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1.  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
2.  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
3.  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
4.  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
8.  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

Results 1-8 (8)