1 (IL-1), and tumor necrosis factor-beta (TNF beta) in synovial tissues in comparison to control tissues of cartilage, ligament and meniscus. Evaluation of tissues both immunochemically and by Hematoxylin and Eosin demonstrated the presence of fibroblast and cells such as macrophages, and multinucleated giant cells in the synovium that are capable of producing bone resorption. Synovial fluid from primary and revision patients were evaluated for TNF beta and IL-1 were not statistically different. Overall, the results indicate that the inflammatory cells of the synovium are secreting factors which may act to mediate aseptic loosening of implants.

Objectives: To determine if patients with multiple lower extremity fractures have worse outcomes than do patients with isolated femur fractures, and to determine if the Abbreviated Injury Scale (AIS) should distinguish between single and multiple lower extremity fractures., Design: A retrospective study., Materials and Methods: All blunt trauma patients at least 15 years of age treated at a level 1 trauma center from January 1990 through December 1993. Three groups of patients were selected. Group 1 included 50 patients whose only significant injury was a diaphyseal femur fracture. They had no other long bone fractures, minimal injuries to other body areas, and an Injury Severity Score (ISS) < or = 14. Group 2 was consisted of 29 patients with a femur fracture, at least one other diaphyseal lower extremity fracture, and also an ISS < or = 14. Group 3 consisted of 23 patients who had fracture patterns similar to those of group 2, but also had more severe nonextremity injuries (ISS > or = 15). Hospital morbidity and mortality rates were compared with t tests or chi-square analysis. Type 1 error probability was established at p < 0.05., Measurements and Main Results: Compared with patients in group 1, patients in group 2 had an identical ISS (10.1 vs. 10.6, respectively), but had higher transfusion requirements (0.3 vs. 3.9 units), more days in the intensive care unit (ICU) (0.02 vs. 1.4), a higher incidence of adult respiratory distress syndrome (ARDS) (0 vs. 14%), longer hospital stays (6.0 vs. 14.8 days), greater disability at discharge (disability score 2.2 vs. 3.2), and a higher mortality rate (0 vs. 3.4%; p < 0.05 all variables). Patients in group 3 had worse outcomes than the other two groups: ISS = 30.1; transfusions = 11.9 units; ICU days = 9.1; ARDS incidence = 26%; hospital days = 29.9; disability score = 3.9; mortality = 26% (p < 0.05)., Conclusions: Although AIS and ISS appropriately reflect the impact of extraskeletal injuries in patients with femur fractures, they do not adequately reflect the increased morbidity associated with multiple lower extremity fractures. The AIS-Extremity Score may need to be upgraded for multiple long bone fractures of the lower extremities.

The cost of health care in the United States has been rising steadily during the past 10 years. Total joint arthroplasty, a commonly performed orthopaedic procedure, accounts for approximately $10 billion dollars per year. The objective of this study was to perform a clinician-oriented cost analysis of primary and revision hip and knee arthroplasty. Twenty-five consecutive cases each of total knee arthroplasty, total hip arthroplasty, revision total knee arthroplasty, and revision total hip arthroplasty were analyzed. The length of stay and number of minutes spent in the operating room were significantly higher for the patients with revision hip surgery than for the other groups. The total charges for the prosthesis in the 4 groups exceeded 40% of the total charges for the procedure. Primary hip and knee surgery had similar billed costs, and work for revision hip surgery has a significantly higher billed cost than physician's work. The implant selection process by an orthopaedic surgeon performing arthroplasty of the hip and knee needs to include economic aspects.

Traumatic ruptures of the triceps are very rare among tendon injuries. A unique case of hypocalcemic tetany that induced spontaneous triceps tendon avulsion with associated bilateral quadriceps tendon ruptures is reported. The current orthopaedic literature is reviewed, and a new application of an existing surgical treatment for repair of the major tendon ruptures is described.

Observations of wear damage were performed on 12 retrieved porous coated anatomic (PCA) tibial components, all of which were removed because of excessive polyethylene wear. Density measurements of the remaining polyethylene were obtained as a function of depth from the surface of the components. Comparison to previous results from similar studies of total condylar type knee components and total hip acetabular components revealed distinct differences between the types and severity of damage, emphasizing the influence of design factors on the corresponding wear damage. These results confirm previous conclusions that nonconforming articulating surfaces on thin polyethylene components will be at higher risk of damage than more conforming surfaces on thicker components. It also appears that the high cyclic loads to which polyethylene implants are subjected in vivo are most responsible for the degradation in properties of the material near the articulating surface, although the heat pressing of the articulating surface of the PCA components may contribute to the problem.

Four hundred eighty-seven porous-coated anatomic (PCA) total arthroplasties were performed by the same surgeon between January 1982 and December 1989. Forty-three patients developed an effusion, pain, or decreased range of motion after a period of pain-free function. Average time to onset of symptoms was 4.5 years. Joint fluid aspirations were sterile and revealed the presence of high-density polyethylene crystals, best seen under a polarizing microscope. Thirty-three of these patients were arthroscopically evaluated. Extensive polyethylene wear and delamination were identified. Wear was most extensive on the medial tibial plateau. Patellar polyethylene wear was also identified. Substantial femoral component abrasions were present in areas where exposure of the tibial and patellar base plates had occurred. Diffuse granulomatous synovial tissue revealed an extensive foreign-body giant-cell reaction to polyethylene particles. In all patients, temporary symptomatic relief was obtained after arthroscopy. Thirty-two patients have, subsequently, had revision surgery. Intraoperative findings and biopsies at the time of revision confirmed the arthroscopic observations. Arthroscopy allowed the accurate diagnosis of polyethylene wear, provided temporary symptomatic relief, and facilitated preoperative revision planning. Polyethylene wear in PCA total knee replacements was related to patient characteristics (larger, younger, more active patients), nonconforming femotibial articular surfaces, thin polyethylene, heat-pressed polyethylene, and nonrigid mechanical attachment of polyethylene to metal base plate. Younger, more active, larger patients with total knee arthroplasties should be observed closely for evidence of polyethylene wear.