Methods: Three hundred and eleven patients with an irreparable injury of the medial meniscus or a previous partial medial meniscectomy, treated by a total of twenty-six surgeon-investigators at sixteen sites, were enrolled in the study. There were two study arms, one consisting of 157 patients who had had no prior surgery on the involved meniscus (the "acute" arm of the study) and one consisting of 154 patients who had had one, two, or three prior meniscal surgical procedures (the "chronic" arm). Patients were randomized either to receive the collagen meniscus implant or to serve as a control subject treated with a partial meniscectomy only. Patients underwent frequent clinical follow-up examinations over two years and completed validated outcomes questionnaires over seven years. The patients who had received a collagen meniscus implant were required by protocol to have second-look arthroscopy at one year to determine the amount of new tissue growth and to perform a biopsy to assess tissue quality. Reoperation and survival rates were determined.
Results: In the acute group, seventy-five patients received a collagen meniscus implant and eighty-two were controls. In the chronic group, eighty-five patients received the implant and sixty-nine were controls. The mean duration of follow-up was fifty-nine months (range, sixteen to ninety-two months). The 141 repeat arthroscopies done at one year showed that the collagen meniscus implants had resulted in significantly (p = 0.001) increased meniscal tissue compared with that seen after the original index partial meniscectomy. The implant supported meniscus-like matrix production and integration as it was assimilated and resorbed. In the chronic group, the patients who had received an implant regained significantly more of their lost activity than did the controls (p = 0.02) and they underwent significantly fewer non-protocol reoperations (p = 0.04). No differences were detected between the two treatment groups in the acute arm of the study.
Conclusions: New biomechanically competent meniscus-like tissue forms after placement of a collagen meniscus implant, and use of the implant appears safe. The collagen meniscus implant supports new tissue ingrowth that appears to be adequate to enhance meniscal function as evidenced by improved clinical outcomes in patients with a chronic meniscal injury. The collagen meniscus implant has the utility to be used to replace irreparable or lost meniscal tissue in patients with a chronic meniscal injury. The implant was not found to have any benefit for patients with an acute injury.
Level of Evidence: Therapeutic
Methods: As part of a study involving audiotaping of 886 visits between patients and orthopaedic surgeons, fifty-nine patients sixty years of age or older who were considering surgery were recruited to participate in semistructured telephone interviews at five to seven days and one month after the visit. Patients were asked about their perceptions of the visit and how they made their decision about surgery. These interviews were analyzed to identify patients' concerns with the use of qualitative content analysis and then compared with the audiotaped visits to determine whether these concerns were actually raised during the visit and, if so, how well the orthopaedic surgeons responded. Analyses based on patient race (black or white) were also performed.
Results: One hundred and sixty-four concerns pertaining to (1) the surgery (anticipated quality of life after the surgery, the care facility, the timing of the operation, and the patient's capacity to meet the demands of the surgery) and (2) the surgeons (their competency, communication, and professional practices) were identified. Patients raised only 53% of their concerns with the orthopaedic surgeons and were selective in what they disclosed; concerns about the timing of the operation and about the care facility were frequently raised, but concerns about their capacity to meet the demands of the surgery and about the orthopaedic surgeons were not. Orthopaedic surgeons responded positively to 66% of the concerns raised by the patients. Only two concerns were raised in response to direct surgeon inquiry.
Conclusions: Patients raised only half their concerns regarding surgery with orthopaedic surgeons. Orthopaedic surgeons are encouraged to fully address how patients' capacity to meet the demands of the surgery, defined by their resources (such as social support, transportation, and finances) and obligations (to family members, employers, and religion), may impinge on their willingness to accept recommended surgery.
]]>Methods: We included 850 consecutive patients with a hip fracture who were admitted to the hospital during one year in a prospective study. Three cutoff limits for a comparison of early and late operation were defined. The outcome (the ability to return to independent living, risk for the development of pressure ulcers, length of the hospital stay, and mortality rate) for patients who had an operation within twenty-four, thirty-six, and forty-eight hours was compared with the outcome for those who had an operation at a later time.
Results: Patients who had the operation more than thirty-six and forty-eight hours after admission were less likely to return to independent living within four months (odds ratio, 0.44 and 0.33, respectively), whereas there was no significant difference with use of the twenty-four-hour cutoff limit. The incidence of pressure ulcers in the groups that had the operation later was increased at all three cutoff limits (a delay of more than twenty-four hours, more than thirty-six hours, and more than forty-eight hours) (odds ratio, 2.19, 3.42, and 4.34, respectively). The length of hospitalization was also increased in the groups that had the later operation (median, fourteen compared with eighteen days, fifteen compared with nineteen days, and fifteen compared with twenty-one days, respectively) (p < 0.001 for all comparisons). The importance of surgical timing remained significant after adjusting for several possible confounders (p < 0.05).
Conclusions: Early compared with late operative treatment of patients with a hip fracture is associated with an improved ability to return to independent living, a reduced risk for the development of pressure ulcers, and a shortened hospital stay.
Level of Evidence: Therapeutic
Methods: We performed a prospective, randomized, controlled single-blind study involving sixty-three patients, twenty-six of whom had a combined ankle and popliteal block and thirty-seven of whom had an ankle block alone. All patients underwent an elective osseous surgical procedure on the forefoot. Postoperative pain was evaluated with use of a visual analogue scale and a verbal response form. Patient satisfaction was also recorded.
Results: The patients who had had a combined popliteal and ankle block had significantly less pain at six hours postoperatively (p = 0.011), twenty-four hours postoperatively (p < 0.001), and at discharge (p = 0.014). This group of patients also had higher satisfaction with pain relief.
Conclusions: A popliteal block in conjunction with an ankle block provides significantly better pain relief than does an ankle block alone in patients undergoing forefoot surgery.
Level of Evidence: Therapeutic
Methods: A decision model was constructed for a cost-utility analysis of periacetabular osteotomy compared with total hip arthroplasty. Outcome probabilities and effectiveness were derived from the literature. Effectiveness was expressed in quality-adjusted life years gained. Cost data were compiled and verified from our institution. Costs and utilities were discounted in accord with the United States Panel on Cost-Effectiveness in Health and Medicine. Principal outcome measures were average incremental costs, incremental effectiveness, incremental quality-adjusted life years, and net health benefits. Multivariate sensitivity analysis was used to assess the contribution of included variables in the model's outcomes.
Results: For Tönnis grade-1 coxarthrosis, periacetabular osteotomy dominates with an average incremental cost-effectiveness of $7856 per quality-adjusted life year and an average incremental effectiveness of 0.15. For Tönnis grade-2 coxarthrosis, periacetabular osteotomy is, on the average, more cost-effective than total hip arthroplasty with an incremental cost-effectiveness of $824 per quality-adjusted life year, but it is less effective than total hip arthroplasty, on the average, with an incremental effectiveness of –1.4 quality-adjusted life years. Periacetabular osteotomy becomes more cost-effective at a longevity of 5.5 years for Tönnis grade-1 coxarthrosis and 18.25 years for Tönnis grade-2 coxarthrosis. In Tönnis grade-3 coxarthrosis, total hip replacement becomes the dominant treatment strategy.
Conclusions: Periacetabular osteotomy is, on the average, more cost-effective in Tönnis grade-1 and grade-2 coxarthrosis, while it is both more costly and less effective in Tönnis grade-3 coxarthrosis. These findings can inform clinical decision-making in the absence of long-term data. On the basis of this model, periacetabular osteotomy is preferable to total hip arthroplasty in Tönnis grade-1 and grade-2 coxarthrosis when the patient is sufficiently young and when functionality in sports is important.
Level of Evidence: Economic and decision analysis,
Methods: During a five-year period, 201 patients (219 hips) were prospectively randomized to be treated with a total hip arthroplasty with either a polished (Ra, 0.18 to 0.3 µm) or a precoated roughened (Ra, 1.8 to 2.3 µm) cemented femoral component with similar geometry. There were no significant differences between the patient groups in terms of age, sex, weight, preoperative diagnosis, component size, or cement grade. So-called third-generation cementing techniques were used. One hundred and thirteen polished components and 106 precoated roughened components were followed for a mean of 5.3 years. Complete clinical and radiographic data were available for 134 hips at a minimum of five years (mean, 6.1 years; range, five to ten years) postoperatively.
Results: In the entire cohort of 219 hips, there was no significant difference (log rank p = 0.66) in survival, with the end point defined as component removal for any reason or definite radiographic loosening, between the precoated components (96.2%; 95% confidence interval, 90.9% to 100%) and the polished components (97.1%; 95% confidence interval, 93.8% to 100%). There was a periprosthetic fracture in three hips with a polished component. Two precoated roughened components were revised because of loosening, and two polished components were revised: one because of loosening and one because of a nonunion of a periprosthetic fracture. There was no significant difference between the groups with regard to the Harris hip scores or the clinical results. There was also no significant difference with regard to the presence or number of bone-cement radiolucent lines.
Conclusions: Kaplan-Meier survival analysis showed no significant differences between two types of cemented femoral components with similar geometry but substantially different surface finishes at seven years. In the patient population selected for treatment with a cemented femoral component, the surface finish may not be a crucial factor affecting component survival at a minimum of five years, provided that good cement technique is used.
Level of Evidence: Therapeutic
Methods: Seven human cadaver specimens were loaded during five separate maneuvers with external rotation or abduction torques applied to the hip in neutral alignment and in moderate flexion or extension. Tensile strain within the acetabular labrum was measured with use of the technique of roentgen stereophotogrammetric analysis.
Results: Substantial tensile strains were generated within the labrum during each of the loading maneuvers, with no significant difference in strain being noted between the maneuvers. Maximum strain in the anterior part of the labrum averaged 13.6% ± 7.8% in the axial direction and 8.4% ± 3.0% in the circumferential direction. The highest mean and maximum strain values were found at the two o'clock position of the labrum, with the highest strain concentration at the bone-labrum interface.
Conclusions: External rotation and abduction maneuvers of the morphologically normal human hip joint in moderate flexion or extension can generate substantial tensile strains in the anterior part of the acetabular labrum. This finding supports the hypothesis that injury to the anterior part of the labrum may occur from recurrent twisting or pivoting maneuvers of the hip joint in moderate flexion or extension without femoroacetabular impingement.
Clinical Relevance: The substantial amounts of tensile strain generated during loading of the morphologically normal hip are indicative of a mechanical process that may accelerate the onset of degenerative disease.
]]>Methods: Eight patients, between twelve and fifteen years old, with a large (>4 cm2) osteochondral fracture of the lateral femoral condyle were treated with open reduction and internal fixation with use of multiple polyglycolic acid rods. Each patient was evaluated at more than five years (a mean of nine years) after the index procedure with a clinical assessment, during which the knee was scored according to the International Knee Documentation Committee and Cincinnati knee rating systems, plain radiographs were made, and magnetic resonance imaging scans were acquired.
Results: The majority of patients scored well on both knee rating systems, with no poor results. Five of the eight patients had normal findings on knee radiographs, and three had radiographs that showed minor changes. Magnetic resonance imaging scans of all cpatients demonstrated intact articular cartilage in the lateral compartment with no area of full-thickness articular cartilage loss. No evidence of articular cartilage thinning was seen in two knees; a small area of <2 cm2 of cartilage thinning, in four; a moderate area of 2.7 cm2 of cartilage thinning, in one; and a large area of 11.2 cm2 of abnormal cartilage signal, in one knee.
Conclusions: Osteochondral fracture of the lateral femoral condyle is an injury to which adolescents with ligamentous laxity of the knee are prone. Our results show that internal fixation of these osteochondral fragments with bioabsorbable implants is possible and is a worthwhile option.
Level of Evidence: Therapeutic
Methods: We conducted a retrospective data analysis of Medicare claims generated by a 5% sample of all Medicare enrollees from 1997 through 2004. The patient sample consisted of all 97,142 individuals with a new diagnosis of vertebral compression fracture from 1997 through 2004. Controls were matched for age, sex, race, and Medicare buy-in status, with a five-to-one control-case ratio. The survival of a patient was measured from the earliest date of a new fracture until death or until the end of the study. The patients with a fracture were compared with the controls by calculation of the mortality rates, with use of Kaplan-Meier analysis and the Cox regression method. Demographic subpopulation analysis and analysis by comorbidity levels were performed as well.
Results: Medicare patients with a vertebral fracture had an overall mortality rate that was approximately twice that of the matched controls. The survival rates following a fracture diagnosis, as estimated with the Kaplan-Meier method, were 53.9%, 30.9%, and 10.5% at three, five, and seven years, respectively, which were consistently and significantly lower than the rates for the controls. The mortality risk following a fracture was greater for men than for women. The difference in mortality between the patients with a vertebral compression fracture and the controls was greatest when the patients were younger at the time of the fracture; this difference declined as the age at the time of the fracture increased.
Conclusions: This study establishes the mortality risk associated with vertebral fractures for elderly patients of all ages and ethnicities and both sexes in the Medicare population; however, it does not imply a causal relationship. The difference in mortality between patients with a fracture and controls is higher than previously reported, even after controlling for comorbidities.
Level of Evidence: Prognostic
Level of Evidence: Therapeutic
Methods: A Markov decision model was used to evaluate the impact of hospital volume on the cost-effectiveness of computer-assisted knee arthroplasty in a theoretical cohort of sixty-five-year-old patients with end-stage arthritis of the knee to coincide with the peak incidence of knee arthroplasty in the United States.
Results: Computer-assisted surgery becomes less cost-effective as the annual hospital volume decreases, as the cost of the navigation increases, and as the impact on revision rates decreases. Centers at which 250, 150, and twenty-five computer-navigated total knee arthroplasties are performed per year will require a reduction of the annual revision rate of 2%, 2.5%, and 13%, respectively, per year over a twenty-year period for computer navigation to be cost-effective.
Conclusions: Computer navigation is less likely to be a cost-effective investment in health-care improvement in centers with a low volume of joint replacements, where its benefit is most likely to be realized. However, it may be a cost-effective technology for centers with a higher volume of joint replacements, where the decrease in the rate of knee revision needed to make the investment cost-effective is modest, if improvements in revision rates with the use of this technology can be realized.
Level of Evidence: Economic and decision analysis,
Methods: Twelve consecutive infants (twenty-four feet) with clubfoot deformity associated with distal arthrogryposis were managed with the Ponseti method and were retrospectively reviewed at a minimum of two years. The severity of the foot deformity was classified according to the grading system of Diméglio et al. The number of casts required to achieve correction was compared with published data for the treatment of idiopathic clubfoot. Recurrent clubfoot deformities or complications during treatment were recorded.
Results: Twenty-two clubfeet in eleven patients were classified as Diméglio grade IV, and two clubfeet in one patient were classified as Diméglio grade II. Initial correction was achieved in all clubfeet with a mean of 6.9 ± 2.1 casts (95% confidence interval, 5.6 to 8.3 casts), which was significantly greater than the mean of 4.5 ± 1.2 casts (95% confidence interval, 4.3 to 4.7 casts) needed in a cohort of 219 idiopathic clubfeet that were treated during the same time period by the senior author with use of the Ponseti method (p = 0.002). Six feet in three patients had a relapse after initial successful treatment. All relapses were related to noncompliance with prescribed brace wear. Four relapsed clubfeet in two patients were successfully treated with repeat casting and/or tenotomy; the remaining two relapsed clubfeet in one patient were treated with extensive soft-tissue-release operations.
Conclusions: Our early-term results support the use of the Ponseti method for the initial treatment of distal arthrogrypotic clubfoot deformity. Longer follow-up will be necessary to assess the risk of recurrence and the potential need for corrective clubfoot surgery in this patient population, which historically has been difficult to treat nonoperatively.
Level of Evidence: Therapeutic
Methods: We reviewed the cases of 182 patients with idiopathic clubfoot (273 feet) who were initially treated nonoperatively. Seventy-seven patients (119 feet) were excluded because they had either received a combination of nonoperative treatments or had undergone surgery prior to testing. Gait analysis was performed when the children were approximately two years of age. Temporal and kinematic data were classified as abnormal if they were more than one standard deviation from normal.
Results: Gait analysis was performed on 105 patients (fifty-six treated with casts and forty-nine treated with physical therapy) with 154 involved feet (seventy-nine treated with casts and seventy-five treated with physical therapy). These patients were an average of two years and three months of age, and their initial Diméglio scores ranged between 10 and 17. No significant differences in cadence parameters were found between the two groups. The rate of normal kinematic ankle motion in the sagittal plane was higher in the group treated with physical therapy (65% of the feet) than it was in the group treated with the Ponseti cast technique (47%) (p = 0.0317). More children treated with physical therapy walked with knee hyperextension (37% of the feet) (p < 0.0001), an equinus gait (15%) (p = 0.0051), and footdrop (19%) (p = 0.0072); only one patient treated with casts walked with an equinus gait, and only three demonstrated footdrop. In contrast, more of the patients in the cast-treatment group demonstrated excessive stance-phase dorsiflexion (48% of the feet) (p < 0.0001) and a calcaneus gait (10%). More feet in the physical therapy group had an increased internal foot progression angle (44% compared with 24% in the cast-treatment group; p = 0.0144) and increased shank-based foot rotation (73% compared with 57% in the cast-treatment group; p = 0.05).
Conclusions: While the rate of normal kinematic ankle motion in the sagittal plane was 65% in the group treated with physical therapy, the gait abnormalities that were seen in that group were characterized by mild equinus and/or footdrop. The rate of normal kinematic ankle motion in the sagittal plane was 47% in the cast-treatment group, but the most common gait abnormality in this group was mildly increased dorsiflexion in the stance phase. The rates of calcaneus gait and equinus gait were ≤15% in each nonoperative group. The differences between the physical therapy and cast-treatment groups may, in part, be the result of the percutaneous Achilles tendon lengthening that is performed as part of the Ponseti cast technique but not as part of the physical therapy program.
Level of Evidence: Therapeutic
Methods: The medical records of all children with arthrogryposis who had been followed for a minimum of two years after treatment with elbow capsulotomy and triceps lengthening were retrospectively reviewed. The postoperative range of motion and ability to reach the mouth were compared with the preoperative status.
Results: Posterior capsulotomy with triceps lengthening was performed in twenty-nine elbows of twenty-three children with an average age of thirty-five months (range, seven months to thirteen years). The average duration of follow-up was 5.4 years. The arc of motion of all twenty-nine elbows improved from an average of 32° (range, 0° to 75°) preoperatively to an average of 66° (range, 10° to 125°) at the time of final follow-up. All children were able to reach the mouth using passive assistance (e.g., table-push, trunk-sway, and cross-arm techniques), and twenty-two children were able to feed themselves independently. No child underwent subsequent tendon transfer surgery.
Conclusions: Elbow capsulotomy with triceps lengthening successfully increases passive elbow flexion and the arc of elbow motion of children with arthrogryposis, enabling hand-to-mouth activities. In contrast to studies in which tendon transfer surgery was used to increase elbow flexion, none of the children in this series underwent subsequent tendon transfer surgery.
Level of Evidence: Therapeutic
Level of Evidence: Therapeutic
Methods: Osteochondral explants (n = 48) that had been harvested from the metacarpophalangeal joints of three-year-old cows were exposed to media with varying osmolarity (0 to 480 mOsm) for ninety seconds to allow in situ chondrocytes to respond to the altered osmotic environment. Explants were then wounded with a scalpel through the full thickness of articular cartilage, incubated in the same media for 2.5 hours, and transferred to 340-mOsm Dulbecco's Modified Eagle Medium (control medium) with further incubation for seven days. The spatial distribution of in situ chondrocyte death, percentage cell death, and marginal cell death at the wounded cartilage edge were compared as a function of osmolarity and time (2.5 hours compared with seven days) with use of confocal laser scanning microscopy.
Results: In situ chondrocyte death was mainly localized to the superficial tangential zone of injured articular cartilage for the range of medium osmolarities (0 to 480 mOsm) at 2.5 hours and seven days. Therefore, a sample of articular cartilage from the superficial region (which included the scalpel-wounded cartilage edge) was studied with use of confocal laser scanning microscopy to compare the effects of osmolarity on percentage and marginal cell death in the superficial tangential zone. Compared with the control explants exposed to 340-mOsm Dulbecco's Modified Eagle Medium, percentage cell death in the superficial tangential zone was greatest for explants exposed to 0-mOsm (distilled water) and least for explants exposed to 480-mOsm Dulbecco's Modified Eagle Medium at 2.5 hours (13.0% at 340 mOsm [control], 35.5% at 0 mOsm, and 4.3% at 480 mOsm; p ≤ 0.02 for paired comparisons) and seven days (9.9% at 340 mOsm [control], 37.7% at 0 mOsm, and 3.5% at 480 mOsm; p ≤ 0.01 for paired comparisons). Marginal cell death in the superficial tangential zone decreased with increasing medium osmolarity at 2.5 hours (p = 0.001) and seven days (p = 0.002). There was no significant change in percentage cell death from 2.5 hours to seven days for explants initially exposed to any of the medium osmolarities.
Conclusions: Medium osmolarity significantly affects chondrocyte death in wounded articular cartilage. The greatest chondrocyte death occurs at 0 mOsm. Conversely, increased medium osmolarity (480 mOsm) is chondroprotective. The majority of cell death occurs within 2.5 hours, with no significant increase over seven days.
Clinical Relevance: These experiments suggest that the osmolarity of irrigation solutions could be manipulated to reduce chondrocyte death resulting from mechanical injury during arthroscopic and open articular surgery.
]]>Methods: Four hundred and sixteen knees with an Anatomic Modular Knee primary total knee replacement had five to eighteen years of follow-up and a posterior cruciate ligament-retaining polyethylene tibial insert that had been sterilized with either gamma radiation in air (from 1987 to 1993) or gamma radiation in an inert gas (from 1993 to 1995), or by means of a nonirradiation gas-plasma method (from 1995 to 2001). Readings were taken from 1975 weight-bearing anteroposterior radiographs of the knee on which the top surface of the metal tibial tray had nearly projected as a line. In each tibiofemoral compartment, loss of polyethylene thickness was calculated as the standard thickness of the insert minus the measured magnification-corrected thickness. For each sterilization method, thickness loss was plotted versus the corresponding follow-up time, and a mixed linear regression model was used to quantify the change in thickness over time. Multiple linear regression analysis was used to determine whether loss of thickness was associated with implant factors, patient variables, and early postoperative limb alignment.
Results: According to the mixed model regression coefficients, loss of medial compartment thickness was greatest for inserts that had been sterilized with gamma radiation in air (0.15 mm/yr), least for those sterilized with gamma radiation in an inert gas (0.02 mm/yr), and of an intermediate magnitude for those sterilized with a nonirradiation method (0.06 mm/year); loss of lateral compartment thickness ranged from 0.03 to 0.06 mm/yr. Notably, no insert irradiated in an inert gas showed a loss of thickness of >1 mm, and no nonirradiated insert showed a loss of >2 mm. Loss of medial compartment thickness in inserts sterilized with radiation in air increased significantly with a greater polyethylene shelf age, lesser patient age, and more varus alignment of the limb in the early postoperative period (p < 0.01).
Conclusions: In this total knee design, tibial polyethylene performance improved markedly after discontinuation of the gamma radiation in air sterilization technique. Future concerns are that bearings sterilized with radiation in an inert gas may oxidize in vivo and develop fatigue wear because of free radicals generated during sterilization with radiation and that nonirradiated bearings may undergo greater losses in thickness from routine burnishing since they lack the cross-linking that accompanies sterilization with radiation.
Level of Evidence: Therapeutic
Methods: Forty-three failed Osteonics constrained tripolar implants were revised at our institution between September 1997 and April 2005. All revisions related to the constrained acetabular component only were considered as failures. All of the devices had been inserted for recurrent or intraoperative instability during revision procedures. Seven different methods of implantation were used. Operative reports and radiographs were reviewed to identify the modes of failure.
Results: The average time to failure of the forty-three implants was 28.4 months. A total of five modes of failure were observed: failure at the bone-implant interface (type I), which occurred in eleven hips; failure at the mechanisms holding the constrained liner to the metal shell (type II), in six hips; failure of the retaining mechanism of the bipolar component (type III), in ten hips; dislocation of the prosthetic head at the inner bearing of the bipolar component (type IV), in three hips; and infection (type V), in twelve hips. The mode of failure remained unknown in one hip that had been revised at another institution.
Conclusions: The Osteonics constrained tripolar total hip arthroplasty implant is a complex device involving many parts. We showed that failure of this device can occur at most of its interfaces. It would therefore appear logical to limit its application to salvage situations.
Level of Evidence: Therapeutic
Diabetic patients with neuropathy or vasculopathy have higher complication rates than both diabetic patients without these comorbidities and nondiabetic patients.
Unstable ankle fractures in diabetic patients without neuropathy or vasculopathy are best treated with open reduction and internal fixation with use of standard techniques.
Patients with neuropathy or vasculopathy are at increased risk for both soft-tissue and osseous complications, including delayed union and nonunion. Careful soft-tissue management as well as stable, rigid internal fixation are crucial to obtaining a good outcome.
Prolonged non-weight-bearing and subsequently protected weight-bearing are recommended following both operative and nonoperative management of ankle fractures in patients with diabetes.
]]>Methods: We surveyed members of the Canadian Orthopaedic Association to identify attitudes toward intimate partner violence. With use of a systematic random sample, 362 surgeons were mailed questionnaires. The questionnaire consisted of three sections: (1) the general attitude of the orthopaedic surgeon toward intimate partner violence, (2) the attitude of the orthopaedic surgeon toward victims and batterers, and (3) the clinical relevance of intimate partner violence in orthopaedic surgery. Up to three follow-up mailings were performed to enhance response rates.
Results: A total of 186 orthopaedic surgeons responded (a response rate of 51%), and 167 (91%) of them were men. Most orthopaedic surgeons (95%) estimated that <10% of their patients were victims of intimate partner violence, and most respondents (80%) believed that it was exceedingly rare (a prevalence of <1%). The concept of mandatoryscreening for intimate partner violence was met with uncertainty by 116 surgeons (64%). Misconceptions were perpetuated by surgeons who believed that inquiring about intimate partner violence was an invasion of the victim's privacy, that investigating intimate partner violence was not part of their duty, that victims choose to be a victim, and that victims play a proactive role in causing their abuse. By the completion of the survey, the majority of surgeons (91%) believed that knowledge about intimate partner violence was relevant to their surgical practice.
Conclusions: Discomfort with the issue and lack of education have led to misconceptions among Canadian orthopaedic surgeons about intimate partner violence. The relevance of intimate partner violence to surgical practice is well understood, but studies regarding its prevalence are needed as a first step to change the current paradigm in orthopaedic surgery.
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