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Letters to the Editor published in the past 120 days:

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38 Letters to the Editor published for 21 different topic sources.

Articles			Letters
	Prenatal Diagnosis and Treatment: Prenatal Diagnosis and Treatment of Congenital Differences of the Hand and Upper Limb Bae et al. (1 July 2009) [Full text] [PDF]		Prenatal Diagnosis of Undefined Soft Tissue Tumors Lukas A. Lisowski   (28 October 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Factors Affecting Willingness to Undergo Carpal Tunnel Release Gong et al. (1 September 2009) [Abstract] [Full text] [PDF]		Dr. Chung and colleagues respond to Mr. Papanna Moon Sang Chung, MD, PhD, et al.   (13 October 2009) Good Article with Severe Limitations Madhavan Chikkapapanna Papanna   (13 October 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures? Koenig et al. (1 September 2009) [Abstract] [Full text] [PDF]		Drs. Koenig and Koval respond to Dr. Slobogean Karl M. Koenig, MD, et al.   (6 October 2009) Is Early Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures? Gerard P. Slobogean, MD, MPH   (6 October 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture Browne et al. (1 September 2009) [Abstract] [Full text] [PDF]		Dr. Browne and colleagues respond to Mr. O'Neill James A. Browne, MD, et al.   (28 October 2009) Resident Duty Hour Reform Associated with Increased Recording of Morbidity Following Hip Fracture Barry J. O'Neill   (28 October 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study Ricci et al. (1 September 2009) [Abstract] [Full text] [PDF]		Dr. Wright responds to Drs. Bernstein and Ahn James G. Wright, MD, MPH, FRCSC   (6 October 2009) Not a Level I Therapeutic Study Joseph Bernstein, MD, et al.   (6 October 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses A Prospective Randomized Study Kim et al. (1 August 2009) [Abstract] [Full text] [PDF]		Dr. Kim and colleagues respond to Mr. Malviya Young-Hoo Kim, MD, et al.   (19 August 2009) Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses Ajay Malviya   (19 August 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Complication Reporting in Orthopaedic Trials. A Systematic Review of Randomized Controlled Trials Goldhahn et al. (1 August 2009) [Abstract] [Full text] [PDF]		Dr. Goldhahn and colleagues respond to Drs. Cheng and Zhang Sabine Goldhahn, MD, et al.   (11 September 2009) Concern Regarding Complications Reporting in Orthopaedic Trials Tao Cheng, MD, PhD, et al.   (11 September 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous Fixation. A Prospective Randomized Trial Rozental et al. (1 August 2009) [Abstract] [Full text] [PDF]		Dr. Rozental responds to Mr. Holmes and colleagues Tamara D. Rozental, MD   (29 October 2009) Group Homogeneity William JM Holmes, MBChB, MRCSEd, et al.   (29 October 2009) Dr. Rozental responds to Dr. Kumar Tamara D. Rozental, MD   (2 September 2009) Letter to the Editor Sudeep Kumar, MBBS, MS(Ortho)   (2 September 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Surgical Treatment of Three and Four-Part Proximal Humeral Fractures Solberg et al. (1 July 2009) [Abstract] [Full text] [PDF]		Dr. Solberg and colleagues respond to Mr. Clarke and Mr. Nunn Brian D. Solberg, MD, et al.   (9 September 2009) Surgical Treatment of Three and Four-Part Proximal Humeral Fractures Jon V. Clarke, et al.   (9 September 2009) Read every Letter to the Editor related to this article
	Scientific Articles: The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty Marchant et al. (1 July 2009) [Abstract] [Full text] [PDF]		Glycemic Control and Outcomes after Joint Arthroplasty N. Wah Cheung   (28 August 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Unstable Distal Radial Fractures Treated with External Fixation, a Radial Column Plate, or a Volar Plate. A Prospective Randomized Trial Wei et al. (1 July 2009) [Abstract] [Full text] [PDF]		Unstable Distal Radial Fracture Treatment Benedict A. Rogers, et al.   (25 August 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate. Results of a Prospective, Multicenter, Observational Study Südkamp et al. (1 June 2009) [Abstract] [Full text] [PDF]		Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot Gerhard G. Konrad, MD, et al.   (5 August 2009) Does Patient Age Affect Outcome with PHILOS Plates? James O. Smith, et al.   (5 August 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. A Concise Follow-up, at a Minimum of Twenty Years, of Previous Reports Della Valle et al. (1 May 2009) [Abstract] [Full text] [PDF]		Dr. Della Valle and colleagues respond to Mr. Whitehouse and Mr. Bannister Craig J. Della Valle, MD, et al.   (5 August 2009) Definition of Failure Michael R. Whitehouse, MBChB, BSc, M(ScOrthEng), MRCS(Eng), et al.   (5 August 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Effect of an Unrepaired Fracture of the Ulnar Styloid Base on Outcome After Plate-and-Screw Fixation of a Distal Radial Fracture Souer et al. (1 April 2009) [Abstract] [Full text] [PDF]		Dr. Ring and colleagues respond to Mr. Al-Fakayh David Ring, MD, PhD, et al.   (11 September 2009) Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures Omar Al-Fakayh   (11 September 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Medical Errors in Orthopaedics. Results of an AAOS Member Survey Wong et al. (1 March 2009) [Abstract] [Full text] [PDF]		Orthopaedics – Matching Precision with Safety Sukhmeet S Panesar, et al.   (28 July 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Effect of Innominate and Femoral Varus Derotation Osteotomy on Acetabular Development in Developmental Dysplasia of the Hip Spence et al. (1 November 2009) [Abstract] [Full text] [PDF]		Surgical Treatment of Developmental Dysplasia of the Hip - Our Experience Zoran S. Vukasinovic, et al.   (17 November 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures Wall et al. (1 June 2008) [Abstract] [Full text] [PDF]		Dr. Wall and colleagues respond to Dr. Thakkar Eric J. Wall, MD, et al.   (3 November 2009) Complication Comparison of Titanium and Stainless Steel Elastic Nails Navin N. Thakkar   (3 November 2009) Read every Letter to the Editor related to this article
	Case Reports: Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation of Distal Radial Fractures. A Report of Three Cases Bhattacharyya and Wadgaonkar (1 February 2008) [Full text] [PDF]		Dr. Bhattacharyya responds to Dr. Lucchina and Mr. Fusetti Timothy Bhattacharyya, MD   (5 August 2009) Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation of Distal Radius Stefano Lucchina, MD, et al.   (28 July 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Cast-Saw Burns: Evaluation of Skin, Cast, and Blade Temperatures Generated During Cast Removal Shuler and Grisafi (1 December 2008) [Abstract] [Full text] [PDF]		Plaster Cutter Injuries Milind M. Deshpande, et al.   (8 September 2009) Read every Letter to the Editor related to this article
	Current Concepts Review: Diagnosis of Periprosthetic Infection Bauer et al. (1 April 2006) [Abstract] [Full text] [PDF]		Dr. Bauer and colleagues respond to Dr. Pignatti Thomas W. Bauer, MD, PhD, et al.   (1 October 2009) Letter to the Editor Giovanni Pignatti, MD   (1 October 2009) Read every Letter to the Editor related to this article
	Scientific Articles: Extracellular Matrix Bioscaffolds for Orthopaedic Applications. A Comparative Histologic Study Valentin et al. (1 December 2006) [Abstract] [Full text] [PDF]		Dr. Badylak and Ms. Valentin respond to Dr. James and colleagues Stephen F. Badylak, DVM, PhD, MD, et al.   (18 November 2009) TissueMend is not chemically crosslinked nor does it elicit a classic foreign body response Kenneth S. James, PhD, et al.   (18 November 2009) Read every Letter to the Editor related to this article

Prenatal Diagnosis and Treatment: Prenatal Diagnosis and Treatment of Congenital Differences of the Hand and Upper Limb Bae et al. (1 July 2009) [Full text] [PDF] Prenatal Diagnosis and Treatment of Congenital Differences of the Hand and Upper... Prenatal Diagnosis of Undefined Soft Tissue Tumors 28 October 2009 Lukas A. Lisowski, Orthopaedic Surgeon The Royal Infirmary of Edinburgh, Scotland Send letter to journal: Re: Prenatal Diagnosis of Undefined Soft Tissue Tumors lalisowski{at}gmail.com Lukas A. Lisowski To the Editor: In the article by Bae et al. (1), a nice overview is given on the prenatal diagnosis of structural hand and upper limb malformations. Recommendations on prenatal counseling of parents having a child with such a deformation will become increasingly important as more deformities are expected to be diagnosed prenatally by improved diagnostic techniques. My only concern is how parents should be counseled on prenatally detected undefined soft tissue tumors. This topic is not addressed in Bae's paper. As the diagnosis is mostly based on clinical findings, radiography, and fine needle biopsy or tissue sampling, its ideal management is controversial and difficult. How should future recommendations be defined? The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References 1. Bae DS, Barnewolt CE, Jennings RW. Prenatal diagnosis and treatment of congenital differences of the hand and upper limb. J Bone Joint Surg Am. 2009;91 Suppl 4:31-9.

Scientific Articles: Factors Affecting Willingness to Undergo Carpal Tunnel Release Gong et al. (1 September 2009) [Abstract] [Full text] [PDF] Factors Affecting Willingness to Undergo Carpal Tunnel Release Dr. Chung and colleagues respond to Mr. Papanna 13 October 2009 Moon Sang Chung, MD, PhD, Professor Seoul National University Hospital, Seongnam, South Korea, Hyun Sik Gong, MD, PhD, Goo Hyun Baek, MD, PhD, Joo Han Oh, MD, PhD, Young Ho Lee, MD, PhD, and Suk Ha Jeon, MD Send letter to journal: Re: Dr. Chung and colleagues respond to Mr. Papanna hsgong{at}snu.ac.kr Moon Sang Chung, MD, PhD, et al. We thank Mr. Papanna for his interest in our paper. We included only those patients with idiopathic carpal tunnel syndrome, i.e. carpal tunnel syndrome, without a known cause. We excluded those who had wrist or forearm fractures, or pre-existing complex regional pain syndrome. We did not mention those conditions in our article, but we feel Mr. Papanna's point is a good one, and those diagnoses deserved to be mentioned. We routinely use a tourniquet during the operation for a short duration of about 5 minutes and we suture the incision after the tourniquet is released. Factors Affecting Willingness to Undergo Carpal Tunnel Release Good Article with Severe Limitations 13 October 2009 Madhavan Chikkapapanna Papanna, Registrar in Orthopaedics Luton and Dunstable Hospital NHS Foundation Trust, Luton, United Kingdom Send letter to journal: Re: Good Article with Severe Limitations drmadhavan{at}hotmail.com Madhavan Chikkapapanna Papanna To the Editor: I read the article by Gong et al. (1) with great interest. I would like to ask the authors if there were any patients in the study who had wrist or forearm fractures, if any subject had pre-existing complex regional pain syndrome and, lastly, whether a tourniquet was used during the operation. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. Reference 1. Gong HS, Baek GH, Oh JH, Lee YH, Jeon SH, Chung MS. Factors affecting willingness to undergo carpal tunnel release. J Bone Joint Surg Am. 2009;91:2130-6.

Scientific Articles: Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures? Koenig et al. (1 September 2009) [Abstract] [Full text] [PDF] Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable... Drs. Koenig and Koval respond to Dr. Slobogean 6 October 2009 Karl M. Koenig, MD, Physician Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, Kenneth J. Koval, MD Send letter to journal: Re: Drs. Koenig and Koval respond to Dr. Slobogean karlkoenig51{at}hotmail.com Karl M. Koenig, MD, et al. We sincerely appreciate the commentary posted by Dr. Slobogean regarding our decision model. His points are well taken. Our results should be interpreted with caution by the practitioner in the treatment of distal radius fractures. While we believe the decision model to be robust in its findings, the QALY gain by operative treatment is small and its true clinical significance remains to be seen. The utility data is taken from a relatively small sample and may be subject to reliability questions. However, the lack of such data in the literature highlights the importance of our unique time-trade off exercise in wrist fracture outcome evaluations. Further work is necessary to evaluate the clinical outcomes and economic implications of changes in wrist fracture treatment. However, given the widespread increase in the rates of ORIF for distal radius fractures, it is necessary to make an attempt to quantify our patients’ preferences in this matter. In that light, our model gives some credence to the notions that 1) the average patient may prefer an early operation to cast treatment, despite the inherent risks of surgery, if the chance of a good functional outcome is improved, and 2) more elderly patients are less inclined to take those risks. However, we agree that further evaluation of this treatment strategy is needed before widespread adoption should be considered. Is Early Internal Fixation Preferred to Cast Treatment for Well-Reduced Unstable... Is Early Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures? 6 October 2009 Gerard P. Slobogean, MD, MPH University of British Columbia, Vancouver, Canada Send letter to journal: Re: Is Early Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures? gsloboge{at}interchange.ubc.ca Gerard P. Slobogean, MD, MPH To the Editor: I wish to comment on the recently published work by Koenig and colleagues (1). Using their base case analysis, early internal fixation results in an additional 0.08 quality-adjusted life years (29 days) compared to non-operative treatment (24.33 vs 24.25 years). Although the authors present one- and two-way sensitivity analyses to demonstrate the relative stability of their model, I believe it is premature to adopt an early internal fixation strategy based on their results. Koenig’s model describes utilities for five health states. The utilities for each health state were obtained using a time-tradeoff (TTO) method in a convenience sample of 51 orthopaedic patients. The difference in utility between the perfect health and other fracture health states was extremely small (0.008 for painless malunion, 0.015 for painless functional deficit, and 0.043 for painful malunion). Without information regarding the measurement error and retest reliability of the TTO technique, it is difficult to know if these utility estimates are statistically or psychometrically meaningful. Regardless, it should be noted that the reported differences in utilities between the health states might not be clinically significant. A minimum important difference for the following three generic health utility questionnaires has been estimated: Health Utilities Index Mark 3 (0.06), Short-Form-6D (0.03), Euroqol-5D (0.05) (2). Furthermore, it should also be recognized that there are several methods for obtaining utility values, and that different values are obtained depending on the method used (3). In fact, the variation in the resultant quality-adjusted life years (QALYs) can affect the conclusions of economic attractiveness in a cost-effectiveness analysis (4). Finally, although not an objective of the current study, one should be encouraged to consider the costs associated with a new technology or treatment strategy. What is the incremental cost the healthcare system would be willing to pay for a gain of 29 quality-adjusted life days over a 25-year time horizon? The work presented by Koenig et al. is an initial step towards answering a relevant clinical question; however, significant uncertainty regarding the true expected value of each strategy remains. Additional modeling, clinical studies, and economic analyses should be performed before early internal fixation of well-reduced unstable distal radius fractures is routinely practiced. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References 1. Koenig KM, Davis GC, Grove MR, Tosteson AN, Koval KJ. Is early internal fixation preferred to cast treatment for well-reduced unstable distal radial fractures? J Bone Joint Surg Am. 2009;91:2086-93. 2. Marra CA, Woolcott JC, Kopec JA, Shojania K, Offer R, Brazier JE, Esdaile JM, Anis AH. A comparison of generic, indirect utility measures (the HUI2, HUI3, SF-6D, and the EQ-5D) and disease-specific instruments (the RAQoL and the HAQ) in rheumatoid arthritis. Soc Sci Med. 2005;60:1571-82. 3. Hunink M, Glasziou P, Siegel J, Weeks J, Pliskin J, Elstein A, Weinstein M. Decision making in health and medicine. New York: Cambridge University Press; 2001. 4. Marra CA, Marion SA, Guh DP, Najafzadeh M, Wolfe F, Esdaile JM, Clarke AE, Gignac MA, Anis AH. Not all "quality-adjusted life years" are equal. J Clin Epidemiol. 2007;60:616-24.

Scientific Articles: Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture Browne et al. (1 September 2009) [Abstract] [Full text] [PDF] Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture Dr. Browne and colleagues respond to Mr. O'Neill 28 October 2009 James A. Browne, MD, Orthopaedic Fellow in Adult Reconstruction Mayo Clinic, Chad Cook, PhD, MBA, PT; Steven A. Olson, MD; Michael P. Bolognesi, MD Send letter to journal: Re: Dr. Browne and colleagues respond to Mr. O'Neill browne_james{at}yahoo.com James A. Browne, MD, et al. We thank Mr. O’Neill for his interest in our paper and for sharing his own perspective on duty-hour restrictions. We agree that the delivery of healthcare is a complex process and that patient care depends on many variables. While interesting, the assertion that residents now have more time and energy to document co-morbidities and complications for their patients is pure speculation. Conversely, one could also theorize that resident physicians, in an attempt to maximize time involved in patient care and their operative experience, are neglecting their administrative duties in order to satisfy their work-hour restrictions. Given the constraints of the 80-hour work week, residents could be expected to spend a lower percentage of their time on documentation to optimize other aspects of their training. By this logic, one would expect the rate of documented complications to decline. We prefer to base our argument on the available evidence. There is no data, to our knowledge, that supports an improvement in documentation habits of residents when duty hour restrictions are imposed. However, the increased number of resident handoffs following duty hour reform has been well documented (1). Multiple studies have demonstrated deficits in communication and information transfer leading to adverse patient outcomes (2-6). The available evidence clearly supports the assertion that transfers of patient care from one physician to another may be associated with an adverse event. Needless to say, our particular study methodology was not structured to allow us to look at this specific factor as it relates to the observed complications, so we are left to extrapolate from other available studies. Furthermore, we believe that it is highly unlikely that hospitals in the United States would rely exclusively on resident documentation to determine the final reporting of complications. Reimbursement is largely dependent upon accurate coding and documentation. At our institution, the coding for final discharge diagnoses and coding of co-morbidities and complications is completed by a group of individuals who specialize in this activity, and does not rely on a single resident’s documentation for accuracy. Perhaps secondary to differences in the reimbursement systems, the National Health Service in the United Kingdom may not be analogous to the U.S. healthcare system in the role of resident physicians and documentation. The American College of Surgeons has been explicit in stating that it is inappropriate for teaching hospitals to rely upon residents to perform tasks that are not directly related to either education or patient care (7). The issue of duty hours and patient care is both complex and important. We acknowledge the limitations of using an administrative database in our study. It is our hope that this preliminary study will lead to a critical review of this issue in the interest of patient care and encourage other investigators to find data from the U.S. healthcare system that confirm or refute our observations. References 1. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1:257-66. 2. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121:866-72. 3. Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. Medication discrepancies in resident sign-outs and their potential to harm. J Gen Intern Med. 2007;22:1751-5. 4. Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Consequences of inadequate sign-out for patient care. Arch Intern Med. 2008;168:1755-60. 5. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14:401-7. 6. Okie S. An elusive balance--residents' work hours and the continuity of care. N Engl J Med. 2007;356:2665-7. 7. American College of Surgeons. Statement on residency work hours. http://www.facs.org/fellows_info/statements/st-39.html. Accessed 2009 Oct 21. Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture Resident Duty Hour Reform Associated with Increased Recording of Morbidity Following Hip Fracture 28 October 2009 Barry J. O'Neill, Registrar in Orthopaedic & Trauma Surgery Limerick Regional Hospitals, Ireland Send letter to journal: Re: Resident Duty Hour Reform Associated with Increased Recording of Morbidity Following Hip Fracture barryoneill1922{at}gmail.com Barry J. O'Neill To the Editor: As an orthopaedic trainee who was employed by the National Health Service in the United Kingdom when the European Working Time Directive was implemented, I can sympathize entirely with the motivational factors behind the recent study by Browne et al (1). The number of training hours lost to trainees in the 'interests' of trainee well-being, with (in the UK system at least) little or no flexibility and no allowance for trainee discretion, is frustrating in the extreme. So I have to applaud Browne et al. on their attempt to highlight some of the problems that the new restrictions have produced. I would however, raise a point that I think has been entirely overlooked in this particular study. The methodology of the study states that data were collected from the Nationwide Inpatient Sample (NIS), which is simply a summary of recorded discharge data. The authors use this system to highlight an increase in the incidence of pneumonia, hematoma, transfusion, and renal complications. They go on to say that, "consistent with our results, some recent studies have suggested that limiting work hours has had an adverse impact on patient outcome". The suggestion is that an increased number of hand-offs and an increase in the number of clinicians caring for each patient, have resulted in an increase in post-surgical complications such as pneumonia, hematoma, transfusion, and renal complications. In my experience, patients who develop these particular complications do so because of a variety of factors, and to suggest that an increase in the incidence of these complications is related to the new restricted working hours seems a bit simplistic. I would put it to Browne et al., that the incidence of these complications has in fact not changed significantly since the introduction of the resident duty hour reform, but that the resident duty hour reform has simply resulted in an increase in the documentation of complications on discharge summaries logged in the NIS. Put simply, residents now have more time and more energy at the end of a shift to complete their documentation fully and to record complications on discharge summaries that previously may not have been documented at all. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. Reference 1. Browne JA, Cook C, Olson SA, Bolognesi MP. Resident duty-hour reform associated with increased morbidity following hip fracture. J Bone Joint Surg Am. 2009;91:2079-85.

Scientific Articles: Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective Comparative Study Ricci et al. (1 September 2009) [Abstract] [Full text] [PDF] Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective... Dr. Wright responds to Drs. Bernstein and Ahn 6 October 2009 James G. Wright, MD, MPH, FRCSC, Associate Editor for Evidence-Based Orthopaedics The Journal of Bone & Joint Surgery Send letter to journal: Re: Dr. Wright responds to Drs. Bernstein and Ahn james.wright{at}sickkids.ca James G. Wright, MD, MPH, FRCSC Dr. Bernstein is correct that, due to an editorial error, this paper should have been rated as a Prognostic rather than a Therapeutic study. As a prospective cohort study, consistent with JBJS Levels of Evidence criteria, this study was designated as Level I. Is After-Hours Orthopaedic Surgery Associated with Adverse Outcomes? A Prospective... Not a Level I Therapeutic Study 6 October 2009 Joseph Bernstein, MD University of Pennsylvania, Philadelphia, Pennsylvania, Jaimo Ahn, MD, PhD Send letter to journal: Re: Not a Level I Therapeutic Study orthodoc{at}uphs.upenn.edu Joseph Bernstein, MD, et al. To the Editor: The article by Ricci et al. (1) was incorrectly designated as a Level I (therapeutic) study. According to the JBJS guidelines, a Level I therapeutic study is a randomized controlled trial, and this study was not that. The study perhaps could be considered under Prognostic Studies-Investigating the Effect of a Patient Characteristic on the Outcome of Disease (in this case, the "Patient Characteristic" is the time of the operation). In the JBJS guidelines, a Prognostic Study can be considered Level I if it were, "High-quality". Of course, the height of quality is a subjective judgment, but we question whether this study is of sufficiently high quality to be deemed Level I. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. Reference 1. Ricci WM, Gallagher B, Brandt A, Schwappach J, Tucker M, Leighton R. Is after-hours orthopaedic surgery associated with adverse outcomes? A prospective comparative study. J Bone Joint Surg Am. 2009;91:2067-72.

Scientific Articles: Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses A Prospective Randomized Study Kim et al. (1 August 2009) [Abstract] [Full text] [PDF] Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total... Dr. Kim and colleagues respond to Mr. Malviya 19 August 2009 Young-Hoo Kim, MD, Professor and Director Joint Replacement Center of Korea at Ewha Womans University School of Medicine, Seoul, South Korea, Yoowang Choi, MD; Jun-Shik Kim, MD Send letter to journal: Re: Dr. Kim and colleagues respond to Mr. Malviya younghookim{at}ewha.ac.kr Young-Hoo Kim, MD, et al. We appreciate Dr. Malviya's comments regarding our article, "Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses A Prospective Randomized Study" (1). 1. The NexGen CR-Flex total knee prosthesis was designed to increase the contact area between the posterior femoral condyles and the tibial polyethylene liner at high flexion angles and thereby potentially decrease polyethylene wear and osteolysis. Furthermore, it was designed to enhance knee flexion and to prevent so-called paradoxic translational motion by providing asymmetric femoral condyles as a result of a 2 mm increase in the thickness of the posterior condyles (on both the medical and lateral sides) of the femoral component; this may allow posterior femoral rollback with increasing knee flexion (2). The NexGen CR-Flex prosthesis was not designed to provide an increased posterior condylar offset by 2 mm. As Dr. Malviya pointed out, the amount of bone resected from the posterior femoral condyles was 2 mm greater when the knee was to be treated with the NexGen CR-Flex prosthesis. However, the 2 mm greater bone resection is replaced with 2 mm thicker posterior femoral condyles of NexGen CR-Flex femoral component. As a result, the final posterior femoral condylar offset would be similar in both NexGen CR-Flex and NexGen standard CR prostheses. 2. An a priori power calculation was performed with 5° considered to be a clinically relevant improvement in knee flexion. The standard deviation of 9° is not used for 5° relevant improvement in flexion, but it is used for the amount of knee flexion (eg. 131°±13.9°). If the power analysis was performed using an independent t-test, Dr. Malviya's comments are right. However, we did power analysis using paired t-test [(using Simple Interactive Statistical Analysis) calculator online with "pairwise analysis", the power was 1 (100%)]. Therefore, there is somewhat of a discrepancy between two test methods in terms of sample size. 3. The mean preoperative range of knee flexion is very high in the Asian patients group (1,3-5) compared to the Western patients group. As we discussed in the Discussion section of our article, a high degree of flexion was achieved with both NexGen CR-Flex and NexGen standard CR prostheses, which may have clouded the possible advantage of the NexGen CR-Flex implant. Several factors may have played a role in the achievement of a high degree of flexion in both groups in the current and previous series (3,4), including the preponderance of women, the low body-mass index of the patients, the use of a less-invasive approach, the relatively good preoperative range of motion, and the effective restoration of the joint line and the posterior femoral condylar offset. References 1. Kim YH, Choi Y, Kim JS. Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study. J Bone Joint Surg Am. 2009;91:1874-81. 2. Bertin KC, Komistek RD, Dennis DA, Hoff WA, Anderson DT, Langer T. In vivo determination of posterior femoral rollback for subjects having a NexGen posterior cruciate-retaining total knee arthroplasty. J Arthroplasty. 2002;17:1040-8. 3. Kim YH, Sohn KS, Kim JS. Range of motion of standard and high-flexion posterior stabilized total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am. 2005;87:1470-5. 4. Kim YH, Choi Y, Kwon OR, Kim JS. Functional outcome and range of motion of high-flexion posterior cruciate-retaining and high-flexion posterior cruciate-substituting total knee prostheses. A prospective, randomized study. J Bone Joint Surg Am. 2009;91:753-60. 5. Kim YH, Kim JS, Choi Y, Kwon OR. Computer-assisted surgical navigation does not improve the alignment and orientation of the components in total knee arthroplasty. J Bone Joint Surg Am. 2009;91:14-9. Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total... Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses 19 August 2009 Ajay Malviya, Specialist Registrar, Orthopaedics Wansbeck General Hospital, Ashington, United Kingdom Send letter to journal: Re: Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses drajaymalviya{at}gmail.com Ajay Malviya To the Editor: Kim et al. (1) have published the three-year results of the outcome following NexGen CR and NexGen CR-Flex knee prostheses. They have found no significant difference between the range of flexion between the two groups of patients. This may be because of several reasons: 1. The NexGen CR-Flex prosthesis aims to provide an increased posterior condylar offset by 2 mm. In the Methods section, the authors state that, “The amount of bone resected from the posterior femoral condyle was 2 mm greater when the knee was to be treated with the NexGen CR-Flex prosthesis than when it was to be treated with the standard NexGen CR prosthesis”. If this is done, then the final posterior condylar offset will be the same for both the groups (as noted in the study, Table V), and the aim of achieving the extra 2 mm offset would not be realized. 2. A post hoc power analysis with the figures quoted in Table III (Gp 1 Mean Flexion 1310 sd 13.9; Gp 2 Mean Flexion 1330 sd 10.4; Sample size 54 each group) shows a one-tail test power of 21.2% and a two-tail test power of 13.5%. This obviously shows that the study is clearly underpowered to detect a difference in between the two groups. The authors did do a power analysis prior to the study using 5° as clinically relevant difference in flexion, with a standard deviation of 9°. Can they please clarify why they used 9° as the standard deviation which is more than the difference they were aiming for? 3. The mean amount of flexion preoperatively was 128°, which is obviously quite high as compared to a typical group with arthritis requiring knee replacement (2). This may contribute to the limited improvement of flexion noted in this study. The role of posterior condylar offset in improving range of motion following knee replacement has been proven in several independent studies (3,4,5). It may well be that the current study does not show any difference because of technical, methodological and epidemiological issues. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References 1. Kim YH, Choi Y, Kim JS. Range of motion of standard and high-flexion posterior cruciate-retaining total knee prostheses a prospective randomized study. J Bone Joint Surg Am. 2009;91:1874-81. 2. Lizaur A, Marco L, Cebrian R. Preoperative factors influencing the range of movement after total knee arthroplasty for severe osteoarthritis. J Bone Joint Surg Br. 1997;79:626–9. 3. Bellemans J, Banks S, Victor J, Vandenneucker H, Moemans A. Fluoroscopic analysis of the kinematics of deep flexion in total knee arthroplasty. Influence of posterior condylar offset. J Bone Joint Surg Br. 2002;84:50-3. 4. Massin P, Gournay A. Optimization of the posterior condylar offset, tibial slope, and condylar roll-back in total knee arthroplasty. J Arthroplasty. 2006;21:889-96. 5. Malviya A, Lingard EA, Weir DJ, Deehan DJ. Predicting range of movement after knee replacement: the importance of posterior condylar offset and tibial slope. Knee Surg Sports Traumatol Arthrosc. 2009;17:491-8. Epub 2009 Jan 13.

Scientific Articles: Complication Reporting in Orthopaedic Trials. A Systematic Review of Randomized Controlled Trials Goldhahn et al. (1 August 2009) [Abstract] [Full text] [PDF] Complication Reporting in Orthopaedic Trials. A Systematic Review of Randomized... Dr. Goldhahn and colleagues respond to Drs. Cheng and Zhang 11 September 2009 Sabine Goldhahn, MD, Physician AO Clinical Investigation and Documentation, Dübendorf, Switzerland, Laurent Audigé, PhD, DVM, Raman Mundi, BHSc, Beate Hanson, MD, MPH, Mohit Bhandari, MD, MSc, Jörg Goldhahn, MD, MAS Send letter to journal: Re: Dr. Goldhahn and colleagues respond to Drs. Cheng and Zhang sabine.goldhahn{at}aofoundation.org Sabine Goldhahn, MD, et al. Thank you very much for your interest and helpful comments. We totally agree that the use of a validated questionnaire is always the best choice in evidence-based medicine. In fact, we use only validated instruments in our multicenter studies. However, this study was a first attempt to quantify the size of the problem related to complication reporting in orthopaedic surgery. We were surprised by the magnitude of the problem and agree that further evaluations should include validated assessment tools. We focused in this study on orthopaedic studies only. This was the reason for not citing your quoted references. The references show one more time the tremendous need to establish uniform criteria for complication reporting in the field of orthopaedic surgery. While in some cases it is not clear what is considered a complication, your concerns about measuring them goes much farther. This has to be addressed in the next project. Complication Reporting in Orthopaedic Trials. A Systematic Review of Randomized... Concern Regarding Complications Reporting in Orthopaedic Trials 11 September 2009 Tao Cheng, MD, PhD Sixth Affiliated People's Hospital, Shanghai Jiao Tong University, China, Xian-Long Zhang, MD, PhD, Professor Send letter to journal: Re: Concern Regarding Complications Reporting in Orthopaedic Trials zhangxianlong2009{at}hotmail.com Tao Cheng, MD, PhD, et al. To the Editor: We read with interest the paper by Goldhahn et al. (1) which elucidated the disparity in the quality of complication reporting in the orthopaedic literature and we wish to bring attention to three important issues. First, Goldhahn et al. asserted that two external reviewers used a nonstandardized, nonvalidated checklist for the assessment of complication reporting in the randomized controlled trials. As we know, a checklist tool must be reliable in order to be useful in clinical or research practice. In fact, there are a wide variety of techniques available, such as the kappa coefficient, to measure agreement or reliability including intraobserver and interobserver reliability. Second, the authors stated in the discussion section that a validated checklist is unavailable given the novelty of the field of complication reporting. However, ten standard criteria for reporting outcomes in surgery have been established (2,3) that, in our opinion, can be applied directly to the field of orthopaedics. They include the following : Method of accruing data defined; Duration of follow-up indicated; Outpatient information included; Definitions of complications provided; Mortality rate and causes of death listed; Morbidity rate and total complications indicated; Procedure-specific complications included; Severity grade utilized; Length-of-stay data; and Risk factors included in the analysis (2). Third, based on the fact that the modality used to detect complications is unclear in many studies, it is difficult to assess the true frequency of their occurrence or compare interventions. For example, it is possible that the disagreement in results regarding deep vein thrombosis is due to the difference between the methods of thrombus detection (4). Frequently, authors of the reviewed trials suggested that "no complications" occurred during the study period. In fact, the lack of an appropriate diagnostic modality makes it impossible to determine some asymptomatic complications such as low-grade infection and subclinical deep vein thrombosis. Recognizing the problems, we strongly recommend reporting the diagnostic modality and threshold value for complications, especially "implant-related" complications. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Goldhahn S, Sawaguchi T, Audigé L, Mundi R, Hanson B, Bhandari M, Goldhahn J. Complication reporting in orthopaedic trials. A systematic review of randomized controlled trials. J Bone Joint Surg Am. 2009;91:1847-53. 2. Martin RC 2nd, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg. 2002;235:803-13. 3. Khuri SF. The NSQIP: a new frontier in surgery. Surgery. 2005;138:837-43. 4. Wheeler HB, Anderson FA Jr. Diagnostic methods for deep vein thrombosis. Haemostasis. 1995;25:6-26.

Scientific Articles: Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous Fixation. A Prospective Randomized Trial Rozental et al. (1 August 2009) [Abstract] [Full text] [PDF] Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction... Dr. Rozental responds to Mr. Holmes and colleagues 29 October 2009 Tamara D. Rozental, MD, Assistant Professor Harvard Medical School, Boston, MA Send letter to journal: Re: Dr. Rozental responds to Mr. Holmes and colleagues trozenta{at}bidmc.harvard.edu Tamara D. Rozental, MD We thank the authors for their thoughtful questions and remarks. We agree that post-operative immobilization likely plays an important role in explaining the lower DASH scores among patients treated with closed reduction and percutaneous pinning (and have included this as part of our title). Since post-operative immobilization is routinely employed following closed reduction and percutaneous pinning, we believe it is an important factor to consider when deciding on a treatment method for unstable fractures of the distal radius. Although our numbers were small, we were not able to detect any differences between age groups and believe that our study findings apply to young and elderly patients alike. Finally, the standard deviation in our return to work data is explained by the fact that several patients did not choose to take any time away from work during/after their treatment. We hope this helps to clarify the data and, once again, thank the authors for their comments. Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction... Group Homogeneity 29 October 2009 William JM Holmes, MBChB, MRCSEd, Doctor , A. Roche, M. Webb Send letter to journal: Re: Group Homogeneity willjmholmes{at}googlemail.com William JM Holmes, MBChB, MRCSEd, et al. To the Editor: We read the article by Rozental et al. (1) with great interest and welcome the authors' attempt to add more prospective studies to this highly controversial area of clinical practice (2). We also congratulate the authors on the regular and thorough follow up. We note from their introduction that they had a specific emphasis on "early functional recovery". One point we would like to make is that plaster immobilization is likely to affect the 6-week DASH score in the closed reduction and percutaneous fixation group when compared to those with ORIF and post-operative splinting. This makes it difficult to study early outcomes without inadvertently measuring the effect of plaster vs. splint, rather than the specific intervention desired. Furthermore, one of the difficulties encountered in all studies that attempt to compare interventions is that, in order to get sufficient numbers to provide statistical analysis, large age ranges exists for each group (19-77 years versus 24-79 years). This often makes it difficult to draw significant conclusions as age has a large bearing on patients perceived outcomes and functional ability - the requirements of a 17 year old are very different from those of a 79 year old. Furthermore, since occupation was not studied in the paper, it furthermore highlights the difficulty in grouping together such a heterogeneous population. Lastly, we admire the attempt look at return to work as this provides good patient-orientated outcome measure, but the statistics in this paper implied that return to work was 17+/-21 days versus 26+/-27 days. This would indicate that some patients returned to work 4 days prior to their injury, making the analysis difficult to interpret. Can the authors explain these numbers? The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1837-46. 2. Henry MH. Distal radius fractures: current concepts. J Hand Surg Am. 2008;33:1215-27. Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction... Dr. Rozental responds to Dr. Kumar 2 September 2009 Tamara D. Rozental, MD, Assistant Professor in Orthopaedic Surgery Harvard Medical School, Boston, MA Send letter to journal: Re: Dr. Rozental responds to Dr. Kumar trozenta{at}bidmc.harvard.edu Tamara D. Rozental, MD We thank Dr. Kumar for his comments. The age and fracture distribution among both patients groups was similar. Furthermore, given that reductions were maintained in both patient groups, we did not feel that age or the presence of osteoporotic bone significantly affected our results. For these reasons, we did not conduct a separate analysis by age. As is our standard protocol, patients with fragility fractures and those with other risk factors for osteoporosis were referred for bone mineral density testing. Treatment for underlying osteopenia and osteoporosis was then determined on a case-by-case basis. All closed reductions and percutaneous pinnings were performed under regional anesthesia with sedation and/or general anesthesia. We obtained an adequate closed reduction in all cases and there was no cross-over to the open reduction group after randomization (see Figure 1). The technique for placement of Kirschner wires is described in our Methods section. Wires were placed through small stab incisions in the radial styloid and along the dorsal-ulnar aspect of the distal radius. No wires were placed volarly. Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction... Letter to the Editor 2 September 2009 Sudeep Kumar, MBBS, MS(Ortho), Senior Resident Surgeon, Orthopaedics All India Institute Of Medical Sciences, New Delhi, India Send letter to journal: Re: Letter to the Editor drsudeeportho{at}gmail.com Sudeep Kumar, MBBS, MS(Ortho) To the Editor: I read with interest the paper by Rozental et al. (1) and would like to raise some points and put forward a few questions to the authors: 1). There was no mention of which age group was affected most by which type of fracture. There are high chances of failure of Kirschner wire fixation in A1 and A2 fractures in elderly osteoporotic population. Thus the result could vary according to patient age. Therefore, it is difficult to generalize the results without taking patient age into consideration. An age-wise differentiation of the fractures and the analysis of the results should have been done. 2). What were the criteria used to define osteoporosis and was screening for osteoporosis done in any age group or were any additional precautions taken or drug supplementation given preoperatively and postoperatively in these patients? 3). There was no mention in your paper regarding the type of anesthesia or sedation used for the closed reduction group. Many times under hematoma block consideration, it is very difficult to achieve a good closed reduction. So, if the fractures were manipulated under general anesthesia and the reduction obtained was not satisfactory, did the surgeon proceed with open reduction or accept the unsatisfactory reduction? 4). Were the wires placed dorsally or volarly? If the wires were inserted dorsally, how were the tendons protected and, if they were placed volarly, what was the method used to protect the neurovascular structures? The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. Reference 1. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1837-46.

Scientific Articles: Surgical Treatment of Three and Four-Part Proximal Humeral Fractures Solberg et al. (1 July 2009) [Abstract] [Full text] [PDF] Surgical Treatment of Three and Four-Part Proximal Humeral Fractures Dr. Solberg and colleagues respond to Mr. Clarke and Mr. Nunn 9 September 2009 Brian D. Solberg, MD , Charles N. Moon, MD; Dennis P. Franco, MD; Guy D. Paiement, MD Send letter to journal: Re: Dr. Solberg and colleagues respond to Mr. Clarke and Mr. Nunn brian{at}briansolbergmd.com Brian D. Solberg, MD, et al. Thank you for your inquiry which raises several valid points regarding our analysis of these injuries. The first question pertains to the severity of the fracture patterns we triaged to each group and the bias this introduced into the data analysis. As the question indicates, there is no Level 1 data regarding the management of these injuries so most series are based on commonly accepted treatment protocols with retrospective data analysis. In our series, all patients were over 55 years of age and the vast majority of the fractures in both groups were secondary to trip and fall injuries. In that regard, the two groups were similar. Of the 71 patients in the hemiarthroplasty group prior to exclusion, 37 had a ‘head split’ pattern, 17 had anatomic neck displacement of greater than 2 cm, 9 had impaction of the articular surface and 6 were dislocated for more than 24 hours. Whether the above patterns represent more severe injuries in this population remains unanswered but these patterns are not thoroughly addressed in Neer’s original classification (1). However, all patients with a documented rotator cuff tear were excluded from the final study groups so there was no bias introduced by this variable. The second question pertains to the overall respective complication rates of hemiarthroplasty and ORIF. We struggled with this question as the number of possible complications is very large. For example, should humeral head osteonecrosis be considered a complication of the injury or the treatment of the injury? Should asymptomatic osteonecrosis be considered a complication of locked plate treatment? Since this complication cannot happen in the hemiarthroplasty group, should it be compared? In the ORIF group, there were 3 infections (8%), 6 head perforations (16%) and 4 patients with loss of fixation (12%). There was some overlap and the above complications were observed in 11/38 patients (29%). In the hemiarthroplasty group, three patients developed a wound infection (6%), and seven (15%) developed a tuberosity nonunion with an overall complication rate of 10/48 (21%). Our series did not have the statistical power to discern between these two groups (p=0.18). A post-hoc analysis indicated that we would need 85 patients in each group to achieve statistical significance assuming that an 8% difference in complication rates was real. Furthermore, the rate of iatrogenic complications such as screw perforation and loss of fixation decreased over time as our intra-operative technique for evaluating implant position and humeral head reduction improved. In examining the complications within the ORIF group, the rate of complication in the valgus patterns was 4/26 (15%) vs. 7/12 (58%) in the varus patterns (p=0.04). This is consistent with previously published data indicating that the complication rate is more a function of initial fracture pattern than the severity using the Neer classification (2). The purpose of our series was not to compare hemiarthroplasty to ORIF across the board but to identify fracture patterns which can have better outcomes with ORIF and identify which ones yielded equivocal outcomes to hemiarthroplasty in a similar cohort of patients. The evidence presented this paper, although not definitive, robustly supports the use of a locked plate in many 3-part and 4-part fractures. What was definitive was that patients with initial valgus displacement had better outcomes and lower complication rates irrespective of Neer fracture type while varus fracture patterns had a higher complication rate and equivocal outcomes compared to hemiarthroplasty, an observation that has been documented previously in the literature (3). As we referenced in the manuscript, classifying these injuries based on the Neer or OTA systems was difficult as reported by other authors (4), however, neither one takes initial humeral head displacement into consideration. In our series, this was the singlemost important criterion influencing final outcome. References 1. Neer CS 2nd. Displaced proximal humeral fractures. II. Treatment of three-part and four-part displacement. J Bone Joint Surg Am. 1970;52:1090-103. 2. Solberg BD, Moon CN, Franco DP, Paiement GD. Locked plating of 3- and 4-part proximal humerus fractures in older patients: The effect of initial fracture pattern on outcome. J Orthop Trauma. 2009;23:113-9. 3. Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73:295-8. 4. Siebenrock KA, Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus. J Bone Joint Surg Am. 1993;75:1751-5. Surgical Treatment of Three and Four-Part Proximal Humeral Fractures Surgical Treatment of Three and Four-Part Proximal Humeral Fractures 9 September 2009 Jon V. Clarke, Specialist Registrar West of Scotland Orthopaedic Rotation, United Kingdom, Tom Nunn Send letter to journal: Re: Surgical Treatment of Three and Four-Part Proximal Humeral Fractures jvclarke{at}doctors.org.uk Jon V. Clarke, et al. To the Editor: We read with interest the article by Solberg et al. (1) which highlights the challenges of managing a complex fracture pattern which often has poor outcomes regardless of treatment (2), particularly in osteoporotic bone. We appreciate that the authors acknowledged a number of limitations in this retrospective review, but feel some important issues have been overlooked. Firstly, the two study groups differed with respect to the severity of the fractures sustained. The more complex patterns, including intra-articular fractures and those with associated rotator cuff tears, underwent prosthetic replacement as they were deemed unsuitable for internal fixation. While the authors felt they were unable to correct for this potential bias, it would not have been unreasonable to exclude these patients given that hemiarthroplasty was considered the only surgical option in these cases. Subsequently do the authors feel this would then alter the statistically significant outcomes? Secondly, it is noted that overall complication rates in both treatment groups were high but those managed with locking plates appear higher. Statistical comparison with regard to this appears missing from the text and we question whether the authors feel this would be of value? As yet there is no level I evidence comparing prosthetic replacement with internal fixation for Neer 3- and 4-part fractures, possibly due to the relative rarity of this injury (3) and the subsequent difficulties in recruiting sufficient numbers of patients prospectively. In summary we merely wish to question whether the evidence presented in this paper is robust enough to conclude that locked plate fixation results in better outcomes than hemiarthroplasty. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Solberg BD, Moon CN, Franco DP, Paiement GD. Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009;91:1689-97. 2. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001:72:365-71. 3. Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation. J Bone Joint Surg Br. 2006;88:502-8.

Scientific Articles: The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty Marchant et al. (1 July 2009) [Abstract] [Full text] [PDF] The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After... Glycemic Control and Outcomes after Joint Arthroplasty 28 August 2009 N. Wah Cheung, Consultant Endocrinologist Westmead Hospital, University of Sydney, NSW, Australia Send letter to journal: Re: Glycemic Control and Outcomes after Joint Arthroplasty wah{at}westgate.wh.usyd.edu.au N. Wah Cheung To the Editor: Marchant et al. have found that patients with uncontrolled diabetes have worse perioperative outcomes after joint arthroplasty than patients with controlled diabetes who, in turn, have worse outcomes than those without diabetes (1). The classification of diabetes control was determined from ICD-9 codes. While this reflects glycemic control to a degree, a better determinant would be a biochemical measure such as serum glucose at the time of hospital admission. We have previously found a relationship between admission blood glucose levels, hospital mortality, and length of stay (LOS) in patients admitted through our Emergency Department (2). In light of the publication by Marchant et al., we analyzed our data for the subset of 489 patients who had a Diagnosis Related Group and ICD-10 code indicating their admission was related to a bone and joint disorder. As there were no deaths in this cohort, we used LOS as the outcome of interest. Using linear regression, the relative LOS per unit increase in blood glucose level was 1.07 (95%CI 1.03-1.10, p<0.001), after adjustment for age and sex; i.e., for every one mmol/L increase in blood glucose level, LOS increased by 7%. The relative LOS for those with a blood glucose level over 8 mmol/L compared to those with a level under 8 mmol/L was 1.31 (95%CI 1.03-1.65), after adjustment; i.e., their average length of stay was 31% longer. It seems likely that increased LOS in our study was related to increased hospital complications. Our data therefore support the finding that glucose control influences outcomes of patients admitted to hospital for acute musculoskeletal conditions. In addition to increased morbidity, this has significant cost implications to the health system. Further research needs to be conducted to determine if interventions for hyperglycemia result in better outcomes for these patients. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References 1. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009;91:1621-9. 2. Cheung NW, Li S, Ma G, Crampton R. The relationship between admission blood glucose levels and hospital mortality. Diabetologia. 2008;51:952-5.

Scientific Articles: Unstable Distal Radial Fractures Treated with External Fixation, a Radial Column Plate, or a Volar Plate. A Prospective Randomized Trial Wei et al. (1 July 2009) [Abstract] [Full text] [PDF] Unstable Distal Radial Fractures Treated with External Fixation, a Radial Column... Unstable Distal Radial Fracture Treatment 25 August 2009 Benedict A. Rogers, Specialist Registrar St George's Hospital, London, United Kingdom, Chike Emeagi, Nick Little Send letter to journal: Re: Unstable Distal Radial Fracture Treatment benedictrogers{at}hotmail.com Benedict A. Rogers, et al. EDITOR'S NOTE: The authors were invited to respond to the letter but, to date, have not done so. To the Editor: We read with interest the July 2009 article by Wei et al. (1) entitled, “Unstable Distal Radial Fractures Treated with External Fixation,a Radial Column Plate, or a Volar Plate...” and would like to make the following points. 1. In the Materials and Methods, the authors define the three treatment arms of the study. The external fixator group incorporates “additional augmentation” that includes patients that required cancellous bone allograft and/or “the additional use of small buttress plates”. No detail is given to these additional surgical procedures, all of which can significantly influence clinical outcome (2). Subsequently, can the outcome in this group be solely attributable to external fixation as this study states? 2. Previous studies suggest a statistical correlation between instability of the distal radioulnar joint (DRUJ) and worse clinical outcomes (3-5). No assessment has been detailed in this study of DRUJ instability and indeed the Orthopaedic Trauma Association classification does clearly differentiate involvement of the DRUJ. Do the authors feel that DRUJ instability is a possible confounding factor in the outcome of these fractures? 3. It is recognized that a correlation exists between functional outcome and the restoration of the radiocarpal and radioulnar relationships (6,7). Further, carpal alignment in relation to the distal radial articular surface after healing may also be an important factor in the outcomes of treatment of distal radial fractures (8). As this study provides no direct evaluation of carpal alignment following treatment, such as the scapholunate angle, do the authors consider carpal alignment a significant factor in wrist function? 4. The relative bone mineral density (BMD) of each of the three treatment arms studied is not provided in the results. Whilst the quantification of the BMD may be superfluous in routine clinical practice, for a clinical study evaluating three different surgical techniques, including locking plates, the results should be matched for BMD (9). Specifically, should the reader assume all patients are osteoporotic by the nature of the fracture and their age, and if so is this assumption a valid one? The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Wei DH, Raizman NM, Bottino CJ, Jobin CM, Strauch RJ, Rosenwasser MP. Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate. A prospective randomized trial. J Bone Joint Surg Am. 2009;91:1568-77. 2. Dodds SD, Cornelissen S, Jossan S, Wolfe SW. A biomechanical comparison of fragment-specific fixation and augmented external fixation for intra-articular distal radius fractures. J Hand Surg Am. 2002;27:953-64. 3. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Orthop Relat Res. 2000;229-35. 4. Lindau T, Aspenberg P. The radioulnar joint in distal radial fractures. Acta Orthop Scand. 2002;73:579-88. 5. Lindau T, Runnquist K, Aspenberg P. Patients with laxity of the distal radioulnar joint after distal radial fractures have impaired function, but no loss of strength. Acta Orthop Scand. 2002;73:151-6. 6. Gartland JJ Jr, Werley CW. Evaluation of healed Colles' fractures. J Bone Joint Surg Am. 1951;33-A:895-907. 7. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647-59. 8. Catalano LW 3rd, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J Jr. Displaced intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am. 1997;79:1290-302. 9. Nordvall H, Glanberg-Persson G, Lysholm J. Are distal radius fractures due to fragility or to falls? A consecutive case-control study of bone mineral density, tendency to fall, risk factors for osteoporosis, and health-related quality of life. Acta Orthop. 2007;78:271-7.

Scientific Articles: Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the Locking Proximal Humerus Plate. Results of a Prospective, Multicenter, Observational Study Südkamp et al. (1 June 2009) [Abstract] [Full text] [PDF] Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the... Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot 5 August 2009 Gerhard G. Konrad, MD, Orthopaedic Surgeon University Hospital Freiburg, Germany, Norbert P. Südkamp, MD Send letter to journal: Re: Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot gerhard.konrad{at}uniklinik-freiburg.de Gerhard G. Konrad, MD, et al. The authors would like to thank Drs. Smith and Moonot for their interest in our study. They raised several points which deserve further comment. We have the following explanations to offer: An analysis of the complication rate with respect to patient age was initially not performed in the study. However, after reanalyzing the data we separated two groups of patients: Group 1 younger than 60 years (n = 65, 42% of all patients) and Group 2 older than 60 years (n = 90, 58% of all patients). 43 of the 62 complications (69%) were encountered in Group 2. The mode of failure of the three cases of plate breakage was related to surgical technique. In all three cases, a nonunion of the fracture was present after initial malreduction of the fracture. Due to the nonunion, a stress concentration onto the plate occurred which is biomechanically highly predictive for plate breakage. Therefore the implant breakage was not related to the type of plate and its metallic composition. Although rates of primary screw perforation into the glenohumeral joint and other technique-related complications were observed in our study, we believe that it is not necessary that these fractures be treated exclusively by a shoulder or upper-extremity specialist. Because of the increasing numbers of proximal humeral fractures more generalists will likely be treating these patients. If a trauma surgeon uses the correct surgical technique a good functional outcome can be expected. However, since these fractures are difficult to treat, a trauma surgeon needs to be well versed in the technique and must have adequate surgical skill and assistance to perform the operation correctly. An appropriate fracture reduction prior to the fixation with the locking proximal humerus plate is indispensable. A final image intensifier check with multiple radiographic views including an axial view is also necessary in all cases. Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the... Does Patient Age Affect Outcome with PHILOS Plates? 5 August 2009 James O. Smith, Specialty Registrar, Orthopaedics St. Mary's Hospital, Isle of Wight, United Kingdom, Pradeep Moonot Send letter to journal: Re: Does Patient Age Affect Outcome with PHILOS Plates? jsmith{at}doctors.org.uk James O. Smith, et al. To the Editor: We read the article by Südkamp et al. (1) with interest. Treatment of these fractures remains controversial, in part due to the scarcity of prospective studies evaluating this technique. This careful multicenter study, with good numbers, lacking in previous papers, helps to define more clearly the indications for the use of the proximal humeral locking plate. Previous studies have compared the outcome in younger and older patients (2-4). However, they showed differences in the Constant score as well as the rate of complications. This may be due to the small sample size. We would therefore welcome further analysis into complication rates with respect to patient age in the present study. Discussion of the mode of failure of the three cases of implant breakage would also have been helpful. One of the previous studies reported a case of plate breakage because the plate was applied to the humeral shaft incorrectly (3). Was plate breakage in the present case series related to the type of plate and its metallic composition (titanium or steel) or due to surgical technique? We also note a high rate (21 patients) of primary screw perforation into the glenohumeral joint. This has not been seen in previous case series (2-4). Do the authors believe that, due to these reasons, fixation of these fractures using the proximal humeral locking plate should be done by upper limb specialist surgeons? The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, Luo C, Plecko M, Wendt K, Köstler W, Konrad G. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009;91:1320-8. 2. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Related Res. 2006;442:115-20. 3. Moonot P, Ashwood N, Hamlet M. Early results for the treatment of three- and four- part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint Surg Br. 2007;89:1206-9. 4. Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal humeral fractures with a locking compression plate: a retrospective evaluation of 72 patients followed for a minimum of 1 year. Acta Orthop Scand. 2004;75:741-5.

Scientific Articles: Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. A Concise Follow-up, at a Minimum of Twenty Years, of Previous Reports Della Valle et al. (1 May 2009) [Abstract] [Full text] [PDF] Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. A Concise... Dr. Della Valle and colleagues respond to Mr. Whitehouse and Mr. Bannister 5 August 2009 Craig J. Della Valle, MD, Associate Professor Rush University Medical Center, Chicago, Illinois, Aaron G. Rosenberg, MD; Joshua J. Jacobs, MD; Jorge O. Galante, MD Send letter to journal: Re: Dr. Della Valle and colleagues respond to Mr. Whitehouse and Mr. Bannister craigdv{at}yahoo.com Craig J. Della Valle, MD, et al. We thank Mr. Whitehouse and Bannister for their interest in our work. The primary reason for our reviewing this series of patients was to determine the durability of cementless fixation for acetabular reconstruction in primary total hip arthroplasty as we are unaware of any other series that report these results at a minimum of twenty years. Nonetheless, we reported in our manuscript survivorship with, “a reoperation on the hip for any problem related to the acetabular metal shell (e.g. loosening, polyethylene wear or periacetabular osteolysis)…”as one of the endpoints; survivorship with this endpoint was 86% at twenty years. Thus, in contradistinction to your concern regarding reporting on, “one part of one component”, survivorship for acetabular component and liner was reported. We also went on to include a description of an additional eight hips in which a liner change had been recommended by one of us, but not yet performed. Further, in response to your concern of a, “trend in orthopaedics...to report only the survival of one component of a construct” the survivorship of the femoral component was also described in our report. Given the popularity of cementless fixation of the acetabular component in North America, the lack of prior data at the time point described and the known shortfalls of the first generation, non-circumferentially porous coated femoral component used in this early series, a focus on the acetabular component seems warranted. We would agree that the lack of complete radiographic follow-up is a limitation of this work. Despite our concerted efforts to encourage patients to return for radiographic follow-up, many simply will not as they are oftentimes of an advanced age and or asymptomatic. Survivorship analysis, however, does correct for this to a certain extent, with the reported 95% confidence intervals that widen, as the number of patients from the original data set are lost. Finally, Mr. Whitehouse and Bannister in their letter represent survival rates without taking into account censored data and resultant effects on confidence intervals. Understandably, since computing survival estimates with error estimates (i.e. confidence intervals) is nearly impossible without the raw data, but use of a “worst case scenario” is overly simplistic and biases interpretation in a way that we feel misrepresents the data. We do not intend to portray the HG-1 cup as an implant free of problems; it had a poor locking mechanism, a less than ideal (rough) concave surface and, by modern standards, a sub-optimal bearing surface that all contributed to a high rate of wear related problems. Fixation, however, has been impressive. It is our hope that with improvements in bearing technology and contemporary cup design, the rate of re-operation for wear related sequalae will decrease in the future with a lower rate of re-operation for our patients. Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. A Concise... Definition of Failure 5 August 2009 Michael R. Whitehouse, MBChB, BSc, M(ScOrthEng), MRCS(Eng), Hip Fellow University of Bristol, Bristol, United Kingdom, G.C. Bannister, MD, FRCS Send letter to journal: Re: Definition of Failure mikerwhitehouse{at}gmail.com Michael R. Whitehouse, MBChB, BSc, M(ScOrthEng), MRCS(Eng), et al. To the Editor: We read with interest the recent article by Della Valle et al. (1). There are a number of points we feel need to be raised with regard to the authors’ conclusions. The authors report a 96% survival rate at their final follow-up with aseptic loosening as the defined end point. As the authors themselves point out, this is not the major mode of failure of this design of acetabular component. There is a trend in orthopaedic surgery for investigators to report the survival of one component of a construct. But this paper is even more selective, identifying one part of one component, the metal shell. Assuming best-case analysis, the data presented in Table II indicates a survival of the acetabular component of 65% at 20 years. Isolated liner exchange is associated with a high risk of subsequent dislocation (2,3). The percentages presented in the paper are based on an assumed population available for study of 204 patients (184 patients). Only 124 hips in 111 patients were available for study with 69 deaths (75 hips) and 4 patients lost to follow up (5 hips). Thirty-two percent of these patients did not have radiographs performed, therefore silent osteolysis and wear could not be assessed. As silent osteolysis is an important failure mode that currently makes up the majority of our revision burden, we feel this cohort is significant (4). Indeed, the associated loss of bone stock with osteolysis means that it is a more serious failure mode than the more predictable aseptic loosening of the cemented cup, failure of which stimulated this design. According to the date presented, 10 out of 124 shells had been revised at 20 years (92% survival); a further 21 liners had been revised or revision had been recommended in this group (75% survival including revised shells). Excluding patients without radiographs, this gives a 43.5% known survival on the basis of a worst-case analysis. Seventy-five hips had clinical and radiographic evaluation (60.5% survival worst-case analysis) and 25 of these demonstrated osteolysis, indicating a likely need for revision (40.3% survival). It is difficult to extract how many of these overlap with hips having a liner exchange performed or recommended. We would suggest that revision for any cause or the impending need for revision would give a more helpful representation of outcome when reporting on total joint replacement procedures. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Della Valle CJ, Mesko NW, Quigley L, Rosenberg AG, Jacobs JJ, Galante JO. Primary total hip replacement with a porous-coated acetabular component. A concise follow-up, at a minimum of twenty years, of previous reports. J Bone Joint Surg Am. 2009;91:1130-5. 2. Blom AW, Astle L, Loveridge J, Learmonth ID. Revision of an acetabular liner has a high risk of dislocation. J Bone Joint Surg Br. 2005;87:1636-8. 3. Lie SA, Hallan G, Furnes O, Havelin LI, Engesaeter LB. Isolated acetabular liner exchange compared with complete acetabular component revision in revision of primary uncemented acetabular components: a study of 1649 revisions from the Norwegian Arthroplasty Register. J Bone Joint Surg Br. 2007;89:591-4. 4. Utting MR, Raghuvanshi M, Amirfeyz R, Blom AW, Learmonth ID, Bannister GC. The Harris-Galante porous-coated, hemispherical, polyethylene-lined acetabular component in patients under 50 years of age: a 12- to 16-year review. J Bone Joint Surg Br. 2008;90:1422-7.

Scientific Articles: Effect of an Unrepaired Fracture of the Ulnar Styloid Base on Outcome After Plate-and-Screw Fixation of a Distal Radial Fracture Souer et al. (1 April 2009) [Abstract] [Full text] [PDF] Effect of an Unrepaired Fracture of the Ulnar Styloid Base on Outcome After Plate-and-Screw... Dr. Ring and colleagues respond to Mr. Al-Fakayh 11 September 2009 David Ring, MD, PhD, Physician Massachusetts General Hospital, Jesse B. Jupiter, MD, J. Sebastiaan Souer, MD Send letter to journal: Re: Dr. Ring and colleagues respond to Mr. Al-Fakayh dring{at}partners.org David Ring, MD, PhD, et al. Mr. Al-Fakayh clearly restates part of the rationale that has led many of us to think of base of ulnar styloid fractures as a marker for poor outcome, which our data clearly show is not the case. Mr. Al-Fakayh also correctly restates the shortcoming of our study — that there was no specific evaluation of DRUJ instability; however, the 2-year follow-up and few symptoms and no procedures related to the DRUJ is fairly convincing. At a minimum, our data confirm that the concern regarding base of ulnar styloid fractures is overstated. In terms of pure science, we agree with Mr. Al-Fakayh’s proposed study design; however, does data such as ours make randomization to operative treatment of an ulnar styloid base fracture in 50% of patients unethical? We think the next study might be a prospective cohort study with specific evaluation of the DRUJ, or perhaps a clinical trial comparing two nonoperative treatments (for instance free forearm motion immediately versus immobilization in mid-supination for several weeks). For this to be meaningful, we will need to develop a clear definition and an objective and quantifiable measure of DRUJ instability. In any case, we are all in agreement that science will be the ultimate arbiter of this debate. Effect of an Unrepaired Fracture of the Ulnar Styloid Base on Outcome After Plate-and-Screw... Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures 11 September 2009 Omar Al-Fakayh, Specialist Registrar Aberdeen Royal Infirmary, Aberdeen, United Kingdom Send letter to journal: Re: Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures alfakayh{at}hotmail.co.uk Omar Al-Fakayh To the Editor: I read with great interest the study by Souer et al. (1) and I have a few comments. It is well known that distal radius fracture is associated with ulnar styloid fracture in more than 40% of cases (2). It has been suggested that injuries to the ulnar styloid will lead to instability of the distal radio-ulnar joint (DRUJ) (3,4). The authors suggested that there is no difference between the groups regarding DRUJ stability, although it was not assessed clinically or radiographically. As previous research has identified, distal radioulnar joint instability may lead to long-term problems with wrist pain (5) and May et al. found that all distal radial fractures complicated by distal radioulnar joint instability were accompanied by an ulnar styloid fracture (3). I agree with the authors that comparing outcomes between patients with ulnar styloid fractures and those without will provide some information about the impact of the unrepaired ulnar styloid fracture on the outcome of distal radius fracture fixation. However, the best way to answer this question is to select a group of distal radius fracture patients with associated ulnar styloid fractures only and then to randomize them to have the ulnar styloid fixed or not and compare the outcomes of these two cohorts of patients. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References 1. Souer JS, Ring D, Matschke S, Audige L, Marent-Huber M, Jupiter JB, AOCID Prospective ORIF Distal Radius Study Group. Effect of an unrepaired fracture of the ulnar styloid base on outcome after plate-and-screw fixation of a distal radial fracture. J Bone Joint Surg Am. 2009;91:830-8. 2. Logan AJ, Lindau TR. The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment. Strategies Trauma Limb Reconstr. 2008;3:49–56. 3. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with distal radius fractures: incidence and implications for distal radioulnar joint instability. J Hand Surg Am. 2008;27:965–71. 4. Stoffelen D, De Smet L, Broos P. The importance of the distal radioulnar joint in distal radial fractures. J Hand Surg Br. 1998;23:507-11. 5. Cheng HS, Hung LK, Ho PC, Wong J. An analysis of causes and treatment outcome of chronic wrist pain after distal radial fractures. Hand Surg. 2008;13:1-10.

Scientific Articles: Medical Errors in Orthopaedics. Results of an AAOS Member Survey Wong et al. (1 March 2009) [Abstract] [Full text] [PDF] Medical Errors in Orthopaedics. Results of an AAOS Member Survey Orthopaedics – Matching Precision with Safety 28 July 2009 Sukhmeet S Panesar, Clincal Advisor to the Medical Director National Patient Safety Agency, London, United Kingdom, Bhavesh Patel, Kevin Cleary Send letter to journal: Re: Orthopaedics – Matching Precision with Safety sukhmeet.panesar{at}npsa.nhs.uk Sukhmeet S Panesar, et al. To the Editor: We welcome the article by Wong et al. (1) which has made a great contribution to the literature on patient safety in orthopaedic surgery. Similarly, across the Atlantic, key advances are being made to understand patient safety. We are privileged to have the existence of the National Patient Safety Agency (NPSA). The Department of Health (UK) has been spearheading the patient safety agenda through the creation of the NPSA which has led to the development of the Reporting and Learning System (RLS) database of patient safety incidents which are reported by all the hospitals in England and Wales (2). Running since 2003, this database is now the largest of its kind in the world, already having received over three million reports of episodes of care that could or did result in iatrogenic harm (3). Undoubtedly, the database has its limitations owing to its nature of being a self-reporting, voluntary system with a blame-free culture. There is a also a great deal of under-reporting. However, important nuggets of information can be obtained. The largest proportions of these patient safety incidents originate from medical specialties (34%), surgical specialties (15%), mental health (13%) and obstetrics and gynecology (10%). Our top categories of patient safety incidents reported in trauma and orthopaedic surgery include patient accident (which includes collision with objects, contact with sharps, inappropriate patient handling or positioning and slips, trips and falls). These account for 18490/47229 (39.1%) incidents. Treatment and procedure account for 6960/47229 (14.7%), medication account for 3790/47229 (8.02%) and infrastructure (staffing, facilities and environment) account for 3183/47229 (6.7%) of the total burden of patient safety incidents. We are trying to shift the paradigm of our database, which skeptics believe is limited, to warning, communication and detection of rare patient safety incidents such as bone cement implantation syndrome (4,5). Our specialty demands the utmost expertise in treating insult to bone and the modern era demands that we apply the same expertise in understanding and mitigating against errors that could occur in trauma and orthopaedic surgery. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Wong DA, Herndon JH, Canale ST, Brooks RL, Hunt TR, Epps HR, Fountain SS, Albanese SA, Johanson NA. Medical errors in orthopaedics. Results of an AAOS member survey. J Bone Joint Surg Am. 2009;91:547-57. 2. Department of Health. High quality care for all: NHS Next Stage Review final report. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825. Accessed 2009 Jul 16. 3. National Patient Safety Agency National Reporting and Learning Service. Patient safety incident reports in the NHS: National Reporting and Learning System Data Summary. Issue 11 (Feburary 2009) - ENGLAND. http://www.npsa.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=26473. Accessed 2009 Jul 24. 4. Vincent C, Aylin P, Franklin BD, Holmes A, Iskander S, Jacklin A, Moorthy K. Is health care getting safer? BMJ. 2008;337:a2426. 5. National Patient Safety Agency Rapid Response Reports. Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur. March 11, 2009. http://www.npsa.nhs.uk/nrls/alerts-and-directives/rapidrr/mitigating-risks-when-using-bone-cement-in-hip-surgery/. Accessed 2009 Jul 24.

Scientific Articles: Effect of Innominate and Femoral Varus Derotation Osteotomy on Acetabular Development in Developmental Dysplasia of the Hip Spence et al. (1 November 2009) [Abstract] [Full text] [PDF] Effect of Innominate and Femoral Varus Derotation Osteotomy on Acetabular Development... Surgical Treatment of Developmental Dysplasia of the Hip - Our Experience 17 November 2009 Zoran S. Vukasinovic, Professor of Orthopaedics Institute for Orthopaedic Surgery "Banjica" Belgrade, Serbia, Zoran Bascarevic, Nemanja Slavkovic, Zorica Zivkovic Send letter to journal: Re: Surgical Treatment of Developmental Dysplasia of the Hip - Our Experience zvukasin{at}beotel.net Zoran S. Vukasinovic, et al. To the Editor: We read the paper by Spence et al. (1) with great interest. Living in Serbia, a country with a high incidence of developmental dysplasia of the hip (DDH) (2.4%), and working in the country's biggest orthopaedic hospital, we have acquired great experience in the surgical treatment of this disease. We started forty years ago, in a study conducted by Predrag Klisic (2). Our first treatment option was open hip reduction combined with a Chiari pelvic osteotomy and a femoral varus derotation osteotomy. Later on, the Chiari osteotomy was replaced by the Salter innominate osteotomy, and the femoral varus derotation osteotomy was replaced by femoral derotation with shortening. Currently, our treatment protocol is as follows (3,4): 1. Open reduction with a Salter innominate osteotomy and femoral derotation shortening osteotomy in all patients, aged 2 to 8 years with a hip dislocation. 2. In older children, 8-12 years of age, the combination of procedures is similar, but the Salter osteotomy is replaced by triple pelvic osteotomy. 3. In cases with femoral head deformities due to postreduction osteonecrosis (such as coxa plana) where postoperative spherical congruence cannot be achieved, a Chiari pelvic osteotomy is performed. 4. We do not perform surgical reduction of a dislocated hip in children over 12 years of age. 5. In less serious cases, hip dysplasia and subluxation, we perform an isolated pelvic osteotomy or a combination of pelvic and femoral osteotomies without opening the hip joint. This treatment option can be used even in adolescents. Using this protocol, acetabular development is very good in younger children and much better than it was previously when we performed isolated pelvic or femoral osteotomies. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Spence G, Hocking R, Wedge JH, Roposch A. Effect of innominate and femoral varus derotation osteotomy on acetabular development in developmental dysplasia of the hip. J Bone Joint Surg Am. 2009;91:2622-36. 2. Klisic P, Jankovic LJ, Basara V. [Open reduction with pelvic osteotomy and femoral shortening]. Acta Orthop Belg. 1990;56:269-74. French. 3. Gavrankapetanovic I, Vukasinovic Z. Surgical treatment of late developmental displacement of the hip. J Bone Joint Surg Br. 2005;87:1307. 4. Vukasinović Z, Vucetić C, Cobeljić G, Bascarević Z, Slavković N. [Developmental dislocation of the hip is still important problem--therapeutic guidelines]. Acta Chir Iugosl. 2006;53:17-9. Serbian.

Scientific Articles: Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric Femoral Fractures Wall et al. (1 June 2008) [Abstract] [Full text] [PDF] Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric... Dr. Wall and colleagues respond to Dr. Thakkar 3 November 2009 Eric J. Wall, MD, Director, Orthopaedic Surgery Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, Viral Jain, MD, Vagmin Vora, MD, Charles Mehlman, DO, MPH, Alvin H. Crawford, MD Send letter to journal: Re: Dr. Wall and colleagues respond to Dr. Thakkar eric.wall{at}cchmc.org Eric J. Wall, MD, et al. Thank you for your comments and the questions. Following are our answers to your questions: 1. How many patients had a mismatch in nail (TEN or SS elastic) diameter as seen in Fig 2-B (the nails are of a different diameter)? Except for the patient illustrated, none of the other 15 patients with malunion had any mismatching of the nails. Overall, less than 5% of our patients had mismatched nail placement, the patients were evenly distributed among the stainless steel and titanium groups (three and two respectively). 2. Did you use more than two nails in any single case? We have found that a child who weighs more than 40 kg or is over 11 years of age requires more than two nails; otherwise, malunion may occur. We have not used more than 2 nails in any of our patients in the study except the two cases of implant breakage. 3. In the case of breakage, was it breakage of both nails (all nails in a single case) or just one of the nails and was there malunion in that case? How much did that patient weigh? We had two cases of nail breakage. The nail breakage was seen in one patient with titanium nails with a resultant malunion. Only one nail was broken. This was treated by re-reduction and introduction of a third nail. The other patient had stainless steel nails, which did show breakage of one nail without malunion (according to our criteria) and was treated by insertion of a third nail. 4. You have mentioned that the stainless steel nails were custom made to order. Which type of steel material was used, 316L or 316LVM? What were the mechanical properties in terms of ultimate tensile strength and percentage of elongation upon tensile stress? Which company made the custom-made nails? Can you tell us whether the stainless steel nails were more flexible than the TEN nails supplied by Synthes (Synthes, Paoli, Pennsylvania)? Howmedica (Rutherford, NJ) was the supplier of the stainless steel nails. The company was integrated into Stryker in the year 1999. All of our stainless steel nails were 316LVM. Mechanical testing of these nails was not done for the present study. According to the surgeons’ clinical experience, the titanium nail feels more flexible than the stainless steel nail (1-3). References 1. Mahar AT, Lee SS, Lalonde FD, Impelluso T, Newton PO. Biomechanical comparison of stainless steel and titanium nails for fixation of simulated femoral fractures. J Pediatr Orthop. 2004;24:638-41. 2. Mani US, Sabatino CT, Sabharwal S, Svach DJ, Suslak A, Behrens FF. Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model. J Pediatr Orthop. 2006;26:182-7. 3. Arens S, Schlegel U, Printzen G, Ziegler WJ, Perren SM, Hansis M. Influence of materials for fixation implants on local infection. An experimental study of steel versus titanium DCP in rabbits. J Bone Joint Surg Br. 1996;78:647-51. Complications of Titanium and Stainless Steel Elastic Nail Fixation of Pediatric... Complication Comparison of Titanium and Stainless Steel Elastic Nails 3 November 2009 Navin N. Thakkar, Consulting Orthopedic Surgeon, Director Pragna Orthopedic Hospital, Ahmedabad, India Send letter to journal: Re: Complication Comparison of Titanium and Stainless Steel Elastic Nails naveenthakkar{at}gmail.com Navin N. Thakkar To the Editor: I read the article by Wall et al. (1) with great interest. It is a really interesting observation and we are also having the same experience in our practice. I would like to know from your data, which is not mentioned in your article: 1. How many patients had a mismatch in nail (TEN or SS elastic) diameter as seen in Fig 2-B (the nails are of a different diameter)? 2. Did you use more than two nails in any single case? We have found that a child who weighs more than 40 kg or is over 11 years of age requires more than two nails; otherwise, malunion may occur. 3. In the case of breakage, was it breakage of both nails (all nails in a single case) or just one of the nails and was there malunion in that case? How much did that patient weigh? 4. You have mentioned that the SS nails were custom made to order. Which type of steel material was used, 316L or 316LVM? What were the mechanical properties in terms of ultimate tensile strength and percentage of elongation upon tensile stress? Which company made the custom-made nails? Can you tell us whether the stainless steel nails were more flexible than the TEN nails supplied by Synthes (Synthes, Paoli, Pennsylvania)? The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. Reference 1. Wall EJ, Jain V, Vora V, Mehlman CT, Crawford AH. Complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. J Bone Joint Surg Am. 2008;90:1305-13.

Case Reports: Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation of Distal Radial Fractures. A Report of Three Cases Bhattacharyya and Wadgaonkar (1 February 2008) [Full text] [PDF] Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation... Dr. Bhattacharyya responds to Dr. Lucchina and Mr. Fusetti 5 August 2009 Timothy Bhattacharyya, MD, Orthopaedic Surgeon NIH/NIAMS Send letter to journal: Re: Dr. Bhattacharyya responds to Dr. Lucchina and Mr. Fusetti bhattacharyyat{at}mail.nih.gov Timothy Bhattacharyya, MD I greatly appreciate the letter by Dr. Lucchina. His letter highlights the simple fact that these drill guides are very easy to miss and be left in the patient. As this is a relatively new phenomenon, the proper management of a retained drill guide has not been established. His experience demonstrates that removal after fracture union is an option; however, it would seem that early removal is better than late to prevent flexor tendon rupture. Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation... Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation of Distal Radius 28 July 2009 Stefano Lucchina, MD Hand Unit, Locarno's Regional Hospital, Locarno, Switzerland, Cesare Fusetti Send letter to journal: Re: Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation of Distal Radius stefano.lucchina{at}handregistry.com Stefano Lucchina, MD, et al. To the Editor: We read with interest the article by Bhattacharyya et al (1). We appreciate the description of complications of volar locking plates, but we disagree with the conclusion that, when a locking-plate drill guide is inadvertently left in place, it should be removed as soon as possible so as to prevent flexor tendon rupture. In one case, we inadvertently left the drill guide in place. Before closing the skin, as usual, the pronator quadratus muscle was replaced to cover the plate and create a gliding layer for the flexor tendons. After 1 year, with fracture-healing confirmed, the plate and drill guide were removed without incident. Neither tendon ruptures, nor flexor tendon tenosynovitis were detectable intraoperatively. Therefore, in the case of inadvertent retention of angled drill guides, immediate return to the operating room is not mandatory if the pronator quadratus has been used to cover the fixation devices. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated. References 1. Bhattacharyya T, Wadgaonkar AD. Inadvertent retention of angled drill guids after volar locking plate fixation of distal radial fractures. A report of three cases. J Bone Joint Surg Am. 2008;90:401-3. 2. Orbay JL, Badia A, Indriago IR, Infante A, Khouri RK, Gonzalez E, Fernandez DL. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg. 2001;5:204-11.

Scientific Articles: Cast-Saw Burns: Evaluation of Skin, Cast, and Blade Temperatures Generated During Cast Removal Shuler and Grisafi (1 December 2008) [Abstract] [Full text] [PDF] Cast-Saw Burns: Evaluation of Skin, Cast, and Blade Temperatures Generated During... Plaster Cutter Injuries 8 September 2009 Milind M. Deshpande, Consulting Orthosurgeon Vivekanand Hospital, Hubli, Karnataka, India, Harish Tople, MS; Sandeep Fowkar, MS Send letter to journal: Re: Plaster Cutter Injuries milinddeshpande{at}sancharnet.in Milind M. Deshpande, et al. To the Editor: The injuries caused by the electric plaster cutter, though superficial most of the time, leaves the patient unhappy! I prefer to demonstrate by applying the oscillating saw to my forearm before I begin cutting so that the patient is comfortable getting the saw onto his cast. Injuries are more likely to occur if the cast has been applied by someone else and you have to remove it! Injuries are also more likely in the inexperienced hand. The fragile skin of the elderly population exposes the 'still learning phenomenon' even in the experienced hand!! Lastly, to be on the safer side, I prefer to cut away from bony prominences and surface marked neurovascular structures. The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

Current Concepts Review: Diagnosis of Periprosthetic Infection Bauer et al. (1 April 2006) [Abstract] [Full text] [PDF] Diagnosis of Periprosthetic Infection Dr. Bauer and colleagues respond to Dr. Pignatti 1 October 2009 Thomas W. Bauer, MD, PhD, Physician The Cleveland Clinic, Cleveland, Ohio, Javad Parvizi, MD, Naomi Kobayashi, MD, PhD, Viktor Krebs, MD Send letter to journal: Re: Dr. Bauer and colleagues respond to Dr. Pignatti osteoclast{at}aol.com Thomas W. Bauer, MD, PhD, et al. Dr. Pignatti correctly notes that, when we quoted (1) Spangehl’s 1999 study (2), we accidentally reversed the percents for the CRP and ESR predictive values, and transcribed the sensitivity of CRP as 86% instead of 96%. We appreciate Dr. Pignatti bringing those details to our attention. Our interpretation that Dr. Spangehl's findings indicated the CRP level to be an overall better indication of infection than the ESR is correct. Additional studies have also shown that both analytes are nonspecific markers of inflammation, that there may be differences in the magnitude of elevation and the time course of normalization based on the type of operation (for example, total hip versus total knee arthroplasty) (3), and that the CRP returns to normal more rapidly than the ESR (3-5). We agree with Dr. Spangehl's comment that, when used in the appropriate clinical context, "these investigations become useful as a safe and economical screening tool with which to exclude infection" (2). References 1. Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am. 2006;88:869-82. 2. Spangehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthoplasties. J Bone Joint Surg Am. 1999;81:672-83. 3. Bilgen O, Atici T, Durak K, Karaeminoǧullari, Bilgen MS. C-reactive protein values and erythrocyte sedimentation rates after total hip and total knee arthroplasty. J Int Med Res. 2001;29:7-12. 4. Moreschini O, Greggi G, Giordano MC, Nocente M, Margheritini F. Postoperative physiopathological analysis of inflammatory parameters in patients undergoing hip or knee arthroplasty. Int J Tissue React. 2001;23:151-4. 5. Shih LY, Wu JJ, Yang DJ. Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty. Clin Orthop. 1987;225:238-46. Diagnosis of Periprosthetic Infection Letter to the Editor 1 October 2009 Giovanni Pignatti, MD, Orthopaedic Surgeon Istituto Ortopedico Rizzoli, Bologna, Italy Send letter to journal: Re: Letter to the Editor giovanni.pignatti{at}ior.it Giovanni Pignatti, MD To the Editor: I was reading the paper by Bauer et al. (1). On page 873, it is reported that, "Spangehl et al. (2) prospectively evaluated several different diagnostic tests that had been performed in a series of 202 revision hip arthroplasties. If inflammatory arthropathies were excluded, the erythrocyte sedimentation rate was found to have a sensitivity of 82% and a specificity of 85%. The predictive value of a negative test was only 58%, while the predictive value of a positive result was 95%. The C- reactive protein level was found to be a better indicator of infection than the erythrocyte sedimentation rate, with the C-reactive protein level having a sensitivity of 86%, a specificity of 92%, and predictive values for negative and positive tests of 74% and 99%, respectively". In the original paper of Spangehl et al. (2), it is reported that erythrocyte sedimentation rate, "showed a sensitivity of 0.82 (0.65 to 0.93), a specificity of 0.85 (0.78 to 0.91), a positive predictive value of 0.58 (0.43 to 0.72), and a negative predictive value of 0.95 (0.89 to 0.98)". Moreover, C-reactive protein, "showed a sensitivity of 0.96 (0.78 to 1.00), a specificity of 0.92 (0.85 to 0.96), a positive predictive value of 0.74 (0.55 to 0.87), and a negative predictive value of 0.99 (0.94 to 1.00)". In my opinion, there is something wrong with the figures reported by Bauer et al. The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. References 1. Bauer TW, Parvizi J, Kobayashi N, Krebs V. Diagnosis of periprosthetic infection. J Bone Joint Surg Am. 2006;88:869-82. 2. Spengehl MJ, Masri BA, O'Connell JX, Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am. 1999;81:672-83.

Scientific Articles: Extracellular Matrix Bioscaffolds for Orthopaedic Applications. A Comparative Histologic Study Valentin et al. (1 December 2006) [Abstract] [Full text] [PDF] Extracellular Matrix Bioscaffolds for Orthopaedic Applications. A Comparative Histologic... Dr. Badylak and Ms. Valentin respond to Dr. James and colleagues 18 November 2009 Stephen F. Badylak, DVM, PhD, MD, Professor, Department of Surgery University of Pittsburgh, McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania, Jolene E. Valentin, BS Send letter to journal: Re: Dr. Badylak and Ms. Valentin respond to Dr. James and colleagues badylaks{at}upmc.edu Stephen F. Badylak, DVM, PhD, MD, et al. With regard to the letter by Dr. Kenneth James, Vice President of TEI Biosciences, we appreciate the opportunity to respond to the issues that were raised. First, our manuscript (1) clearly states that TissueMend is not chemically crosslinked (see discussion, page 2685, “...TissueMend does not include chemical crosslinking as a processing step...”). The article also states (Table 1) that processing methods are “proprietary”. The manuscript further describes the morphologic response to the implanted material as being a “typical response to a nonresorbable foreign material...”, but again, no mention is made of any chemical crosslinking. The host response to a nonresorbable material does not necessarily include the presence of multinucleate giant cells. One of the major points of the Valentin article is that each biologic scaffold material elicits a distinct morphologic response which is dictated by several factors including methods of processing. Second, all biologic scaffolds contain natural crosslinks which are susceptible to endogenous mechanisms of degradation. Chemical crosslinking agents such as carbodiimide and glutaraldehyde have typically been used to add strength to biologic scaffolds and/or modify surface antigens in the belief that this is necessary to prevent an adverse immune response. Non-chemical means of inducing crosslinks are also possible including thermal, photo-oxidative, and irradiation methods. Any method of crosslinking has the potential to slow the rate of in-vivo degradation and thus elicit a host response characterized by fibrosis and low-grade chronic inflammation. Since the methods of processing for TissueMend are proprietary, it is not possible to know the cause of the decreased degradation rate. The optimal use of biologic scaffold materials for not only orthopedic applications, but other applications as well, will depend upon an in depth understanding of the mechanisms by which such materials support, maintain, and restore healthy tissue. New data are being published on an almost weekly basis regarding the host immune response to these scaffold materials (2-4), the source and rate of cell recruitment (5, 6), the factors that affect cellular differentiation and organization (7, 8), and the factors that affect downstream remodeling and patient outcome (9). We agree completely with Dr. James that the microenvironment into which these scaffolds are placed is a critical determinant of remodeling (adoption versus adaptation) events. We also believe that an open dialogue regarding such factors is healthy and will lead to a more comprehensive understanding of the potential use of biologic scaffolds by the entire scientific and surgical community. References 1. Valentin JE, Badylak JS, McCabe GP, Badylak SF. Extracellular matrix bioscaffolds for orthopaedic applications. A comparative histologic study. J Bone Joint Surg Am. 2006;88:2673-86. 2. Daly K, Stewart-Akers A, Hara H, Ezzelarab M, Long C, Cordero K, Johnson S, Ayares D, Cooper D, Badylak SF. Effect of the alphaGal epitope on the response to small intestinal submucosa extracellular matrix in a nonhuman primate model. Tissue Eng Part A. 2009 Jun 29 [Epub ahead of print]. 3. Valentin JE, Stewart-Akers AM, Gilbert TW, Badylak SF. Macrophage participation in the degradation and remodeling of extracellular matrix scaffolds. Tissue Eng Part A. 2009;15:1687-94. 4. Badylak SF, Gilbert TW. Immune response to biologic scaffold materials. Semin Immunol. 2008;20:109-16. 5. Reing JE, Zhang L, Myers-Irvin J, Cordero KE, Freytes DO, Heber-Katz E, Bedelbaeva K, McIntosh D, Dewilde A, Braunhut SJ, Badylak SF. Degradation products of extracellular matrix affect cell migration and proliferation. Tissue Eng Part A. 2009;15:605-14. 6. Beattie AJ, Gilbert TW, Guyot JP, Yates AJ, Badylak SF. Chemoattraction of progenitor cells by remodeling extracellular matrix scaffolds. Tissue Eng Part A. 2009;15:1119-25. 7. Brown BN, Valentin JE, Stewart-Akers AM, McCabe GP, Badylak SF. Macrophage phenotype and remodeling outcomes in response to biologic scaffolds with and without a cellular component. Biomaterials. 2009;30:1482-91. 8. Gilbert TW, Stewart-Akers AM, Sydeski J, Nguyen TD, Badylak SF, Woo SL. Gene expression by fibroblasts seeded on small intestinal submucosa and subjected to cyclic stretching. Tissue Eng. 2007;13:1313-23. 9. Derwin, KA et al. Extracellular matrix scaffold devices for rotator cuff repair. J Shoulder Elbow Surg. In press. Extracellular Matrix Bioscaffolds for Orthopaedic Applications. A Comparative Histologic... TissueMend is not chemically crosslinked nor does it elicit a classic foreign body response 18 November 2009 Kenneth S. James, PhD, Vice President, Product Sciences TEI Biosciences, Kevin C. Cornwell, PhD; A. Gerson Greenburg, MD, PhD Send letter to journal: Re: TissueMend is not chemically crosslinked nor does it elicit a classic foreign body response kjames{at}teibio.com Kenneth S. James, PhD, et al. To the Editor: We would like to address statements related to the product TissueMend made in the paper by Valentin et al (1). Subsequent articles referencing this paper have not accurately reported the data presented (2,3), errata to which are now appearing (4). Please note that: • TissueMend is not artificially chemically crosslinked. While explicitly stated as such in the paper, the authors' grouping of TissueMend with the chemically crosslinked products tested in the paper’s abstract and discussion has led some to conclude otherwise. Chemical crosslinking is specifically avoided to preserve the native biopolymer chemistry to permit host adoption and adaptation of the implanted collagen structure and to avoid eliciting a chronic foreign body reaction and encapsulation response associated with chemically crosslinked implants. • TissueMend does not elicit a classic foreign body response. The data presented does not support the statements that the response to TissueMend is, “consistent with the typical response to a nonresorbable foreign material”, or, “associated with the presence of foreign-body giant cells, chronic inflammation, and/or the accumulation of dense, poorly organized fibrous tissue.” To the contrary, Table III explicitly indicates a statistically significant difference in foreign body giant cells to TissueMend (absent) to the chemically crosslinked products Permacol and CuffPatch (present). The absence of an acute or chronic inflammatory/foreign body reaction directed towards the TissueMend implant is similarly evident in Figures 5-A and 5-B. • The authors are correct when stating that, “…the proprietary methodology of making the final product [TissueMend] may be related to its relatively slow rate of degradation”. However, the authors incorrectly suggest that non-crosslinked collagen implants must necessarily be “degraded”. The histological results illustrate that the TissueMend collagen implant has been adopted and adapted by the host, filling with fibroblasts and supporting vasculature, to generate a new, long-lived tissue that effectively heals the small, surgically created partial- thickness muscle defect. This result and the absence of an inflammatory response directed towards the implant and generated tissue is consistent with reports on this same material in other soft tissue repair sites (5,6). However, it should be noted that subsequent adaptation of this implant is dependent on the site of implantation. For example, when specifically evaluated in a tendon repair model, TissueMend is similarly adopted but followed by the progressive adaptation of the implanted dermal collagen fibers into an aligned, oriented collagen fiber architecture comparable to tendon (7). We refer readers to an article by Cornwell et al. for a comprehensive review of the TissueMend technology (7). TissueMend Advanced Soft Tissue Repair Matrix is marketed by Stryker Orthopaedics (Mahwah, NJ) and was developed and is manufactured by TEI Biosciences (Boston, MA). In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from TEI Biosciences. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (TEI Biosciences). References 1. Valentin JE, Badylak JS, McCabe GP, Badylak SF. Extracellular matrix bioscaffolds for orthopaedic applications. A comparative histologic study. J Bone Joint Surg Am. 2006;88:2673-86. 2. Chen J, Xu J, Wang A, Zheng M. Scaffolds for tendon and ligament repair: review of the efficacy of commercial products. Expert Rev Med Devices. 2009;6:61-73. 3. Aurora A, McCarron J, Iannotti JP and Derwin K. Commercially available extracellular matrix materials for rotator cuff repairs: State of the art and future trends. J Shoulder Elbow Surg 2007;16:171S-178S. 4. Aurora A, McCarron J, Iannotti JP, Derwin K. Commercially available extracellular matrix materials for rotator cuff repairs: state of the art and future trends. J Shoulder Elbow Surg. 2007;16(5 Suppl):S171-8. Erratum in: J Shoulder Elbow Surg. 2009 [In press, available online 2009 Aug 27]. 5. Zerris VA, James KS, Roberts JB, Bell E, Heilman CB. Repair of the dura mater with processed collagen devices. J Biomed Mater Res Part B Appl Biomater. 2007;83:580-8. 6. Cook JL, Fox DB, Kuroki K, Jayo M, DeDeyne PG. In vitro and in vivo comparison of five biomaterials used for orthopedic soft tissue augmentation. Am J Vet Res. 2008;69:148-56. 7. Cornwell KG, Landsman A, James KS. Extracellular matrix biomaterials for soft tissue repair. Clin Podiatr Med Surg. 2009;26:507-23.

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