Faculty Bibliography

BACKGROUND: Methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus surgical site infections are an increasing health problem in the United States. To date, no study, as far as we know, has evaluated the prevalence of Staphylococcus aureus colonization in orthopaedic surgeons. The purpose of our study was to assess the prevalence of methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus colonization in orthopaedic surgery attending surgeons and residents at our institution compared with that in our high-risk patients. METHODS: We performed nasal swab cultures in seventy-four orthopaedic attending surgeons and sixty-one orthopaedic surgery residents at our institution, screening for methicillin-resistant Staphylococcus aureus and methicillin-sensitive Staphylococcus aureus. We compared these results with a prospective database of nasal cultures of patients undergoing joint replacement and spine surgery. RESULTS: A total of 135 physicians were screened. Of those physicians, 1.5% were positive for methicillin-resistant Staphylococcus aureus and 35.7% were positive for methicillin-sensitive Staphylococcus aureus. None of the sixty-one residents were positive for methicillin-resistant Staphylococcus aureus. However, 59% were positive for methicillin-sensitive Staphylococcus aureus. Of the seventy-four attending surgeons, 2.7% were positive for methicillin-resistant Staphylococcus aureus and 23.3%, for methicillin-sensitive Staphylococcus aureus. Previous studies at our institution have demonstrated a 2.17% prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus and an 18% rate of methicillin-sensitive Staphylococcus aureus in high-risk patients. Thus, no difference was found between the prevalence of methicillin-resistant Staphylococcus aureus in residents or attending surgeons and that in the high-risk patients. However, the prevalence of methicillin-sensitive Staphylococcus aureus colonization in the surgeons (35.7%) was significantly higher than that in the high-risk patient group (18%) (p < 0.01). CONCLUSIONS: At a major teaching hospital, a higher prevalence of methicillin-sensitive Staphylococcus aureus colonization was found among attending and resident orthopaedic surgeons compared with a high-risk patient group, but the prevalence of methicillin-resistant Staphylococcus aureus colonization was similar

INTRODUCTION: Wrong-site surgery is defined as an operation conducted at the wrong site, on the wrong person, or resulting in the wrong procedure. Since 1993, more than 2200 wrong-site surgeries have been reported by the National Practitioner Data Base. A 2005 survey reported, 5.6% of replying academy fellows encountered a wrong-site surgery incident. Multiple interventions have been since suggested for prevention of these occurrences by the American Academy of Orthopaedic Surgeons and Joint Commission on Accreditation of Healthcare Organizations. MATERIALS AND METHODS: This institutional review board-approved study was conducted to investigate patient compliance and reliability in marking the surgical site. Two hundred patients undergoing orthopedic surgery who agreed to participate were enrolled at the time of preoperative testing and clearance for surgery. The patients received instructions to mark the surgical site with a 'YES.' Patient data collected included age, sex, procedure type and location, history of previous orthopedic surgeries, workmen's compensation status or motor vehicle collision involvement, employment status, primary language, level of education, presence of depression or toxic habits, and the time between enrollment and day of surgery. RESULTS: We achieved an overall compliance rate of 68.2%. There was no difference with respect to sex, tobacco use or history of depression, level of education or occupation, workmen's compensation, or government insurance status. The mean age of compliant patients was 48.6 years versus 53.3 years for those who did not comply (P = 0.05). About 72% of those who spoke English as a primary language complied, as opposed to 49% in others (P = 0.009). The time between enrollment and surgery was 10.4 days in compliant patients versus 23.1 days in noncompliant patients (P = 0.05). No statistically significant difference was noted with all other variables recorded. In no instance did patients mark the wrong side or make any marks likely to contribute to the wrong operation. CONCLUSIONS: Patient's ability to be involved in this preventative measure is independent of most demographic variables previously thought to be significant. However, in view of the 68.2% compliance, patient involvement in surgical site marking is unreliable and may not help in decreasing the chances of wrong-site surgery

The diagnosis and treatment of injuries involving rupture of the interosseous ligament remain challenging. Few studies have considered the effects of rupture of the interosseous ligament on deep forearm muscle function. The objective of this study was to quantify the attachment areas of the deep forearm muscles on the interosseous ligament. The origins of the extensor indicis, extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus, lexor pollicis longus, and lexor digitorum profundus were digitized from 11 cadavers. Three-dimensional modeling techniques were used to quantify the origin area on bone and the interosse- ous ligament. The extensor pollicis longus and the abductor pollicis longus attached primarily to the interosseous liga- ment (81% and 62%, respectively). Although the other deep forearm muscles had larger origins on bone, relatively large areas on the interosseous ligament were observed, ranging from 31% to 47%. The muscle origins on the interosseous ligament were veriied histologically, where striated muscle originated directly from the dense connective tissue of the interosseous ligament. Due to their relatively large attach- ment areas on the interosseous ligament, the function of the deep forearm muscles might be altered after an interos- seous ligament rupture. Therefore, symptoms such as pain and weakness of the deep forearm muscles could serve as a basis for screening patients with injuries of the interosse- ous ligament. Furthermore, the data may help to elucidate factors limiting the healing of the interosseous ligament. Future studies should focus on quantifying the effect of an interosseous ligament rupture on the function of the deep forearm muscles and developing reconstructions that con- sider this function.

Shoulder pain is a common complaint seen at the primary physician's clinic, and it is the third most common musculoskeletal complaint after back and neck pain. Shoulder pain can have a wide range of etiologies: trauma caused from a sprain or a simple muscle strain to a large tear of one of the shoulder stabilizer muscles. Some shoulder pathologies can cause chronic pain and limitation in shoulder range of motion such as impingement syndrome, adhesive capsulitis, calcified tendonitis, cervical radiculopathy, glenohumeral osteoarthritis, and biceps tendonitis. The physician who attempts to diagnose the cause for his patient's shoulder pain faces a great challenge due to the large number of etiologies that can lead to such a complaint. The physician has a large number of tools at his disposal starting from a thorough history emphasizing the time and character of the shoulder pain, range of motion and the ability to do everyday activities, to a wide range of imaging modalities such as X-ray, ultrasound and magnetic resonance imaging. Most of the causes of shoulder pain are adequately treated non-surgically with treatments such as physiotherapy, antiinflammatory medication and local corticosteroid injections. However, some situations necessitate surgical intervention in order to correct and restore the patient's prior level of shoulder function. The physician's ability to correctly diagnose and recommend appropriate lines of treatment, taking into consideration the patient's problem, age, medical condition and prior level of function is the secret to successful treatment, recovery of the patient's shoulder function and most important, patient satisfaction.

Tennis elbow typically presents as pain and localized tenderness at the lateral aspect of the elbow. It is the most common diagnosis related to the elbow. Microtrauma at the vicinity of the Extensor Carpi Radialis Brevis muscle is postulated to be the cause of this clinical entity. Initial treatment should be conservative and is successful in up to 90% of cases. Modalities such as patient education, physiotherapy, use of splints, anti-inflammatory medication, complementary medicine and eventually local injections are all acceptable treatment methods. Surgical treatment of tennis elbow should be used only as a last resort. Both open and arthroscopic methods are acceptable and their results are considered to be excellent.

Injury to the spinal accessory nerve in the posterior triangle of the neck results in trapezius paralysis and shoulder dysfunction. The most common etiology is iatrogenic and has been reported extensively in adults. We report 3 cases of spinal accessory nerve injury recognized postoperatively in children and discuss the microsurgical treatment, results, and simple strategies to avoid this complication.

Acute distal clavicular osteolysis was first described in 1936. Since then, distal clavicular osteolysis (DCO) has been separated into traumatic and atraumatic pathogeneses. In 1982 the first series of male weight trainers who developed ADCO was reported. The association of weightlifting and ADCO is especially important considering how routine a component weights are to the male athlete's training. The pathogenesis of DCO has often been debated. The most widely accepted etiology involves a connection between microfractures of the subchondral bone and subsequent attempts at repair, which is consistent with repetitive microtrauma. Symptoms usually begin with an insidious aching pain in the AC region that is exacerbated by weight training. On examination, patients have point tenderness over the affected AC joint and pain with a cross-body adduction maneuver. Although DCO may seem like an easy and quick diagnosis, one must rule out other possibilities. Avoidance of provocative maneuvers, modification of weight training techniques, ice massage, and nonsteroidal anti-inflammatory drugs (NSAID) constitute the basis of initial treatment. Much of the literature supports the same general indications for surgery. These include point tenderness of the AC joint, evident abnormal signs with AC joint scintigraphy and AC radiographs, lack of response to conservative treatment, and an unwillingness to give up or modify weight training or manual labor. Distal clavicle resection has provided good results. Distal clavicle osteolysis is a unique disease most likely due to an overuse phenomenon

Locked plate technology has evolved in an effort to overcome the limitations associated with conventional plating methods, primarily for improving fixation in osteopenic bone. The development of screw torque and plate-bone interface friction is unnecessary with locked plate designs, significantly decreasing the amount of soft tissue dissection required for implantation, preserving the periosteal blood supply, and facilitating the use of minimally invasive percutaneous bridging fixation techniques. The locked plate is a fixed-angle device because angular motion does not occur at the plate screw interface. The use of locked plate technology allows the orthopaedic surgeon to manage fractures with indirect reduction techniques while providing stable fracture fixation. The secure 'feel' of locked plates, ease of application, and the low incidence of complications noted in early clinical reports have contributed to the proliferation of this technology. Along with reports of clinical successes, as the use of fixed angle/locked plates has increased, clinical failures are being noticed. This review will focus on the biomechanics of locked plate technology, appropriate indications for its use, laboratory and clinical comparisons to conventional plating techniques, and potential mechanisms of locked plate failure that have been observed

A case of severe hip pain and limb shortening due to intrapelvic migration of the acetabular cup and protrusion of the femur component is reported in a 55-year-old female [New York, USA]. She presented to the clinic with a complaint of right hip pain which started intermittently a few months before visiting the clinic, but has increased and become debilitating in the past three weeks. The pain was accompanied by lateral thigh paresthesia and weakness. On examination, the right lower extremity appears shorter with decreased light touch sensation on posterolateral aspect of thigh. The patient was unable to raise leg and the range of motion of the hip was limited due to pain. X-ray of the right hip and femur presented a comminuted fracture of the acetabulum and iliac bone with central dislocation of the femoral head into the hemipelvis and migration of the acetabular cup into the pelvis, with breakage and displacement of proximal cerclage wires. Computed tomography angiog! raphy/pyelography, arteriogram and intravenous pyelogram showed the above findings without any internal haemorrhage or further pathology. A two-stage revision repair was planned. At the time of reimplantation, continuity of the acetabulum was verified. And a large uncontained acetabular defect was noted including the entire anterior wall, anterior column, and medial wall. A large superior defect was noted as well. Wire mesh was used to contain the defect which was filled with morselized allograft. A Burch-Schneider cage was placed over the graft. And a constrained polyethylene liner was cemented into the cage. The proximal femur had a small greater trochanteric fragment that was not united. The top three inches of the proximal femur had a defect involving over a third of its circumference, extending below the isthmus, with poor bone quality. This bone was resected and modular Mega-Prosthesis was cemented into the remaining femur. The trochanteric fragment was reattached to ! the prosthesis. At follow-up, the patient was doing well, scar was wel l healed and patient was able to ambulate with a walker