The “50% Rule” in Arthroscopic and Orthopaedic Surgery

The "50% rule" is used commonly to guide treatment of partial tears of tendons and ligaments. The purpose of this study was to examine the history and validity of the 50% rule in arthroscopic and orthopaedic surgery. A PubMed search yielded 1,039 articles that were reviewed to identify the origins of the 50% rule for hand flexor tendon lacerations, partial anterior cruciate ligament tears, partial-thickness rotator cuff tears, and partial injuries of the long head of the biceps tendon. The rule appears to have evolved from the hand literature toward somewhat arbitrary application for other orthopaedic conditions. Little scientific information is available to support the 50% rule for these disparate entities. In our Level V opinion, the 50% rule allows surgeons to use subjective discretion in the management of prevalent orthopaedic conditions but there is very little scientific support for this ubiquitous decision-making criterion. Pedowitz RA, Higashigawa K, Nguyen V. Arthroscopy. 2011 Sep 1. [Epub ahead of print] PMID: 21889867 PDF

Double Bundle ACL Reconstruction

1. Clinical comparison of two suspensory fixation devices for anatomic double-bundle anterior cruciate ligament reconstruction. Kondo E, Yasuda K, Miyatake S, Kitamura N, Tohyama H, Yagi T. Knee Surg Sports Traumatol Arthrosc. 2011 Sep 29. [Epub ahead of print] PMID: 21960032

2. MRI of double-bundle ACL reconstruction: evaluation of graft findings. Kiekara T, Järvelä T, Huhtala H, Paakkala A. Skeletal Radiol. 2011 Sep 30. [Epub ahead of print] PMID: 21959568

Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures.

Treatment of ankle fractures is often based on fracture type and surgeon's individual judgment. Literature concerning the treatment options and outcome are dated and frequently contradicting. The aim of this study was to determine the clinical and functional outcome after AO-Weber B-type ankle fractures in operatively and conservatively treated patients and to determine which factors influenced outcome. Van Schie-Van der Weert EM, Van Lieshout EM, De Vries MR, Van der Elst M, Schepers T. Arch Orthop Trauma Surg. 2011 Sep 30. [Epub ahead of print] PMID: 21959696

Midterm Results of the Treatment of Cartilage Defects in the Knee Using Alginate Beads Containing Human Mature Allogenic Chondrocytes.

This investigation provided useful information on the efficacy of the implantation of alginate beads containing human mature allogenic chondrocytes for the treatment of cartilage lesions in the knee. The midterm clinical outcome of the presented technique was satisfactory. However, these results were not confirmed by the MRI findings. Dhollander AA, Verdonk PC, Lambrecht S, Verdonk R, Elewaut D, Verbruggen G, Almqvist KF.

Am J Sports Med. 2011 Sep 29. [Epub ahead of print] PMID: 21960559

American Journal of Medical Quality: 2 new articles

1. Improving Awareness of Best Practices to Reduce Surgical Site Infection: A Multistakeholder Approach. Skoufalos A, Clarke JL, Napp M, Abrams KJ, Berman B, Armellino D, Schilling ME, Pracilio V. Am J Med Qual. 2011 Sep 29. [Epub ahead of print] PMID: 21960647

2. Commentary: Persistent Gaps in VTE Prophylaxis in Orthopedic Surgery: Will New Educational Strategies Help? Karcher RB, Sison A, Weber SE, Sheldon P Jr, Kahn KA, Tapson VF. Am J Med Qual. 2011 Sep 29. [Epub ahead of print] No abstract available. PMID: 21960646

A Cell-free Scaffold-based Cartilage Repair Provides Improved Function Hyaline-like Repair at One year

Bone marrow stimulation techniques in cartilage repair such as drilling are limited by the formation of fibrous to hyaline-like repair tissue. It has been suggested such techniques can be enhanced by covering the defect with scaffolds. We present an innovative approach using a polyglycolic acid (PGA)-hyaluronan scaffold with platelet-rich-plasma (PRP) in drilling. Alberto Siclari MD, Gennaro Mascaro MD, Chiara Gentili MD, Ranieri Cancedda PhD, Eugenio Boux MD. Clinical Orthopaedics and Related Research. Published online: October, 2011.

Systematic Reviews: 3 new ones in PubMed

1. Sutures versus Staples for the Management of Surgical Wounds: A Meta-Analysis of Randomized Controlled Trials. Iavazzo C, Gkegkes ID, Vouloumanou EK, Mamais I, Peppas G, Falagas ME.

Am Surg. 2011 Sep;77(9):1206-21. PMID: 21944632

2. Arthroplasty options in femoral-neck fracture: answers from the national registries. Kannan A, Kancherla R, McMahon S, Hawdon G, Soral A, Malhotra R. Int Orthop. 2011 Sep 20. [Epub ahead of print] PMID: 21931966

3. Quality Indicators in Pediatric Orthopaedic Surgery: A Systematic Review. Kennedy A, Bakir C, Brauer CA. Clin Orthop Relat Res. 2011 Sep 13. [Epub ahead of print] PMID: 21912995

Emerging Ideas: Interleukin-12 Nanocoatings Prevent Open Fracture-associated Infections.

Infection is a major clinical complication of orthopaedic implants and prosthetic devices, and patients with traumatic open fractures have a high risk of infection that may exceed 30%. Surgical trauma, burns, and major injuries such as traumatic open fractures induce immunosuppression, decrease resistance to infection, and decrease production of T helper type 1 (Th1) cytokines. QUESTIONS/HYPOTHESES: Exogenous interleukin-12 p70 (IL-12p70 or IL-12), a natural cytokine that plays a central role in Th1 response and bridges innate and adaptive immunities, will reduce open fracture-associated infection. Li B, McKeague AL. Clin Orthop Relat Res. 2011 Nov;469(11):3262-5. Epub 2010 Nov 23. PMID: 21104353

Ultrasound Related Ortho Articles

1. Comparison of ultrasound and nerve stimulation techniques for interscalene brachial plexus block for shoulder surgery in a residency training environment: a randomized, controlled, observer-blinded trial. Thomas LC, Graham SK, Osteen KD, Porter HS, Nossaman BD. Ochsner J. 2011 Fall;11(3):246-52. PMID: 21960758

2. Groin pain following hip resurfacing: a case-control study. McArthur JR, Costa M, Griffin DR, Krikler SJ, Parsons N, Foguet PR. Hip Int. 2011 Sep 26:0. [Epub ahead of print] PMID: 21960449

3. Noninflammatory Pseudotumor Simulating Venous Thrombosis After Metal-on-Metal Hip Resurfacing. Maurer-Ertl W, Friesenbichler J, Liegl-Atzwanger B, Kuerzl G, Windhager R, Leithner A. Orthopedics. 2011 Oct 5;34(10):e678-81. PMID: 21956066

4. Contralateral deep venous thrombosis after hip arthroscopy. Alaia MJ, Zuskov A, Davidovitch RI.

Orthopedics. 2011 Oct 5;34(10):e674-7. PMID: 21956065

5. Ultrasonography as a diagnostic tool in assessing deltoid ligament injury in supination external rotation fractures of the ankle. Henari S, Banks LN, Radiovanovic I, Queally J, Morris S. Orthopedics. 2011 Oct 5;34(10):e639-43.  PMID: 21956059

Outcomes of reduction more than 7 days after injury in supracondylar humeral fractures in children.

The results of this study suggest that it is possible to obtain an anatomic reduction of a type II pediatric supracondylar humeral fracture even after 7 days from the injury. Such a delay in surgery does not appear to lead to longer surgeries, a higher incidence of open reduction, or to alter the final alignment or range of motion of the elbow. However, the risk of developing an avascular necrosis of the humeral trochlea must be considered. Silva M, Wong TC, Bernthal NM. J Pediatr Orthop. 2011 Oct-Nov;31(7):751-6. PMID: 21926872

Reliability and necessity of computerized tomography in distal tibial physeal injuries.

Addition of CT in complex distal tibial physeal fractures did not increase interobserver reliability to classify the fracture or the treatment decision. Surgeons reported that the CT was most useful to plan screw placement and changed their treatment decision in about a fifth of the cases. Thawrani D, Kuester V, Gabos PG, Kruse RW, Littleton AG, Rogers KJ, Holmes L, Thacker MM. J Pediatr Orthop. 2011 Oct-Nov;31(7):745-50. PMID: 21926871

NIH program allows junior investigators to bypass traditional post-doc training

A program designed to accelerate the entry of outstanding junior investigators into independent researcher positions immediately following completion of their graduate research degree or clinical residency has announced its first recipients. The National Institutes of Health Director's Early Independence Awards (EIA) is part of an NIH-wide effort to empower the biomedical research workforce, particularly through the support of investigators early in their careers. NIH

Remedy Is Elusive as Metallic Hips Fail at a Fast Rate

BOSTON — As surgeons here sliced through tissue surrounding a failed artificial hip in a 53-year-old man, they discovered what looked like a biological dead zone. There were matted strands of tissue stained gray and black; a large strip of muscle near the hip no longer contracted. New York Times

Minor amputation in patients with diabetes mellitus and severe foot ulcers achieves good outcomes.

In this population-based survey, the goal of avoiding major amputation was achieved in almost two thirds of minor amputations, but at the price of long healing times. In almost all amputations, the patient had deep infection and/or gangrene. In spite of this, 64% of all amputations, and 79% of amputations in surviving patients, healed at a level below the ankle. This indicates that minor amputations in these patients are worthwhile. Svensson H, Apelqvist J, Larsson J, Lindholm E, Eneroth M. J Wound Care. 2011 Jun;20(6):261-2, 264, 266 passim. PMID: 21727875

European Journal of Trauma and Emergency Surgery: 3 new [epub ahead of print] articles

What are the predictors of scapula fractures in high-impact blunt trauma patients and why do we miss them in the emergency department?

Causes of inpatient death for patients with warfare-related limb trauma and logistic regression analysis of the risk factors

Biomechanical comparison of two locking plate systems for the distal tibia

Trauma Scenarios helps to educate trainees in the realm of trauma medicine

Trauma medicine is a high-stakes world that requires reflexive decision-making, and the vast range of injuries and issues that the patients face in traumas can lend to unpredictable outcomes. In a field with so many intangible factors, time and knowledge are crucial factors to success. In the fields of emergency medicine and trauma surgery, trainees and practitioners depend on quickly accessible information to help them make their decisions.

The minds behind this and other surgical education apps, DD Surgical (created by Drs. Dangleben and Lee), target this app at advanced users–likely surgeons and emergency medicine physicians.  iMedicalApps

European Journal of Orthopaedic Surgery & Traumatology: 3 new full text articles

Arthroscopic capsular shift technique and volume reduction PDF

Closed femoral intramedullary nailing in the lateral decubitus position with the aid of intraoperative skeletal traction PDF

Dynamic hip screw versus proximal femoral nail for treatment of trochanteric hip fractures: an outcome analyses with a minimum 2 years of follow-up PDF

New Clinical Treatment Guideline Outlines Recommendations to Reduce Blood Clots After Hip and Knee Replacement

An updated clinical practice guideline released last week by the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recommends how to reduce the likelihood of blood clots after hip or knee replacement surgery, procedures that more than 800,000 Americans undergo each year. The new guideline suggests use of preventive treatments and advises against routinely screening patients after surgery using ultrasound imaging.  AAOS

Commonly used supplement may improve recovery from spinal cord injuries

Sasha Rabchevsky, associate professor of physiology, Patrick Sullivan, associate professor of anatomy and neurobiology, and Samir Patel, senior research scientist -- all of the UK Spinal Cord and Brain Injury Research Center (SCoBIRC) -- have discovered that in experimental models, severe spinal cord injury can be treated effectively by administering the supplement acetyl-L-carnitine or ALC, a derivative of essential amino acids that can generate metabolic energy, soon after injury. The results were reported at the recent National Neurotrauma Society Symposium in July 2011, and will be presented again at the Society for Neuroscience meeting in November 2011.  Eurekalert!

Journal of Trauma: Recent combat related articles from PubMed

1. Antimicrobial prescribing practices following publication of guidelines for the prevention of infections associated with combat-related injuries. Tribble DR, Lloyd B, Weintrob A, Ganesan A, Murray CK, Li P, Bradley W, Fraser S, Warkentien T, Gaskins LJ, Seillier-Moiseiwitsch F, Millar EV, Hospenthal DR; IDCRP TIDOS group. J Trauma. 2011 Aug;71(2 Suppl 2):S299-306. PMID: 21814096 PDF

2. Prevention of infections associated with combat-related extremity injuries. Murray CK, Obremskey WT, Hsu JR, Andersen RC, Calhoun JH, Clasper JC, Whitman TJ, Curry TK, Fleming ME, Wenke JC, Ficke JR; Prevention of Combat-Related Infections Guidelines Panel. J Trauma. 2011 Aug;71(2 Suppl 2):S235-57. PMID: 21814090 PDF

13. Incidence of Pulmonary Embolus in Combat Casualties With Extremity Amputations and Fractures. Gillern SM, Sheppard FR, Evans KN, Graybill JC, Gage FA, Forsberg JA, Dunne JR, Tadaki DK, Elster EA. J Trauma. 2011 Sep;71(3):607-613. PMID:  21908998 PDF

Making the Grade: Hammond completes orthopedic surgery residency

James Hammond attended Camdenton High School, was a member of the 1995 Camdenton High School State Champion Football Team and graduated in 1996. He attended Southwest Missouri State University, where he competed in the triple jump for the men’s track team and was voted “Most Valuable Freshman”. Majored in Sports Medicine and Athletic Training where he earned several scholarships and was named “Athletic Trainer of the Year”. LakeNewsOnline

IOS Fixator app successfully integrates mobile medical technology into a surgical workflow

Designed as a reference for the benefit of surgeons and physicians, IOS fixator contains a simple straightforward guide to the use of the STORM (Staffordshire Orthopaedic Reduction Machine) and the Intelligent Orthopaedic Services (IOS) External fixator for the treatment of tibial fractures.

The app can also be used in the preoperative planning stages when planning external fixation using the specific IOS device. The app uses the camera on either the iPhone, iPod Touch or iPad to take a picture of an X-ray (XR) of a tibial fracture. The use of a scaling ball is important to reduce the errors associated with magnification during XR and the first step in the pre-op planning stage is calibrating the size. Intuitive touch gestures make calibration straightforward. iMedicalApps

Long Head of Biceps Brachii Tendon Evaluation: Accuracy of Preoperative Ultrasound.

Shoulder ultrasound is an accurate method to confirm a normal biceps tendon or full-thickness tear, but is less accurate in the diagnosis of partial-thickness tear and nontear abnormalities. Skendzel JG, Jacobson JA, Carpenter JE, Miller BS. AJR Am J Roentgenol. 2011 Oct;197(4):942-948. PMID: 21940583 PDF

Future Uses for the iPad in the Operating Room: a Game Changer ?

As we discussed in the first of this two part series, mobile devices are already entering the world of the surgeon. Currently, it is mostly downloadable apps that promise to help surgeons with the informational portions of their tasks, such as tracking the cases they have done, e.g. Surgichart or helping in the consent process, e.g. Surgery Risk

While apps that are dedicated to the technical aspects of surgery, such as the excellent AO Surgery Reference, are becoming available, in the future we will see the iPad (or its brethren) actually in the operating room. Why ? Because the iPad has many characteristics that make it a great an advanced surgical instrument. iMedicalApps

Radiographically undetected coracoid fractures diagnosed by sonography. Report of seven cases

Coracoid process fractures are rare and can be overlooked on routine radiographs due to the anatomical orientation of the CP and superimposition of adjacent bone structures. Early fracture detection reduces morbidity and allows for proper treatment. Sonography of the shoulder is usually performed for evaluation of peri-articular soft tissues. To the best of our knowledge, sonographic diagnosis of CP fracture has not been reported in the literature. We present a retrospective review of seven cases of sonographically detected coracoid fractures which were undiagnosed at previous standard radiographs. The US diagnosis was confirmed in three subjects, two with CT and in one patient with axillary view radiograph. Rajesh Botchu1, Kwang Jae Lee1, Stefano Bianchi. Skeletal Radiology. Online Date Friday, September 23, 2011 PDF

The “sliver sign”: a specific radiographic sign of acute lateral patellar dislocation

The objective of this work is to assess the prevalence of the sliver sign, defined as an intraarticular linear or curvilinear ossific density, in association with knee effusion in patients with acute knee trauma, as a predictor of recent lateral patellar dislocation (LPD). John P. Haas, Mark S. Collins, Michael J. Stuart. Skeletal Radiology. Online Date Saturday, September 24, 2011 PDF

Patient Education Possibilities?: AOSSM/AAOS Announce New Orthopaedic Sports Medicine Media Guide

The Sports Medicine Media Guide: An illustrated Resource on the Most Common Injuries and Treatments in Sports is now available online and in print from the American Orthopaedic Society for Sports Medicine (AOSSM) and the American Academy of Orthopaedic Surgeons (AAOS). The new, 33-page guide provides comprehensive, easy-to-understand descriptions of common sports injuries, from ankle sprains and concussions, to cardiac arrest and heat stroke.

 “AOSSM and AAOS have worked to create a guide for media professionals that we hope will provide clear, unbiased information about sports injuries and treatments for athletes of all ages and skill levels,” said David Geier, MD, Chair, AOSSM Public Relations Committee. “This guide is a must-have resource for sports reporters who want to simply and accurately explain common sports injuries,” said Michael F. Schafer, Chair, AAOS Communications Cabinet. The Guide is divided into 20 chapters, each focusing on a specific injury and providing information on cause, diagnosis and treatment; as well as related definitions, statistics and resources. Sports Media Guide PDF  AAOS

Ultrasound-Guided Versus Anatomic Landmark-Guided Ankle Blocks: A 6-Year Retrospective Review.

This study demonstrates that the USG technique of ankle block improves clinical efficacy compared with a conventional ALG technique, particularly in the hands of less-experienced practitioners. Chin KJ, Wong NW, Macfarlane AJ, Chan VW. Reg Anesth Pain Med. 2011 Sep 20. [Epub ahead of print] PMID: 21941219

Is gallows humor in medicine wrong?

Doctors and other medical professionals occasionally joke about their patients' problems. Some of these jokes are clearly wrong, but some joking between medical professionals is not only ethical, it can actually be beneficial, concludes an article in the Hastings Center Report.

The author, Katie Watson, bridges the worlds of medical ethics and comedy: she is an assistant professor in the Medical Humanities and Bioethics Program at the Feinberg School of Medicine at Northwestern University and she teaches improvisation and writing at The Second City Training Center in Chicago. What prompted her to explore the ethics of gallows humor in medicine was the story a doctor friend told her in which, years earlier, he and other residents tried unsuccessfully to save a teenage pizza delivery boy who had been shot while delivering their dinner.

After finding the pizza box where the boy dropped it before running from his attackers, one of the residents made a joke: "How much you think we ought to tip him?" The residents laughed, and then ate the pizza. Eurekalert!

Non-verbal clues guide doctor-patient relationships, clinical judgments, U-M study finds

Subtle and unspoken clues exchanged by patients and doctors exert an influence on medical care, according to a new study by the University of Michigan Health System. Researchers analyzed video recordings of routine checkups and conducted follow-up interviews with participants to help elucidate signals sent and received on both sides of the examination table.

The method shows promise for improving medical decision making by allowing doctors to better understand how they make judgments and what messages they may be unwittingly conveying to patients, the researchers explain.

The study found that patients relied on non-verbal clues to evaluate the doctor-patient relationship, focusing on whether the doctor seemed hurried or put them at ease. Doctors, on the other hand, reported that patients' tacit clues influenced their medical judgments. The results were published Sept. 26 in the Journal of Evaluation in Clinical Practice.  Eurekalert!

Scientists model the pathways of pain-blocking meds

Benzocaine, a commonly used local anesthetic, may more easily wiggle into a cell's membrane when the membrane is made up of compounds that carry a negative charge, a new study shows. The finding could help scientists piece together a more complete understanding of the molecular-level mechanisms behind pain-blocking medicines, possibly leading to their safer and more effective use. Eurekalert!

Injectable calcium sulfate/mineralized collagen-based bone repair materials with regulable self-setting properties.

An injectable and self-setting bone repair materials (nano-hydroxyapatite/collagen/calcium sulfate hemihydrate, nHAC/CSH) was developed in this study. The nano-hydroxyapatite/collagen (nHAC) composite, which is the mineralized fibril by self-assembly of nano-hydrocyapatite and collagen, has the same features as natural bone in both main hierarchical microstructure and composition. It is a bioactive osteoconductor due to its high level of biocompatibility and appropriate degradation rate. However, this material lacks handling characteristics because of its particle or solid-preformed block shape. Herein, calcium sulfate hemihydrate (CSH) was introduced into nHAC to prepare an injectable and self-setting in situ bone repair materials. Chen Z, Liu H, Liu X, Cui FZ. J Biomed Mater Res A. 2011 Sep 20. doi: 10.1002/jbm.a.33212. [Epub ahead of print] PMID: 21936045

MSK Injections may be the complete one-stop for review and planning of simple musculoskeletal procedures

Elsevier partnered with orthopedic surgeons, such as Dr. Mark Miller (of “Miller Review of Orthopedics” fame) to compile a comprehensive list of musculoskeletal exams and injection/aspiration techniques. The app is available for the iOS platform, and utilizes videos, text, and illustrations to aid in the diagnosis and management of common orthopedic complaints. iMedicalapps

"Intersection syndrome" of the foot: treated by endoscopic release of master knot of Henry.

 Intersection syndrome of the forearm is a painful condition in the area where the muscle bellies of the abductor pollicis longus and extensor pollicis brevis cross the common wrist extensors. A similar case of the foot with marked fibrosis at the interconnection of flexor hallucis longus and flexor digitorum tendons is reported and the fibrous interconnection was extended proximally. This was successfully treated with endoscopic release of the master knot of Henry. Lui TH, Chow FY. Knee Surg Sports Traumatol Arthrosc. 2011 May;19(5):850-2. Epub 2011 Feb 3. PMID: 21290112

Radiographically undetected coracoid fractures diagnosed by sonography. Report of seven cases

Coracoid process fractures are rare and can be overlooked on routine radiographs due to the anatomical orientation of the CP and superimposition of adjacent bone structures. Early fracture detection reduces morbidity and allows for proper treatment. Sonography of the shoulder is usually performed for evaluation of peri-articular soft tissues. To the best of our knowledge, sonographic diagnosis of CP fracture has not been reported in the literature. We present a retrospective review of seven cases of sonographically detected coracoid fractures which were undiagnosed at previous standard radiographs. The US diagnosis was confirmed in three subjects, two with CT and in one patient with axillary view radiograph. Rajesh Botchu, Kwang Jae Lee, Stefano Bianchi. Skeletal Radiology. Online Date Friday, September 23, 2011