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Letters to the Editor published in the past 365 days:

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127 Letters to the Editor published for 65 different topic sources.

Articles    Letters
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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]
Jump to Letter to the Editor Prenatal Diagnosis of Undefined Soft Tissue Tumors
Lukas A. Lisowski   (28 October 2009)
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Surgical Techniques:
Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical Technique
Dimakopoulos et al. (1 March 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Dimakopoulos and colleagues respond to Dr. Abboud
Panayiotis Dimakopoulos, MD, et al.   (21 April 2009)
Jump to Letter to the Editor Transosseous Suture Fixation Technique For Proximal Humerus Fractures
Joseph A. Abboud, MD   (21 April 2009)
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Scientific Articles:
Factors Affecting Willingness to Undergo Carpal Tunnel Release
Gong et al. (1 September 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Chung and colleagues respond to Mr. Papanna
Moon Sang Chung, MD, PhD, et al.   (13 October 2009)
Jump to Letter to the Editor Good Article with Severe Limitations
Madhavan Chikkapapanna Papanna   (13 October 2009)
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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]
Jump to Letter to the Editor Drs. Koenig and Koval respond to Dr. Slobogean
Karl M. Koenig, MD, et al.   (6 October 2009)
Jump to Letter to the Editor Is Early Fixation Preferred to Cast Treatment for Well-Reduced Unstable Distal Radial Fractures?
Gerard P. Slobogean, MD, MPH   (6 October 2009)
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Scientific Articles:
Resident Duty-Hour Reform Associated with Increased Morbidity Following Hip Fracture
Browne et al. (1 September 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Browne and colleagues respond to Mr. O'Neill
James A. Browne, MD, et al.   (28 October 2009)
Jump to Letter to the Editor Resident Duty Hour Reform Associated with Increased Recording of Morbidity Following Hip Fracture
Barry J. O'Neill   (28 October 2009)
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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]
Jump to Letter to the Editor Dr. Wright responds to Drs. Bernstein and Ahn
James G. Wright, MD, MPH, FRCSC   (6 October 2009)
Jump to Letter to the Editor Not a Level I Therapeutic Study
Joseph Bernstein, MD, et al.   (6 October 2009)
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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]
Jump to Letter to the Editor Dr. Kim and colleagues respond to Mr. Malviya
Young-Hoo Kim, MD, et al.   (19 August 2009)
Jump to Letter to the Editor Range of Motion of Standard and High-Flexion Posterior Cruciate-Retaining Total Knee Prostheses
Ajay Malviya   (19 August 2009)
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Scientific Articles:
Complication Reporting in Orthopaedic Trials. A Systematic Review of Randomized Controlled Trials
Goldhahn et al. (1 August 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Goldhahn and colleagues respond to Drs. Cheng and Zhang
Sabine Goldhahn, MD, et al.   (11 September 2009)
Jump to Letter to the Editor Concern Regarding Complications Reporting in Orthopaedic Trials
Tao Cheng, MD, PhD, et al.   (11 September 2009)
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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]
Jump to Letter to the Editor Dr. Rozental responds to Mr. Holmes and colleagues
Tamara D. Rozental, MD   (29 October 2009)
Jump to Letter to the Editor Group Homogeneity
William JM Holmes, MBChB, MRCSEd, et al.   (29 October 2009)
Jump to Letter to the Editor Dr. Rozental responds to Dr. Kumar
Tamara D. Rozental, MD   (2 September 2009)
Jump to Letter to the Editor Letter to the Editor
Sudeep Kumar, MBBS, MS(Ortho)   (2 September 2009)
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Scientific Articles:
Surgical Treatment of Three and Four-Part Proximal Humeral Fractures
Solberg et al. (1 July 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Solberg and colleagues respond to Mr. Clarke and Mr. Nunn
Brian D. Solberg, MD, et al.   (9 September 2009)
Jump to Letter to the Editor Surgical Treatment of Three and Four-Part Proximal Humeral Fractures
Jon V. Clarke, et al.   (9 September 2009)
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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]
Jump to Letter to the Editor Glycemic Control and Outcomes after Joint Arthroplasty
N. Wah Cheung   (28 August 2009)
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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]
Jump to Letter to the Editor Unstable Distal Radial Fracture Treatment
Benedict A. Rogers, et al.   (25 August 2009)
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Editorial:
Further Emphasis on Evidence
Heckman (1 July 2009) [Full text] [PDF]
Jump to Letter to the Editor Documentation of Levels of Proficiency of Caregivers in Reporting Evidence
Jin Bo Tang, et al.   (17 July 2009)
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Scientific Articles:
Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist
Sammer and Shin (1 June 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Drs. Shin and Sammer respond to Dr. Strauch
Alexander Y. Shin, MD, et al.   (15 July 2009)
Jump to Letter to the Editor Standard of treatment?
Robert J. Strauch, MD   (16 June 2009)
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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]
Jump to Letter to the Editor Drs. Konrad and Südkamp respond to Mr. Smith and Mr. Moonot
Gerhard G. Konrad, MD, et al.   (5 August 2009)
Jump to Letter to the Editor Does Patient Age Affect Outcome with PHILOS Plates?
James O. Smith, et al.   (5 August 2009)
Jump to Letter to the Editor Drs. Konrad and Südkamp respond to Drs. Court-Brown and McQueen
Gerhard G. Konrad, MD, et al.   (22 July 2009)
Jump to Letter to the Editor Treatment of Proximal Humeral Fractures
Charles M. Court-Brown, MD, FRCSEd(Orth), et al.   (8 July 2009)
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Evidence-Based Orthopaedics:
Arthroscopic Surgery Did Not Provide Additional Benefit to Physical and Medical Therapy for Osteoarthritis of the Knee
Moseley (1 May 2009) [Full text] [PDF]
Jump to Letter to the Editor Randomized trials of arthroscopy for knee arthrosis can still have bias
Omer A. Ilahi, MD   (10 June 2009)
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The Orthopaedic Forum:
Orthopaedic Education—Are We Attracting the Best and the Brightest?
Emery et al. (1 May 2009) [Full text] [PDF]
Jump to Letter to the Editor Dr. Emery and colleagues respond to Dr. Rutherford
Sanford E. Emery, MD, MBA, et al.   (24 June 2009)
Jump to Letter to the Editor The Best and Brightest
Rob Rutherford, MD   (1 June 2009)
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Scientific Articles:
Screw Fixation Compared with Suture-Button Fixation of Isolated Lisfranc Ligament Injuries
Panchbhavi et al. (1 May 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi
Vinod K. Panchbhavi, MD, FRCS, et al.   (2 June 2009)
Jump to Letter to the Editor Suture-Button Fixation of Isolated Lisfranc Injuries
Benedict A. Rogers, et al.   (2 June 2009)
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Scientific Articles:
Evidence for an Inherited Predisposition Contributing to the Risk for Rotator Cuff Disease
Tashjian et al. (1 May 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Drs. Tashjian and Cannon-Albright respond to Drs. Jain and Higgins
Robert Z. Tashjian, MD, et al.   (29 June 2009)
Jump to Letter to the Editor Genetic Predisposition to Rotator Cuff Tears
Nitin B. Jain, MD, et al.   (29 June 2009)
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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]
Jump to Letter to the Editor Dr. Della Valle and colleagues respond to Mr. Whitehouse and Mr. Bannister
Craig J. Della Valle, MD, et al.   (5 August 2009)
Jump to Letter to the Editor Definition of Failure
Michael R. Whitehouse, MBChB, BSc, M(ScOrthEng), MRCS(Eng), et al.   (5 August 2009)
Jump to Letter to the Editor Dr. Della Valle and colleagues respond to Drs. Schreurs and de Kam
Craig J. Della Valle, MD, et al.   (30 June 2009)
Jump to Letter to the Editor Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component: Outcome in young patients?
B. Willem Schreurs, MD, PhD, et al.   (30 June 2009)
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Scientific Articles:
Comparison of Surgeon and Physiotherapist-Directed Ponseti Treatment of Idiopathic Clubfoot
Janicki et al. (1 May 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Are we really that busy?
Lewis E. Zionts, MD   (16 June 2009)
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Scientific Articles:
Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade Partial-Thickness Supraspinatus Tears
Kamath et al. (1 May 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Galatz and colleagues respond to Dr. Bernstein
Leesa M. Galatz, MD, et al.   (10 June 2009)
Jump to Letter to the Editor Association of Partial Thickness Tears of the Rotator Cuff and Shoulder Pain
Joseph Bernstein   (10 June 2009)
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Scientific Articles:
Prediction of Midfoot Instability in the Subtle Lisfranc Injury. Comparison of Magnetic Resonance Imaging with Intraoperative Findings
Raikin et al. (1 April 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Raikin and colleagues respond to Dr. Summerhays and colleagues
Steven M. Raikin, MD, et al.   (28 May 2009)
Jump to Letter to the Editor Prediction of Midfoot Instability in Subtle Lisfranc Injury
Ben J. Summerhays, DPM, et al.   (28 May 2009)
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Scientific Articles:
Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty
Hintermann et al. (1 April 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Hintermann and colleagues respond to Dr. Kini
Beat Hintermann, MD, et al.   (30 April 2009)
Jump to Letter to the Editor Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty
Sunil Gurpur Kini, MBBS, MS(Ortho), DNB(Ortho), MNAMS(Ortho)   (30 April 2009)
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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]
Jump to Letter to the Editor Dr. Ring and colleagues respond to Mr. Al-Fakayh
David Ring, MD, PhD, et al.   (11 September 2009)
Jump to Letter to the Editor Effect of Ulnar Styloid Injury on Outcome Following Fixation of Distal Radial Fractures
Omar Al-Fakayh   (11 September 2009)
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The Orthopaedic Forum:
Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need
Day et al. (1 March 2009) [Full text] [PDF]
Jump to Letter to the Editor Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need
Ashley T. Simela, DO   (21 April 2009)
Jump to Letter to the Editor Dr. Day responds to Dr. Stuart
Charles S. Day, MD   (13 April 2009)
Jump to Letter to the Editor Musculoskeletal Education of Physician Assistants
Wayne C. Stuart, MD   (18 March 2009)
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Scientific Articles:
Association Between Decreased Bone Mineral Density and Severity of Distal Radial Fractures
Clayton et al. (1 March 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Drs. Clayton and McQueen respond to Dr. Hollevoet
Robert A. E. Clayton, BSc(Hons), et al.   (13 April 2009)
Jump to Letter to the Editor Association of Bone Mineral Density and Fracture Displacement of Distal Radius Fractures
Nadine Hollevoet   (7 April 2009)
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Scientific Articles:
Medical Errors in Orthopaedics. Results of an AAOS Member Survey
Wong et al. (1 March 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Orthopaedics – Matching Precision with Safety
Sukhmeet S Panesar, et al.   (28 July 2009)
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The Orthopaedic Forum:
The Need for Increased Access to the U.S. Health-Care System
Bible et al. (1 February 2009) [Full text] [PDF]
Jump to Letter to the Editor Mr. Bible and Dr. Friedlaender respond to Dr. Novack
Jesse E. Bible, BS, et al.   (10 March 2009)
Jump to Letter to the Editor We Need AAOS Leadership
Eric N. Novack   (26 February 2009)
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Scientific Articles:
Patient and Surgeon Radiation Exposure: Comparison of Standard and Mini-C-Arm Fluoroscopy
Giordano et al. (1 February 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Baumhauer and colleagues respond to Drs. Opreanu and Kepros
Judith F. Baumhauer, MD, et al.   (10 March 2009)
Jump to Letter to the Editor Is Intra-operative Fluoroscopy Harmful?
Razvan C. Opreanu, et al.   (26 February 2009)
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Scientific Articles:
Shoulder Strength in Asymptomatic Individuals with Intact Compared with Torn Rotator Cuffs
Kim et al. (1 February 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Is the Asymptomatic Shoulder Asymptomatic?
Jerrold M. Gorski, MD   (17 February 2009)
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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]
Jump to Letter to the Editor Surgical Treatment of Developmental Dysplasia of the Hip - Our Experience
Zoran S. Vukasinovic, et al.   (17 November 2009)
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Scientific Articles:
Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation of the Components in Total Knee Arthroplasty
Kim et al. (1 January 2009) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Kim and colleagues respond to Drs. Ferretti and Conteduca
Young-Hoo Kim, MD, et al.   (29 April 2009)
Jump to Letter to the Editor Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation of the...
Andrea Ferretti, MD, et al.   (29 April 2009)
Jump to Letter to the Editor Dr. Kim and colleagues respond to Dr. Matziolis and Mr. Perka
Young-Hoo Kim, MD, et al.   (1 April 2009)
Jump to Letter to the Editor Computer Assisted Surgical Navigation for Total Knee Arthroplasty
Georg Matziolis, et al.   (18 March 2009)
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Scientific Exhibits:
Squeaking Hips
Walter et al. (1 November 2008) [Full text] [PDF]
Jump to Letter to the Editor Dr. Walter and colleagues respond to Dr. Hamilton
William L. Walter, MBBS, FRACS, PhD, et al.   (16 December 2008)
Jump to Letter to the Editor Squeaking Hips
Henry W. Hamilton   (26 November 2008)
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Tribological and Metal Ion Issues:
Tribology and Wear of Metal-on-Metal Hip Prostheses: Influence of Cup Angle and Head Position
Williams et al. (1 August 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Fisher and colleagues respond to Mr. Jain
John Fisher, BSc, PhD, et al.   (19 March 2009)
Jump to Letter to the Editor Tribology and Wear of Metal-on-Metal Hip Prostheses
Rohit Jain   (19 March 2009)
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Surgical Techniques:
Outcome at Forty-five Years After Open Reduction and Innominate Osteotomy for Late-Presenting Developmental Dislocation of the Hip. Surgical Technique
Wedge et al. (1 October 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Wedge responds to Mr. Cove
John H. Wedge, MD, FRCS(C)   (22 July 2009)
Jump to Letter to the Editor Anatomic Typo
Richard Cove, FRCS(Orth)   (13 July 2009)
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Selected Instructional Course Lecture:
The Use of Bone Morphogenetic Protein in Lumbar Spine Surgery
Rihn et al. (1 September 2008) [Full text] [PDF]
Jump to Letter to the Editor Drs. Rihn and Albert respond to Dr. Smoljanovic and colleagues
Jeffrey A. Rihn, MD, et al.   (26 February 2009)
Jump to Letter to the Editor Transient Bone Resorption Associated with Use of rhBMP-2 in Lumbar Fusion Surgery
Tomislav Smoljanovic, MD, PhD, et al.   (26 February 2009)
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Scientific Articles:
Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery. An Animal Study
Okubadejo et al. (1 September 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Drs. Okubadejo and Riew respond to Drs. Rathmell and Wainger
Gbolahan Okubadejo, MD, et al.   (13 January 2009)
Jump to Letter to the Editor Clarifying mechanism of neurologic injury following intra-arterial injection of particulate steroid
James P. Rathmell, MD, et al.   (13 January 2009)
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Scientific Articles:
Inpatient Compared with Home-Based Rehabilitation Following Primary Unilateral Total Hip or Knee Replacement: A Randomized Controlled Trial
Mahomed et al. (1 August 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Financial Limitations of Hospital at Home within the NHS
Victoria J Ashall, et al.   (24 November 2008)
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Scientific Articles:
Cell Count and Differential of Aspirated Fluid in the Diagnosis of Infection at the Site of Total Knee Arthroplasty
Ghanem et al. (1 August 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Ghanem and colleagues respond to Dr. Elsissy and colleagues
Elie Ghanem, MD, et al.   (16 June 2009)
Jump to Letter to the Editor Inconsistencies in Units Used to Report Cell Counts From Aspirates of Infected Arthroplasties
Peter G. Elsissy, MD, et al.   (16 June 2009)
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Case Reports:
Proximal Femoral Fracture After Hip Resurfacing Managed with Blade-Plate Fixation. A Case Report
Weinrauch and Krikler (1 June 2008) [Full text] [PDF]
Jump to Letter to the Editor An Alternative Method to Treat Proximal Femoral Fractures After Hip Resurfacing Arthroplasty
Neil M Orpen, et al.   (1 December 2008)
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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]
Jump to Letter to the Editor Dr. Wall and colleagues respond to Dr. Thakkar
Eric J. Wall, MD, et al.   (3 November 2009)
Jump to Letter to the Editor Complication Comparison of Titanium and Stainless Steel Elastic Nails
Navin N. Thakkar   (3 November 2009)
Jump to Letter to the Editor Dr. Wall and colleagues respond to Dr. Gulati and colleagues
Eric J. Wall, MD, et al.   (5 February 2009)
Jump to Letter to the Editor Complications of Elastic Nail Fixation of Pediatric Femoral Fractures
Divesh Gulati, et al.   (5 February 2009)
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Scientific Articles:
Subchondral Fracture Following Arthroscopic Knee Surgery. A Series of Eight Cases
MacDessi et al. (1 May 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. MacDessi and colleagues respond to Dr. Pape and Mr. Kohn
Samuel J. MacDessi, FRACS, et al.   (24 March 2009)
Jump to Letter to the Editor There might be more questions to be answered...
Dietrich Pape, MD, et al.   (3 February 2009)
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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]
Jump to Letter to the Editor Dr. Bhattacharyya responds to Dr. Lucchina and Mr. Fusetti
Timothy Bhattacharyya, MD   (5 August 2009)
Jump to Letter to the Editor Inadvertent Retention of Angled Drill Guides After Volar Locking Plate Fixation of Distal Radius
Stefano Lucchina, MD, et al.   (28 July 2009)
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The Orthopaedic Forum:
Driving After Musculoskeletal Injury. Addressing Patient and Surgeon Concerns in an Urban Orthopaedic Practice
Chen et al. (1 December 2008) [Full text] [PDF]
Jump to Letter to the Editor Dr. Rodriguez responds to Dr. Lowe
Edward K. Rodriguez, MD, PhD   (14 January 2009)
Jump to Letter to the Editor Medical Decision Making, NOT Public Safety Officer
William D. Lowe, MD   (14 January 2009)
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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]
Jump to Letter to the Editor Plaster Cutter Injuries
Milind M. Deshpande, et al.   (8 September 2009)
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Scientific Articles:
The Value Added by Electrodiagnostic Testing in the Diagnosis of Carpal Tunnel Syndrome
Graham (1 December 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Graham responds to Mr. Kamath and Mr. Stothard
Brent Graham, MD   (24 March 2009)
Jump to Letter to the Editor Value of A History Based Questionaire In The Diagnosis of Carpal Tunnel Syndrome
Vijay Kamath, et al.   (24 March 2009)
Jump to Letter to the Editor Autonomic Dysfunction in Carpal Tunnel Syndrome
Venkat R. Mekala, et al.   (5 February 2009)
Jump to Letter to the Editor Dr. Graham responds to Dr. Ring
Brent A. Graham, MD, MSc, FRCSC   (22 December 2008)
Jump to Letter to the Editor Is carpal tunnel still a syndrome?
David Ring, MD   (4 December 2008)
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Scientific Articles:
Randomized Trial of Reamed and Unreamed Intramedullary Nailing of Tibial Shaft Fractures
the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fractures (SPRINT) Investigators (1 December 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor The SPRINT investigators respond to Drs. Sarmiento and Latta
Mohit Bhandari, MD, et al.   (20 January 2009)
Jump to Letter to the Editor Important Information Missing
Augusto Sarmiento, MD, et al.   (20 January 2009)
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Case Reports:
Early Failure of a Cross-Linked Polyethylene Acetabular Liner. A Case Report
Moore et al. (1 November 2008) [Full text] [PDF]
Jump to Letter to the Editor Dr. Eberhardt and colleagues respond to Dr. McGrory
Alan W. Eberhardt, PhD, et al.   (12 January 2009)
Jump to Letter to the Editor Offset Crosslinked Liners: How Safe?
Brian J. McGrory, MD   (3 December 2008)
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Scientific Articles:
Distal Femoral Extension Osteotomy and Patellar Tendon Advancement to Treat Persistent Crouch Gait in Cerebral Palsy
Stout et al. (1 November 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Novacheck and colleagues respond to Dr. Morais Filho
Tom F. Novacheck, MD, et al.   (1 December 2008)
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Scientific Articles:
Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
Richard et al. (1 November 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Drs. Richard and Ruch respond to Dr. Kini
Marc J. Richard, MD, et al.   (25 November 2008)
Jump to Letter to the Editor Traumatic Valgus Instability of the Elbow: Pathoanatomy and Results of Direct Repair
Sunil Gurpur Kini, MBBS,M.S(Ortho),D.N.B(Ortho)   (25 November 2008)
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Scientific Articles:
Electrical Stimulation for Long-Bone Fracture-Healing: A Meta-Analysis of Randomized Controlled Trials
Mollon et al. (1 November 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Bhandari and colleagues respond to Dr. Pienkowski
Mohit Bhandari, MD, FRCSC, et al.   (19 February 2009)
Jump to Letter to the Editor Capacitive Coupled Stimulation is Different From Electromagnetic Stimulaltion
David Pienkowski, PhD   (10 February 2009)
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Scientific Articles:
A Comparison of Two Nonoperative Methods of Idiopathic Clubfoot Correction: The Ponseti Method and the French Functional (Physiotherapy) Method
Richards et al. (1 November 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Richards and colleagues respond to Ms. Issler-Wuthrich
B. Stephens Richards, MD, et al.   (5 February 2009)
Jump to Letter to the Editor Ponseti and the French Method: a European perspective
Ursula Issler-Wüthrich, et al.   (20 January 2009)
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Topics in Training:
Design and Implementation of a System-Based Course in Musculoskeletal Medicine for Medical Students
Bilderback et al. (1 October 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Marino and colleagues respond to Dr. Queally and colleagues
Andrew A. Marino, PhD, et al.   (22 December 2008)
Jump to Letter to the Editor Undergraduate and Post Graduate Teaching of Musculoskeletal Medicine
Joseph M Queally, et al.   (25 November 2008)
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Scientific Articles:
The Early Effects of Tendon Transfers and Open Capsulorrhaphy on Glenohumeral Deformity in Brachial Plexus Birth Palsy
Waters and Bae (1 October 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Contracture release and glenohumeral remodeling in brachial plexus birth palsy
Michael L. Pearl, MD, et al.   (12 February 2009)
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Scientific Articles:
Prophylactic Bypass Grafting and Long-Term Bracing in the Management of Anterolateral Bowing of the Tibia and Neurofibromatosis-1
Ofluoglu et al. (1 October 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Davidson and colleagures respond to Dr. El-Rosasy
Richard S Davidson, MD, et al.   (26 November 2008)
Jump to Letter to the Editor Prophylactic Bypass Grafting in the Management of congenital tibial dysplasia
Mahmoud A. El-Rosasy   (26 November 2008)
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Scientific Articles:
Use of a Postoperative Lumbar Corset After Lumbar Spinal Arthrodesis for Degenerative Conditions of the Spine. A Prospective Randomized Trial
Yee et al. (1 October 2008) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Yee responds to Dr. Dabke
Albert JM Yee, MD, FRCS(C)   (10 March 2009)
Jump to Letter to the Editor Use of Lumbar Corset after Lumbar Spinal Arthrodesis
Harshad V. Dabke   (22 December 2008)
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Current Concepts Review:
Preventing the Development of Chronic Pain After Orthopaedic Surgery with Preventive Multimodal Analgesic Techniques
Reuben and Buvanendran (1 June 2007) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Concerns Regarding Off-Label Prescribing Based On Evidence Free Medicine
James T. Howell, MD, et al.   (1 April 2009)
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Scientific Articles:
Immobilization in External Rotation After Shoulder Dislocation Reduces the Risk of Recurrence. A Randomized Controlled Trial
Itoi et al. (1 October 2007) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Itoi and colleagues respond to Dr. Kain and colleagues
Eiji Itoi, MD, PhD, et al.   (24 June 2009)
Jump to Letter to the Editor Results of Using A Shoulder External Rotation Brace For Primary Dislocation Of The Shoulder
Nakul Kain, et al.   (16 June 2009)
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Femoral Head Bone-Preserving Procedures:
Survivorship Analysis and Radiographic Outcome Following Tantalum Rod Insertion for Osteonecrosis of the Femoral Head
Veillette et al. (1 November 2006) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. McKee responds to Dr. Pandher and colleagues
Michael D. McKee, MD, FRCSC   (17 February 2009)
Jump to Letter to the Editor Clinical Failure of Tantalum Rod without Radiological Progression
Dilbans S. Pandher, MS(Orth), et al.   (14 January 2009)
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Current Concepts Review:
Diagnosis of Periprosthetic Infection
Bauer et al. (1 April 2006) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Bauer and colleagues respond to Dr. Pignatti
Thomas W. Bauer, MD, PhD, et al.   (1 October 2009)
Jump to Letter to the Editor Letter to the Editor
Giovanni Pignatti, MD   (1 October 2009)
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Scientific Articles:
Extracellular Matrix Bioscaffolds for Orthopaedic Applications. A Comparative Histologic Study
Valentin et al. (1 December 2006) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Badylak and Ms. Valentin respond to Dr. James and colleagues
Stephen F. Badylak, DVM, PhD, MD, et al.   (18 November 2009)
Jump to Letter to the Editor TissueMend is not chemically crosslinked nor does it elicit a classic foreign body response
Kenneth S. James, PhD, et al.   (18 November 2009)
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Scientific Articles:
Use of rhBMP-2 in Combination with Structural Cortical Allografts: Clinical and Radiographic Outcomes in Anterior Lumbar Spinal Surgery
Burkus et al. (1 June 2005) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Dr. Burkus and colleagues respond to Dr. Smoljanovic and colleagues
J. Kenneth Burkus, MD, et al.   (19 March 2009)
Jump to Letter to the Editor Continuing Questions Regarding Adverse Effects Of Spinal Interbody Fusion Using rhBMP-2/ACS
Tomislav Smoljanovic, MD, PhD, et al.   (24 February 2009)
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Surgical Techniques:
Anterior Cruciate Ligament Reconstruction with a Four-Strand Hamstring Tendon Autograft
Williams et al. (1 March 2005) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Anterior Cruciate Ligament Reconstruction with a Four-Strand Hamstring Tendon Autograft
Nikolaos V. Bardakos, MD   (1 June 2009)
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Scientific Articles:
Biodegradable Poly-d,l-Lactic Acid-Polyethylene Glycol Block Copolymers as a BMP Delivery System for Inducing Bone
Saito et al. (1 April 2001) [Abstract] [Full text] [PDF]
Jump to Letter to the Editor Novel Bone Methodologies: The Biomimetic Implant
Benjamin W. Kenny, et al.   (19 March 2009)
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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
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Lukas A. Lisowski,
Orthopaedic Surgeon
The Royal Infirmary of Edinburgh, Scotland

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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.

Surgical Techniques:
 Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical Technique
 Dimakopoulos et al. (1 March 2009) [Abstract] [Full text] [PDF]
Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical Technique
Dr. Dimakopoulos and colleagues respond to Dr. Abboud		 21 April 2009
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Panayiotis Dimakopoulos, MD,
Professor of Orthopaedic Surgery, Chairman
Shoulder and Elbow Unit, Orthopaedic Department, University Hospital of Patras, Greece,
Andreas Panagopoulos, MD; Georgios B. Kasimatis, MD

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Re: Dr. Dimakopoulos and colleagues respond to Dr. Abboud

pa.dimakopoulos{at}gmail.com Panayiotis Dimakopoulos, MD, et al.

We thank Dr. Abboud for his interest in our article and we appreciate the opportunity to clarify certain points regarding the, “Transosseous Suturing Fixation” technique.

No fluoroscopic imaging is needed with this technique since it is an open one, allowing for a very good view of the operating field. We would point out that with the ability to rotate the arm in both external and internal rotation, introperative visualization of the fracture fragments is easily obtained both anteriorly and posteriorly. We have not found it necessary to use fluoroscopy intraoperatively with this technique.

Plates are a reasonable alternative for proximal humeral fractures but they do have disadvantages. We used proximal humeral plates extensively in the past but, in many instances, the fixation was unstable, especially in 3- and 4-part valgus impacted fractures. Although precontoured proximal humeral plates permit better bony purchase and more stable fixation, they do not allow for as good a tensioning of the tuberosities as provided by the sutures themselves. At present, our current indication for plate osteosynthesis is the 2-part fracture of the surgical neck, using a plate which also enables the placement of sutures for even better stabilization.

The concept of non-anatomic fracture reduction obviates many of the main disadvantages of earlier techniques. Screw purchase is not always possible in the exact place that it was initially planned, hardware and tuberosities may impinge and the final function of the rotator cuff muscles is occasionally compromised. Figure 11 is the postoperative radiograph of a 4-part valgus impacted fracture fixed by the “Transosseous Suturing” technique. In this type of fracture, we accept a non-anatomic reduction in order to avoid disimpaction of the head part from its valgus impacted status, thus minimizing the risk of further disruption of the vulnerable blood supply to the head. In order to restore the mechanics of the rotator cuff, we pull and fix the tuberosities below the top of the head, producing a non-anatomic, yet functional situation (as shown in Figure 8). Overall, what matters most is to provide a stable osteosynthesis with adequate tensioning of the rotator cuff, without impingement.
Transosseous Suture Fixation of Proximal Humeral Fractures. Surgical Technique
Transosseous Suture Fixation Technique For Proximal Humerus Fractures		 21 April 2009
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Joseph A. Abboud, MD,
Clinical Assistant Professor of Orthopaedic Surgery
3B Orthopaedics, University of Pennsylvania Health System, PA

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Re: Transosseous Suture Fixation Technique For Proximal Humerus Fractures

Joseph.Abboud{at}uphs.upenn.edu Joseph A. Abboud, MD

To the Editor:

I read with interest the paper by Dimakopoulos et al. (1) and would like to pose the following questions to the authors:

1. To what extent do they use fluoroscopic imaging intraoperatively?

2. Have they had any problems using plates, particularly the precontoured proximal humeral locking plates, with this technique?

3. Could they comment further on the importance of anatomic fracture reduction? When are they willing to accept a non-anatomic reduction such as they show in figure 11?

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. Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of proximal humeral fractures. Surgical technique. J Bone Joint Surg Am. 2009;91 Suppl 2 Pt 1:8-21.

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
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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

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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
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Madhavan Chikkapapanna Papanna,
Registrar in Orthopaedics
Luton and Dunstable Hospital NHS Foundation Trust, Luton, United Kingdom

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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
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Karl M. Koenig, MD,
Physician
Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,
Kenneth J. Koval, MD

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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
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Gerard P. Slobogean, MD, MPH
University of British Columbia, Vancouver, Canada

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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
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James A. Browne, MD,
Orthopaedic Fellow in Adult Reconstruction
Mayo Clinic,
Chad Cook, PhD, MBA, PT; Steven A. Olson, MD; Michael P. Bolognesi, MD

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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
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Barry J. O'Neill,
Registrar in Orthopaedic & Trauma Surgery
Limerick Regional Hospitals, Ireland

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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
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James G. Wright, MD, MPH, FRCSC,
Associate Editor for Evidence-Based Orthopaedics
The Journal of Bone & Joint Surgery

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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
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Joseph Bernstein, MD
University of Pennsylvania, Philadelphia, Pennsylvania,
Jaimo Ahn, MD, PhD

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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
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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

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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
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Ajay Malviya,
Specialist Registrar, Orthopaedics
Wansbeck General Hospital, Ashington, United Kingdom

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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
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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

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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
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Tao Cheng, MD, PhD
Sixth Affiliated People's Hospital, Shanghai Jiao Tong University, China,
Xian-Long Zhang, MD, PhD, Professor

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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
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Tamara D. Rozental, MD,
Assistant Professor
Harvard Medical School, Boston, MA

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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
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William JM Holmes, MBChB, MRCSEd,
Doctor ,
A. Roche, M. Webb

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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
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Tamara D. Rozental, MD,
Assistant Professor in Orthopaedic Surgery
Harvard Medical School, Boston, MA

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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
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Sudeep Kumar, MBBS, MS(Ortho),
Senior Resident Surgeon, Orthopaedics
All India Institute Of Medical Sciences, New Delhi, India

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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
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Brian D. Solberg, MD ,
Charles N. Moon, MD; Dennis P. Franco, MD; Guy D. Paiement, MD

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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
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Jon V. Clarke,
Specialist Registrar
West of Scotland Orthopaedic Rotation, United Kingdom,
Tom Nunn

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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
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N. Wah Cheung,
Consultant Endocrinologist
Westmead Hospital, University of Sydney, NSW, Australia

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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
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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.

Editorial:
 Further Emphasis on Evidence
 Heckman (1 July 2009) [Full text] [PDF]
Further Emphasis on Evidence
Documentation of Levels of Proficiency of Caregivers in Reporting Evidence		 17 July 2009
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Jin Bo Tang,
Professor
Nantong University, Nantong, China,
Xiao T. Wang, Bella Avanessian

Send letter to journal:
Re: Documentation of Levels of Proficiency of Caregivers in Reporting Evidence

jinbotang{at}yahoo.com Jin Bo Tang, et al.

To the Editor:

Since 1992, when the term "evidence-based medicine" first appeared in the medical literature (1), there has been an upsurge in the establishment of practice guidelines that adhere to its principles. The JBJS apparently took the lead in the orthopedic field in emphasizing the "evidence" (2,3). Evidence-based medicine ranks clinical evidence with respect to the influence of biases that beset medical research. However, we want to express our concern regarding a key issue in documenting the "evidence". Thus far, the clinical research reports regarding evidence-based medicine have been based solely on study design; whereas information about the degree of proficiency of professionals who conduct these studies is rarely documented.

To varying extents in all medical practices, treatment outcomes are influenced and biased by the skill with which medical personnel perform procedures. In clinical studies, because experience with implemented techniques is not paralleled by job position, simply categorizing caregivers as residents, attending surgeons, or consultants, etc., provides little, if any, scientific information regarding their expertise in specific techniques adopted in clinical studies. Individuals grouped into one such category often differ in their abilities to perform specific techniques. Because of such differences, in reports of treatments that rely heavily on methodology, the use of technique-performance evaluation criteria is critical for clear, objective interpretation of treatment outcomes. This concept holds particular importance in comparable studies conducted at different institutions or in different geographical areas which exhibit divergences in prevalence of, and consequently physicians exposure to, the study condition.

We proposed a method for the documentation of physicians' technique-experience levels as fitting one of the following categories:

Level I. Non-specialist. A physician in training, or a general physician/surgeon.

Level II. Specialist, less experienced. A specialist who has not yet acquired in-depth knowledge or high-volume experience in the use of the study technique(s). His/her lesser degree of experience can be judged by: 1. a shorter duration of practice as a specialist (i.e. < 5 years), and/or 2. a limited exposure to the investigated disorder.

Level III. Specialist, experienced. A physician who has obtained sufficient experience in the use of the treatment techniques pertinent to the study.

Level IV. Specialist, highly-experienced. A specialist who possesses in-depth knowledge of and experience in the use of techniques under study. He/she has been a leading participant in studies relevant to the disorder or techniques.

Level V. Expert. The pioneer of the technique in the study, or a recognized contributor to the advancement of knowledge and or treatments related to the disorder being investigated.

We believe that documentation of levels of experience would benefit a clinical report. First, doing so would facilitate scientific comparison and appraisal of reported treatment outcomes from different reports. Categorizing levels of experience in a report would allow for scientific analysis of the impact of physicians' capability on treatment outcomes. It may even enable statistical analysis of the relationship of physicians' proficiency levels with treatment outcomes. Second, documentation of levels of experience would merit the appraisal of clinical outcomes reported from different regions of the world. Worldwide the levels of physicians' experience with a disease vary enormously because of the divergence in the natural incidence of the disease in different regions in various parts of the world. Third, the use of criteria to scale levels of experience can indicate how capable study participants are at validating the efficacy of a given treatment procedure. Physicians with lower levels of experience would be less qualified.

We suggest that the expertise levels of the physicians who conduct the treatment be reported, perhaps, under "Methods" with further specification of the percentage of subjects treated by each experience-category, and as a supplement of currently used "Level of Evidence".

The approach we have presented is an example of a much-needed, standardized method for reporting a caregiver's technique-proficiency, an essential element currently missing in the documentation of procedure-based clinical studies. By eliminating a large degree of bias from their interpretation, such a system would enhance the utility of clinical studies in evaluating the efficacy of clinical treatments.

We wish that the JBJS and our colleagues in such a specialty that heavily relies on the proficiency of caregivers put emphasis on this issue and present their technique-proficiency in clinical reports.

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. Evidence-Based Medicine Working Group. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA. 1992;268:2420-5.

2. Hanzlik S, Mahabir RC, Baynosa RC, Khiabani KT. Levels of evidence in research published in The Journal of Bone and Joint Surgery (American Volume) over the last thirty years. J Bone Joint Surg Am. 2009;91:425-8.

3. Heckman JD. Further emphasis on evidence. J Bone Joint Surg Am. 2009;91:1557.

Scientific Articles:
 Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist
 Sammer and Shin (1 June 2009) [Abstract] [Full text] [PDF]
Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist
Drs. Shin and Sammer respond to Dr. Strauch		 15 July 2009
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Alexander Y. Shin, MD,
Professor and Consultant of Orthopaedic Surgery
Mayo Clinic, Rochester, Minnesota,
Douglas M. Sammer, MD

Send letter to journal:
Re: Drs. Shin and Sammer respond to Dr. Strauch

Shin.Alexander{at}mayo.edu Alexander Y. Shin, MD, et al.

We would like to thank Dr. Strauch for his comments. As the purpose of our study was to compare open irrigation and debridement (I&D) with arthroscopic I&D, we did not evaluate or discuss needle aspiration as a treatment for septic arthritis of the wrist. Additionally, since there are no high-quality randomized controlled trials comparing surgical I&D with needle aspiration, an argument can be made that there is no definitive gold standard for treating septic arthritis of the wrist. However, the predominant opinions in the hand surgery literature are that prompt surgical drainage is the primary treatment for septic arthritis of the wrist. For example, Rashkoff et al. (1) suggested that, “any treatment short of arthrotomy in the face of the diagnosis is ill-advised". Stevanovic and Sharpe called septic arthritis in the hand and wrist a, “surgical emergency” and suggested that serial aspiration is “therapeutically unpredictable” (2). Dr. Strauch’s comments highlight the divide between the surgical and medical literature. While there are some articles that support needle aspiration for the treatment of septic arthritis, these are predominantly found in the rheumatologic literature (3,4). There are likely multiple reasons for this difference, but one possible explanation is that rheumatologists tend to treat a different part of the spectrum of septic arthritis than do hand surgeons. Regardless, a prospective randomized comparison of the three methods (open I&D, arthroscopic I&D, and needle aspiration) would certainly provide more information about the respective roles for each approach. However, because of the low incidence of septic arthritis in the wrist, this would be logistically difficult, and would likely require a multi-center effort.

References

1. Rashkoff ES, Burkhalter WE, Mann RJ. Septic arthritis of the wrist. J Bone Joint Surg Am. 1983;65:824-8.

2. Stevanovic MV, Sharpe F. Acute infections in the hand. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, editors. Green’s operative hand surgery. 5th ed. Philadelphia: Elsevier; 2005. p 77-81.

3. Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, Walker D, Coakley G. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-5.

4. Goldenberg DL, Brandt KD, Cohen AS, Cathcart ES. Treatment of septic arthritis: comparison of needle aspiration and surgery as initial modes of joint drainage. Arthritis Rheum. 1975;18:83-90.
Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist
Standard of treatment?		 16 June 2009
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Robert J. Strauch, MD
Columbia University Medical Center, New York, New York

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Re: Standard of treatment?

robertjstrauch{at}hotmail.com Robert J. Strauch, MD

To the Editor:

I read with interest the article by Drs. Sammer and Shin in which they compare arthroscopic and open treatment of septic arthritis of the wrist(1). However, I would raise the point that the authors' statement in the opening paragraph that, "...open irrigation and debridement remains the standard of treatment for the (septic) wrist", is not supported by the current medical literature to date(2).

While the shoulder and hip are not amenable to easy aspiration, aspiration of the wrist joint is usually a simple matter, often performed by non-surgeons as well as orthopaedic surgeons. To date, there have been no convincing studies supporting open or arthroscopic drainage of the septic wrist compared with needle aspiration. In my own practice, I have been quite satisfied using needle aspiration and intravenous antibiotics for the successful treatment of the majority of patients with septic arthritis of the wrist. Therefore, while arthroscopic drainage of the septic wrist may be superior to open drainage, it may not be superior to needle aspiration alone--a point not discussed anywhere in the article.

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.Douglas M. Sammer and Alexander Y. Shin Comparison of Arthroscopic and Open Treatment of Septic Arthritis of the Wrist J Bone Joint Surg Am 2009; 91: 1387-1393

2. Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, Walker D, Coakley G. Management of septic arthritis: a systematic review. Ann Rheum Dis. 2007;66:440-5. Epub 2007 Jan 12.

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
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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
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James O. Smith,
Specialty Registrar, Orthopaedics
St. Mary's Hospital, Isle of Wight, United Kingdom,
Pradeep Moonot

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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.
Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the...
Drs. Konrad and Südkamp respond to Drs. Court-Brown and McQueen		 22 July 2009
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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 Drs. Court-Brown and McQueen

gerhard.konrad{at}uniklinik-freiburg.de Gerhard G. Konrad, MD, et al.

The authors would like to thank Drs. Court-Brown and McQueen for their interest in our study. They raised several points which deserve further comment. We have the following explanations to offer: We agree that it is important to define the indications for surgical treatment of proximal humeral fractures, especially because proximal humeral fractures are common and are getting more common as the prevalence of osteoporotic fractures increases. However, the aim of the present study was to evaluate the functional outcome and complication rate after open reduction and internal fixation of proximal humeral fractures with the Locking Proximal Humerus Plate. There was no control group for conservative treatment. Therefore with the data available out of this study it is not possible to determine which fractures will do better with surgical treatment. In our study all fractures either met the indications for operative treatment outlined by Neer, i.e. an angulation of the articular surface of more than 45º or a displacement between the major fracture segments of more than 1 cm, or were unstable when tested with passive motion using an image intensifier. Nondisplaced stable fractures and fractures with minimal displacement and adequate stability as well as fractures involving only the greater or lesser tuberosity were not considered for treatment with the plate. Therefore the patients in our study presumably represent a selection which will end up with a lower Constant score after conservative treatment compared to the patients in the study by Court-Brown and McQueen. In their study, all patients had an impacted valgus fracture (B1.1) of the proximal humerus. The distribution of fracture types according to the AO classification and gender is shown in Figure 1. Also the results for different fracture types is mentioned in the manuscript and there was no significant difference in the Constant score between fracture types according to the AO classification at the final follow-up.
Open Reduction and Internal Fixation of Proximal Humeral Fractures with Use of the...
Treatment of Proximal Humeral Fractures		 8 July 2009
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Charles M. Court-Brown, MD, FRCSEd(Orth),
Professor of Orthopaedic Trauma
University of Edinburgh, Edinburgh, Scotland,
Margaret McQueen, MD FRCSEd(Orth)

Send letter to journal:
Re: Treatment of Proximal Humeral Fractures

courtbrown{at}aol.com Charles M. Court-Brown, MD, FRCSEd(Orth), et al.

To the Editor:

We read the article by Südkamp et al. (1) with interest. The authors have written yet another paper on the advantages and disadvantages of a locking proximal humeral plate and while we have no doubt that the study was performed well we believe that they have sidestepped the real issue which is who should be treated with these plates.

They report a mean Constant score of 70.6 one year after surgery in 187 patients with proximal humeral fractures. They do not detail the results for different fracture types but our analysis of the paper suggests that about 105 fractures were AO A2, A3 or B1 fractures and it seems reasonable to assume that they achieved better results with these simpler fractures than in the AO B2, B3 and Type C fractures that they also treated. We believe that the results reported by Südkamp et al. are no better than are achieved with non-operative management. In previously published studies (2,3) we documented mean Constant scores of 64, 65 and 72 for AO A2, A3 and B1 fractures one year after non-operative management. The average ages of our groups were 74, 68 and 71 years respectively, these being considerably more than the average age of Dr Südkamp’s patients which was 63 years. Age is obviously very important to outcome. We documented a mean Constant score of 75.7 in patients with B1 fractures who were 60 – 69 years of age compared with 67.1 in patients who were 80 – 89 years of age (2). When age is considered, we believe that there is no evidence that the locking plate actually improves the outcome in most patients.

We do not doubt that there are patients with proximal humeral fractures who benefit from surgery and that the fracture type, age of patient, general mobility and the presence of clinical and social comorbidities influence surgeons in their choice of treatment. However, the literature is deficient in helping us consider which fractures will do better with surgical treatment. This is important as proximal humeral fractures are common and are getting more common as the prevalence of osteoporotic fractures increases. It is important that shoulder surgeons and trauma surgeons start doing more than simply assessing yet another plate.

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, Voight 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. Court-Brown CM, McQueen MM. Two-part fractures and fracture dislocations. Hand Clin. 2007:23;397–414.

3. Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment. J Bone Joint Surg Br. 2002:84;504–8.

Evidence-Based Orthopaedics:
 Arthroscopic Surgery Did Not Provide Additional Benefit to Physical and Medical Therapy for Osteoarthritis of the Knee
 Moseley (1 May 2009) [Full text] [PDF]
Arthroscopic Surgery Did Not Provide Additional Benefit to Physical and Medical...
Randomized trials of arthroscopy for knee arthrosis can still have bias		 10 June 2009
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Omer A. Ilahi, MD,
Orthopedic Surgeon
Texas Arthroscopy & Sports Medicine Institute, Houston, Texas

Send letter to journal:
Re: Randomized trials of arthroscopy for knee arthrosis can still have bias

oilahi{at}mysurgeon.com Omer A. Ilahi, MD

To the Editor:

In the May 2009, "Evidence-Based Medicine" section of the Journal, an article by Kirkley et al. that was published in the New England Journal of Medicine (1), was summarized and a commentary was provided by Dr. Moseley (2). Contrary to Dr. Moseley's conclusions in the commentary, I see evidence of major selection bias in the article by Kirkley et al.

What’s striking in the study of Kirkley et al. (1) is that, over a 6 ½ year period at a major Canadian center for arthroscopic surgery, and involving 7 orthopedic surgeons, only “…277 patients were assessed for eligibility”. That works out to about 6 patients per surgeon per year! Yet knee osteoarthrosis is a very common finding among patients presenting for orthopedic evaluation of knee pain. That so few patients were assessed for eligibility in the trial suggests major selection bias. The number actually enrolled in the trial was even less - 188.

I have firsthand knowledge of major selection bias in a previous article on this very subject published by Moseley et al. in the New England Journal of Medicine (3). In that study, Moseley et al. recruited a similar number of patients at a Veterans Administration Hospital over a much shorter period of time than did Kirkley. Most of the patients in that investigation had already been evaluated by me as I was in charge of the arthroscopy service at that institution during the majority of the study enrollment and I offered knee arthroscopy to those I thought would benefit from it. Some of the patients whom I thought would not benefit from arthroscopic intervention found their way into Dr. Moseley’s investigation as they wanted something to be done.

So, that randomized, double-blind, sham surgery controlled trial (3) basically showed that knee arthroscopy is of little benefit in patients with knee pain and arthrosis - if an orthopedic surgeon after evaluating them determines they would not benefit from such intervention! Any other conclusion regarding the efficacy of arthroscopy in patients with knee arthrosis can not be reliably drawn from that investigation.

For the above reasons, I have substantial concerns that, in the study of Kirkley et al.,(1) subjects considered for the study were selected, whether consciously or not, from those deemed unlikely to benefit from knee arthroscopy.

Of course, I have my own bias. My view, shaped in part by former mentors (including Dr. Moseley), is that knee arthroscopy gives little lasting benefit for symptomatic gonarthrosis, but can be of significant benefit for pain generated from arthroscopically correctable pathology, whether or not the joint has underlying arthrosis.

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. Kirkley A, Birmingham TB, Litchfield RB, Giffin JR, Willits KR, Wong CJ, Feagan BG, Donner A, Griffin SH, D'Ascanio LM, Pope JE, Fowler PJ. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008;359:1097-107.

2. Moseley B. Arthroscopic surgery did not provide additional benefit to physical and medical therapy for osteoarthritis of the knee. J Bone Joint Surg Am. 2009;91:1281. Comment on: New Engl J Med. 2008;359:1097-107.

3. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-8.

The Orthopaedic Forum:
 Orthopaedic Education—Are We Attracting the Best and the Brightest?
 Emery et al. (1 May 2009) [Full text] [PDF]
Orthopaedic Education—Are We Attracting the Best and the Brightest?
Dr. Emery and colleagues respond to Dr. Rutherford		 24 June 2009
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Sanford E. Emery, MD, MBA,
Orthopaedic Surgeon
West Virginia University, Morgantown, West Virginia,
James P. Waddell, MD; Andrea E. Waddell, MD; Michael McCaslin, CPA; Kevin Black, MD

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Re: Dr. Emery and colleagues respond to Dr. Rutherford

semery{at}hsc.wvu.edu Sanford E. Emery, MD, MBA, et al.

We appreciate Dr. Rutherford's comment regarding women in orthopaedic surgery and are in full agreement. The latest ACGME data (2007-2008 academic year) show that women constitute only 12.4% of residents in orthopaedics; this is only slightly higher than neurosurgery which has the lowest prevalence of women of all major subspecialties-- 11.1%. The number of women entering our subspecialty is not changing rapidly either. In 2006-2007 only 11% of orthopaedic residents were women.

Of interest, this topic will be the subject of a symposium at the American Orthopaedic Association annual meeting in 2010. Obviously, more tangible progress is needed in this area.
Orthopaedic Education—Are We Attracting the Best and the Brightest?
The Best and Brightest		 1 June 2009
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Rob Rutherford, MD,
Orthopedic Surgeon
FMS (University of Washington)

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Re: The Best and Brightest

rutherford39{at}roadrunner.com Rob Rutherford, MD

To the Editor:

I commend Dr. Emery and colleagues for the article "Orthopaedic Education--Are We Attracting the Best and Brightest?" (1). What I did not see in the symposium was reference to the fact that orthopedics has one of the lowest percentages of women of any specialty, whereas about half the graduates of US medical schools are women. Until this imbalance is addressed and corrected, are we attracting only half of the best and brightest?

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. Emery SE, Waddell JP, Waddell AE, McCaslin M, Black K. Orthopaedic education--are we attracting the best and the brightest? J Bone Joint Surg Am. 2009;91:1253-63.

Scientific Articles:
 Screw Fixation Compared with Suture-Button Fixation of Isolated Lisfranc Ligament Injuries
 Panchbhavi et al. (1 May 2009) [Abstract] [Full text] [PDF]
Screw Fixation Compared with Suture-Button Fixation of Isolated Lisfranc Ligament...
Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi		 2 June 2009
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Vinod K. Panchbhavi, MD, FRCS,
Associate Professor, Orthopedic Surgery
University of Texas Medical Branch, Galveston, Texas,
Clark Andersen, BS

Send letter to journal:
Re: Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi

vkpanchb{at}utmb.edu Vinod K. Panchbhavi, MD, FRCS, et al.

We thank Dr. Rogers and Mr.Emeagi for their interest in our work. The following are our responses to the points raised:

1. We agree that PMMA in the tibia can alter the tibia’s mechanical properties. However, this is not pertinent to our study, whose area of interest, the Lisfranc joint, lies far from the tibia. Testing the effects of loading was standardized in all specimens, and the MTS machine and the PMMA in the tibia were merely means to replicate body weight.

2. Current practice when treating a Lisfranc ligament injury is to immobilize the foot for three months in a non-weight-bearing cast after screw fixation of the Lisfranc joint. It is hoped that the Lisfranc ligament heals by three months, after which the screw is taken out, and only then walking, weight bearing, and cyclic loading are allowed. As noted in our article, after the three-month period, if the Lisfranc ligament does not reconstitute itself it is hoped that the suture-button may help support the Lisfranc joint. The objective in our study was strictly defined to first compare the strength of fixation achieved by a screw (the current standard of practice) to that of a suture-button. Testing cyclic loading and the endurance limit is our objective for future studies.

3. Technical feasibility limits the use of the suture-button to repairing the diastasis due to ligamentous disruption between the medial cuneiform and the base of the second metatarsal bones. For example, a suture-button cannot be used to stabilize associated fractures such as those in the bases of the metatarsals or disruption of the first metatarso-cuneiform joint.

4. We feel that further cadaver and clinical studies are necessary to evaluate the use of the suture-button technique in Lisfranc injuries. We would like to take this opportunity to reemphasize that we do not advocate any clinical use or extrapolation based on this study. The implication of this study is that the suture-button technique in the future may prove to be an acceptable alternative to a screw in stabilizing Lisfranc injury.

5. We agree that the age group of the specimens is not representative, as these injuries usually occur in younger patients. However, younger-age specimens are harder to obtain and were not necessary for this study as the right and left sides of the same cadaver served to standardize the methods used.
Screw Fixation Compared with Suture-Button Fixation of Isolated Lisfranc Ligament...
Suture-Button Fixation of Isolated Lisfranc Injuries		 2 June 2009
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Benedict A. Rogers,
Specialist Registrar
South West Thams, London, England,
C. Emeagi

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Re: Suture-Button Fixation of Isolated Lisfranc Injuries

benedictrogers{at}hotmail.com Benedict A. Rogers, et al.

To the Editor:

We read with interest the article by Panchbhavi et al. (1) and would like to make the following points:

1. The tibial intramedullary canal was filled with polymethylmethacrylate (PMMA) prior to the loading protocol. It is known from spinal studies that PMMA significantly alters the biomechanical properties of bone (2). Do the authors know how their tibial model compares with the normal physiological stresses?

2. Cyclical loading has been shown to more accurately recreate the loads that are transmitted through the foot (3). Have the authors any indication as to the response of the suture button technique, such as the endurance limit, when exposed to repetitive stresses of Lisfranc joint?

3. Myerson described that different types of Lisfranc injury (4) result from different force vectors and require different surgical techniques (5).Did this study take into account the different types of Lisfranc injuries and is the suture button technique suitable for all types of injury?

4. The implication of this study to clinical practice is unclear. Numerous techniques have been documented regarding the stabilization of these injuries (6,7) not all of which have been considered in this study.

5. The mean age of tibial/foot specimens used was 80 years, suggesting that the specimens had reduced intrinsic ligament strength. Extrapolating this cadaveric study to the treatment of these injuries, that are commonly seen in a younger population, must be done with caution.

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. Panchbhavi VK, Vallurupalli S, Yang J, Andersen CR. Screw fixation compared with suture-button fixation of isolated Lisfranc ligament injuries. J Bone Joint Surg Am. 2009;91:1143-8.

2. Gilbert JL, Ney DS, Lautenschlager EP. Self-reinforced composite poly(methyl methacrylate): static and fatigue properties. Biomaterials. 1995;16:1043-55.

3. Daniels TR, Lau JT, Hearn TC. The effects of foot position and load on tibial nerve tension. Foot Ankle Int. 1998;19:73-8.

4. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20:655-64.

5. Rajapakse B, Edwards A, Hong T. A single surgeon's experience of treatment of Lisfranc joint injuries. Injury. 2006;37:914-21.

6. Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 2005;26:462-73.

7. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986;6:225-42.

Scientific Articles:
 Evidence for an Inherited Predisposition Contributing to the Risk for Rotator Cuff Disease
 Tashjian et al. (1 May 2009) [Abstract] [Full text] [PDF]
Evidence for an Inherited Predisposition Contributing to the Risk for Rotator Cuff...
Drs. Tashjian and Cannon-Albright respond to Drs. Jain and Higgins		 29 June 2009
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Robert Z. Tashjian, MD,
Assistant Professor
Department of Orthopaedics, University of Utah School of Medicine, Salt Lake City, Utah,
Lisa A. Cannon-Albright, PhD

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Re: Drs. Tashjian and Cannon-Albright respond to Drs. Jain and Higgins

Robert.Tashjian{at}hsc.utah.edu Robert Z. Tashjian, MD, et al.

We appreciate the interest Dr. Jain and Dr. Higgins had in our recent work investigating a possible genetic predisposition for rotator cuff disease. We will attempt to address each of the concerns of Drs. Jain and Higgins in the following response.

ICD-9 Codes: As Drs. Jain and Higgins point out, we have recognized the limitations of using ICD-9 coding in this study and have attempted to underscore these concerns to the reader by discussing them. We agree with Drs. Jain and Higgins that an accurate diagnosis is paramount in every study. As described, we have restricted our phenotype definition to those individuals with rotator cuff repair surgery or with a diagnosis of rotator cuff disease. This restriction limits our sample size, and thus our power, but does not result in any bias. All individuals with hospital data, including relatives of cases and relatives of matched controls, are similarly censored. Only a bias specific to relatives of controls that increased censoring of their affected relatives, or a bias specific to relatives (both close and distant) of cases that decreased censoring of their affected relatives could be invoked to support the claim that the results are affected by our use of ICD-9 and CPT coding. Because we can assume uniform censoring of phenotype data, the statistics presented are robust, and very likely only conservatively estimate the true extent of the genetic predisposition to rotator cuff disease.

With regards to CPT surgical coding, we agree with Drs. Jain and Higgins that identification of patients using the presence of a rotator cuff repair surgery would be optimal. As presented, we identified 244 individuals with a history of rotator cuff surgery. Although this is a small sample size to use for the GIF analysis, we did perform it. The mean case GIF was 3.12 and the mean control GIF was 2.75; respective p-values were not significant (p = 0.24 and 0.51), but we observed an excess of relationships of distance 2, 4, 6, and 8 (second cousins), supporting the hypothesis of more distant relationships between these cases than expected.

With regards to the comments on degenerative rotator cuff tearing, we did not make the assumption that degenerative rotator cuff tears have a genetic predisposition. Therefore, we agree with Drs. Jain and Higgins that this cannot be supported by the data and we have in no place in this manuscript made this assumption. Rather we have made the assumption that, “rotator cuff disease”, which likely includes degenerative tears, has a genetic predisposition. While this may be unfamiliar to some researchers, most clinicians, coders and billers will recognize the ICD-9 code 840.4 as a way to classify patients who have a rotator cuff related problem as well as some antecedent history of trauma. Included in this group are patients with likely an underlying degenerative process who had some level (from very low to higher level energy) of injury at various time points (from very acute to very remote). Consequently, inclusion of these patients does not preclude the possibility of a degenerative process. More importantly, we are not attempting to define the familial patterns of a degenerative process, rather a genetic process. Consequently, we believe it is just as important to include the patients with the 840.4 code as those coded with a rotator cuff tear. Patients may have an underlying genetic profile that predisposes them to a rotator cuff injury that requires treatment that other individuals without an underlying genetic predisposition may not sustain despite the same level of trauma. We are attempting to capture this population of patients at risk for rotator cuff related injury, therefore inclusion of the 840.4 patients was justified.

We agree with Drs. Jain and Higgins that the best evidence for a genetic predisposition would be available in early onset tears, which we have presented. Although the numbers of affected relatives observed is small, as the Drs. Jain and Higgins note, the significance of the statistical test performed supports our conclusion.

Information on missing data: As described in our manuscript, we did not screen any relatives for this study. We relied on the existence of hospital diagnosis data for approximately 1 million patients who also have at least 3 generations of genealogy data. As noted, we recognize that there is censorship of any relative who is not in the genealogy data and/or who was not a patient at the University of Utah after 1994. However, this censorship applies uniformly to relatives of both cases and to the relatives of their matched controls and does not introduce any bias, but rather leads to conservative estimates of risk.

Age of participants: We agree with Drs. Jain and Higgins that increasing age in various generations has an impact on risk of rotator cuff disease. For this reason, as discussed, we estimated expected numbers of cases by age (and sex), using 5 year birth year cohorts.

Conclusion: The suggestion that these results represent, “a familial association with shoulder pain visits” might be reasonable if we only saw an excess in first-degree, or maybe even in second-degree relatives. However, invoking a, ”familial association” in the face of significant excess risk in third-degree relatives would require the assumption that individuals with affected relatives as distant as first cousins (third degree in the RR analysis) or second cousins (genetic distance = 8 in the GIF analysis) are more likely to visit a clinic regarding shoulder pain because their relative did this. The significant excess clustering we observed in close and distant relatives strongly supports much more than a, “familial association with shoulder pain visits”.

In conclusion, we agree with Drs. Jain and Higgins that more detailed studies will help clarify the genetic predisposition to rotator cuff disease that we have strongly supported in this study. Screening studies of high-risk Utah pedigrees are planned.
Evidence for an Inherited Predisposition Contributing to the Risk for Rotator Cuff...
Genetic Predisposition to Rotator Cuff Tears		 29 June 2009
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Nitin B. Jain, MD,
Physician
Spaulding Rehabilitation Hospital and Harvard Medical School, Boston, Massachusetts,
Laurence D. Higgins, MD

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Re: Genetic Predisposition to Rotator Cuff Tears

njain1{at}partners.org Nitin B. Jain, MD, et al.

To the Editor:

We congratulate Tashjian et al. on their timely study of the genetic epidemiology of rotator cuff disease (1). The authors studied 3,091 patients with rotator cuff disease from the Utah Population Database and concluded that their data “strongly supports a heritable predisposition to rotator cuff disease”. After a careful review of the manuscript, we would like to raise several issues that may impact these conclusions:

• ICD-9 codes were used to determine cases of rotator cuff disease, a limitation that the authors have acknowledged. However, an accurate diagnosis of rotator cuff disease is of paramount importance for this study. As the readership will appreciate, there still does not exist a standardized methodology for diagnosing rotator cuff tears. It is largely based on expert clinician’s impression and imaging findings. This scenario is further complicated since asymptomatic individuals may have rotator cuff tears on imaging. The prevalence of documented rotator cuff tears on imaging in patients without symptoms is reported to be 40% in subjects >50 years, 54% in those >60 years (2), and 65% in persons over 70 years (3). Often, patients with shoulder pain are diagnosed with rotator cuff tears in primary care settings without supporting clinical and imaging evidence leading to less reliable diagnostic data. It can be argued that, if the bias in diagnosis is non-differential, the results will be biased towards the null. However, the reliability of the outcome variable in this study is a key issue, and is unavailable and likely low. Moreover, the proportion of patients with rotator cuff disease is small as compared to the population sizes (202 of 23,700 patients versus 409 of 117,063 controls in first degree relatives). Hence,if many patients who were deemed to have rotator cuff disease did not,the p-values and relative risks would become statistically non-significant.

• CPT codes for rotator cuff repair would be a more reliable way to study genetic predisposition since it is unlikely that a patient would be coded as having a repair unless the patient had a rotator cuff tear. The authors do not provide data on genetic predisposition in patients that underwent rotator cuff repair. This would be a valuable addition even if the sample size is small.

It is plausible that degenerative cuff tears have a genetic predisposition but this assumption cannot be supported the the data. Approximately one-third (n=1,076) of the cases included in the study are based on an ICD-9 code for “rotator cuff traumatic strain”.

The best evidence for a genetic predisposition would be available from cuff tears in younger individuals who otherwise would not be expected to have a rotator cuff tear (except in cases of trauma). The authors have diligently performed this analysis in patients younger than 40 years. However, small sample sizes (8 cases among 8,266 second degree patient relatives and 11 cases among 41,624 second degree control relatives) make it difficult to reach conclusions based on this analysis.

• Information on missing data would be useful. Were all first, second, and third degree relatives screened for rotator cuff tear? What about relatives who lived out-of-state but may still have a diagnosis of rotator cuff tear? It is also possible that many patients do not seek medical care despite symptomatic cuff tear. This could be a substantial number of patients. Given the small number of patients with rotator cuff tears from a large population base, even one of these biases, if differential, could alter the results.

• Finally,the age of participants in first, second, and third degree relatives groups is not presented. Increasing age is associated with increased likelihood of rotator cuff tear (4,5). If the median age of first degree relatives is higher, the prevalence of rotator cuff disease would be expected to be higher in this group.

In conclusion, the ability to assign a pathoanatomic diagnosis of rotator cuff disease based on the data in this study is limited and uncertain in a percentage of cases. Therefore, the authors have likely shown a familial association with shoulder pain visits, which could indeed reflect genetic associations with rotator cuff disease or impingement. The study raises a range of important questions. More detailed studies that use a more reliable and valid rotator cuff disease diagnosis will be needed to address these questions. The use of genetic biomarkers will also help to quantify the associations objectively.

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. Tashjian RZ, Farnham JM, Albright FS, Teerlink CC, Cannon-Albright LA. Evidence for an inherited predisposition contributing to the risk for rotator cuff disease. J Bone Joint Surg Am. 2009;91:1136-42.

2. Milgrom C, Schaffler M, Gilbert S, van Holsbeeck M. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender. J Bone Joint Surg Br. 1995;77:296-8.

3. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77:10-5.

4. Wendelboe AM, Hegmann KT, Gren LH, Alder SC, White GL Jr, Lyon JL. Associations between body-mass index and surgery for rotator cuff tendinitis. J Bone Joint Surg Am. 2004;86-A:743-7.

5. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88:1699-704.

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
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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
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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.
Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. A Concise...
Dr. Della Valle and colleagues respond to Drs. Schreurs and de Kam		 30 June 2009
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Craig J. Della Valle, MD,
Associate Professor of Orthopaedic Surgery
Rush University Medical Center,
Nathan W. Mesko, MD; Laura Quigley, MS; Aaron G. Rosenberg, MD; Joshua J. Jacobs, MD; Jorge O. Galante, MD

Send letter to journal:
Re: Dr. Della Valle and colleagues respond to Drs. Schreurs and de Kam

craigdv{at}yahoo.com Craig J. Della Valle, MD, et al.

We thank Drs. Schreurs and de Kam for their interest in our work. As they point out in their letter, 10 of the 204 acetabular components were revised; eight of those at the time of revision surgery were found to be well-fixed and two were loose. Four of the eight well- fixed components were removed for the treatment of osteolysis.

While we agree that osteolysis can lead to loosening, these cups were not,in fact, found to be loose at the time of revision; therefore, they were not considered to have been failures for our survivorship analysis which considered acetabular component loosening as an endpoint. However, they were considered as failures for the survivorship analysis that considered a reoperation on the hip for a problem related to the acetabular component.

Looking back at the cases that were revised for osteolysis, we would not currently remove those components, but rather prefer to use particulate graft around the component and perform a modular polyethylene liner exchange.

Regarding the results of cementless acetabular reconstruction in younger patients, our cohort is actually quite unique, as the mean patient age at the time of surgery was 52 years. Thus we believe that our paper does yield some insight into this question. As we have continued to follow this cohort, the surviving patients are not unexpectedly the patients who underwent surgery at a younger age.

In the subset of patients who were less than 50 years old at the time of surgery, only one patient (who had undergone bilateral total hips) was lost to follow-up. In terms of the age-specific details of those who underwent revisions of the acetabular component, six of the ten revisions were in patients who were less than 50 years old at the time of the index arthroplasty. Four of these six revisions were performed for loosening (two patients) or osteolysis (two patients), with the remaining two being revised secondary to infection. These six revisions were performed at a mean of 196.3 months postoperatively; if the two infections are excluded, the mean time to revision was 179.8 months (range 123-230 months). Table III in the paper, which stratifies patients by age, shows the strong effect of age on the prevalence of osteolysis and the performance of modular polyethylene liner exchanges with the majority of wear related issues identified in patients who were less than 50 years old at the time of surgery.

It is important to stress that this experience is with a first generation device, and it is our hope that the wear-related complications observed in this series will be decreased with modern cementless designs that have incorporated improvements that include better polyethylene congruency and locking mechanisms and bearing surfaces (such as cross-linking).
Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component. A Concise...
Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component: Outcome in young patients?		 30 June 2009
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B. Willem Schreurs, MD, PhD,
Orthopedic Surgeon
Department of Orthopedics, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands,
Daniel de Kam, MD

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Re: Primary Total Hip Arthroplasty with a Porous-Coated Acetabular Component: Outcome in young patients?

b.schreurs{at}orthop.umcn.nl B. Willem Schreurs, MD, PhD, et al.

To the Editor:

We read the paper by Della Valle and colleagues (1) with great interest and we congratulate the team on their excellent results. Their minimum 20 years survival data using a metal shell is impressive with only 10 of 204 acetabular components being revised.

We would question, however, their interpretation that only two of these 10 cups were revised for aseptic loosening. It is difficult to accept that cups which have been removed to treat acetabular osteolysis, which is an essential part of the aseptic loosening process, were not considered as aseptic failures.

We believe the authors can provide additional valuable information by also reporting the outcomes of hips in younger patients. At the moment, there are no long-term reports on the outcome of non-cemented cups in young patients at a minimum follow-up of 20 years. The authors have a large group of patients in their study (79 hips) who underwent THA when they were younger than 50. It would be very interesting if the authors can provide more detailed data of this specific group. From the paper it can be inferred that, of these 79 hips, 10 had a liner exchange (10/79 = 13%), and osteolysis was seen in at least 26 of the 79 hips (33%). We would surmise that, with further follow up, these percentages will increase with time.

For the whole study group of 124 hips available at a minimum of 20 years, only 60% of the patients had a radiograph available. As most liner exchanges are seen in the younger patients, it can also be inferred that the majority of of patients who underwent a liner exchange(8 for the whole group) were from the younger age group. Based on this calculation and these assumptions, it seems that at least over 50% of the patients under 50 years will have cup wear or osteolysis problems.

It is also unknown how many of the patients lost to follow up were from the under 50 age group and how many of the 10 revisions were performed in this group. It would be very helpful if the authors could provide this additional information, so that the outcomes of non-cemented cups in young patients can be compared to the published results of cemented cups in young patients that are already available in literature.

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. Della Valle CJ, Mesko NW, Quigley L, Rosenberg AG, Jacobs JJ, Galante JO. Primary total hip arthroplasty 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.

Scientific Articles:
 Comparison of Surgeon and Physiotherapist-Directed Ponseti Treatment of Idiopathic Clubfoot
 Janicki et al. (1 May 2009) [Abstract] [Full text] [PDF]
Comparison of Surgeon and Physiotherapist-Directed Ponseti Treatment of Idiopathic...
Are we really that busy?		 16 June 2009
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Lewis E. Zionts, MD,
Physician
Orthopaedic Hospital, Geffen School of Medicine at UCLA, Los Angeles, California

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Re: Are we really that busy?

LZionts{at}laoh.ucla.edu Lewis E. Zionts, MD

To the Editor:

I read with great interest the article by Dr. Janicki and colleagues entitled,"Comparison of Surgeon and Physiotherapist-Directed Ponseti Treatment of Idiopathic Clubfoot" (1). Although I was not surprised by their conclusion, that infants with idiopathic clubfoot can be managed by ancillary personnel without “compromising the quality of care”, I found myself wondering, who would want to forgo one of those activities that embodies the very essence of our profession?

In my experience, one of the most meaningful activities in which I have engaged as a physician over the years has been the treatment of an infant’s clubfoot. What makes this endeavor particularly satisfying is that it is one of the few activities that involve extended, personal, hands-on contact with the patient. I believe that most parents genuinely appreciate the fact that the treatment is being rendered to their child by the person who they view as the most knowledgeable and well-trained member of the health care team – the physician. There are few conditions I treat for which the gratitude of parents, grandparents, and other family members is more profoundly expressed. We do have skilled ancillary personnel in our clinic who can help the parents deal in depth, if necessary, with educational, cast, and orthotic issues that may arise. These individuals enable us to take care of our patients without unduly compromising our schedules.

I realize from my interaction with our residents that our profession has become increasingly technically oriented. I also acknowledge that there are certain cost concerns in the practice of medicine. However, I would hope that, before we turn over as rewarding an activity as the treatment of idiopathic clubfoot to our nurses and physical therapists, we reflect on the reasons we originally chose to become physicians. More importantly, we should take into account the comfort the family derives when the physician personally attends to the care of their child.

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. Janicki JA, Narayanan UG, Harvey BJ, Roy A, Weir S, Wright JG. Comparison of surgeon and physiotherapist-directed Ponseti treatment of idiopathic clubfoot. J Bone Joint Surg Am. 2009;91:1101-8.

Scientific Articles:
 Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade Partial-Thickness Supraspinatus Tears
 Kamath et al. (1 May 2009) [Abstract] [Full text] [PDF]
Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade...
Dr. Galatz and colleagues respond to Dr. Bernstein		 10 June 2009
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Leesa M. Galatz, MD,
Associate Professor, Shoulder and Elbow Service
Washington Universtiy in St. Louis School of Medicine,
Jay Keener, MD; Ken Yamaguchi, MD

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Re: Dr. Galatz and colleagues respond to Dr. Bernstein

galatzl{at}wudosis.wustl.edu Leesa M. Galatz, MD, et al.

We agree with Dr. Bernstein’s statement that not all partial thickness rotator cuff tears are painful. It should be emphasized that our article applies to partial thickness rotator cuff tears in patients who have failed non-operative treatment, and thus came to surgery. The results and recommendations from our study are specific to symptomatic tears and should not be generalized to asymptomatic ones or those that respond to conservative treatment. As noted by Dr. Bernstein, it is widely accepted that many individuals have asymptomatic partial thickness rotator cuff tears and/or tendinosis which may be evident on MRI. The natural history and potential for full-thickness progression of these tears is unknown. We agree with Dr. Bernstein’s concerns given that we are currently studying the natural history of asymptomatic partial thickness tears as part of our ongoing NIH R01 investigation. We appreciate Dr. Bernstein’s comments and reiterate that our results do not apply for partial rotator cuff tears that can be treated non-operatively.

Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade...
Association of Partial Thickness Tears of the Rotator Cuff and Shoulder Pain		 10 June 2009
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Joseph Bernstein,
Physician
University of Pennsylvania, Philadelphia, Pennsylvania

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Re: Association of Partial Thickness Tears of the Rotator Cuff and Shoulder Pain

orthodoc{at}uphs.upenn.edu Joseph Bernstein

To the Editor:

The opening sentence of the paper, “Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade Partial-Thickness Supraspinatus Tears” by Kamath et al. (1) is extremely troubling. The authors assert, without citation, that, “Partial-thickness tears of the rotator cuff are a common source of shoulder pain”.

Forgetting for a moment whether designating the condition of tendinosis as a, “partial tear”, and thereby implying that this lesion is one in need of “repair”, it is the case that partial-thickness tears of the rotator cuff are also found in asymptomatic individuals. At best then, we can say that, “partial-thickness tears of the rotator cuff are associated with shoulder pain”. I believe that the relationship of partial-thickness rotator cuff tears and shoulder pain must be deemed incidental, not causal.

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. Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon integrity and functional outcome after arthroscopic repair of high-grade partial-thickness supraspinatus tears. J Bone Joint Surg Am. 2009;91:1055-62.

Scientific Articles:
 Prediction of Midfoot Instability in the Subtle Lisfranc Injury. Comparison of Magnetic Resonance Imaging with Intraoperative Findings
 Raikin et al. (1 April 2009) [Abstract] [Full text] [PDF]
Prediction of Midfoot Instability in the Subtle Lisfranc Injury. Comparison of Magnetic...
Dr. Raikin and colleagues respond to Dr. Summerhays and colleagues		 28 May 2009
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Steven M. Raikin, MD,
Orthopaedic Surgeon
Thomas Jefferson University Hospital, Philadelphia, PA,
Adam C. Zoga, MD; William B. Morrison, MD

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Re: Dr. Raikin and colleagues respond to Dr. Summerhays and colleagues

steven.raikin{at}rothmaninstitute.com Steven M. Raikin, MD, et al.

We thank Dr. Summerhays and colleagues for their letter regarding our study on “Prediction of Midfoot Instability in Subtle Lisfranc Injury” (1).

With regard to the bundles, we did not find isolated ligamentous bands between the medial cuneiform and the second metatarsal base. Instead, we consistently observed two intimate but distinct ligamentous bundles running between the planatar central cuneiform and the second/third metatarsal bases. These bundles are morphologically analagous to the two bundles of an anterior cruciate ligament (ACL) and may very well be contained within one synovial sheath. With recently improved MRI technology and gradient strength, we routinely observe both of these bundles on all high-quality examinations. In this study, we grouped the two bundles together (which may represent the “Lisfranc” and pC1-M2M3 ligaments) describing a rupture as incompetence of both bundles, which may in fact occur as a single entity (as with the ACL) during the injury mechanism.

With regard to the question about the existence of the pC2-M2 ligament, Sarrafian does describe a variant of a ligament band running between the plantar lateral aspect of the second metatarsal and the middle cuneiform. Additionally MRI evaluation of uninjured feet demonstrate a clear capsular band plantarly in this region, akin to a plantar plate like structure. Whether one calls it a thickened joint capsule or a ligament may be a matter of semantics, but the connective tissue at the plantar aspect of the cuneiform-metatarsal articulations was clearly injured in many of our patients, based upon the review of two experienced musculoskeletal radiologists, and was not a reproducible sign of midfoot instability.

Reference

1. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91:892-9.
Prediction of Midfoot Instability in the Subtle Lisfranc Injury. Comparison of Magnetic...
Prediction of Midfoot Instability in Subtle Lisfranc Injury		 28 May 2009
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Ben J. Summerhays, DPM
Wheaton Franciscan Healthcare-St. Joseph's Milwaukee, WI,
J. George Devries, DPM; Michael J. Nute, DPM; Mario N. Ponticello, DPM; Brandon Scharer, DPM

Send letter to journal:
Re: Prediction of Midfoot Instability in Subtle Lisfranc Injury

bensummerhays44{at}hotmail.com Ben J. Summerhays, DPM, et al.

To the Editor:

In their recent article (1), Raiken et al. conclude that MRI is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when there is rupture of the plantar ligament bundle between the medial cuneiform and bases of metatarsals 2 and 3 (pC1-M2M3). The authors also looked to see if injury to other ligamentous structures of the Lisfranc joint could be used to determine instability. We have a few observations regarding this study.

Sarrafian (2) states that the Lisfranc ligament is the first interosseous cuneo1-metatarsal2 ligament arising from the lateral surface of the first cuneiform in front of the intercuneiform ligament, and under the particular surface corresponding to the second metatarsal. The ligament is directed obliquely outward and slightly downward and inserts on the lower half of the medial surface of the second metatarsal base. Sarrafian also states that the ligament is distinct from the dorsal and plantar ligaments (2). In their article (1), Raikin et al. do not make reference to this interosseous ligament.

Kaar et al. (3) found that both the pC1-M2M3 ligament and Lisfranc ligament must be ruptured for transverse instability to occur. Perhaps evaluating the MR images for possible rupture or tear of the interosseous Lisfranc ligament would provide better correlation with Lisfranc joint complex stability. Preidler et al. (4) in their study on the tarsometatarsal joint MR imaging pointed out the effectiveness and ability to view the Lisfranc ligament in all planes of MR imaging.

Raikin et al. (1) state several times that rupture of the plantar cuneiform 2-metatarsal 2 ligament was identified in the majority (18) of the 21 feet, but this was not useful in predicting stability. However, Sarrafian (2), Kaar et al. (3) , and Kura et al. (5) all have found that there is no plantar ligament between the second cuneiform and second metatarsal; thus its absence, or apparent rupture is likely normal anatomy.

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. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc Injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91:892-9.

2. Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographic, functional. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1993. p 205-6.

3. Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning. J Bone Joint Surg Am. 2007;89:2225-32.

4. Preidler KW, Wang YC, Brossmann J, Trudell D, Daenen B, Resnick D. Tarsometatarsal joint: anatomic details on MR images. Radiology. 1996;199:733-6.

5. Kura H, Luo ZP, Kitaoka HB, Smutz WP, An KN. Mechanical behavior of the Lisfranc and dorsal cuneometatarsal ligaments: in vitro biomechanical study. J Orthop Trauma. 2001;15:107-10.

Scientific Articles:
 Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty
 Hintermann et al. (1 April 2009) [Abstract] [Full text] [PDF]
Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty
Dr. Hintermann and colleagues respond to Dr. Kini		 30 April 2009
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Beat Hintermann, MD,
Associate Professor, Chairman
Clinic of Orthopaedic Surgery, Liestal, Switzerland,
Alexej Barg, MD; Markus Knupp, MD; Victor Valderrabano, MD, PhD

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Re: Dr. Hintermann and colleagues respond to Dr. Kini

beat.hintermann{at}ksli.ch Beat Hintermann, MD, et al.

We thank Dr. Kini for his interest and comments on our study and we are grateful for the opportunity to make the following comments:

At the latest follow up, any persisting pain laterally was localized to periarticular soft tissues. This finding can be best explained by the fact that most of the patients included in this study had an average of 3.3 previous operations (range, zero to nine procedures). To exclude the possibility of subtalar arthritis or arthritis in other adjacent joints as the cause of pain, we recommend performing single photon emission computed tomography (SPECT-CT) (1). In seven patients, pain was mainly localized in medial aspect of the ankle at the latest follow-up. The origin of this pain was irritation of periarticular soft tissues and not osseous impingement at the medial side of the ankle in patients in whom the mechanical axis had been restored . It is imperative that the tibial component and the heel are properly aligned to the mechanical axis of leg. If the tibial component is implanted in a varus position, and/or the heel is in valgus, osseous impingement in the medial gutter was seen to occur.

2) In this patient group, all persons were allowed full weight bearing in the cast. However, in some patients, we recommend non-weight bearing for 8 weeks postoperatively. During the first clinical and radiographic follow up at 6 weeks postoperatively, we have measured the range of motion to be slightly less in patients who were non weight bearing when compared to those patients who were fully weight bearing; however, the difference was not statistically significant. At the next follow-up (4 months postoperatively), we did not detect any difference in range of motion between these patient groups.

Newer gait analysis studies show that a nearly normal gait pattern is present in terms of joint kinematics of the knee, ankle, and foot after uneventful mobile-bearing total ankle replacement (2). Dr.Kini stated in his letter that if 10º dorsiflexion is not obtained during the the mid-portion of stance phase, the gait will be similar to what is observed following ankle arthrodesis (3). However, we believe that the ankle mobility gained after this arthroplasty, even in cases with dorsiflexion less than 10º, can decrease the stress forces in the adjacent joint which may slow down the development of osteoarthritis as reported in patients who underwent ankle fusion (4,5).

3) Indeed, malleolar fracture has been reported as a common intraoperative complication with an incidence up to 10% (6,7). In this study, we observed five fractures of the malleoli (including the medial malleolus in three ankles, the lateral malleolus in one ankle, and a bimalleolar fracture in one ankle). Therefore, we now use prophylactic pinning in cases where the malleoli seem to be at risk of fracture.

References

1. Knupp M, Pagenstert GI, Barg A, Bolliger L, Easley ME, Hintermann B. SPECT-CT compared with conventional imaging modalities for the assessment of the varus and valgus malaligned hindfoot. J Orthop Res. 2009 (accepted for publication).

2. Doets HC, van Middelkoop M, Houdijk H, Nelissen RG, Veeger HE. Gait analysis after successful mobile bearing total ankle replacement. Foot Ankle Int. 2007;28:313-22.

3. Conti SF. Gait before and after total ankle arthroplasty with a comparison to arthrodesis. In: International Federation of Foot and Ankle Societies, Triennial Scientific Meeting; 2002; San Francisco, CA.

4. Coester LM, Saltzman CL, Leupold J, Pontarelli W. Long-term results following ankle arthrodesis for post-traumatic arthritis. J Bone Joint Surg Am. 2001;83:219-28.

5. Mazur JM, Schwartz E, Simon SR. Ankle arthrodesis. Long-term follow-up with gait analysis. J Bone Joint Surg Am. 1979;61:964-75.

6. Lee KB, Cho SG, Hur CI, Yoon TR. Perioperative complications of HINTEGRA total ankle replacement: our initial 50 cases. Foot Ankle Int. 2008;29:978-84.

7. Wood PL, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone Joint Surg Br. 2003;85:334-41.
Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty
Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty		 30 April 2009
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Sunil Gurpur Kini, MBBS, MS(Ortho), DNB(Ortho), MNAMS(Ortho),
Registrar, Orthopaedics
Guru Teg Bahadur Hospital, University College of Medical Sciences, Delhi, India

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Re: Conversion of Painful Ankle Arthrodesis to Total Ankle Arthroplasty

drsunilkini{at}gmail.com Sunil Gurpur Kini, MBBS, MS(Ortho), DNB(Ortho), MNAMS(Ortho)

To the Editor:

I read with interest the article by Hintermann et al. (1) and would like to offer the following comments and ask some questions of the authors.

A major concern regarding ankle arthroplasty continues to be the high rate of revision surgeries. SooHoo et al., in a study of 480 ankle replacements performed during a ten-year study period, reported rates of major revision surgery after ankle replacement of 9% at one year and 23% at five years (2).

Alhough the unconstrained mobile bearing ankle prosthesis has yielded good results in the short term,long term results will need to be evaluated with respect to revision rates, especially for polyethylene wear, aseptic loosening, and loss of axial alignment.

I would like to have the authors opinion on the following queries:

1) The authors reported persistent pain after arthroplasty in 24 of 29 ankles. Did they localize the origin of pain? If the cause of pain was subtalar arthritis secondary to arthrodesis, arthroplasty would not have addressed this pathology.

2) Did the authors notice any difference in range of motion in non weight bearing and weight bearing modes? Whatever range of ankle motion is provided by the implant is not necessarily utilized during steady state walking. If 10° dorsiflexion is not obtained during the mid-portion of stance phase, then, from a functional perspective, the gait adopted is similar to what is observed following an ankle arthrodesis.

3) Keeping in mind the high rate of intraoperative malleolar fractures reported in literature (4), do the authors recommend prophylactic pinning in all cases?

4) Was medial ankle pain/impingement a prominent finding in postoperative follow-up?

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. Hintermann B, Barg A, Knupp M, Valderrabano, V. Conversion of painful ankle arthrodesis to total ankle artrhoplasty. J Bone Joint Surg Am. 2009;91:850-8.

2. SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am. 2007;89:2143-9.

3. Conti SF. Gait before and after total ankle arthroplasty with a comparison to arthrodesis. In: International Federation of Foot and Ankle Societies Triennial Scientific Meeting. 2002; San Francisco, CA.

4. Wood PL, Deakin S. Total ankle replacement. The results in 200 ankles. J Bone Joint Surg Br. 2003;85:334-41.

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
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David Ring, MD, PhD,
Physician
Massachusetts General Hospital,
Jesse B. Jupiter, MD, J. Sebastiaan Souer, MD

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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
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Omar Al-Fakayh,
Specialist Registrar
Aberdeen Royal Infirmary, Aberdeen, United Kingdom

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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.

The Orthopaedic Forum:
 Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need
 Day et al. (1 March 2009) [Full text] [PDF]
Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need
Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need		 21 April 2009
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Ashley T. Simela, DO,
Intern-Physician
North Shore University Hospital, Plainview, NY

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Re: Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need

asimela{at}hotmail.com Ashley T. Simela, DO

To the Editor:

I read with great interest the article “Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need” (1). As a recent osteopathic medical school graduate and current orthopaedic surgery intern, I contemplated whether or not osteopathic medical students received more musculoskeletal preclinical education when compared to their allopathic colleagues. After a brief literature search, I came across an article by Alan R. Stockard, DO, and Thomas Wesley Allen, DO, in the June 2006 issue of The Journal of the American Osteopathic Association(JOAO) entitled, “Competence Levels in Musculoskeletal Medicine: Comparison of Osteopathic and Allopathic Medical Graduates” (2).

Given the osteopathic medical profession's emphasis on the musculoskeletal system, one might assume that osteopathic graduates would have more knowledge of musculoskeletal medicine upon graduation. However, Stockard’s comparison demonstrated that graduating osteopathic students fared only slightly better than their allopathic counterparts. In fact, basic competence in musculoskeletal medicine was not demonstrated by either group(3).

I applaud Dr. Day and his colleagues at Harvard for their effort to expose the current shortcomings in musculoskeletal training. The integrated musculoskeletal curriculum should serve as a model for both osteopathic and allopathic medical educators.

The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her 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 her immediate family, is affiliated or associated.

References

1. Day CS, Yu YR, Yeh AC, Newman LR, Arky R, Roberts DH. Musculoskeletal preclinical medical school education: meeting an underserved need. J Bone Joint Surg Am. 2009;91:733-39.

2. Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006;106:350-5.

3. Ruane JJ. Competence levels in musculoskeletal medicine: a call to action. J Am Osteopath Assoc. 2007;107:197-8.
Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need
Dr. Day responds to Dr. Stuart		 13 April 2009
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Charles S. Day, MD,
Director, Orthopedic Curriculum
Harvard Medical School, Boston, MA

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Re: Dr. Day responds to Dr. Stuart

cday1{at}bidmc.harvard.edu Charles S. Day, MD

It is surprising to learn that a one-year Physician Assistants (PA) didactic program is dedicating more time to musculoskeletal (MSK) topics than two years of a Medical School's pre-clinical program. At our institution, we had allocated only 40 hours to MSK topics before our curriculum change, but even after a change in curriculum, our MSK pre-clinical curriculum time is only 52 hours,still well below the 80 hours at this PA program.

Perhaps the substantial emphasis on MSK teaching in the PA curriculum is a reflection of the percentage of MSK questions on the Physician Assistant National Certifying Examination - coming in just behind cardiovascular and pulmonary questions.

Hopefully, some of the data from our institution and recommendations from national organizations such as the AAMC will be taken into consideration in increasing the percentage of MSK questions on the United States Medical Licensing Examination (USMLE). An increased emphasis on MSK related topics by the USMLE may be the necessary catalyst to increase the time devoted to teaching an MSK curriculum at all medical schools.
Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need
Musculoskeletal Education of Physician Assistants		 18 March 2009
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Wayne C. Stuart, MD,
Assistant Professor, Physician Assistant Program
DeSales University

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Re: Musculoskeletal Education of Physician Assistants

wayne.stuart{at}desales.edu Wayne C. Stuart, MD

To the Editor:

In the article, “Musculoskeletal Preclinical Medical School Education: Meeting an Underserved Need”(1),the authors quote figures from The Association of American Medical Colleges (AAMC) which state that the average time spent on musculoskeletal (MS) education in the pre-clinical years of in medical school is 65 hours(2). This led me to calculate the time we spend teaching topics related to the musculoskeletal system at our PA program at DeSales University (Center Valley, PA).

Over the course of our 12 month didactic phase, we we devote 80 hours to the musculoskeletal system. The subject matter is comprised of anatomy (36 hours), physical examination (12 hours), clinical skills (casting, diabetic foot examination, etc.) (8 hours), an orthopaedics section (12 hours), and a rheumatology section (12 hours). Therefore, we spend roughly 20% more time teaching MS topics in our single year pre-clinical phase than in the two years of medical school.

The importance of musculoskeletal education for PA's is also evidenced by the emphasis given it by the Physician Assistant National Certifying Examination (PANCE, the PA USMLE equivalent). Musculoskeletal topics constitute fully 10% of the examination, more than any other topic other than cardiovascular (16%) and pulmonary (12%) (3).

I thought this information would be of interest to your readers as we move forward to improve the education of our future health care providers.

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. Day CS, Yu YR, Yeh AC, Newman LR, Arky R, Roberts DH. Musculoskeletal preclinical medical school education: meeting an underserved need. J Bone Joint Surg Am. 2009;91;733-9.

2. Association of American Medical Colleges. Curriculum directory course details: musculoskeletal. http://services.aams.org/currdir/section4/start.cfm. Accessed June 8, 2008.

3. National Commission of Certification of Physician Assistants. Exams: Content Blueprint. http://www.nccpa.net/EX_samplediseases.aspx?r=pance. Accessed March 11, 2009.

Scientific Articles:
 Association Between Decreased Bone Mineral Density and Severity of Distal Radial Fractures
 Clayton et al. (1 March 2009) [Abstract] [Full text] [PDF]
Association Between Decreased Bone Mineral Density and Severity of Distal Radial...
Drs. Clayton and McQueen respond to Dr. Hollevoet		 13 April 2009
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Robert A. E. Clayton, BSc(Hons),
Orthopaedic Surgeon
Royal Infirmary of Edinburgh, United Kingdom,
Margaret M. McQueen, MD

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Re: Drs. Clayton and McQueen respond to Dr. Hollevoet

raeclayton{at}onetel.com Robert A. E. Clayton, BSc(Hons), et al.

We thank Dr. Hollevoet for her interest and her comments on our paper and for bringing these other interesting articles to our attention. It is unfortunate that we had not identified the first two very good papers to which she refers. The third paper was published after our paper was submitted. All three papers use slightly different methods of analysis and outcomes from our own. However, taking the four studies together provides strong corroborating evidence that loss of bone mineral density leads to an increase in the severity of distal radius fractures. It will be interesting to see whether there is a similar correlation in other osteoporotic fracture types.
Association Between Decreased Bone Mineral Density and Severity of Distal Radial...
Association of Bone Mineral Density and Fracture Displacement of Distal Radius Fractures		 7 April 2009
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Nadine Hollevoet,
Orthopaedic Surgeon
Department of Orthopaedic Surgery and Traumatology, University Hospital Gent, Belgium

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Re: Association of Bone Mineral Density and Fracture Displacement of Distal Radius Fractures

nadine.hollevoet{at}ugent.be Nadine Hollevoet

To the Editor:

I read the paper by Clayton et al. (1) with much interest. I would point out that, although the authors were unable to cite previous clinical studies investigating an association between osteoporosis and fracture severity or an association between bone mineral density and radiographic outcomes after injury, a number of relevant publications on these subjects do exist.

Xie and Bärenholdt found that bone mineral density of the cortex of the distal radius was lower in displaced than in undisplaced distal radius fractures (2).

We reported that bone mineral density correlated with an increase in ulnar variance of the fractured wrist (3). Increase in ulnar variance gives an indication of fracture severity and is higher with radial shortening and/or change in palmar tilt.

In a recent Japanese study, an association has been shown between bone mineral density and deformity of the distal radius in low-energy Colles' fractures in women above 50 years of age, before treatment (4).

However, only the study of Clayton et al. demonstrated an association between fracture severity and bone mineral density measured with dual-energy X-ray absorptiometry at the hip (1). Xie and Bärenholdt measured bone mineral density with peripheral quantitative tomography at the distal radius. They could not find a difference between displaced and undisplaced distal radius fractures when bone mineral density was measured at the lumbar spine or the femoral neck with Dual-energy X-ray absorptiometry (2). We found that bone mineral density correlated with an increase in ulnar variance when it was measured at the contralateral distal forearm, but not at the hip or lumbar spine (3). Sakai et al. measured bone mineral density of the lumbar spine with dual-energy X- ray absorptiometry (4).

The author did not receive any outside funding or grants in support of her research for or preparation of this work. Neither she nor a member of her 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 her immediate family, is affiliated or associated.

References

1. Clayton RA, Gaston MS, Ralston SH, Court-Brown CM, McQueen MM. Association between decreased bone mineral density and severity of distal radius fractures. J Bone and Joint Surg Am. 2009;91:613-9.

2. Xie X, Bärenholdt O. Bone density and geometric properties of the distal radius in displaced and undisplaced Colles’ fractures: quantitative CT in 70 women. Acta Orthop Scand. 2001;72:62-6.

3. Hollevoet N, Verdonk R. Outcome of distal radius fractures in relation to bone mineral density. Acta Orthop Belg. 2003;69:510-4.

4. Sakai A, Oshige T, Zenke Y, Suzuki M, Yamanaka Y, Nakamura T. Association of bone mineral density with deformity of the distal radius in low-energy Colles’ fractures in Japanese women above 50 years of age. J Hand Surg [Am]. 2008;33:820-6.

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
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Sukhmeet S Panesar,
Clincal Advisor to the Medical Director
National Patient Safety Agency, London, United Kingdom,
Bhavesh Patel, Kevin Cleary

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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.

The Orthopaedic Forum:
 The Need for Increased Access to the U.S. Health-Care System
 Bible et al. (1 February 2009) [Full text] [PDF]
The Need for Increased Access to the U.S. Health-Care System
Mr. Bible and Dr. Friedlaender respond to Dr. Novack		 10 March 2009
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Jesse E. Bible, BS,
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine,
Gary E. Friedlaender, MD

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Re: Mr. Bible and Dr. Friedlaender respond to Dr. Novack

jesse.bible{at}yale.edu Jesse E. Bible, BS, et al.

We thank Dr. Novack for his interest in our review article on access to health-care in the United States, as well as his thoughtful comments. It was not our purpose to “propose and critique specific solutions” to several of the health-care problems highlighted in the article, but rather “to merely highlight key aspects of certain strategies and encourage more dialogue” (p.482). Such discussions are vital to improving orthopaedic care at the local and national level.

One of the issues raised by Dr. Novack involved the 6.5 of the 9 million uninsured children who are eligible for public health-care coverage, but not currently enrolled. The remaining 2.5 million children are not eligible, primarily because their family incomes exceed program eligibility levels. Several possible explanations have been raised to explain the discrepancy between eligibility and enrollment. First, premiums and cost sharing required for Medicaid/SCHIP participation in many states can cause coverage to become less affordable for low-income families and, thereby, reduce participation in public services. Second, is a lack of awareness in how to apply for Medicaid/SCHIP programs. States have recently developed strategies to simplify the enrollment and renewal process to obtain coverage, as well as reduced verification requirements. A deviation from this process of streamlining enrollment was the Deficit Reduction Act of 2005, which requires individuals to provide proof of U.S. citizenship for applying or renewing Medicaid coverage. However, even with this act, an overall increase in enrollment was seen as states invested more money into community-based outreach activities. Such outreach programs will need to have additional funding in order to further increase enrollment, and such resources are unlikely with the current economic crisis.

Another issue mentioned by Dr. Novack is that, “many adults who are currently healthy…choose to forgo paying health insurance premiums when very affordable individual polices exist”. We would agree that many healthy Americans opt out of health insurance thinking or hoping that sickness or injury will not come their way. However, we would disagree with the position that very affordable policies exist for all. National surveys have continuously found the high cost of health insurance coverage as the primary reason people are uninsured. According to a 2008 survey, premiums for employer-sponsored health insurance have been rising four times faster on average than workers’ earnings since 1999 (1). Indeed, the annual premiums for individual family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker (1).

Thirdly, Dr. Novack correctly stated that “illegal immigrants account for many more of the uninsured”. It is likely that the current U.S. Census Bureau reports underestimate the number of noncitizens; however, as mentioned in our article, according to the 2006 Census Report 78.2% of the uninsured individuals in the U.S. are citizens (2). While U.S. citizens encompass more of the uninsured population, noncitizens have a much higher uninsured rate at 45.0% (2).

Lastly, like Dr. Novack, we feel issues of health-care “must be part of the AAOS agenda”, and we find abundant evidence of this commitment. We hope that comments from individual orthopaedic surgeons, such as Novack and ourselves, will serve to strengthen our collective message and resolve these issues on behalf of our patients.

References

1. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2008 Annual Survey. September 2008.

2. DeNavas-Walt C, Proctor BD, Smith J; US Census Bureau. Income, poverty, and health insurance coverage in the United States: 2006. Current Population Reports, P60-233. Washington, DC: U.S. Government Printing Office; 2007.
The Need for Increased Access to the U.S. Health-Care System
We Need AAOS Leadership		 26 February 2009
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Eric N. Novack,
Orthopedic Surgeon

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Re: We Need AAOS Leadership

ericnovack{at}mac.com Eric N. Novack

To the Editor:

I read the article by Bible et al. (1) with the anticipation that perhaps the AAOS and its leadership would finally be taking a stand on the goals of health care and health care reform, but I write to express my disappointment in the tenor of this article. In it,the authors lay out the talking points and proposals with one apparent goal in mind: to keep the AAOS and its leadership 'at the table' regardless of the costs.

Never mind the abundant data showing that the vast majority of uninsured children are ALREADY eligible for health care coverage under existing government programs. Never mind that many adults who are currently healthy choose to forgo paying health insurance premiums when very affordable individual policies exist. Never mind that illegal immigrants account for many more of the uninsured. Those data were omitted from the article.

The most galling sentence to me, however, is on page 476, "It is...presumptuous to propose specific answers to these critical questions". Is not the purpose of such an article to do exactly that-- present, propose and critique specific solutions to enormously important problems facing orthopedists and their patients?

I believe we must stand for principles that put patients first and protect orthopedists' freedom to innovate that has resulted in so many life-saving and function improving advances. These principles must be part of the AAOS agenda. They include:

1. Patients have the right to be in control of their own health and health care.

2. The right of patients to keep their medical history private.

3. The right of the fellows of the AAOS to seek to improve their knowledge and their profession, thus providing the best patient care for a mutually agreed upon fee.

4. The right of patients to spend their own money for their health and health care.

5. The right of doctors and patients to choose to NOT participate in a government-mandated, bureaucrat-controlled health care system.

These simple principles, or those like it, used to be the foundation of our profession. But it seems that to our modern leadership they do not have the salving effect as seeking 'universal health care' and 'reducing health care disparities'. I fear that the Academy may become only a fabulous source of CME, rather than the deserved leader of the country's orthopedic community.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Smith and Nephew). 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. Jesse E. Bible, Richard S. Lee, and Gary E. Friedlaender. The Need for Increased Access to the U.S. Health-Care System J Bone Joint Surg Am 2009;91:476-484.

Scientific Articles:
 Patient and Surgeon Radiation Exposure: Comparison of Standard and Mini-C-Arm Fluoroscopy
 Giordano et al. (1 February 2009) [Abstract] [Full text] [PDF]
Patient and Surgeon Radiation Exposure: Comparison of Standard and Mini-C-Arm Fluoroscopy
Dr. Baumhauer and colleagues respond to Drs. Opreanu and Kepros		 10 March 2009
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Judith F. Baumhauer, MD,
Professor, Department of Orthopaedic Surgery
University of Rochester Medical Center,
Brian D. Giordano, MD; Thomas L. Morgan, PhD; Glenn R. Rechtine, II, MD

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Re: Dr. Baumhauer and colleagues respond to Drs. Opreanu and Kepros

judy_baumhauer{at}urmc.rochester.edu Judith F. Baumhauer, MD, et al.

Drs. Opreanu and Kepros bring up an excellent point regarding the relative radiosensitivity of the various tissues exposed during diagnostic imaging. As we note in our study, when using C-arm fluoroscopy to image a body area in the normal mode, technique factors are adjusted automatically according to the tissue density and cross sectional area. Therefore, during imaging of larger, denser body areas such as the pelvis or spine, technique factors may be increased by a considerable margin, thus subjecting not only the bones and muscles, but also the more radiosensitive underlying visceral organs to elevated levels of radiation. These body areas are routinely imaged using C- arm fluoroscopy during both elective orthopaedic and trauma surgical procedures. In separate publications, we examine radiation exposure to the patient and surgical team during imaging of the cervical spine (1, 2). In conjunction with this current publication, our data would suggest that even more vigilance must be practiced when imaging the musculoskeletal system adjacent to other especially susceptible body areas.

We feel that it is important to note that one cannot receive too little radiation over the course of one’s lifetime. Regardless of the radiosensitivity of the biological tissues being exposed to ionizing radiation, reaching often cited maximal exposure limits (as set forth by regulatory boards such as the NCRP and ICRP) should not be viewed as optimal or desirable. The readers should be aware that these values have been modified throughout the years, and that international standards are stricter than those imposed in the US. When discussing risks associated with radiation exposure, many authors first look at the maximum allowable exposure limits and then extrapolate backwards to determine how many cases may be done before exceeding these limits. In like fashion, Drs. Opreanu and Kepros frame their sentiments relative to threshold levels (that in our study and many other studies are not reached for the surgeon or surgical team). We feel that this manner of reasoning should be reversed. The question we should ask ourselves should be, “how can I change my practice to minimize radiation exposure to my patients and myself?” rather than “how many procedures can I do before I exceed my yearly exposure limit?”

We again remind the reader that the concept of ALARA (As Low As Reasonably Achievable) should be followed at all times. While the exposure levels capable of producing deterministic effects are well known, the cumulative effects of consistent radiation exposure remain unknown. As we point out, epidemiological data suggests that exposure to as “little” as 5 -10 Rem over a lifetime increases the risk of developing cancer (3). This figure applies to both physicians and patients. Interestingly, when we used a highly sensitive portable ion chamber to measure background scatter (even 20 ft from the testing zone), it still recorded 200 μrem/hr during mini-c- arm imaging. While this dose is seemingly inconsequential, it highlights the fact that scatter radiation is present even at great distances from the radiation source and is not zero as some believe. Furthermore, although a radiation dosimeter badge may report zero mrem detected, this is often not the case. Many dosimeters begin registering exposure at 10 mrem. Thus, exposure below this level is reported as zero.

Our study seeks to bring awareness to the fact that the use of fluoroscopy in medicine for indirect visualization is not without risk. As the use of fluoroscopy becomes more and more commonplace in daily practice, we must continue to scrutinize the detrimental effects that its use may pose to our patients and ourselves. Often, physicians and surgeons have no idea how much radiation a patient is exposed to during procedural or diagnostic imaging. Furthermore, many find it difficult to apply exposure levels to an understandable frame of reference that makes such levels relevant and meaningful to them. Rather than using threshold values to determine the number of allowable cases per year, our hope is that physicians and surgeons will begin to alter their practice habits and work backwards from a “worst case scenario” when considering the safety aspects of radiation exposure; ie, careful scrutiny of the necessity of imaging studies, consideration of alternative imaging modalities, limiting the use of live fluoro in the operating room, collimating images, always using protective equipment, consistently practice dose reducing techniques etc.

References

1. Giordano BD, Baumhauer JF, Morgan TL, Rechtine GR. Cervical spine imaging using standard C-arm fluoroscopy. Patient and surgeon exposure to ionizing radiation. Spine. 33(18):1970-1976. 2008.

2. Giordano BD, Baumhauer JF, Morgan TL, Rechtine GR. Cervical spine imaging using mini C-arm fluoroscopy: Patient and surgeon exposure to direct and scatter radiation. Accepted for publication in Journal of Spinal Disorders and Techniques.

3. Brenner DJ, et al. Cancer risks attributable to low doses of ionizing radiation. Assessing what we really know. Proc. Natl. Acad. Sci. USA. 100:13761-6. 2003.
Patient and Surgeon Radiation Exposure: Comparison of Standard and Mini-C-Arm Fluoroscopy
Is Intra-operative Fluoroscopy Harmful?		 26 February 2009
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Razvan C. Opreanu,
MD
Michigan State University/Department of Surgery,
John P. Kepros, MD

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Re: Is Intra-operative Fluoroscopy Harmful?

john.kepros{at}hc.msu.edu Razvan C. Opreanu, et al.

To the Editor:

We read with much interest the recent article by Giordano et al. (1). It addresses an important issue arising from the increasing use of x-ray imaging in medicine. Although the authors correctly concluded that protective safety measures should be enforced when using intra-operative fluoroscopy, it might be useful to the reader to have a more complete understanding about the magnitude of these radiation doses.

The authors recognized that the radiation received during fluoroscopy was very low when compared to the dose of radiation that can cause deterministic (hair loss or burns) or stochastic effects (carcinogenesis or genetic effects). At first look, the dose received by the patient in the worst case scenario seems to be very high, but one must consider that while the amount of radiation is an important parameter in determining the associated risk, the radiosensitivity of the exposed tissues is important as well. For example, muscle and bone are the least radiosensitive tissues in the human body (2).

For a surgeon operating in the standing position, a dose of 0.38 mGy could reach the gonads, the most radiosensitive organs in the body, and generate a more harmful effect than a dose 90 mGy delivered to the foot or hand of a patient. The resulting radiation doses from this study are approximately 6600 and 5 times less, respectively, than the threshold dose for tissue effects in gonads and bone marrow (2.5 Gy and 0.5 Gy) (2).

While safety precautions should be in place in the operating room, one must not overestimate the adverse effects associated with the use of fluoroscopy. Assessment by the authors of lifetime attributable risk of cancer incidence or mortality associated with the consistent use of fluoroscopy would have provided a more realistic understanding about the potential associated risks.

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. Giordano, B.D., et al., Patient and surgeon radiation exposure: comparison of standard and mini-C-arm fluoroscopy. J Bone Joint Surg Am, 2009. 91(2): p. 297-304.

2. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP, 2007. 37(2-4): p. 1-332.

Scientific Articles:
 Shoulder Strength in Asymptomatic Individuals with Intact Compared with Torn Rotator Cuffs
 Kim et al. (1 February 2009) [Abstract] [Full text] [PDF]
Shoulder Strength in Asymptomatic Individuals with Intact Compared with Torn Rotator...
Is the Asymptomatic Shoulder Asymptomatic?		 17 February 2009
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Jerrold M. Gorski, MD,
Orthopedic Surgeon
Winthrop University Hospital, Mineola, NY

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Re: Is the Asymptomatic Shoulder Asymptomatic?

jgorskimd{at}hotmail.com Jerrold M. Gorski, MD

To the Editor:

I was encouraged to write after reading the final question posed by Dr Cofield in his JBJS web Commentary on the article by Kim et al. (1) "I would pose a final philosophical question: Is a person who has a painless rotator cuff tear that is causing weakness really asymptomatic"?

The answer to this pointed question, I believe, lies beyond both philosophy and the simple confusion of symptoms and physical findings. I have observed that the asymptomatic shoulder commonly presents as symptomatic "neck" pain (2, 3). My hope is that further research will prove that the asymptomatic shoulder underlies some chronic neck pain syndromes in which evidence is lacking like whiplash, trapezius spasm, trigger points, fibromyalgia, and thoracic outlet syndrome. I am hopeful that the normative data established by these authors will help their ongoing scientific analysis of the mysterious and highly prevalent asymptomatic shoulder. I hope they address two additional questions in future reports: why does the rotator cuff tear with presumably decreasing usage with age and why is the shoulder asymptomatic?

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 HM, Teefey SA, Zelig A, Galatz LM, Keener JD, Yamaguchi K. Shoulder Strength in Asymptomatic Individuals with Intact Compared with Torn Rotator Cuffs. J Bone Joint Surg Am 2009;91:289-296 2. Gorski JM, Schwartz H. Shoulder Impingement Presenting as Neck Pain. J Bone Joint Surg 85-American 2003;4:635-638.

3. Gorski JM. A New Pain in the Neck. Bulletin of the AAOS, Aug, 2007 27-29.

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
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Zoran S. Vukasinovic,
Professor of Orthopaedics
Institute for Orthopaedic Surgery "Banjica" Belgrade, Serbia,
Zoran Bascarevic, Nemanja Slavkovic, Zorica Zivkovic

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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:
 Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation of the Components in Total Knee Arthroplasty
 Kim et al. (1 January 2009) [Abstract] [Full text] [PDF]
Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation...
Dr. Kim and colleagues respond to Drs. Ferretti and Conteduca		 29 April 2009
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Young-Hoo Kim, MD,
Professor
Ewha Womans University School of Medicine,
Jun-Shik Kim, MD; Yoowang Choi, MD; Oh-Ryong Kwon, MD

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Re: Dr. Kim and colleagues respond to Drs. Ferretti and Conteduca

younghookim{at}ewha.ac.kr Young-Hoo Kim, MD, et al.

Thank you for your interest in our recent article (1). You are correct in stating that since we did not navigate the rotational alignment of the tibial competent, the rotational deviation and the incidence of outliers of the tibial component between the two groups were similar.

Although there was a tendency to have a better alignment in both coronal and sagittal planes in the navigated group, these differences were not significant between the two groups (P > 0.05). Furthermore, we believe that these marginal differences are not clinically meaningful.

Therefore, we believe the title of the paper is appropriate and the conclusions are fully justified by the results.

Reference

1. 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.
Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation...
Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation of the...		 29 April 2009
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Andrea Ferretti, MD,
Chairman
Orthopaedic Department Sant'Andrea Uniuversity Hospital, Rome, Italy,
Fabio Conteduca, MD

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Re: Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation of the...

aferretti51{at}virgilio.it Andrea Ferretti, MD, et al.

To the Editor:

We congratulate Dr. Young-Hoo Kim and co-authors for studying this important topic (1), but we question whether their conclusions are actually supported by the data. After a careful reading of the paper, we have two concerns that we would like to share with the authors.

The first concern is about rotational alignment. The authors did not provide details about the ability of the system used in their study to actually navigate the rotation of the tibial implant. As the majority of the navigation systems currently in use do not allow navigation of the rotation of the tibial insert, the lack of difference in this parameter between standard and CAOS is not surprising.

The second, and more important concern, is about the reported results of coronal and sagittal alignment of the two groups. In analyzing all of the radiographic parameters, as shown in Table III, all the results in the CAOS group are much better when compared to the standard group, with a difference ranging from about 40% (outliers > 3° in tibial sagittal plane) to 100% (outliers > 3° in tibial coronal plane). Even if the differences are not statistically significant according to the statistical method used, the results seem to indicate a strong trend in favor of the CAOS, at least in the radiographic results and in the accuracy of the implant positioning.

Therefore, we believe the title of the paper is misleading and that the conclusions are too strong and not fully justified by the results.

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. 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.
Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation...
Dr. Kim and colleagues respond to Dr. Matziolis and Mr. Perka		 1 April 2009
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Young-Hoo Kim, MD,
Professor
Ewha Womans University School of Medicine, Seoul, South Korea,
Jun-Shik Kim, MD; Yoowang Choi, MD and Oh-Ryong Kwon, MD

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Re: Dr. Kim and colleagues respond to Dr. Matziolis and Mr. Perka

younghookim{at}ewha.ac.kr Young-Hoo Kim, MD, et al.

We thank Drs. Matziolis and Perka for their interest in our recent article(1). We acknowledge errors in our Table E-1 for the outliers in the sagittal (9 navigated vs 24 conventional) and the coronal plane (15 navigated vs 27 conventional). "9 of 160 knees (6%)" should be corrected to, "16 of 160 knees (10%)". Also, "27 of 160 knees (17%)" should be corrected to, "25 of 160 knees (16%)". We did not notice these errors when we submitted the manuscript or on the galley proofs.

The precision of the hip center may be different when comparing different navigation systems. Our previously published data (2) using the Vector Vision CT- free knee (Brain LAB, Munich, Germany) and another previous unpublished data using Ci Version CT-free knee (Brain LAB, Munich, Germany) revealed similar results to those of the current study.

References

1. 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.

2. Kim YH, Kim JS, Yoon SH. Alignment and orientation of the components in total knee replacement with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br. 2007;89:471-6.
Computer-Assisted Surgical Navigation Does Not Improve the Alignment and Orientation...
Computer Assisted Surgical Navigation for Total Knee Arthroplasty		 18 March 2009
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Georg Matziolis,
Consultant Orthopaedic Surgeon
Orthopaedic Department, Center for Musculoskeletal Surgery, Charité - University Hospital Berlin,
Carsten Perka

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Re: Computer Assisted Surgical Navigation for Total Knee Arthroplasty

Georg.Matziolis{at}Charite.de Georg Matziolis, et al.

To the Editor:

I read with interest the paper by Kim et al. (1) in which the authors address the ongoing controversy about the role of navigation in total knee arthroplasty(TKA). Although the number of patients included in the study seems sufficient, I believe that their conclusion that the use of navigation does not result in more accurate implant positioning is not supported by their results.

The data presented in Table E-1 for the tibial outliers in the sagittal (9 navigated vs. 24 conventional) and the coronal plane (15 navigated vs. 27 conventional) show a significant difference in the X² test (p=0.006 for the coronal plane and p=0.047 for the sagittal plane). Although navigated as well as conventional tibial component positioning is based on extramedullary bone landmarks, the computer assistance significantly reduced outliers in both planes.

Regarding the femoral component, the precision with which the hip center is determined is crucial for determining the optimal femoral alignment. Finding the hip center depends on the mathematical algorithm used by each specific navigation system and differs between the systems and even different software versions of the same system. Therefore the conclusion about navigated femoral alignment precision should not be generalized to all navigation systems.

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. 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.

Scientific Exhibits:
 Squeaking Hips
 Walter et al. (1 November 2008) [Full text] [PDF]
Squeaking Hips
Dr. Walter and colleagues respond to Dr. Hamilton		 16 December 2008
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William L. Walter, MBBS, FRACS, PhD,
Orthopaedic Surgeon
Sydney Hip & Knee Surgeons,
Timothy Waters, FRCS(TR&Orth); Mark Gillies, PhD

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Re: Dr. Walter and colleagues respond to Dr. Hamilton

bill.walter{at}hipknee.com.au William L. Walter, MBBS, FRACS, PhD, et al.

We would like to thank Dr Hamilton for the opportunity to further clarify the subject of squeaking in joint replacements. Dr Hamilton focuses in his letter on lubrication but lubrication is only half of the equation. Squeaking in hip replacements (as in car brakes) is due to a phenomenon known in physics as a forced vibration(1). A forced vibration is comprised of a driving force and a dynamic response. In this case the driving force is a frictional driving force due to a breakdown of lubrication. The dynamic response is resonance of one of the components of the hip replacement or the bone - probably resonance of the metallic parts of the hip replacement.

Dr Brian Hills, research on boundary lubrication in the native joint and in hard-on-polyethylene artificial joint has provided valuable insights into these bearings but has only limited relevance to the subject of squeaking in hard-on-hard bearings.

In hard-on-hard bearings there is probably a variety of lubrication mechanisms depending on the loading conditions and joint fluid(2). Just less than 50% of ceramic-on-ceramic retrievals have no measurable wear suggesting that the bearings are always well lubricated in these patients. The remainder have evidence of edge loading wear(3). Under edge loading conditions in hard-on-hard bearings there is grain pullout indicating a breakdown of lubrication and high friction.

The fact that more than 50% of ceramic-on-ceramic retrievals have edge loading wear, yet only 1% to 5% of these bearings squeak tells us that high friction does not always lead to squeak. Noise production as measured in the acoustic analysis also depends also on the part resonating in the audible range.

While we respect Dr Hamilton's knowledgeable opinion, we feel that the statement that ‘orthopaedic surgeons since Sir John have paid little attention to joint lubrication’ is incorrect. In hard-on-hard bearings lubrication is the critical factor determining wear rate. Even when lubrication fails, ceramic-on-ceramic bearings have lower wear than any other bearing material combination available to surgeons today but a well lubricated ceramic-on-ceramic bearing has significant further reduction in wear. Efforts abound to improve lubrication including optimising the surface of the bearing, the clearance, the included angle of the acetabular articulation, the acetabular component position to prevent edge loading and reduce joint reactive force and the femoral component neck geometry. Joint lubrication is at the core of our efforts to improve the function of these bearings.

We did not have the privilege of speaking personally with Sir John Charnley, so we can only judge what he knew by what he published(4). Squeaking was not the problem in Charnley’s day as it is today; the modern designs that have high rates of squeaking were not even being manufactured and squeaking was only motioned briefly in the literature. We feel, therefore, that squeaking can not have been well understood in his day.

1. Main IG. Vibrations and Waves in Physics. 3rd ed. Cambridge: Cambridge University Press; 1993.

2. Scholes SC, Unsworth A. Comparison of friction and lubrication of different hip prostheses. Proc Inst Mech Eng [H]. 2000;214(1):49-57.

3. Lusty PJ, Tai CC, Sew-Hoy RP, Walter WL, Walter WK, Zicat BA. Third-generation alumina-on-alumina ceramic bearings in cementless total hip arthroplasty. J Bone Joint Surg Am. Dec 2007;89(12):2676-2683.

4. Charnley J. Low Friction Arthroplasty of the Hip. Berlin: Springer -Verlag; 1979.

Squeaking Hips
Squeaking Hips		 26 November 2008
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Henry W. Hamilton,
Orthopaedic Surgeon
Port Arthur Health Centre,194 N. Court St., Thunder Bay, Ontario P7A 4V7 Canada.

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Re: Squeaking Hips

drhenryhamilton{at}hotmail.com Henry W. Hamilton

To the Editor:

In the paper by Walter et al. on the subject of “squeaking hips”(1), the authors describe the subject as “poorly understood”. I would disagree with that assessment and point to the important and relevant history of investigations on the subject of joint lubrication.

It was a squeaky Judet prosthesis (an acrylic hemiarthroplasty articulating against bone introduced in 1946) that inspired the late Sir John Charnley to investigate the failure of these prostheses. MacConnail, a professor of anatomy at Cork University had postulated that synovial joints were lubricated hydro-dynamically (by a fluid film). Up to the 1980s, mechanical engineers held to this belief. Hydrodynamic lubrication works well in engine bearings, where there is a contained lubricant, and continuous high-speed rotation. A wedge of fluid lubricant is created by the rotating axel, which can support a heavy load – as soon as the rotation stops, the wedge of fluid collapses, and the opposing surfaces come into to direct contact.

Charnley’s research convinced him that this mechanism could not work in synovial joints where the movement is slow, intermittent and oscillating, and where “stick” does not occur. Charnley concluded that joint lubrication had to be by a boundary mechanism, but was unable to identify the lubricant. This was why Charnley experimented with polytetrafluorethylene, and later used a stainless steel on PE implants.

The late Dr Brian Hills, an Australian paediatric respirologist with a Cambridge degree in physical chemistry took a new approach. He proposed that surfactants, and in particular surface-active- phospholipids, bonded electrostatically to mesothelial surfaces and were the universal lubricating system in the body. Hills published multiple papers on this subject over almost 20 years (2-9).

When hard bearing surfaces move in relationship to each other lubrication may become a problem, e.g. chalk on a blackboard, the metal on metal Birmingham hip, or ceramic on ceramic. A “stick-slip” phenomenon causes vibrations, which may be audible as a squeak. It is odd that orthopaedic surgeons since Sir John have paid so little attention to joint lubrication.

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.William L. Walter, Tim S. Waters, Mark Gillies, Shane Donohoo, Steven M. Kurtz, Amar S. Ranawat, William J. Hozack, and Michael A. Tuke Squeaking Hips J Bone Joint Surg Am 2008; 90: 102-11 2. Hills BA, Butler BD. Surfactants identified in synovial fluid and their ability to act as boundary lubricants. Annals Rheumat Dis. 1984; 43:641-648.

3. Hills BA. Oligolamellar nature of articular surface. J Rheumatol. 1990;17:349-355.

4. Hills BA. Synovial surfactant and the hydrophobic articular surface. J Rheumatol. 1996;23(Editorial):1323-5.

5. Hills BA, Monds MK. Enzymatic identification of the load bearing boundary lubricant in the joint. Br J Rheumatol. 1998;37:137-142.

6. Hills BA, Monds MK. Deficiency of lubricating surfactant lining the articular surfaces of replaced hips and knees. Br J Rheumatol. 1998;37:143-147.

7. Hills BA. Boundary lubrication in vivo. Proc Instn Mech Engrs. 2000;214H:83-94.

8. Purbach B, Hills BA, Wroblewski BM. Surface-active phospholipid in total hip arthroplasty. Clin Orthop Related Res. 2002;396:115-8.

9. Hills BA, Crawford RW. Normal and prosthetic synovial joints are lubricated by surface-active phospholipid. A hypothesis. J Arthroplasty. 2003;18:499-505.I

Tribological and Metal Ion Issues:
 Tribology and Wear of Metal-on-Metal Hip Prostheses: Influence of Cup Angle and Head Position
 Williams et al. (1 August 2008) [Abstract] [Full text] [PDF]
Tribology and Wear of Metal-on-Metal Hip Prostheses: Influence of Cup Angle and...
Dr. Fisher and colleagues respond to Mr. Jain		 19 March 2009
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John Fisher, BSc, PhD,
Professor of Mechanical Engineering
Institute of Medical & Biological Engineering, University of Leeds, United Kingdom,
Sophie Williams, BEng, PhD; Ian Leslie, MEng, PhD; Graham Isaac, BSc, MSc; Zhongmin Jin, BEng, PhD; Eileen Ingham, BSc, PhD

Send letter to journal:
Re: Dr. Fisher and colleagues respond to Mr. Jain

j.fisher{at}leeds.ac.uk John Fisher, BSc, PhD, et al.

Thank you for the interest and attention that you have paid to our paper. We are delighted to offer the following responses to the specific questions you have raised about our study:

Regarding your comments about construct validity, previous studies under standard conditions have demonstrated that even n=3 is sufficient to observe statistical differences. Sample sizes of between n=3 and n=5 have been used in simulator studies over the last ten years (1,2). However as seen in this study, when simulating more extreme conditions particularly with microseparation and rim loading, this type of instability can produce a greater variation in the data set.

Regarding your comments about controlling for micro lateralization, this method has been previously published (3,4 for ceramic-on-ceramic bearings) and validated against clinical retrievals in terms of volumetric wear, wear scar geometry, wear mechanism and debris distribution. Full details of the simulator method can be found in these source references. There is growing recognition that microseparation and superior rim loading, which may be produced by mal-positioned components, soft tissue laxity and offset deficiency has a significant effect on clinical wear rates. We postulate that in surface replacements,lack of flexibility in restoration of the offset, makes this surgical intervention particularly susceptible to elevated rim wear especially with combination with steel cup angles.

Regarding your comment that "The paper also fails to explain why a different mounting of the head was tested with a different number of cycles in study 3." - Studies 1 and 2 tested 28mm metal-on-metal total hip replacements and study 3 a larger diameter (39mm) surface replacement metal on metal bearing. In the surface replacement bearing there is clearly no femoral stem or spigot on which to mount the head in a surface replacement, so a simulated femoral neck and head were created for purposes of wear simulation testing. Clearly, the configuration of the head mounting may have an effect on the biomechanics and wear during microseparation. This is just one of several variables that we are currently investigating under microseparation and rim loading conditions in further studies, (which include a wider range of head sizes, wider range of cup angles, cup version angle, as well as design and metallurgy variables and comparison with ceramic-on-ceramic bearings). This multi-variable study, which is supported by the Furlong Charitable Research Foundation, will involve over 200 million cycles of simulator testing and will last until 2012. The results of the effect of individual and combined variables will be published as the study progresses. We believe these are important findings which may influence the future clinical use of surface replacements and which have not been previously reported, and therefore need to be published as they are generated.

You state that "No confidence intervals were given for the main results." - Confidence limits (95%) are shown in Figures 3, 4 and 5 and in Table 1.

Regarding your comment about internal validity of the study, measurements to assess wear involve quantitative (gravimetric assessment of wear) and therefore observer bias is avoided. It is not normal to blind experiments in laboratory studies with quantitative data. All simulator studies are carried out under strict quality assurance conditions in an ISO accredited laboratory. Over the last decade over one billion cycles of hip simulator studies have been under taken under strictly controlled standardized conditions and published in peer reviewed papers and abstracts.

You state that "Study groups 2 & 3 are not matched and therefore cannot be compared." - See above, because other variables as well as head size change between study groups 2 and 3, such as method of mounting of head, this could also have contributed to the difference in the wear results. Of course, clinically, these are relevant differences between a large head surface replacement and a smaller head total joint. This is a “first in the world“ simulation study of effect of microseparation on surface replacement and further investigation of a wider range of variables is currently on going and will be published shortly. Recent results published during the last year confirm that the microseparation as well as cup angle is a critical determinant of wear in surface replacement metal-on-metal hips (5).

We fully recognize that the study fails to include the effects of version angle which may affect the contact mechanics; this factor will be investigated in the present ongoing work.

References

1. Barbour PS, Stone MH, Fisher J. A hip joint simulator study using simplified loading and motion cycles generating physiological wear paths and rates. Proc Inst Mech Eng [H]. 1999;213;455-67.

2. Firkins PJ, Tipper JL, Ingham E, Stone MH, Farrar R, Fisher J. Influence of simulator kinematics on the wear of metal-on-metal hip prostheses. Proc Inst Mech Eng [H]. 2001;215;119-21.

3. Nevelos J, Ingham E, Doyle C, Streicher R, Nevelos A, Walter W, Fisher J. Microseparation of the centers of alumina-alumina artificial hip joints during simulator testing produces clinically relevant wear rates and patterns. J Arthroplasty. 2000;15;793-95.

4. Stewart T, Tipper J, Streicher R, Ingham E, Fisher J. Long-term wear of HIPed alumina on alumina bearings for THR under microseparation conditions. J Mater Sci Mater Med. 2001;12;1053-56.

5. Fisher J. Tribology of hard on hard bearings under adverse conditions. In: Proceedings of the Institution of Mechanical Engineers, Conference on Bearing Surfaces in Hip Replacement; 2008; London.
Tribology and Wear of Metal-on-Metal Hip Prostheses: Influence of Cup Angle and...
Tribology and Wear of Metal-on-Metal Hip Prostheses		 19 March 2009
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Rohit Jain,
Speciality Registrar, Trauma & Orthopaedics
Wrightington Hospital, United Kingdom

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Re: Tribology and Wear of Metal-on-Metal Hip Prostheses

rohitjain{at}hotmail.co.uk Rohit Jain

To the Editor:

I read the paper by Williams et al. (1) with great interest. Although the limitations of the study are well recognized and discussed by the authors,I would like to draw attention to the following points:

Construct Validity: The size of the sample in each study has not been justified. There are no power calculations available. The authors fail to explain how micro lateralization was controlled through 2 million cycles of wear. The paper also fails to explain why a different mounting of the head was tested with a different number of cycles in study 3. No confidence intervals were given for the main results.

Internal Validity: There is no blinding attempted to address the observer bias. Study groups 2 & 3 are not matched and therefore cannot be compared.

The authors recognize that the study fails to include the effects of version angle which clinically may affect the radiographic appearance of inclination & contact mechanics.

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. Sophie Williams, Ian Leslie, Graham Isaac, Zhongmin Jin, Eileen Ingham, and John Fisher. Tribology and Wear of Metal-on-Metal Hip Prostheses: Influence of Cup Angle and Head Position. J Bone Joint Surg Am 2008; 90: 111-117.

Surgical Techniques:
 Outcome at Forty-five Years After Open Reduction and Innominate Osteotomy for Late-Presenting Developmental Dislocation of the Hip. Surgical Technique
 Wedge et al. (1 October 2008) [Abstract] [Full text] [PDF]
Outcome at Forty-five Years After Open Reduction and Innominate Osteotomy for Late-Presenting...
Dr. Wedge responds to Mr. Cove		 22 July 2009
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John H. Wedge, MD, FRCS(C),
Orthopaedic Surgeon
The Hospital For Sick Children and The University of Toronto, Ontario

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Re: Dr. Wedge responds to Mr. Cove

john.wedge{at}sickkids.ca John H. Wedge, MD, FRCS(C)

I would like to thank Mr. Cove for pointing out an obvious typographical error in our manuscript. The vessel described is indeed a branch of the lateral, rather than the medial circumflex femoral artery.
Outcome at Forty-five Years After Open Reduction and Innominate Osteotomy for Late-Presenting...
Anatomic Typo		 13 July 2009
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Richard Cove, FRCS(Orth),
Orthopaedic Surgeon
Royal Cornwall Hospital, Truro, Cornwall, United Kingdom

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Re: Anatomic Typo

richard_cove{at}yahoo.com Richard Cove, FRCS(Orth)

To the Editor:

I read this paper with interest (1). Just for the sake of keeping the record straight, the authors, describing an anterior approach to the hip, wrote, "A leash of vessels at the inferior end of the wound, marking the ascending branch of the medial circumflex femoral artery, requires cauterization to provide adequate distal exposure." They of course intended to write, "...lateral circumflex femoral artery..."

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. Wedge JH, Thomas SR, Salter RB. Outcome at forty-five years after open reduction and innominate osteotomy for late-presenting developmental dislocation of the hip. Surgical technique. J Bone Joint Surg Am. 2008;90:238-53.

Selected Instructional Course Lecture:
 The Use of Bone Morphogenetic Protein in Lumbar Spine Surgery
 Rihn et al. (1 September 2008) [Full text] [PDF]
The Use of Bone Morphogenetic Protein in Lumbar Spine Surgery
Drs. Rihn and Albert respond to Dr. Smoljanovic and colleagues		 26 February 2009
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Jeffrey A. Rihn, MD,
Department of Orthopaedic Surgery
The Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA,
Todd J. Albert, MD

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Re: Drs. Rihn and Albert respond to Dr. Smoljanovic and colleagues

jrihno16{at}yahoo.com Jeffrey A. Rihn, MD, et al.

We appreciate all of the comments from Dr.Smoljanovic and colleagues. It is clear from their comments that they have given this topic substantial consideration, particularly regarding vertebral osteolysis following the use of rhBMP-2 for interbody fusion. We recognize the point that the authors made in a previous letter to the editor in Spine (1) regarding the findings of Burkus et al (2). In that letter, the authors identify a figure from the paper by Burkus et al (2) in which there appears to be vertebral osteolysis at 6 months follow up that went unreported (1). The findings that we presented in this article, however, were based on the original, peer-reviewed publications by Burkus et al. (2, 3, 4). The writing of our paper predates the publication of this previous letter to the editor as well as many of the references cited in the current letter, two of which are still in press. We realize that additional information regarding the use of BMP in lumbar fusion surgery is available since the writing of our paper (i.e. October/November of 2007).

In regard to the incidence of vertebral osteolysis, Smoljanovic et al.point out that other studies suggest that vertebral osteolysis following the use of rhBMP-2 is far more common than the incidence that we quoted (7% to 18%). The papers referenced by the authors, however, have significant limitations that should be noted in regard to the incidence of vertebral osteolysis. McClellan et al (5) reported on 26 patients who underwent TLIF over a 16 months period by 7 spine surgeons at the same institution. One significant limitation, however, is that the study included only those patients who underwent postoperative CT scan. The study does not state how many patients underwent TLIF procedures over this 16 month period by the 7 participating surgeons who did not have postoperative CT scan and therefore were not included in the study. It is likely, given the time period and the number of participating surgeons, that this number is far greater than the 26 patients who were included in the study. One could argue that those who underwent postoperative CT scan are more likely to have had a problem after surgery (e.g. vertebral osteolysis) compared to those who did not get a postoperative CT scan. Therefore, the reported incidence of vertebral osteolysis by McClellan et al (5) is likely not accurate for the entire group of TLIF patients and may be an overestimate. The study referenced by Vaidya et al (6) evaluated vertebral osteolysis using plain radiographs. However, osteolysis can be difficult to see on plain radiographs. This is especially true for TLIFs performed at the L5-S1 level, due to the overlap of the ileum on the radiographs. In the study by Vaidya et al, over 50% of the TLIF patients had surgery at the L5-S1 level. Indeed, the authors of this letter to the editor state that CT scan rather than plain radiography should be used to assess for vertebral osteolysis.

Smoljanovic et al. are mistaken when they suggest that we associate repeat exposure to BMP with postoperative radiculitis, vertebral osteolysis and edema, and neurocompressive ectopic bone. We actually stated very clearly that there is no clinical evidence that re-exposure to BMP is detrimental and we reference the study by Carreon et al (7) that studied cases of BMP re-exposure and found no added morbidity. The authors of this letter also strongly disagree with the notion that the pathophysiology and relevance of vertebral osteolysis is not currently well understood. They correlate the amount of vertebral osteolysis with the area of contact between the BMP/absorbable collagen sponge and cancellous bone. The references that this statement is based on include three review papers, one of which is still in press. We did acknowledge in our paper that there may be an association between vertebral osteolysis and violation of the endplate and exposure of the underlying cancellous bone to the BMP. Studies also suggest that BMP stimulates osteoclastic activity, which may contribute to osteolysis (8, 9). Although there is a large amount of animal data on the use of BMP, including the study referenced in this letter that uses a nonhuman primate long-bone defect model (10), animal studies that specifically address the issue of vertebral osteolysis and BMP use and definitively describe the pathophysiology of this process are lacking. We recognize that vertebral osteolysis following the use of BMP in interbody fusion represents an important issue that may be more common than we realize. Fortunately, most studies report that it is a self-limiting process that eventually leads to a successful fusion. It nonetheless warrants further basic science and clinical study.

References

1. Smoljanovic T, Pecina M. Re: Burkus J K, Transfeldt E E, Kitchel S H, et al. Clinical and radiographic outcomes of anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2. Spine 2002;27:2396-408. Spine. Jan 15 2008;33(2):224.

2. Burkus JK, Gornet MF, Dickman CA, Zdeblick TA. Anterior lumbar interbody fusion using rhBMP-2 with tapered interbody cages. J Spinal Disord Tech. Oct 2002;15(5):337-349.

3. Burkus JK, Transfeldt EE, Kitchel SH, Watkins RG, Balderston RA. Clinical and radiographic outcomes of anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2. Spine. Nov 1 2002;27(21):2396-2408.

4. Burkus JK, Sandhu HS, Gornet MF. Influence of rhBMP-2 on the healing patterns associated with allograft interbody constructs in comparison with autograft. Spine. Apr 1 2006;31(7):775-781.

5. McClellan JW, Mulconrey DS, Forbes RJ, Fullmer N. Vertebral bone resorption after transforaminal lumbar interbody fusion with bone morphogenetic protein (rhBMP-2). J Spinal Disord Tech. Oct 2006;19(7):483-486.

6. Vaidya R, Sethi A, Bartol S, Jacobson M, Coe C, Craig JG. Complications in the use of rhBMP-2 in PEEK cages for interbody spinal fusions. J Spinal Disord Tech. Dec 2008;21(8):557-562.

7. Carreon LY, Glassman SD, Brock DC, Dimar JR, Puno RM, Campbell MJ. Adverse events in patients re-exposed to bone morphogenetic protein for spine surgery. Spine. 2008;33(4):391-393.

8. Wutzl A, Brozek W, Lernbass I, et al. Bone morphogenetic proteins 5 and 6 stimulate osteoclast generation. J Biomed Mater Res A. Apr 2006;77(1):75-83.

9. Okamoto M, Murai J, Yoshikawa H, Tsumaki N. Bone morphogenetic proteins in bone stimulate osteoclasts and osteoblasts during bone development. J Bone Miner Res. Jul 2006;21(7):1022-1033.

10. Seeherman H, Wozney JM. Delivery of bone morphogenetic proteins for orthopedic tissue regeneration. Cytokine Growth Factor Rev. Jun 2005;16(3):329-345.
The Use of Bone Morphogenetic Protein in Lumbar Spine Surgery
Transient Bone Resorption Associated with Use of rhBMP-2 in Lumbar Fusion Surgery		 26 February 2009
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Tomislav Smoljanovic, MD, PhD,
Orthopaedic Surgeon
Department of Orthopaedic Surgery, School of Medicine & Clinical Hospital Center, Zagreb University,
Ivan Bojanic, MD, PhD; Marko Pecina, MD, PhD

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Re: Transient Bone Resorption Associated with Use of rhBMP-2 in Lumbar Fusion Surgery

drsmoljanovic{at}yahoo.com Tomislav Smoljanovic, MD, PhD, et al.

To the Editor:

We wish to point out several inaccuracies in the recent review by Rihn et al. about the use of recombinant human bone morphogenetic proteins (rhBMP) in lumbar spine surgery (1).

As we pointed out in a previous letter to the editor(2), the dose of rhBMP-2 used per level of lumbar interbody fusion (LIF) was decreased by 30% between the cited studies (3,4)even though the publications reported two sequential phases of a Level I study conducted under strict control of the Food and Drug Administration.

We also disagree with the authors (1) that no transient vertebral osteolysis was associated with the use of rhBMP-2 in the first phase, as unreported vertebral resorption has been identified (5) at CT scans 6 months after rhBMP-2 application (Figure 10) (4). An analysis by our group(6) of reported transient vertebral resorption revealed that patients in whom the resorption developed after rhBMP-2 application in LIF were often susceptible to spacer subsidence, loss of correction, graft migration and the failure of spinal interbody fusion even with additional stabilization of fused levels.(6).What is of interest is how such large resorptions (5) were not associated with any spacer subsidence or loss of correction, especially as no additional instrumentation was used (3,4). Two papers report an incidence of resorption after LIF assisted by rhBMP-2 that is substantially higher than the 7% (7) and 18% (3,8) mentioned by Rihn et al. (1). In addition, McClellan et al. and Vaidya et al. reported an incidence of 69% (9,10), while most recently Vaidya et al. reported an incidence of 82% (11).

Furthermore, Rihn et al.(1) associated repeat BMP exposure with postoperative radiculitis, vertebral osteolysis and edema, and neurocompressive ectopic bone. We do not know how many patients have actually experienced repeat BMP exposure to date, but the analysis of the resorptions revealed that the size of the contact surface between rhBMPs soaked into an absorbable collagen sponge (rhBMPs/ACS) and trabecular bone was responsible for occurrence and clinical manifestations of the resorptions (6,12).The clarification of the finding was offered by Seeherman and Wozney who have shown that rhBMP-2/ACS placed in contact with trabecular bone of the distal femoral core defect in nonhuman primates resulted in significant transient bone resorption at 2 weeks after the surgery (13). This was not the case when a carrier with a slower release of rhBMP (calcium phosphate matrix) was used. The rapid release of rhBMPs at the bone surface which is in contact with the collagen sponge creates favorable conditions for significant osteoclastic reaction prior to the bone formation phase.

Finally, we disagree strongly that the pathophysiology and relevance of the vertebral osteolysis are unknown (1). To avoid occurrence of clinically significant resorption during lumbar interbody fusion(LIF), surgeons should avoid creation of larger contact surfaces between rhBMPs/ACS and trabecular bone. If this is not possible because of the nature of the procedures, manufacturers should consider introducing new carriers with slower initial release of rhBMPs for applications in proximity of trabecular bone. Until then, patients who undergo LIF assisted with rhBMP-2/ACS should be followed using the recently clarified (14) CT scan protocol (15). Although the main determinations of final outcome are the size of the area under the resorptions and the stability of additional spinal instrumentation, early CT scans will detect or confirm the resorptions in the lumbar area even in asymptomatic patients which will allow restriction of activity in such patients until the bone formation phase overtakes the osteoclastic reaction (14).

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. Rihn JA, Gates C, Glassman SD, Phillips FM, Schwender JD, Albert TJ. The use of bone morphogenetic protein in lumbar spine surgery. J Bone Joint Surg Am. 2008;90:2014-25.

2. Smoljanovic T, Pecina M. Unexplained decreasing of rhBMP-2 dose. J Bone Joint Surg Am. Electronically published letter. 23rd October 2007. Available from: http://www.ejbjs.org/cgi/eletters/87/6/1205#5117.

3. Burkus JK, Sandhu HS, Gornet MF. Influence of rhBMP-2 on the healing patterns associated with allograft interbody constructs in comparison with autograft. Spine. 2006;31:775-81.

4. Burkus JK, Transfeldt EE, Kitchel SH, Watkins RG, Balderston RA. Clinical and radiographic outcomes of anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2. Spine. 2002;27:2396-408.

5. Smoljanovic T, Pecina M. Re: Burkus JK, Transfeldt EE, Kitchel SH, et al. Clinical and radiographic outcomes of anterior lumbar interbody fusion using recombinant human bone morphogenetic protein-2. Spine 2002;27:2396-408. Spine. 2008;33:224.

6. Smoljanovic T, Bicanic G, Bojanic I. Update of comprehensive review of the safety profile of bone morphogenetic protein in spine surgery. Neurosurgery. 2009;In press.

7. Lewandrowski KU, Nanson C, Calderon R. Vertebral osteolysis after posterior interbody lumbar fusion with recombinant human bone morphogenetic protein 2: a report of five cases. Spine J. 2007;7:609-14.

8. Burkus JK, Sandhu HS, Gornet MF, Longley MC. Use of rhBMP-2 in combination with structural cortical allografts: clinical and radiographic outcomes in anterior lumbar spinal surgery. J Bone Joint Surg Am. 2005;87:1205-12.

9. McClellan JW, Mulconrey DS, Forbes RJ, Fullmer N. Vertebral bone resorption after transforaminal lumbar interbody fusion with bone morphogenetic protein (rhBMP-2). J Spinal Disord Tech. 2006;19:483-6.

10. Vaidya R, Weir R, Sethi A, Meisterling S, Hakeos W, Wybo CD. Interbody fusion with allograft and rhBMP-2 leads to consistent fusion but early subsidence. J Bone Joint Surg Br. 2007;89:342-5.

11. Vaidya R, Sethi A, Bartol S, Jacobson M, Coe C, Craig JG. Complications in the use of rhBMP-2 in PEEK cages for interbody spinal fusions. J Spinal Disord Tech. 2008;21:557-62.

12. Smoljanovic T, Grgurevic L, Jelic M, Kreszinger M, Haspl M, Maticic D, Vukicevic S, Pecina M. Regeneration of the skeleton by recombinant human bone morphogenetic proteins. Coll Antropol. 2007;31:923-32.

13. Seeherman H, Wozney JM. Delivery of bone morphogenetic proteins for orthopedic tissue regeneration. Cytokine Growth Factor Rev. 2005;16:329-45.

14. Smoljanovic T, Bojanic I, Dapic T. Significance of Early CT Evaluation after the Lumbar Interbody Fusions Assisted with rhBMP-2. Am J Neuroradiol. 2009;In press.

15. Williams AL, Gornet MF, Burkus JK. CT evaluation of lumbar interbody fusion: current concepts. AJNR Am J Neuroradiol. 2005;26:2057-66.

Scientific Articles:
 Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery. An Animal Study
 Okubadejo et al. (1 September 2008) [Abstract] [Full text] [PDF]
Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery....
Drs. Okubadejo and Riew respond to Drs. Rathmell and Wainger		 13 January 2009
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Gbolahan Okubadejo, MD,
Department of Orthopaedic Surgery
University of Pittsburgh,
K. Daniel Riew, MD

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Re: Drs. Okubadejo and Riew respond to Drs. Rathmell and Wainger

gokubadejo{at}hotmail.com Gbolahan Okubadejo, MD, et al.

We thank Drs. Rathmell and Wainger for their comments regarding our paper, “Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery” (1). This study found a 100% correlation between injection of the particulate steroid in the vertebral artery, and eventual mortality of the animal model used in this study - the pig. Nonparticulate steroids did not demonstrate such morbid outcomes.

Drs. Rathmell and Wainger raise the question of whether the findings of this study can be extrapolated to make long-term prognoses. Our animals were kept on ventilator support for only 4 - 6 hours after the insult to the brain with none of the four animals in the Methylprednisolone group able to maintain appropriate oxygenation without ventilator support. No formal neurologic exam could be performed on these obtunded animals. They were sacrificed following the 4 – 6 hour recovery period which was deemed as appropriate for postoperative recovery. In marked contrast, all animals in the nonparticulate group were able to ambulate and appeared completely normal.

As Drs. Rathmell and Wainger point out, it is certainly possible that, had we kept the animals alive for a longer period, they might have recovered. We agree that our results with pigs should not be used to prognosticate the long-term outcome of humans who suffer an immediate complication following particulate steroid injections; human beings are capable of overcoming and recovering from serious neurologic injuries, given enough time and proper rehabilitation. Nevertheless, there are several troubling case reports of catastrophic clinical outcomes following inadvertent injection of particulate steroids into the vertebral artery (2,3,4). In almost all instances, the patients sustained serious neurological deficits or ultimately expired. These reports suggest,unfortunately, that human correlates of our study do exist.

We also agree that, in theory,that it may be possible for artifacts related to tissue processing to produce histological findings similar to what we found. However, as the data in this study were so consistent and reproducible, and had correlates with MRI and clinical findings, we believe that it is reasonable to conclude that the radiographic and histologic changes that were observed are indeed representative of true pathology as opposed to being artifact.

In conclusion, we agree with Drs. Rathmell and Wainger that with our short-term animal study, we cannot judge the permanency of the neural injury following injection of particulate steroids. We believe that our study should serve as a cautionary note when utilizing particulate steroids for injections. Finally, we agree that there needs to be further study regarding the safety and effectiveness of non-particulate steroids before recommending its use.

References

1. Perils of intravascular methylprednisolone injection into the vertebral artery. An Animal Study. Okubadejo GO, Talcott MR, Schmidt RE et al. JBJS Am 2008; 90:1932-1938

2. Derby R, Lee SH, Kim BJ et al. Complications following cervical epidural injections by expert interventionalists in 2003. Pain Physicians 2004; 7:445-449.

3. McMillan MR, Crumpton C. Cortical blindness and neurologic injury complicating cervical transforaminal injection for cervical radiculopathy. Anesthesiology 2003; 99: 509 – 511.

4. Rozin L, Rozin R, Koehler SA et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Path 2003; 24:315 – 355.
Perils of Intravascular Methylprednisolone Injection into the Vertebral Artery....
Clarifying mechanism of neurologic injury following intra-arterial injection of particulate steroid		 13 January 2009
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James P. Rathmell, MD,
Chief, Division of Pain Medicine
Department of Anesthesia & Critical Care, Massachusetts General Hospital, Boston, Massachusetts,
Brian J. Wainger, MD, PhD

Send letter to journal:
Re: Clarifying mechanism of neurologic injury following intra-arterial injection of particulate steroid

jprathmell{at}bics.bwh.harvard.edu