Faculty Bibliography

PURPOSE: Information regarding patient preferences is important to develop more diversity in healthcare providers. To our knowledge, no information exists regarding how patients choose their orthopaedic surgeon. The purpose of this study is to determine which demographic factors, if any, affect patient preferences when choosing an orthopaedic surgeon. METHODS: Five hundred new patients presenting to a large, urban, academic orthopaedic clinic from May 2011 to May 2013 were prospectively asked to participate in this study. Patients were asked to complete a survey designed with the help of the Division of Population Health that focused on demographic, professional and physical attributes of theoretical surgeons. Specifically, patient preference of surgeon age, gender, race, religion, importance of education prestige, training program prestige and number of medical publications were evaluated. Patients were then stratified by age, gender, race, religion, educational level and income level to assess whether their own demographics were related to their preferences. The data was then analyzed to determine whether correlations existed between patient preferences and their own demographics. RESULTS: Five hundred patients agreed to participate in the study. There were 195 (39.0%) males and 281 (56.2%) females with an average age of 40.8 years (SD=20.5), 24 patients (4.8%) did not respond to the question. Two hundred and twelve (42.4%) patients were Caucasian, 116 (23.2%) were Hispanic, 53 (10.6%) were African American, 44 (8.8%) were Asian, 32 (6.4%) were listed as other and 43 (8.6%) did not answer. 78.0% of patients had no preference for their surgeon's gender, but for those who did, both men and woman preferred male surgeons (weak positive correlation, not statistically significant, r=0.096, p=0.373). The majority of patients (84.8%) had no preference for the race of their surgeon, but those that had a preference tended to prefer surgeons of their own ethnicity (p<0.001). With increasing patient education level, medical school, residency and fellowship training prestige had more importance as a selection criterion. Increasing patient education level also demonstrated a corresponding importance given to physician education and training as categorized by the perception of residency training program prestige (p=0.04). A majority of patients (84.0%) had no preference for their surgeon's religion, but for those who did there was a strong correlation (r=0.65), between the patients' own religion and that of the physician (p<0.001). There was universal agreement in perception that neither physician age nor years in practice made any difference as selection criteria when choosing an orthopaedic surgeon (p>0.05). Finally patient income level had no effect on specific criteria when choosing a surgeon. CONCLUSION: The vast majority of patients surveyed had no preference in age, gender, race, or religion of their potential surgeon. However, patients who had preferences in these categories tended to choose surgeons of the same age, race and religion. These findings neither support or refute the need for diverse health care providers in the field of orthopaedics.

The evolving knowledge on Legg-Calve-Perthes (LCP) demonstrates the utility of studying a rare disease systematically by piecing together the biology and mechanics of this condition and applying clinical observations to improve patient care. As treatments of less common diseases are hard to randomize and study in meaningful numbers, long-term study groups have been created to provide insight into this entity that remains an enigma in many aspects. These studies permit a more evidence-approached guide to prognosis and treatment. Meanwhile, basic science research contributes to our understanding of pathophysiology of the disruption and repair processes that lead to LCP, with the goal of clinical translation. This review of LCP aims to give an overview of the condition, with specific focus on recent literature.

Objective Structured Clinical Examinations (OSCEs) have been used extensively in medical schools and residency programs to evaluate various skills, including the six core competencies outlined by the Accreditation Council for Graduate Medical Education (ACGME). Orthopaedic surgery residency programs will be required by the ACGME to assess residents on core competencies in the Milestone Project. Thus, it is important that evaluations be made in a consistent, objective manner. Orthopaedic residency programs can also use simulation models in the examination to accurately and objectively assess residents' skills as they progress through training. The use of these models will become essential as resident work hours are decreased and opportunities to observe skills become more limited. In addition to providing a method to assess competency, OSCEs are a valuable tool for residents to develop and practice important clinical skills. Here, we describe a method for developing a successful OSCE for use in orthopaedic surgical resident training.

Lateral condylar fractures constitute 12% to 20% of all pediatric distal humerus fractures. These fractures are easily missed and when not managed appropriately can displace. Missed fracture is a common cause of nonunion and deformity; thus, a high index of suspicion and adequate clinical and radiographic evaluation are required. Displaced fractures are associated with a high rate of nonunion. Nondisplaced fractures or those displaced </=2 mm are managed with cast immobilization and frequent radiographic follow-up. Fractures displaced >2 mm are managed with surgical fixation. Successful outcomes have been reported with closed reduction, open reduction, and arthroscopically assisted techniques. Complications associated with pediatric lateral condylar fracture include cubitus varus, cubitus valgus, fishtail deformity, and tardy ulnar nerve palsy

Although rare, injury to the triradiate cartilage is both a diagnostic and therapeutic challenge. Trauma to the triradiate cartilage or its blood supply can adversely affect acetabular development due to premature physeal closure. A shallow acetabulum with a lateralized hip joint that is prone to subluxation, premature degenerative changes, chronic pain, and functional limitations can result. We present a case of an acetabular fracture with injury to the triradiate cartilage after low-energy trauma in an adolescent male treated nonoperatively and healed without complications.

The compressive behavior of the bovine distal femoral growth plate was studied in vitro. Strain-rate controlled, compression stress-relaxation experiments were performed on cylindrical bone-growth plate-bone specimens from the interior and periphery of the growth plate. The questions addressed in this study were (a) Can the nonlinear biphasic theory, one with strain-dependent permeability, be used to represent the compressive stress-relaxation behavior of bovine growth plate? (b) How do different assumptions concerning the permeabilities of the chondro-osseous interfaces influence the inferred material properties of the growth plate? and (c) Are there any differences in these properties between the periphery and the interior of the growth plate? Intrinsic biphasic material properties--aggregate modulus (HA), Poisson's ratio (v), and nonlinear strain-dependent permeability coefficients (ko and M)--were calculated from the compression stress-relaxation data with use of a finite element model and a least squares curve-fitting procedure. To verify this constitutive model for the growth plate, an independent set of finite element analyses was performed with use of the determined intrinsic biphasic properties, and comparisons were made between these finite element predictions and two additional sets of experimental data subsequently obtained for the same specimens with use of two slower rates of compression. Excellent agreement was achieved between these finite element predictions and the latter two sets of data. The aggregate modulus was found to be insensitive to the permeability of the chondro-osseous interface. The permeability coefficients were very sensitive to, and the Poisson's ratio was only slightly sensitive to the interface permeability condition. Therefore, the periphery of the growth plate is more compliant and permeable than the interior

The tensile properties of distal femoral growth plates from 12-month-old cows were determined on uniformly prepared straight bone-growth plate-bone specimens (7 x 7 mm2 in cross-section) from predetermined anatomical sites on the physis. Each specimen was distracted to failure using a computer-controlled servo-hydraulic testing machine at a strain rate of 0.004 s-1. It was found that the exponential constitutive law, using finite deformation formulation for strain, provides an excellent description of the stress-strain behavior of all the specimens up to the point of failure. The ultimate stress and both tangent moduli (i.e., the toe region tangent modulus and the tangent modulus calculated at 75% of ultimate strain) varied with anatomical site. The anterior region was the strongest, followed by the posterior/lateral. The anterior and posterior/lateral regions were also the stiffest, whereas the posterior/medial and center regions were the weakest and most compliant. The bone-growth plate-bone specimen exhibited a low ultimate strain (13.8% +/- 6%) that did not vary significantly throughout the growth plate. This result suggests that disruption of the physis may occur in vivo even at the lower distractions currently recommended for the clinical chondrodiatasis procedure for leg lengthening. The biochemical composition of the growth plate in the anatomical regions correlated well with the tensile properties. There was a greater collagen content in the regions that were the stiffest and strongest. The gross morphology of the growth plate of the bovine distal femur is also described in this study. There is a regular pattern to the undulations of the physis at several dimensional levels. Histologic findings showed that orientation of the hypertrophic cell columns and transphyseal septa are aligned nearly parallel to the longitudinal axis of the diaphyseal shaft. This column orientation is not affected by the undulation of the primary contour of the physis, which at certain locations may be inclined as much as 60 degrees relative to the diaphyseal axis. The orientation of the hypertrophic cell columns appears to be one of the dominant microstructural features influencing the tensile behavior of the bone-growth plate-bone specimens

A double-blind controlled trial of thyrotropin releasing hormone (TRH) 150 mg IM daily in 30 patients with amyotrophic lateral sclerosis is reported. The drug/placebo was administered for 2 months, followed by a 2-month "wash-out". Evaluation of strength, functional ability, and respiratory functions was performed. A temporary increase in the strength of some muscles was detected following the administration of TRH, but no change in functional performance was noted. Neither the patients nor the investigators believed the effects were of any marked clinical significance. The course of the illness was not altered.