PRESIDENTIAL ADDRESS - Professionalism: The Essence of Competence -- John D. Lubahn, MD

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Professionalism is a reflection of ethical and moral conduct in the practice of medicine. Most young physicians still learn professionalism by observing senior physicians functioning as role models and mentors. As Shakespeare wrote, “There is nothing either good or bad, but thinking makes it so” (Hamlet, Act II, Scene II). What was considered ethical and common practice 40 years ago, today might be considered unethical. An example is authorship on a scientific publication. Years ago, it was considered appropriate to place the Department Chair’s name as the principal author, regardless of his or her contribution. Today, to include the Chair, if he or she failed to make a significant contribution to the manuscript, could be considered misconduct.

Unicompartmental Knee Arthroplasty: Long-Term Success in Middle-Age and Obese Patients -- Owen B. Tabor, Jr., MD; Owen B. Tabor, MD; Matthew Bernard, MS; Jim Y. Wan, PhD

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The purpose of this study is to report long-term results of unicompartmental knee arthroplasty (UKA) in general and specifically to address the results in middle-age and obese patients. One hundred consecutive medial compartment UKAs performed in 82 patients between 1974 and 1999 were reviewed. Survivorship analysis and Knee Society scores were compiled and stratified based on age at the time of surgery, gender, and body habitus. Mean survivorship of the procedure was 93.7% at 5 years (95% CI 88.8–98.6%), 89.8% at 10 years (83.3–96.1%), 85.9% at 15 years (77.8–93.9%), and 80.2% at 20 years (69.5–90.9%). Females had significantly better survivorship than males at 10, 15, and 20 years. Obese patients had better survivorship than nonobese patients at 20 years. There was no significant difference in survivorship based on age over or under 60 at the time of surgery. The average Knee Society knee score at most recent follow-up was 89.3 and the average function score was 73.1. There were no significant differences in Knee Society scores among the subgroup. UKA offers reliable long-term survival. Age less than 60 and obesity do not appear to be contraindications to the procedure. (Journal of Surgical Orthopaedic Advances 14(2):59–63, 2005) Key words: arthroplasty, obesity, outcome, unicompartmental

Risk Factors, Treatment, and Outcomes Associated With Nonunion of the Midshaft Humerus Fracture -- Edward Green, MD; John D. Lubahn, MD; Jason Evans, MD

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Charts of 28 patients with a diagnosis of delayed union or nonunion were reviewed. There were four delayed unions and 25 nonunions. Comorbidities, risk factors, treatments, and outcomes were evaluated. Comorbidities were common and included cardiovascular, pulmonary, and renal compromise, as well as endocrinopathies and rheumatologic disease. Consensus risk factors included: unstable fractures (comminuted or short oblique, 83% (24/29); advanced age, 57% (16/28); obesity, 35% (9/28); daily tobacco use, 38% (10/28); and multiple long bone fractures, 21% (6/29). Sixty-nine percent (20/29) of the fractures united; 21% (6/29) failed to heal. Healing outcome for 11% (3/29) could not be determined because of death or loss to follow-up. Patients presenting for primary treatment with any of the aforementioned risk factors should be cautioned regarding possible nonunion. (Journal of Surgical Orthopaedic Advances 14(2):64–72, 2005) Key words: comorbidities, delayed union, nonunion

Reliability of Acetabular Measures in Developmental Dysplasia of the Hip -- Brian T. Carney, MD; Marc Rogers, DO; Christin L. Minter, MA

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The purpose of this study was to determine the reliability in the measurement of the acetabular index and the acetabular angle in children with developmental dysplasia of the hip. Seventeen children with unilateral developmental dislocation of the hip treated by closed reduction were reviewed. The acetabular index and the acetabular angle of 34 hips were measured twice by two observers. The method of Bland and Altman as outlined by Loder was used to calculate reliability. Mean age at reduction was 9 months. Radiographs were reviewed at a mean of 58 months following reduction. The intraobserver reliability of the acetabular index in involved hips was š4.1°. The intraobserver reliability of the acetabular angle for involved hips was š3.6°. The interobserver reliability of the acetabular index in involved hips was š13.7°. The interobserver reliability of the acetabular angle for involved hips was š7.8°. To ensure true change, a single observer should document at least an 8° change in the acetabular index or a 7° change in acetabular angle between two radiographs. (Journal of Surgical Orthopaedic Advances 14(2):73–76, 2005) Key words: acetabular angle, acetabular dysplasia, acetabular index, developmental dysplasia of the hip, interobserver/intraobserver reliability

Delayed Presentation of Ipsilateral Femoral Neck Fractures in Diaphyseal Femur Fractures -- Wilford K. Gibson, MD; John Hubbard, MD

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Femoral neck fractures with delayed presentation following ipsilateral femoral diaphyseal fracture stabilization have been described as clandestine, attributed to missed diagnosis, or related to surgical technique. Clandestine fractures are present from time of injury but not detectable. The authors hypothesize that femoral neck fractures with delayed presentation can be clandestine, missed, or caused by surgical technique. A retrospective study and a comprehensive literature review are presented to determine the true incidence and etiology of these fractures. (Journal of Surgical Orthopaedic Advances 14(2):77–81, 2005) Key words: delayed, femoral neck, fractures

Changing Indications for Revision Total Hip Arthroplasty -- Paul F. Lachiewicz, MD; Elizabeth S. Soileau, BSN

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This was a retrospective review of two cohorts of 100 consecutive revisions performed 10 years apart by one surgeon, to determine the major reason for reoperation. For the early cohort, the indications for revision were: loosening of both components (38%), loosening of acetabular component (22%), loose hemiarthroplasty (13%), infection (10%), loosening of femoral component (8%), periprosthetic fracture (6%), recurrent dislocation (2%), and wear (1%). For the recent cohort, the indications for revision have significantly changed: loosening of acetabular component (24%), loosening of femoral component (22%) (p D .0048), recurrent dislocation (16%) (p D .0011), loosening of both components (15%) (p D .0002), wear-osteolysis (7%) (p D .03), infection (7%), loose hemiarthroplasty (6%), and periprosthetic fracture (3%). There has been a change in the indications for revision hip arthroplasty compared with 10 years ago, with a statistically significant increase in revisions for dislocation, wear-osteolysis, and loosening of the femoral component only. (Journal of Surgical Orthopaedic Advances 14(2):82–84, 2005) Key words: dislocation, revision hip arthroplasty, wear

Salvage of Failed Neuropathic Ankle Fractures: Use of Large-Fragment Fibular Plating and Multiple Syndesmotic Screws -- Mark D. Perry, MD; Warren S. Taranow, DO; Arthur Manoli II, MD; and James B. Carr, MD

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The purpose of this study was to develop a salvage procedure for failed fixation of ankle fractures that occurs in patients with sensory neuropathy. Six patients, with insensitivity to a 5.07 monofilament on the plantar surface of their foot (five with diabetes mellitus, one with alcoholic peripheral neuropathy) presented to a foot and ankle referral center with failed traditional fixation of their Weber B and C ankle fractures. Five fractures were the result of trauma. One fracture occurred without a discernable traumatic event. A laterally placed 4.5 DCP plate on the fibula with multiple 4.5-mm syndesmotic screws engaging both cortices of the tibia was used as fixation. All patients postoperatively were immobilized in a nonweightbearing below-knee cast for a minimum of 3 months after surgery. At follow-up, all six patients were satisfied with their results as determined by aligned, functional, and asymptomatic limbs. The patients were especially pleased that after multiple attempts to provide stability to their fractured neuropathic ankles, they had retained their own legs and did not need an amputation. Fibular plate fixation using multiple large-fragment syndesmotic screws provides a reasonable salvage alternative for neuropathic patients with ankle fractures that failed using traditional hardware techniques. (Journal of Surgical Orthopaedic Advances 14(2):85–91, 2005) Key words: ankle fracture, diabetes, neuropathic, revision, syndesmosis

The Outpatient Treatment of Pyogenic Flexor Tenosynovitis -- John T. Bauman, MD; S. John Millon, MD; Stephanie L. Tanner, MS

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Historically, pyogenic flexor tenosynovitis has been treated with surgical debridement followed by hospitalization and administration of intravenous antibiotics. Recently, hand surgeons have treated this disorder on an outpatient basis. We retrospectively reviewed 37 patients with pyogenic flexor tenosynovitis who were managed as outpatients. Each patient underwent operative irrigation and debridement with intraoperative catheter irrigation. Postoperatively, patients were treated with outpatient intravenous antibiotics. Conversion to oral antibiotics was based on intraoperative culture results. Using this protocol, the average length of intravenous antibiotic usage was 3.5 days. Of the 28 patients with documented follow-up, 27 resolved the infection and one had a recurrence of the infection. No amputations were noted. Total active motion measurement was obtained from 15 patients showing good or excellent results in 14 of 15 patients. This preliminary retrospective case cohort suggests favorable results with outpatient treatment of pyogenic flexor tenosynovitis. (Journal of Surgical Orthopaedic Advances 14(2):92–95, 2005) Key words: flexor tendon, infection, pyogenic flexor tenosynovitis, tenosynovitis

Bipolar Femoral Neck–Cup Impingement Observed on Radiographic Examination: Report of a Case -- Brian J. McGrory, MD; B. Andrew Lawhead, PA-C

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Bipolar hemiarthroplasty has been used for both arthritis treatment and, more recently, the treatment of displaced femoral neck fractures. The authors report an unusual care of impingement of the bipolar cup and prosthetic femoral neck. This was noted on radiographs 10 years after bipolar hemiarthroplasty. This example supports the use of unipolar hemiarthroplasty to avoid such impingement. (Journal of Surgical Orthopaedic Advances 14(2):96–98, 2005) Key words: bipolar, failure, hemiarthroplasty, hip, impingement

Identical Type I Congenital Kyphosis in Male Twins: A Brief Report -- James F. Mooney III, MD

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There is limited evidence of familial transmission of congenital spinal deformities. The clinical and surgical histories of two twin male patients with essentially identical congenital kyphotic deformities are reviewed. Each underwent posterior instrumented fusion, and each has maintained position over 2 years since surgical intervention. Identical type I congenital kyphosis in twins is unreported in the literature. Further evaluation of possible genetic factors in the etiology of such deformities is necessary. (Journal of Surgical Orthopaedic Advances 14(2):99–101, 2005) Key words: congenital kyphosis, twins

Septic Arthritis of the Glenohumeral Joint: A Review of 23 Cases -- Edmond Cleeman, MD; Joshua D. Auerbach, MD; Gregory G. Klingenstein, BA; Evan L. Flatow, MD

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Infection of the glenohumeral joint is an uncommon yet devastating condition. The objective of this study was to review the incidence, risk factors, presentation, and treatment for this disorder. Twenty-three culture-positive cases of septic arthritis of the glenohumeral joint were identified and treated at the authors’ institution between 1986 and 2000. Eighty-seven percent of patients had at least one serious systemic illness, and on average had two. Fifty-two percent had a different primary site of infection identified. Staphylococcus aureus was identified as the infectious organism in 70% of cases, 17% of which were found to be methicillin-resistant S. aureus. Patients admitted to the orthopedic service were more likely to undergo surgical treatment. Patients treated surgically had shorter hospital stays than those treated with serial aspirations alone. Shoulder infections affect patients who are older and have multiple systemic diseases. Surgical treatment of shoulder infections, when compared to aspiration alone, is associated with a shorter hospital stay. Glenohumeral infection is a debilitating affliction even when control of the infection can be achieved. (Journal of Surgical Orthopaedic Advances 14(2):102–107, 2005) Key words: glenohumeral joint, septic arthritis, septic shoulder

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