December 2007  Volume XXXVI No. 12 pISSN:1078-4519 eISSN:1934-3418

E-PUBLISHING

E-FOCUS ON RESIDENT TRAINING

171	Guest Editorial — Educating Our Residents: More Important Than Ever Wallace B. Lehman, MD Wallace B. Lehman, MD, is Chief Emeritus and Fellowship Director, Pediatric Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York. Abstract not available. Am J Orthop . 2007;36(12):E171, E189.
172	Resident Work-Hour Rules: A Survey of Residents’ and Program Directors’ Opinions and Attitudes Igor Immerman, MD, Erik N. Kubiak, MD, and Joseph D. Zuckerman, MD Joseph D. Zuckerman, MD, Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 (tel, 212-598-6674; fax, 212-598-6293; e-mail, joseph.zuckerman@med.nyu.edu). In July 2003, the Accreditation Council for Graduate Medical Education (ACGME) established nationwide guidelines for resident working environments and duty hours. Following these guidelines became a requirement for all accredited residency programs. Two years after implementation, we conducted a national survey to assess the opinions and attitudes of orthopedic residents and program directors toward the ACGME work-hour regulations and the effects of these regulations on resident education, resident quality of life, and patient care. Nine hundred seventy-six residents (30% response rate) and 85 program directors (56% response rate) completed the questionnaire. For resident education, junior residents were more likely than senior residents and program directors to perceive the work-hour regulations as having a positive effect on education. There was overall agreement among the 3 groups that resident quality of life had improved as a result of work-hour regulations. For patient care, junior residents viewed the new regulations positively for surgical training and patient care, whereas senior residents and program directors disagreed. This survey showed meaningful differences in the attitudes and opinions of junior residents, senior residents, and program directors toward the new ACGME work-hour regulations. Am J Orthop. 2007;36(12):E172-E179.
180	Faculty Turnover and Resident In-Training Examination and Board Scores John F. Kragh, Jr., MD, Justin Robbins, MD, and John A. Ward, PhD COL John F. Kragh, Jr., MD, Bone and Soft Tissue Trauma Research Program, Room L82-16, Building 3611, US Army Institute of Surgical Research, 3400 Rawley E. Chambers Ave, Fort Sam Houston, TX 78234-6315 (tel, 210-916- 4627; fax, 210-916-3877; e-mail, john.kragh@amedd.army.mil). We tested the association between educator turnover and resident performance. A retrospective study analyzed an orthopedic residency for 12 years. Orthopaedic In-Training Examination (OITE) scores for residents and American Board of Orthopaedic Surgery part 1 scores for graduates were analyzed with linear regression. Turnover was at first low, then rose, and finally dropped; OITE scores went the opposite direction. The OITE score nadir was just after the turnover apex, and the association was significant (P = .008). Turnover was not associated with board scores. Educators and policymakers should know that faculty turnover appears negatively associated with resident OITE performance. Am J Orthop. 2007;36(12):E180-E184.
185	Orthopedic Surgery Residents’ Study Habits and Performance on the Orthopedic In-Training Examination Ryan G. Miyamoto, MD, Gregg R. Klein, MD, Michael Walsh, PhD, and Joseph D. Zuckerman, MD Ryan G. Miyamoto, MD, Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 (tel, 212-920-5499; fax, 212-598-2377; e-mail, miyamr01@med.nyu.edu). The Orthopaedic In-Training Examination (OITE) is a tool used by residency directors to evaluate a resident’s fund of orthopedic knowledge. In this study, we correlated resident study habits and preparation tools with performance on the OITE. Data analysis indicated statistically significant correlations between successful OITE performance and frequent review of current orthopedic journals (Journal of Bone and Joint Surgery–American Edition, r = .6, P < .001; Journal of the American Academy of Orthopaedic Surgeons, r = .36, P = .02), daily orthopedic reading (r = .34, P = .03), increased preparation time for OITE (r = .31, P = .04), and more hours committed to studying (r = .37, P = .01). In addition, residents who emphasized prior OITEs and self-assessment examinations when preparing had higher scores (r = .53, P < .001, and r = .64, P < .001, respectively). Our study results show that several factors, including structured study habits and use of specific study materials, contribute to residents’ successful OITE performance. Adaptation of these findings by current orthopedic residents may have a positive impact on OITE performance. Am J Orthop. 2007;36(12):E185-E188.

642	Ankle Arthroscopy: Room for Growth James P. Tasto, MD James P. Tasto, MD, this journal’s Department Editor for Socioeconomics and Practice Management, is Clinical Professor, Department of Orthopaedic Surgery, University of California, San Diego, and is affiliated with San Diego Sports Medicine & Orthopaedic Center, San Diego, California. He is Past President of the AANA. Abstract not available. Am J Orthop. 2007;36(12):642.
643	Osteochondral Lesions of the Talar Dome James W. Stone, MD James W. Stone, MD, 2901 W. Kinnickinnic River Parkway, Suite 102, Milwaukee, WI 53215 (tel, 414-325-4320; fax, 414-761-1921; e-mail, bonanza83b@aol.com). Abstract not available. Am J Orthop. 2007;36(12):643-646.
648	The Acorn Beath Couple: Articular Salvation for Double-Bundle Femoral Tunnels in Cruciate Ligament Reconstruction Yuri M. Lewicky, MD Yuri M. Lewicky MD, Summit Center Northern Arizona Orthopaedics, 1485 N Turquoise Dr, Suite 200, Flagstaff, AZ 86001 (tel, 800-773-2553; fax, 928-226- 3083; e-mail,lewickyy@summitctr.net). With the recent increase in interest in arthroscopic double-bundle cruciate reconstructions, efficient, safe, and reproducible techniques are needed. This technical trick is applicable to both arthroscopic anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) reconstruction when double-bundle femoral tunnels are performed through an accessory far lateral or far medial incision as with the all-inside femoral tunnel drilling approach. A standard double-bundle cruciate reconstruction technique is applied until placement of the femoral footprint Beath pins in anticipation of tunnel drilling. Femoral footprint targeting with a Beath pin requires use of a far accessory portal. Before the long Beath pin is introduced into the joint, an acorn reamer is placed over the Beath pin to within 5 mm of the pin tip, thus creating an acorn Beath couple. The eyelet pin end is loaded onto a quick-release pin collet driver, leaving the acorn reamer free to turn. The acorn Beath couple is then introduced into the appropriate accessory portal and positioned in the center of the desired femoral footprint. An assistant holds the acorn reamer shaft while the Beath pin is advanced. The collet driver is then disengaged from the pin and replaced with an adjustable chuck and secured to the acorn reamer shaft of the acorn Beath couple. The femoral tunnel is drilled to the appropriate depth, and the Beath pin is pulled out the anterior thigh. Doing so disengages the acorn reamer and allows for safe removal of the reamer from the notch. The technique is then repeated with the coupling of a 4.5 Endobutton reamer and the Beath pin. Am J Orthop. 2007;36(12):648-651.
655	Posterior Shoulder Instability: Comprehensive Analysis of Open and Arthroscopic Approaches Sanjeev Kakar, MD, MRCS, Ilya Voloshin, MD, Elizabeth Krall Kaye, PhD, Keith Crivello, MD, Cory M. Edgar, MD, PhD, Christopher M. Emond, MD, John D. Pryor, MD, and Anthony A. Schepsis, MD Ilya Voloshin, MD, Chief, Shoulder and Elbow Division, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, 601 Elmwood Ave, Box 665, Rochester, NY 14642 (tel, 585-273-3106; fax, 585- 276-2344;email, ilya_voloshin@urmc.rochester.edu). Whether open surgery and arthroscopic repair of posterior shoulder instability have similar success rates remains unknown, but the literature suggests that arthroscopic soft-tissue stabilization procedures equal open surgery in managing posterior shoulder instability. A comprehensive PubMed computer search of the English-language literature from 1988 to 2004 was performed using the key phrase posterior shoulder instability. Studies included in our analysis addressed the surgical treatment of recurrent posterior instability and multidirectional instability with primarily a posterior component of instability; studies were excluded if their minimum follow-up was less than 1 year, if their patients had a history of habitual posterior shoulder instability, or if their patients had either bony procedures or thermal capsulorrhaphy. Data collected from each study included patient demographics, instability classifications (traumatic vs atraumatic), previous shoulder stabilizations, and clinical outcomes. After identifying and reviewing 283 abstracts, we found that 16 articles fulfilled the inclusion criteria—9 open studies (173 patients) and 7 arthroscopic trials (186 patients). The 2 treatment groups had similar sex distributions (P>.25). Mean age was 23 years for the open group and 26 years for the arthroscopic group (P<.02). Clinical outcomes were rated satisfactory by 72% of patients in the open group and 83% of patients in the arthroscopic group (P<.55), controlling for age. Eighty-five percent of patients treated with an open technique and 81% of patients treated arthroscopically returned to sports (P<.82). This study demonstrated no statistical difference in clinical outcomes for patients treated with either open or arthroscopic surgery for posterior shoulder instability. Am J Orthop. 2007;36(12):655-659.
660	Multidirectional Instability of the Shoulder in Elite Female Gymnasts Jill Caplan, MD, Terrill P. Julien, BS, James Michelson, MD, and Robert J. Neviaser, MD Jill Caplan, MD, Department of Orthopedic Surgery, 2150 Pennsylvania Avenue, Suite 7-416, Washington, DC 20037 (tel, 202-741-3311; fax, 202-741-3313; e- mail, cappyj@gwu.edu). Multidirectional instability (MDI) of the shoulder is symptomatic laxity in 2 or more directions, 1 of which is inferior. MDI is well described in overhead athletes (eg, baseball players, tennis players, swimmers) but not in gymnasts. We conducted this study to estimate the incidence of any type of shoulder pathology in elite gymnasts, to estimate MDI incidence in this population, and to determine which if any circumstances place these gymnasts at higher risk for developing MDI. An 18-question multiple-choice questionnaire was administered to 70 female US collegiate gymnastics teams. Potential risk factors were cross-matched against those gymnasts with traumatic shoulder injuries and again against those gymnasts who met MDI study inclusion criteria. Of the 1115 questionnaires distributed, 457 (34 teams) were returned. Twenty-two percent of gymnasts suffered from a traumatic shoulder injury, and 11% met study inclusion criteria. There was a statistically significant (P =.02) relationship between generalized ligamentous laxity and traumatic shoulder instability but not MDI. Incidence of atraumatic or traumatic shoulder injuries in gymnasts is higher than previously recognized. Although this study did not reveal any potential risk factors, it does provide several avenues for more specific research. Am J Orthop. 2007;36(12):660-665.
669	Delayed Rupture of the Flexor Pollicis Longus Tendon After Routine Volar Placement of a T-Plate on the Distal Radius Scott F. M. Duncan, MD, and Andrew J. Weiland, MD Scott F. M. Duncan, MD, Mayo Clinic Hospital, 5777 E Mayo Blvd, Scottsdale, AZ 85054. Abstract not available. Am J Orthop. 2007;36(12):669-670.
672	Dislocation and Instability After Arthroscopic Capsular Release for Refractory Frozen Shoulder Reuben Gobezie, MD, Iván H. Pacheco, MD, Charles J. Petit, MD, and Peter J. Millett, MD, MSc Peter J. Millett, MD, MSc, Attention Clinical Research, Steadman Hawkins Research Foundation, Suite 1000, Vail, CO 81657 (tel, 970-479-5876; fax, 970- 479-9753; e-mail, drmillett@steadman-hawkins.com). Abstract not available. Am J Orthop. 2007;36(12):672-674.
675	Measurement of Intraoperative Nerve Conduction Velocities During Anterior Interosseous Nerve Decompression Jeffrey P. Garrett, MD, David W. Cole, MD, and David S. Ruch, MD Jeffrey P. Garrett, MD, Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157 (tel, 336-716-3949; fax, 336-716-7310; e-mail, jgarrett@wfubmc.edu). Abstract not available. Am J Orthop . 2007;36(12):675-677.
680	A Biomechanical Study of Simulated Femoral Neck Fracture Fixation by Cannulated Screws: Effects of Placement Angle and Number of Screws Earl Walker, MD, Debi P. Mukherjee, ScD, MBA, Alan L. Ogden, BME, Kalia K. Sadasivan, MD, and James A. Albright, MD Debi P. Mukherjee, ScD, MBA, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71130 (tel, 318-675-6180; fax, 318- 675-6186; e-mail: dmukhe@lsuhsc.edu). The angle of placement of hip screws to fix femoral neck fractures is still a controversial subject, and it must be addressed. In the study reported here, we compared the relative stiffness of fixation of simulated Pauwels type III femoral neck fractures fixed with either 2 or 3 cannulated screws implanted at 135°, 145°, and 150°. Each femur was fixed with 2 or 3 cannulated screws and tested under axial loading and anteroposterior (AP) bending. Then each femur was fatigued to 1000 cycles and tested to failure. Fourteen femurs were tested. Results showed that axial stiffness values were not statistically different at different angles. AP bending stiffness of the high-angle (150°) construct was significantly higher than that of either of the other 2 constructs (for 2 screws only). Two-screw fixation appears to be adequate; adding a third screw may not be necessary. Am J Orthop. 2007;36(12):680-684.
685	Superior Labral Anterior to Posterior (SLAP) Tears Paul D. Clifford, MD Paul D. Clifford, MD, Department of Radiology, Applebaum Outpatient Center, University of Miami, 1115 NW 14th St, Miami, FL 33136-2106 (tel, 305-243- 5449; fax, 305-243-8422; e-mail, pclifford@med.miami.edu). Abstract not available. Am J Orthop. 2007;36(12):685-686.

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CURRENT TRENDS IN SHOULDER ARTHROPLASTY

Educational support provided by DePuy Orthopaedics, Inc.

3	Introduction Gerald R. Williams, Jr., MD Gerald R. Williams, Jr., MD, is Professor of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania. Abstract not available. Am J Orthop. 2007;36(12 suppl1):3.
4	Humeral Resurfacing Arthroplasty: Rationale, Indications, Technique, and Results Kirk L. Jensen, MD Kirk L. Jensen, MD, is Director, East Bay Shoulder Clinic, Orinda and Oakland, California. Humeral head resurfacing arthroplasty has evolved into a reliable method of shoulder arthroplasty designed to restore the natural anatomy of an arthritic or damaged articular humeral surface. Recent implant changes have improved the ability of the surface replacement implants to recreate the humeral head surface and the initial implant fixation. Instrument changes have improved the ability to place the implant in the anatomical position that recreates an individual’s humeral articular surface posterior offset, neck-shaft angle, and version. These implant and instrument changes have led to a more refined surgical technique that avoids the complications associated with use of stemmed implants. Minimal bone resection occurs in shoulder resurfacing arthroplasty—the result being bone stock preservation, which is important in active or young patients with shoulder arthritis. Cementless surface replacements have been shown to provide results comparable to those of stemmed implants similar in diagnosis and follow-up. In this article, I outline the current rationale for resurfacing arthroplasty implants and the indications for their use. I also present the surgical technique and review the results of proximal humeral resurfacing arthroplasty. Am J Orthop. 2007;36(12 suppl1):4-8.
9	Variation in Neck-Shaft Angle: Influence in Prosthetic Design Joseph P. Iannotti, MD, PhD, Steven B. Lippitt, MD, and Gerald R. Williams, Jr., MD Joseph P. Iannotti, MD, PhD, is Maynard Madden Professor and Chairman, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio. Surgeons performing anatomical reconstruction of the shoulder during prosthetic replacement should consider the size of the humeral head and the placement of the head within the humerus. Prosthetic systems with a wide range of modular head sizes, eccentric tapers, and adjustable neck-shaft angles and versions help surgeons to better adapt a prosthesis to a patient’s bone anatomy. Surgical technique remains critical for proper placement of the prosthesis and for correction of other soft-tissue and bony abnormalities associated with the pathology. In this article, we review some principles of prosthetic design and surgical technique to anatomically reconstruct the humeral head. We also review the clinical consequences of prosthetic humeral head malpositioning. Am J Orthop. 2007;36(12 suppl1):9-14.
15	Alternative Bearing Surfaces—Do We Need Them? Gerald R. Williams, Jr., MD, and Joseph P. Iannotti, MD, PhD Gerald R. Williams, Jr., MD, is Professor, Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania. In this article, we describe briefly the biological mechanisms responsible for aseptic glenoid loosening, review current alternative bearing surfaces, and provide data supporting use of these surfaces for glenoid components. Am J Orthop. 2007;36(12 suppl1):15-17.
18	The Arthritic, Cuff-Deficient Shoulder—When Is Hemiarthroplasty Enough? Carl Basamania, MD, FACS, and Jeffrey Visotsky, MD, FACS Carl Basamania, MD, FACS, is Orthopaedic Surgeon, Triangle Orthopaedic Associates, Durham, North Carolina. This article outlines the role of hemiarthroplasty in the treatment of cuff-tear arthropathy. Rotator cuff tear arthropathy, kinematics, and classification are reviewed. Am J Orthop. 2007;36(12 suppl1):18-21.
22	Total Reverse Shoulder Arthroplasty: European Lessons and Future Trends Ludwig Seebauer, MD Ludwig Seebauer, MD, is Chairman, Center of Orthopaedics, Traumatology, and Sports Medicine, Klinikum Bogenhausen, Munich, Germany. In the late 1980s, Grammont introduced a new reverse total shoulder arthroplasty (TSA), with a hemisphere directly attached to the glenoid surface and with medial positioning of the center of rotation to overcome former shortcomings. Over the past few years, results from several mid- and long-term clinical studies of this new TSA have demonstrated that unexpectedly good functional outcomes and pain relief (Constant-Score, 60-69) could be achieved, even in patients with progressive superior migration, joint destruction, and rotator cuff deficiency. In all these studies, however, limited range of passive internal rotation and no improvement in active external rotation capacity were reported. In addition, glenoid erosion (“inferior glenoid notching”) was reported in all these studies as a frequent phenomenon, occurring in 10% to 42%. The clinical impact of inferior notching is the subject of controversy, and its correlation with glenoid component loosening is not clear. In addition, rates of perioperative and postoperative complications (eg, dislocations, infections, hematomas, fractures) seem to be higher with this new TSA than with the conventional TSA. Improvements in prosthesis design and implantation technique (eg, easier and more reproducible surgical technique) should contribute to better range of motion, lower complication rates, and a lower frequency and lesser amount of inferior glenoid notching. Am J Orthop. 2007;36(12 suppl1):22-28

CURRENT CONCEPTS IN FIXATION: VOLUME VIII

Educational support provided by Biomet Trauma.

1	New and Improved Robert F. Ostrum, MD Robert F. Ostrum, MD, is Chief of Orthopaedic Trauma, Cooper University Hospital, Camden, New Jersey. Abstract not available. Am J Orthop. 2007;36(12 suppl2):1.
2	Internal Fixation of Digtal Radius Fractures Richard Y. Kim, MD, and Melvin P. Rosenwasser, MD Richard Y. Kim, MD, is Co-Director of Hand Surgery, Hackensack University Medical Center, Hackensack, New Jersey. When adequate fracture reduction cannot be achieved with closed techniques, internal fixation can restore anatomy and improve functional outcomes. Volar plating, dorsal plating, and radial plating are well-described techniques that are useful in isolation or in combination, depending on the specific fracture pattern. In this article, we review each of these techniques and provide case examples to illustrate their applicability. Am J Orthop. 2007;36(12 suppl2):2-7.
8	Operative Treatment of Intra-Articular Distal Humerus Fractures Charalampos G. Zalavras, MD, PhD, Elizabeth T. McAllister, MD, Anshuman Singh, MD, and John M. Itamura, MD Charalampos G. Zalavras, MD, PhD, is Associate Professor, Los Angeles County + USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, California. Intra-articular distal humerus fractures can be among the most challenging injuries treated by orthopedic surgeons. The goals of surgical treatment are anatomical restoration of the articular surface and stable fixation of the fracture fragments to allow for early motion. However, the bone stock of the distal humerus is limited, and stable fixation may be difficult to achieve in the case of a low fracture pattern, comminution, or osteoporosis. In this article, we provide practical recommendations for surgical management of these complex fractures. Am J Orthop. . 2007;36(12 suppl2):8-12.
13	Plating of Tibial Pilon Fractures Michael S. Sirkin , MD Michael S. Sirkin, MD, is Chief of Orthopaedic Trauma Services and Associate Professor of Clinical Orthopaedics, University of Medicine and Dentistry of New Jersey, and New Jersey Medical School, Newark, New Jersey. Successful treatment of pilon fractures requires a thorough understanding of the injury, proper timing of treatment, and use of the proper implant placed in the correct location. This article describes the factors involved in treatment decisions. Am J Orthop. 2007;36(12 suppl2):13-17.

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