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1.  A Simplified Method for the Aspiration of Bone Marrow from Patients Undergoing Hip and Knee Joint Replacement for Isolating Mesenchymal Stem Cells and In Vitro Chondrogenesis 
Bone Marrow Research  2016;2016:3152065.
The procedure for aspiration of bone marrow from the femur of patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) may vary from an OR (operating room) to OR based on the surgeon's skill and may lead to varied extent of clotting of the marrow and this, in turn, presents difficulty in the isolation of mesenchymal stem cells (MSCs) from such clotted bone marrow. We present a simple detailed protocol for aspirating bone marrow from such patients, isolation, and characterization of MSCs from the aspirated bone marrow specimens and show that the bone marrow presented no clotting or exhibited minimal clotting. This represents an economical source and convenient source of MSCs from bone marrow for use in regenerative medicine. Also, we presented the detailed protocol and showed that the MSCs derived from such bone marrow specimens exhibited MSCs characteristics and generated micromass cartilages, the recipe for regenerative medicine for osteoarthritis. The protocols we presented can be used as standard operating procedures (SOPs) by researchers and clinicians.
PMCID: PMC4766320  PMID: 27057356
2.  The Epidemiology of Primary Anterior Shoulder Dislocations in Patients Aged 10-16 Years and Age-Stratified Risk of Recurrence 
Orthopaedic Journal of Sports Medicine  2015;3(7 suppl2):2325967115S00051.
Most clinical studies pertaining to shoulder dislocation use age cutoffs of 16 years, and at present, only small case series of patients aged 10-16 years guide our management. Using a general population cohort aged 10 to 16 years, we sought to: 1) determine the overall and demographic-specific incidence density rate (IDR) of primary anterior shoulder dislocation requiring closed reduction (CR), and 2) determine the rate of and risk factors for repeat shoulder CR.
Using administrative databases, we identified all patients who underwent CR of a primary anterior shoulder dislocation by a physician in Ontario between April 2002 and September 2010 (the index event). Exclusion criteria included age (16 years), posterior dislocation, and prior shoulder dislocation or surgery. The IDR was calculated for the entire cohort and compared by age and sex subgroups. The main outcome, repeat shoulder CR, was sought until September 2012. A time-to-event analysis (cumulative incidence function) was used to determine the incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years for the entire cohort and subgroups based on age (10-12, 13, 14, 15, and 16 years). A competing risk model identified risk factors for repeat shoulder CR, which were reported using hazard ratios (HR) with 95% confidence intervals (CI).
We identified 2,066 patients aged 10-16 years who underwent CR following a primary anterior shoulder dislocation, of which, 1,937 met the exclusion criteria. The median age was 15.0 years and 79.7% were male. The IDR was 20.1 per 100,000 person-years, and was highest among 16 year-old males (164.4 per 100,000 person-years). In contrast, primary anterior shoulder dislocation was rare among patients aged 10-12 years [5.9% (N=115) of all primary dislocations]. Repeat shoulder CR was observed in 740 patients (38.2%) after a median of 0.8 years. The overall cumulative incidence of repeat shoulder CR at six-months, one-year, two-years, and five-years was 13.0%, 21.3%, 29.2%, and 36.2%, respectively; however, the cumulative incidence by age (Figure 1) revealed the rate of repeat shoulder CR to be highest among 14-16 year-olds (37.2-42.3%), and considerably less among patients aged 10-13 years (0-25.0%). Male sex (HR 1.2, p=0.04; interpreted as a 20% increased risk for males as compared to females) and patient age (HR 1.2, p<0.001; interpreted as a 20% increased risk for each year over age 10) significantly influenced the risk of a repeat shoulder CR. Overall, 31.2% (N=604) of patients underwent shoulder stabilization, of which, half underwent surgery following the index shoulder CR (49.9%, N=369).
Primary anterior shoulder dislocations are common among 14-16 year olds, and the rate of recurrence in this age group following non-operative management mirrors that of 17-20 year olds in previously published data. In contrast, both the incidence of primary anterior dislocation and rate of recurrence are considerably lower for patients aged 10-13 years. Going forward, clinicians should treat and counsel patients aged 14-16 years, particularly males, as they do older adolescents (17-20 years); however, patients 13 years of age or younger should be counselled regarding their low risk for recurrence.
PMCID: PMC4901608
3.  Factors That Influence the Choice to Undergo Surgery for Shoulder and Elbow Conditions 
Knowledge of the factors that influence the willingness of patients considering elective orthopaedic surgery is essential for patient-centered care. To date, however, these factors remain undefined in the orthopaedic population with shoulder and elbow disorders.
In a cohort of patients seeking surgical consultation for shoulder or elbow conditions, we sought to identify factors that influenced the willingness and decision to undergo surgery.
In this prospective study, 384 patients completed a questionnaire collecting socioeconomic and health status data before consultation from June 2009 to December 2010. An additional 120 patients who were offered surgery after consultation completed a second questionnaire on their perceptions and concerns regarding surgery. Logistic regression analyses were used to identify factors influencing the willingness and decision to undergo surgery.
Lower income (odds ratio [OR], 0.02; CI, 0.02–0.08; p < 0.001) and living alone (OR, 0.25; CI, 0.08–0.77; p = 0.015) were negative predictors of willingness to consider surgery. Physical functioning did not influence willingness (p = 0.994). A greater perceived level of the likelihood of surgical success by the patient (OR, 41.84; CI, 5.24–333.82; p < 0.001) and greater fluency in the English language (OR, 28.39; CI, 3.49–230.88; p = 0.002) were positive predictors of willingness. Willingness to consider surgery as a possible treatment option before the consultation was a predictor of patients’ ultimate decisions to undergo surgery (OR, 4.56; CI, 1.05–19.76; p = 0.042). Patients expressing concern about surgery being an inconvenience to daily life, however, were less likely to decide to proceed with surgery (OR, 0.12; CI, 0.02–0.68; p = 0.017).
Many of the identified factors may act as barriers to potentially beneficial surgical interventions. Although most are not modifiable, an awareness of the influence of individual demographics and possible perceptions of patients’ choices may show that more in-depth questioning and provisions for cultural differences may be required during the consultation to enable patients to make fully informed decisions. Future studies using qualitative methods would provide a greater in-depth understanding of patients’ perceptions regarding surgery and their decision to proceed. Larger or more homogeneous cohorts also would enable additional identification of these factors for different shoulder and elbow conditions.
Level of Evidence
Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.
PMCID: PMC3916628  PMID: 24186468
4.  The Application of Wearable Technology in Surgery: Ensuring the Positive Impact of the Wearable Revolution on Surgical Patients 
Frontiers in Surgery  2014;1:39.
Wearable technology has become an important trend in consumer electronics in the past year. The miniaturization and mass production of myriad sensors have made possible the integration of sensors and output devices in wearable platforms. Despite the consumer focus of the wearable revolution some surgical applications are being developed. These fall into augmentative, assistive, and assessment functions and primarily layer onto current surgical workflows. Some challenges to the adoption of wearable technologies are discussed and a conceptual framework for understanding the potential of wearable technology to revolutionize surgical practice are presented.
PMCID: PMC4286964  PMID: 25593963
wearable technology; wearable devices; augmented reality; outcome assessment (health care); surgery; computer-assisted
5.  Defects in Tendon, Ligament, and Enthesis in Response to Genetic Alterations in Key Proteoglycans and Glycoproteins: A Review 
Arthritis  2013;2013:154812.
This review summarizes the genetic alterations and knockdown approaches published in the literature to assess the role of key proteoglycans and glycoproteins in the structural development, function, and repair of tendon, ligament, and enthesis. The information was collected from (i) genetically altered mice, (ii) in vitro knockdown studies, (iii) genetic variants predisposition to injury, and (iv) human genetic diseases. The genes reviewed are for small leucine-rich proteoglycans (lumican, fibromodulin, biglycan, decorin, and asporin); dermatan sulfate epimerase (Dse) that alters structure of glycosaminoglycan and hence the function of small leucine-rich proteoglycans by converting glucuronic to iduronic acid; matricellular proteins (thrombospondin 2, secreted phosphoprotein 1 (Spp1), secreted protein acidic and rich in cysteine (Sparc), periostin, and tenascin X) including human tenascin C variants; and others, such as tenomodulin, leukocyte cell derived chemotaxin 1 (chondromodulin-I, ChM-I), CD44 antigen (Cd44), lubricin (Prg4), and aggrecan degrading gene, a disintegrin-like and metallopeptidase (reprolysin type) with thrombospondin type 1 motif, 5 (Adamts5). Understanding these genes represents drug targets for disrupting pathological mechanisms that lead to tendinopathy, ligamentopathy, enthesopathy, enthesitis and tendon/ligament injury, that is, osteoarthritis and ankylosing spondylitis.
PMCID: PMC3842050  PMID: 24324885
6.  Shoulder Dislocation In Ontario, Canada From 1994 To 2011: The Incidence, Rate And Risk Factors For Recurrence 
Orthopaedic Journal of Sports Medicine  2013;1(4 Suppl):2325967113S00013.
Recurrent shoulder dislocation is influenced by age, activity level and bone loss. Original estimates of recurrence risk approached 90% among persons under the age of 20, but declined with increasing age. Recent literature, however, suggests that the rate of recurrent dislocation is lower. The goals of this study were to: (1) define the incidence of primary shoulder dislocation in Ontario, Canada, and (2) identify the rate of and risk factors for recurrent dislocation among demographic variables.
Administrative databases (OHIP) were used to build the cohort of patients aged 15 to 70 that underwent a primary closed shoulder reduction by a physician in Ontario between July 1994 and October 2009. Exclusions included: associated humeral neck fracture, posterior dislocation, previous shoulder dislocation, prior shoulder arthroplasty, and non-Ontario residents. After cohort entry, subsequent shoulder relocations by a physician were sought. The yearly incidence (per 100,000 person-years) was calculated among all eligible Ontario residents. Kaplan-Meier survival curves to subsequent dislocation were generated. A Prentice, Williams and Peterson conditional proportional hazards survivorship model of time-to-recurrence was applied examining the influence of age, gender, income quintile, physician specialty and concurrent tuberosity fracture at index dislocation on the risk of recurrence (alpha set at 0.05). Hazard Ratios (HR) with confidence intervals were calculated.
The primary dislocation cohort consisted of 37,356 patients. Median age was 34 years (IQR 22-50) and 74% were male. The average yearly incidence of primary shoulder dislocation was 23.1/100,000 person-years overall, but 45.2/100,000 person-years for patients younger than 20. Recurrent dislocation events were identified in 23% of the cohort (8573 patients), most of whom were younger (median age 24 years) and male (80%). In fact, patients younger than 20 had a 37.8% rate of recurrence (HR 1.9 (1.7-2.1), p<0.0001; compared to patient aged 36-40). Kaplan-Meier survival curves showed most recurrent dislocations took place in the first year: 93.4% at 6-months, 89.4% at 1-year, 85.2% at 2-years and 79.4% at 5-years. Protective factors against recurrence included primary relocation performed by an Orthopaedic Surgeon (HR 0.87 (0.79-0.94), p=0.001), age over 50 years (5.5% rate; HR 0.70 (0.61-0.80, p<0.0001) and an associated tuberosity fracture (HR 0.51 (0.42-0.63), p<0.0001), while lowest income quintile was a risk factor for recurrence (HR 1.1 (1.04-1.16), p=0.0007). Interestingly, at 2.5 years from the primary dislocation, only 14.7% of the cohort had undergone surgical shoulder stabilization.
Patients under 20 had twice the incidence of primary dislocation and twice the risk of recurrent shoulder dislocation compared to the median cohort age. A recurrence rate of 38% in patients under 20 is high, but less than previous reports.
PMCID: PMC4588933
7.  Arthroscopic proficiency: methods in evaluating competency 
BMC Medical Education  2013;13:61.
The current paradigm of arthroscopic training lacks objective evaluation of technical ability and its adequacy is concerning given the accelerating complexity of the field. To combat insufficiencies, emphasis is shifting towards skill acquisition outside the operating room and sophisticated assessment tools. We reviewed (1) the validity of cadaver and surgical simulation in arthroscopic training, (2) the role of psychomotor analysis and arthroscopic technical ability, (3) what validated assessment tools are available to evaluate technical competency, and (4) the quantification of arthroscopic proficiency.
The Medline and Embase databases were searched for published articles in the English literature pertaining to arthroscopic competence, arthroscopic assessment and evaluation and objective measures of arthroscopic technical skill. Abstracts were independently evaluated and exclusion criteria included articles outside the scope of knee and shoulder arthroscopy as well as original articles about specific therapies, outcomes and diagnoses leaving 52 articles citied in this review.
Simulated arthroscopic environments exhibit high levels of internal validity and consistency for simple arthroscopic tasks, however the ability to transfer complex skills to the operating room has not yet been established. Instrument and force trajectory data can discriminate between technical ability for basic arthroscopic parameters and may serve as useful adjuncts to more comprehensive techniques. There is a need for arthroscopic assessment tools for standardized evaluation and objective feedback of technical skills, yet few comprehensive instruments exist, especially for the shoulder. Opinion on the required arthroscopic experience to obtain proficiency remains guarded and few governing bodies specify absolute quantities.
Further validation is required to demonstrate the transfer of complex arthroscopic skills from simulated environments to the operating room and provide objective parameters to base evaluation. There is a deficiency of validated assessment tools for technical competencies and little consensus of what constitutes a sufficient case volume within the arthroscopy community.
PMCID: PMC3643847  PMID: 23631421
Arthroscopy; Competency; Surgical training; Task performance
8.  Function Plateaus by One Year in Patients With Surgically Treated Displaced Midshaft Clavicle Fractures 
Based on short-term (1 year or less) followup, primary fixation of displaced midshaft clavicle fractures reportedly results in better function compared with that reported for nonoperative methods. Whether better function persists beyond 1 year is unclear.
For displaced midshaft clavicle fractures, do the better mean Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley Shoulder (CSS) scores for operative versus nonoperative treatment at 1 year change between 1- and 2-year followup?
Patients and Methods
We previously reported 132 patients in a randomized prospective trial at 1 year, and here we report a further followup of 95 of the 132 patients (72%) at 2 years after injury. We evaluated all patients with the DASH and CSS scores.
The mean DASH and CSS scores were similar at 2 years compared with 1 year postinjury for both the nonoperated and operated patients. The mean scores for the operated patients remained higher than those in the nonoperative group (DASH operative 4.1 ± 7.0 versus DASH nonoperative 11.4 ± 19.7, CSS operative 97.1 ± 4.5 versus CSS nonoperative 91.6 ± 14.1) at 2 years postinjury.
The improvement in DASH and CSS scores seen with primary fixation of displaced clavicle fractures persists at 2 years but does not differ from values seen after 1 year of followup, suggesting a clinical steady state has been reached whereby outcome is unlikely to change with time.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3210276  PMID: 21590485
9.  Resident self-assessment of operative experience in primary total knee and total hip arthroplasty: Is it accurate? 
Canadian Journal of Surgery  2012;55(4 Suppl 2):S153-S157.
A prerequisite for a valuable surgical case log is the ability to perform an accurate self-assessment. Studies have shown mixed results when examining residents’ ability to self-assess on varying tasks. We sought to examine the correlation between residents’ self-assessment and staff surgeons’ evaluation of surgical involvement and competence in performing primary total knee (TKA) and hip arthroplasty (THA).
We used the intraclass correlation coefficient (ICC) to evaluate interobserver agreement between residents’ self-perception and staff surgeons’ assessment of involvement. An assessment of competency was performed using a categorical global scale and evaluated with the κ statistic. We piloted a structured surgical skills assessment form as an additional objective appraisal of resident involvement.
We analyzed assessment data from 65 primary TKA and THA cases involving 17 residents and 17 staff surgeons (93% response rate). The ICC for resident involvement between residents and staff surgeons was 0.80 (95% confidence interval [CI] 0.69–0.88), which represents substantial agreement. The agreement between residents and staff surgeons about residents’ competency to perform the case had a κ value of 0.67 (95% CI 0.50–0.84). The ICC for resident, staff surgeon and third-party observer using the piloted skills assessment form was 0.82 (95% CI 0.75–0.88), which represents substantial agreement.
This study supports the ability of orthopedic residents to perform self-assessments of their degree of involvement and competency in primary TKA and THA. Staff surgeons’ assessment of resident involvement correlated highly with the surgical skills assessment form. Self-assessment is a valuable addition to the surgical case log.
PMCID: PMC3432254  PMID: 22854152
10.  Crowd Intelligence for the Classification of Fractures and Beyond 
PLoS ONE  2011;6(11):e27620.
Medical diagnosis, like all products of human cognition, is subject to error. We tested the hypothesis that errors of diagnosis in the realm of fracture classification can be reduced by a consensus (group) diagnosis; and that digital imaging and Internet access makes feasible the compilation of a diagnostic consensus in real time.
Twelve orthopaedic surgeons were asked to evaluate 20 hip radiographs demonstrating a femoral neck fracture. The surgeons were asked to determine if the fractures were displaced or not. Because no reference standard is available, the maximal accuracy of the diagnosis of displacement can be inferred from inter-observer reliability: if two readers disagree about displacement, one of them must be wrong. That method was employed here. Additionally, virtual reader groups of 3 and 5 individual members were amalgamated, with the response of those groups defined by majority vote. The purpose of this step was to see if increasing the number of readers would improve accuracy. In a second experiment, to study the feasibility of amassing a reader group on the Internet in real time, 40 volunteers were sent 10 periodic email requests to answer questions and their response times were assessed.
The mean kappa coefficient for individual inter-observer reliability for the diagnosis of displacement was 0.69, comparable to prior published values. For 3-member virtual reader groups, inter-observer reliability was 0.77; and for 5-member groups, it was 0.80. In the experiment studying the feasibility of amassing a reader group in real time, the mean response time was 594 minutes. For all cases, a 9-member group (theoretically 99% accurate) was amassed in 135.8 minutes or less.
Consensus may improve diagnosis. Amassing a group for this purpose on the Internet is feasible.
PMCID: PMC3223187  PMID: 22132118
14.  Drilling sounds are used by surgeons and intermediate residents, but not novice orthopedic trainees, to guide drilling motions 
Canadian Journal of Surgery  2008;51(6):442-446.
The purpose of our study was to investigate the impact of distracting noise on the performance on a simulated orthopedic bone drilling skill when that noise blocks routine auditory feedback associated with the sounds of the drill.
Medical students (n = 11), intermediate residents (postgraduate years 3–5, n = 10) and surgeons (n = 8) each drilled 20 bicortical holes in a femur bone from a lamb: 10 holes without and 10 holes with the presence of distracting noise. We quantified surgical outcome in the form of plunge depth using computer-assisted objective methods.
Novice participants plunged more than did the intermediate trainees and surgeons (p < 0.001). With the addition of distracting noise, the plunges of both intermediate residents and surgeons were affected.
Distracting noise impairs orthopedic bone drilling performance, and the ability to use drilling sounds to guide drilling motions is part of surgical expertise.
PMCID: PMC2592586  PMID: 19057732

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