Publications by authors named "Lucas Murnaghan"

37 Publications

Development of a certification examination for orthopedic sports medicine fellows

Can J Surg 2020 03 6;63(2):E110-E117. Epub 2020 Mar 6.

From Mount Sinai Hospital, Toronto, Ont. (Dwyer, Theodoropoulos); Toronto Western Hospital, Toronto, Ont. (Chahal, Ogilvie-Harris); and Women’s College Hospital, Toronto, Ont. (Dwyer, Chahal, Murnaghan, Theodoropoulos, Cheung, McParland, Ogilvie-Harris).

Background: The purpose of this study was to develop a multifaceted examination to assess the competence of fellows following completion of a sports medicine fellowship.

Methods: Orthopedic sports medicine fellows over 2 academic years were invited to participate in the study. Clinical skills were evaluated with objective structured clinical examinations, multiple-choice question examinations, an in-training evaluation report and a surgical logbook. Fellows’ performance of 3 technical procedures was assessed both intraoperatively and on cadavers: anterior cruciate ligament reconstruction (ACLR), arthroscopic rotator cuff repair (RCR) and arthroscopic shoulder Bankart repair. Technical procedural skills were assessed using previously validated task-specific checklists and the Arthroscopic Surgical Skill Evaluation Tool (ASSET) global rating scale.

Results: Over 2 years, 12 fellows were assessed. The Cronbach α for the technical assessments was greater than 0.8, and the interrater reliability for the cadaveric assessments was greater than 0.78, indicating satisfactory reliability. When assessed in the operating room, all fellows were determined to have achieved a minimal level of competence in the 3 surgical procedures, with the exception of 1 fellow who was not able achieve competence in ACLR. When their performance on cadaveric specimens was assessed, 2 of 12 (17%) fellows were not able to demonstrate a minimal level of competence in ACLR, 2 of 10 (20%) were not able to demonstrate a minimal level of competence for RCR and 3 of 10 (30%) were not able to demonstrate a minimal level of competence for Bankart repair.

Conclusion: There was a disparity between fellows’ performance in the operating room and their performance in the high-fidelity cadaveric setting, suggesting that technical performance in the operating room may not be the most appropriate measure for assessment of fellows’ competence.
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http://dx.doi.org/10.1503/cjs.015418DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828964PMC
March 2020

A Comparison of Quadriceps Tendon Autograft With Bone-Patellar Tendon-Bone Autograft and Hamstring Tendon Autograft for Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Quantitative Synthesis.

Clin J Sport Med 2019 Jun 19. Epub 2019 Jun 19.

Orthopaedic Sports Medicine (UTOSM), University of Toronto, Women's College Hospital, Toronto, ON, Canada.

Objective: There is growing enthusiasm for the increased use of quadriceps tendon (QT) autograft for primary anterior cruciate ligament reconstruction (ACLR). The purpose of this analysis was to synthesize and quantitatively assess the available evidence comparing QT autograft with hamstring tendon (HT) and bone-patellar tendon-bone (BPTB) autografts, regarding functional outcomes, knee stability, anterior knee pain, and revision rates.

Data Sources: A search in MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials for eligible studies up to May 2018 was conducted. Two reviewers selected studies based on inclusion criteria and assessed methodological quality. Outcomes analyzed were anterior knee pain, graft failure rates, knee stability, functional outcomes, and adverse events. Pooled analyses were performed for continuous and dichotomous variables where appropriate.

Main Results: Ten studies (1 randomized trial and 9 nonrandomized cohorts) met our inclusion criteria, which included 1398 patients. The analysis showed no statistical difference in anterior knee pain when comparing QT and HT autografts, but a significant difference between QT and BPTB autografts [odds ratio, 0.15 (95% confidence interval, 0.08-0.27); P < 0.001]. There were no differences between all 3 autografts in revision rates, knee stability, and patient-reported functional outcomes.

Conclusions: Quadriceps tendon autograft is a suitable graft alternative for primary ACLR, as it achieves good clinical outcomes with a low incidence of anterior knee pain. Given the limited quality of the included studies, there is a need for a well-designed multicenter randomized control trial comparing QT autograft with other primary ACL autografts to confirm our findings.

Level Of Evidence: Level IV systematic review.
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http://dx.doi.org/10.1097/JSM.0000000000000765DOI Listing
June 2019

Graft-Tunnel Mismatch in Endoscopic ACL Reconstruction: Reliability of Measuring Tunnel Lengths and Intra-articular Distance.

Orthop J Sports Med 2018 Dec 21;6(12):2325967118816317. Epub 2018 Dec 21.

University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada.

Background: A continued technical challenge for surgeons performing bone-patellar tendon-bone anterior cruciate ligament (ACL) reconstruction with endoscopic techniques is graft-tunnel mismatch. If tibial tunnel and intra-articular distances could be reliably estimated, surgeons could adjust the length of the femoral tunnel to minimize graft-tunnel mismatch.

Purpose/hypothesis: To determine whether arthroscopic measurement of the following was reliable: femoral tunnel distance (FTD), tibial tunnel distance (TTD), intra-articular distance (IAD), and total distance (TD; sum of these 3 measurements). It was hypothesized that intraoperative measurement of these distances would be reliable.

Study Design: Controlled laboratory study.

Methods: Eight sports fellowship-trained orthopedic surgeons independently performed arthroscopic measurements of the FTD, TTD, IAD, and TD in 7 cadaveric knees in which femoral and tibial tunnels had been drilled. Each surgeon performed the measurements twice using an EndoButton depth gauge. Following this, each parameter was measured open with a medial parapatellar approach. Finally, a computed tomography (CT) scan of each knee was performed, with the FTD, TTD, and IAD measured by a musculoskeletal radiologist. Inter- and intrarater reliability of the arthroscopic measurements was calculated, as well as the correlation between arthroscopic measurements and open and CT measurements.

Results: Interrater reliability for the arthroscopic measurements was 0.8 for FTD, 0.89 for TTD, 0.61 for IAD, and 0.76 (range, 0.54-0.93) for TD. Intrarater reliability was 0.94 for FTD, 0.97 for TTD, 0.83 for IAD, and 0.93 for TD. The correlation between arthroscopic and open measurements was 0.9 for FTD, 0.94 for TTD, 0.4 for IAD, and 0.84 for TD. The correlation between arthroscopic and CT measurements was 0.85 for FTD, 0.92 for TTD, and 0.71 for IAD.

Conclusion: The results of this study show that arthroscopic measurement of FTD and TTD has a high degree of intra- and interrater reliability, while that of IAD and TD demonstrates high intrarater reliability but moderate interrater reliability.

Clinical Relevance: Reliable measurement of the TTD and IAD can potentially allow adjustment of the FTD, minimizing graft-tunnel mismatch in endoscopic ACL reconstruction.
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http://dx.doi.org/10.1177/2325967118816317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6304709PMC
December 2018

Mobile Web-Based Follow-up for Postoperative ACL Reconstruction: A Single-Center Experience.

Orthop J Sports Med 2017 Dec 22;5(12):2325967117745278. Epub 2017 Dec 22.

University of Toronto Orthopaedic Sports Medicine, Women's College Hospital, Toronto, Ontario, Canada.

Background: The initial 6 weeks after surgery has been identified as an area for improvement in patient care. During this period, the persistence of symptoms that go unchecked can lead to unscheduled emergency room and clinic visits, calls to surgeons' offices, and readmissions.

Purpose: To analyze postoperative data from a previous study examining postoperative outcomes in 2 patient populations following breast reconstruction and anterior cruciate ligament (ACL) reconstruction with use of a patient-centered mobile application. Here, the authors establish whether this method of follow-up can provide useful insight specific to the orthopaedic patient population, and they determine whether the mobile platform has the potential to modify their postoperative treatment. In addition, the authors examine its utility for orthopaedic physicians and patients.

Study Design: Case series; Level of evidence, 4.

Methods: Eligible patients undergoing ACL reconstruction from 2 surgeons were consecutively recruited to use a mobile smartphone application that allowed physicians to monitor their recovery at home. Data from 32 patients were collected via the application and analyzed to evaluate recovery trends during the first 6 postoperative weeks. Following completion of the study, patients and physicians were interviewed on their experience.

Results: Data collected from each question in the mobile application provided insightful trends on daily real-time indicators of postoperative recovery. The application identified 1 patient who required in-person reassessment to rule out a possible infection, following surgeon review of an uploaded image. It was estimated that the majority of patients could have avoided follow-up at 2 and 6 weeks, owing to the application's efficacy. Participants described their satisfaction with the device as excellent (43%), good (40%), fair (10%), and poor (7%), and 94% (n = 30) of patients reported that they would respond to questions using a similar application in the future. Both physicians rated their experience as positive and identified useful traits in the web portal.

Conclusion: This system can accurately assess patient recovery; it has the potential to change how postoperative orthopaedic patients are followed, and it is well received by patients and physicians. Recognition of the study's limitations and employment of user feedback to improve the current application are essential before a formal randomized controlled trial is conducted.
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http://dx.doi.org/10.1177/2325967117745278DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5753986PMC
December 2017

The Reliability of Assessing Radiographic Healing of Osteochondritis Dissecans of the Knee.

Am J Sports Med 2017 May 11;45(6):1370-1375. Epub 2017 Apr 11.

Investigation performed at the Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.

Background: The reliability of assessing healing on plain radiographs has not been well-established for knee osteochondritis dissecans (OCD).

Purpose: To determine the inter- and intrarater reliability of specific radiographic criteria in judging healing of femoral condyle OCD.

Study Design: Cohort study (Diagnosis); Level of evidence, 3.

Methods: Ten orthopedic sports surgeons rated the radiographic healing of 30 knee OCD lesions at 2 time points, a minimum of 1 month apart. First, raters compared pretreatment and 2-year follow-up radiographs on "overall healing" and on 5 subfeatures of healing, including OCD boundary, sclerosis, size, shape, and ossification using a continuous slider scale. "Overall healing" was also rated using a 7-tier ordinal scale. Raters then compared the same 30 pretreatment knee radiographs in a stepwise progression to the 2-, 4-, 7-, 12-, and 24-month follow-up radiographs on "overall healing" using a continuous slider scale. Interrater and intrarater reliability were assessed using intraclass correlations (ICC) derived from a 2-way mixed effects analysis of variance for absolute agreement.

Results: Overall healing of the OCD lesions from pretreatment to 2-year follow-up radiographs was rated with excellent interrater reliability (ICC = 0.94) and intrarater reliability (ICC = 0.84) when using a continuous scale. The reliability of the 5 subfeatures of healing was also excellent (interrater ICCs of 0.87-0.89; intrarater ICCs of 0.74-0.84). The 7-tier ordinal scale rating of overall healing had lower interrater (ICC = 0.61) and intrarater (ICC = 0.68) reliability. The overall healing of OCD lesions at the 5 time points up to 24 months had interrater ICCs of 0.81-0.88 and intrarater ICCs of 0.65-0.70.

Conclusion: Interrater reliability was excellent when judging the overall healing of OCD femoral condyle lesions on radiographs as well as on 5 specific features of healing on 2-year follow-up radiographs. Continuous scale rating of OCD radiographic healing yielded higher reliability than the ordinal scale rating. Raters showed substantial to excellent agreement of OCD overall radiographic healing measured on a continuous scale at 2, 4, 7, 12, and 24 months after starting treatment.
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http://dx.doi.org/10.1177/0363546517698933DOI Listing
May 2017

Reliability and Validity of the Arthroscopic International Cartilage Repair Society Classification System: Correlation With Histological Assessment of Depth.

Arthroscopy 2017 Jun 2;33(6):1219-1224. Epub 2017 Feb 2.

Department of Surgery, Division of Orthopedics, University of Toronto Orthopaedic Sports Medicine, Toronto, Ontario, Canada; Women's College Hospital, Toronto, Ontario, Canada; Mt Sinai Hospital, Toronto, Ontario, Canada.

Purpose: To determine the interobserver reliability of the International Cartilage Repair Society (ICRS) grading system of chondral lesions in cadavers, to determine the intraobserver reliability of the ICRS grading system comparing arthroscopy and video assessment, and to compare the arthroscopic ICRS grading system with histological grading of lesion depth.

Methods: Eighteen lesions in 5 cadaveric knee specimens were arthroscopically graded by 7 fellowship-trained arthroscopic surgeons using the ICRS classification system. The arthroscopic video of each lesion was sent to the surgeons 6 weeks later for repeat grading and determination of intraobserver reliability. Lesions were biopsied, and the depth of the cartilage lesion was assessed. Reliability was calculated using intraclass correlations.

Results: The interobserver reliability was 0.67 (95% confidence interval, 0.5-0.89) for the arthroscopic grading, and the intraobserver reliability with the video grading was 0.8 (95% confidence interval, 0.67-0.9). A high correlation was seen between the arthroscopic grading of depth and the histological grading of depth (0.91); on average, surgeons graded lesions using arthroscopy a mean of 0.37 (range, 0-0.86) deeper than the histological grade.

Conclusions: The arthroscopic ICRS classification system has good interobserver and intraobserver reliability. A high correlation with histological assessment of depth provides evidence of validity for this classification system.

Clinical Relevance: As cartilage lesions are treated on the basis of the arthroscopic ICRS classification, it is important to ascertain the reliability and validity of this method.
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http://dx.doi.org/10.1016/j.arthro.2016.12.012DOI Listing
June 2017

Accuracy of non-arthrographic 3T MR imaging in evaluation of intra-articular pathology of the hip in femoroacetabular impingement.

Skeletal Radiol 2017 Mar 14;46(3):299-308. Epub 2016 Dec 14.

Department of Medical Imaging, Joint Department of Medical Imaging, Division of Musculoskeletal Imaging, University of Toronto, Toronto, Canada.

Objective: To investigate the accuracy of non-arthrographic 3-T MRI compared to hip arthroscopy in the assessment of labral and cartilaginous pathology in patients with suspected FAI.

Materials And Methods: Following IRB approval and waived consent, 42 consecutive cases of suspected FAI with non-arthrographic 3-T MRI and arthroscopy of the hip were reviewed. High-resolution TSE MR imaging was evaluated in consensus by two musculoskeletal radiologists, blinded to arthroscopic findings, for the presence of labral tears and articular cartilage lesions. Acetabular cartilage was categorized as normal, degeneration/fissuring, delamination, or denudation. MRI findings were compared to arthroscopy. Sensitivity, specificity, accuracy, and predictive values for MRI were calculated using arthroscopy as the standard of reference.

Results: Forty-two hips in 38 patients with a mean age of 29 (range 13-45 years) were assessed. Mean interval between MRI and arthroscopy was 154 days (range 27-472 days). MRI depicted 41 cases with labral tears (sensitivity 100%, specificity 50%, accuracy 98%, PPV 98%, NPV 100%), 11 cases with femoral cartilage abnormalities (sensitivity 85%, specificity 100%, accuracy 95%, PPV 100%, NPV 94%), and 36 cases with acetabular cartilage lesions (sensitivity 94% specificity 67%, accuracy 90%, PPV 94%, NPV 67%). Of the 36 cases with acetabular cartilage lesions on MRI, 7 were characterized as degeneration/fissuring, 26 as delamination, and 3 as denudation, with discordant results between MRI and arthroscopy for grading of articular cartilage in ten cases.

Conclusion: Non-arthrographic 3-T MR imaging is a highly accurate technique for evaluation of the labrum and cartilage in patients with clinically suspected FAI.
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http://dx.doi.org/10.1007/s00256-016-2551-zDOI Listing
March 2017

Education of parents in Pavlik harness application for developmental dysplasia of the hip using a validated simulated learning module.

J Child Orthop 2016 Aug 24;10(4):289-93. Epub 2016 Jun 24.

Division of Orthopaedic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.

Background: The Pavlik harness is the most common initial treatment for developmental dysplasia of the hip worldwide. During treatment, parents are required to re-apply the harness at home. Teaching parents how to apply the harness is therefore paramount to success. While simulated learning for medical training is commonplace, it has not yet been trialed in teaching parents how to apply a Pavlik harness.

Methods: A group of parents underwent a simulated learning module for Pavlik harness application. Parents were evaluated pre- and post-exposure and at one month after testing. A validated objective structured assessment of technical skill (OSATS) and a global rating scale (GRS) specific to Pavlik harness application were used for evaluation. A control group of parents was also tested at both time points. A clinical expert group was used to determine competency. ANOVA and t tests were used to assess differences between groups and over time.

Results: Parent scores on the OSATS improved to the level of expert clinicians both immediately post-intervention and at retention testing. However, on the GRS, only half were considered competent due to their inability to achieve the required hip positions. The control group did not improve nor were they considered competent.

Conclusions: The use of a simulated learning module improves both the confidence and skill level of parents in the application of the Pavlik harness. However, the challenges parents face in understanding the more detailed subtleties of medical care suggest that they still require an appropriate level of supervision by clinicians to ensure effective treatment.
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http://dx.doi.org/10.1007/s11832-016-0751-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4940246PMC
August 2016

Skill Acquisition and Retention Following Simulation-Based Training in Pavlik Harness Application.

J Bone Joint Surg Am 2016 May;98(10):866-70

Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada

Background: Simulation-based learning is increasingly prevalent in many surgical training programs, as medical education moves toward competency-based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated condition, where the standard of care for patients less than six months of age is an orthotic device such as the Pavlik harness. However, despite widespread use of the Pavlik harness and the potential complications that may arise from inappropriate application, we know of no previously described formal training curriculum for Pavlik harness application.

Methods: We developed a video and model-based simulation learning module for Pavlik harness application. Two novice groups (residents and allied health professionals) were exposed to the module and, at pre-intervention, post-intervention, and retention testing, were evaluated on their ability to apply a Pavlik harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skills (OSATS) and a global rating scale (GRS) specific to Pavlik harness application. A control group that did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik harness alone would affect skill acquisition. All groups were compared with a group of clinical experts, whose scores were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t tests and analysis of variance (ANOVA).

Results: Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik harness (p < 0.05) to the level of the expert clinicians, and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve, nor did they achieve competency.

Conclusions: The simulation-based learning module was shown to be an effective tool for teaching the application of a Pavlik harness, and learners demonstrated retainable skills post-intervention. This learning module can form the cornerstone of formal teaching of Pavlik harness application for developmental dysplasia of the hip.
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http://dx.doi.org/10.2106/JBJS.15.00905DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123626PMC
May 2016

Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee: A Multicenter Reliability Study.

Am J Sports Med 2016 Jul 6;44(7):1694-8. Epub 2016 Apr 6.

Rady Children's Hospital-San Diego, San Diego, California, USA.

Background: Several systems have been proposed for classifying osteochondritis dissecans (OCD) of the knee during surgical evaluation. No single classification includes mutually exclusive categories that capture all of the salient features of stability, chondral fissuring, and fragment detachment. Furthermore, no study has assessed the reliability of these classification systems.

Purpose: To determine the intra- and interobserver reliability of a novel, comprehensive arthroscopic classification system with mutually exclusive OCD lesion types.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: The Research in OsteoChondritis of the Knee (ROCK) study group developed a classification system for arthroscopic evaluation of OCD of the knee that includes 6 arthroscopic categories-3 immobile types and 3 mobile types. To optimize comprehensibility and applicability, each was developed with a memorable name, a brief description, a line diagram corresponding to the archetypal arthroscopic appearance, and an arthroscopic photograph depicting this archetype. Thirty representative arthroscopic videos were evaluated by 10 orthopaedic surgeon raters, who classified each lesion. After 4 weeks, the raters again classified the OCD lesions depicted in the 30 videos in a new, randomly selected order. Reliability was assessed via the intraclass correlation coefficient (ICC).

Results: The interobserver reliability of this novel arthroscopy classification was estimated by an ICC of 0.94 (95% CI, 0.91-0.97) for the first round and 0.95 (95% CI, 0.93-0.98) for the second round. According to the standards for the magnitude of the reliability coefficient of Altman, these ICCs indicate that interobserver reliability was very good. The intraobserver reliability was estimated by an ICC of 0.96 (95% CI, 0.95-0.97), which indicates that the intraobserver reliability was similarly very good.

Conclusion: The ROCK OCD knee arthroscopy classification system demonstrated excellent intra- and interobserver reliability. In light of this reliability, this classification system may be used clinically and to facilitate future research, including multicenter studies for OCD.
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http://dx.doi.org/10.1177/0363546516637175DOI Listing
July 2016

Development and Assessment of a Distal Radial Fracture Model as a Clinical Teaching Tool.

J Bone Joint Surg Am 2016 Mar;98(5):410-6

Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada The Wilson Centre, Toronto General Hospital, Toronto, Ontario, Canada Women's College Hospital, Toronto, Ontario, Canada The Hospital for Sick Children, Toronto, Ontario, Canada

Background: Simulation-based learning is increasingly prevalent in the curricula of many surgical training programs. Newly developed simulators must undergo rigorous validity testing before they are used to assess and evaluate surgical trainees. We describe the development of a model that simulates a distal radial fracture requiring closed reduction and cast application and demonstrate its validity.

Methods: We developed a model for simulated treatment of a distal radial fracture with use of a modified Sawbones forearm. Ten junior and ten senior orthopaedic residents were videotaped performing a closed reduction and applying a cast on the model. After each procedure, standard anteroposterior and lateral radiographs of the forearm model were obtained. Two blinded orthopaedic surgeons then rated each resident using a task-specific checklist (Objective Structured Assessment of Technical Skills [OSATS]) and a global rating scale (GRS) as well as radiographic measurements of palmar tilt and three-point index.

Results: Compared with the junior residents, senior residents had significantly higher OSATS (p < 0.001) and GRS scores (p < 0.001). The groups did not differ significantly with respect to radiographic palmar tilt (p = 0.86) and three-point index (p = 0.43). All residents were able to restore anatomical alignment, with a mean palmar tilt of 9.1°. In addition, the mean three-point index of all residents was acceptable (0.76). There was a strong correlation between OSATS and GRS scores (r > 0.87; p < 0.01). The inter-rater reliability was high (≥ 0.79) for the OSATS, GRS, and radiographic measurements.

Conclusions: We developed an educational model that simulates a distal radial fracture requiring closed reduction and cast application. We demonstrated construct validity, as the GRS and OSATS tools were able to differentiate senior from junior residents. We were unable to differentiate trainees using radiographic assessment, as all residents restored anatomical alignment and had comparable three-point index scores.
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http://dx.doi.org/10.2106/JBJS.O.00565DOI Listing
March 2016

Preoperative Femoral Nerve Block for Hip Arthroscopy: A Randomized, Triple-Masked Controlled Trial.

Am J Sports Med 2015 Nov 24;43(11):2680-7. Epub 2015 Sep 24.

Division of Orthopaedic Surgery, St Michael's Hospital, Toronto, Ontario, Canada.

Background: Arthroscopy has become a standard method of treatment for a variety of intra-articular hip disorders. While most arthroscopic hip procedures are performed as outpatient surgeries, patients can still experience significant postoperative pain and opioid-associated side effects.

Purpose: The potential benefits of a preoperative femoral nerve block (FNB) in hip arthroscopy were explored in a previous retrospective review. The study objective was to confirm these findings in a prospective randomized study.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Fifty patients undergoing hip arthroscopy were included in this prospective, single-center, randomized controlled trial that was patient-, operator-, and assessor-blinded. Patients received either a preoperative ultrasound-guided FNB with 20 mL of 0.5% bupivacaine (FNB group) or normal saline (control group). Nerve blockade was confirmed via standardized sensory testing before the induction of general anesthesia. The primary endpoint was cumulative consumption of oral morphine equivalent at 24 hours after discharge. Secondary endpoints included opioid use at various time points, pain scores, Quality of Recovery (QoR-27) score, incidence of nausea and vomiting, time to discharge, block-related complications, falls at 24 hours, and patient satisfaction.

Results: Fifty patients completed the study, including 27 in the FNB group and 23 in the control group. Most patient characteristics were statistically similar between groups except for operative time, which was longer in the control group. Cumulative oral morphine consumption was lower in the FNB group at 48 hours; there was no difference at 24 hours or 7 days postoperatively. Pain scores were significantly lower up to 6 hours postoperatively in the FNB group compared with control; however, rebound pain was observed at 24 hours after discharge in patients who received FNB. There was no difference in most secondary outcomes. Importantly, a total of 6 patients in the FNB group reported falls (without injury) within the first 24 hours postoperatively compared with none in the control group. Patient satisfaction with pain control was high in both groups at all time points.

Conclusion: Preoperative FNB may improve early pain control after hip arthroscopy. However, given the observed risk of falls, the routine use of FNB for outpatient hip arthroscopy cannot be recommended.
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http://dx.doi.org/10.1177/0363546515602468DOI Listing
November 2015

Taking a Chance or Playing It Safe: Reframing Risk Assessment Within the Surgeon's Comfort Zone.

Ann Surg 2015 Aug;262(2):253-9

*Department of Surgery and †The Wilson Centre, University of Toronto, Toronto, Ontario, Canada ‡Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada.

Objectives: The purpose of this study was to explore how risk is perceived and experienced by the surgeon and how risk is actively managed in individual practice.

Background: Risk in surgery has been examined from system-wide and personality perspectives. Although these are important, little is known about the perspective of the individual surgeon.

Methods: A constructivist grounded theory study was conducted to explore surgeons' perspectives on risk in the context of their personal "Comfort Zones." Semistructured, 60-minute interviews were conducted with 18 surgeons who were purposively sampled for sex and subspecialty with a snowballing strategy applied to sample for differences in reputation (conservative vs aggressive). Data were collected and analyzed in an iterative manner until thematic saturation was reached.

Results: Surgeons described cases that were inside or outside of their personal comfort zones. When considering cases at the boundary of their comfort zones, participants described a variety of factors that could make them feel more or less comfortable. Specific strategies used to modulate this border were also described. Two perspectives on risk taking became apparent: the procedure-centric perspective described how surgeons viewed their colleagues whereas the surgeon-centric perspective described how surgeons viewed themselves.

Conclusions: A framework for understanding surgeon's unique assessment of risk was elaborated. Increased awareness of the factors and strategies identified in this study can foster critical self-reflection by surgeons of their own risk assessments and those of their colleagues, and provide avenues for more explicit educational strategies for surgical training.
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http://dx.doi.org/10.1097/SLA.0000000000001068DOI Listing
August 2015

A Qualitative Investigation of Return to Sport After Arthroscopic Bankart Repair: Beyond Stability.

Am J Sports Med 2015 Aug 15;43(8):2005-11. Epub 2015 Jun 15.

Department of Surgery, University of Toronto, Toronto, Ontario, Canada Orthopaedic Sports Medicine Program, University of Toronto, Toronto, Ontario, Canada Women's College Hospital, Toronto, Ontario, Canada Mount Sinai Hospital, Toronto, Ontario, Canada.

Background: Arthroscopic shoulder stabilization is known to have excellent functional results, but many patients do not return to their preinjury level of sport, with return to play rates reported between 48% and 100% despite good outcome scores.

Purpose: To understand specific subjective psychosocial factors influencing a patient's decision to return to sport after arthroscopic shoulder stabilization.

Study Design: Case series; Level of evidence, 4.

Methods: Semistructured qualitative interviews were conducted with patients aged 18 to 40 years who had undergone primary arthroscopic shoulder stabilization and had a minimum 2-year follow-up. All patients participated in sport before surgery without any further revision operations or shoulder injuries. Qualitative data analysis was performed in accordance with the Strauss and Corbin theory to derive codes, categories, and themes. Preinjury and current sport participation was defined by type, level of competition, and the Brophy/Marx shoulder activity score. Patient-reported pain and shoulder function were also obtained.

Results: A total of 25 patients were interviewed, revealing that fear of reinjury, shifts in priority, mood, social support, and self-motivation were found to greatly influence the decision to return to sport both in patients who had and had not returned to their preinjury level of play. Patients also described fear of sporting incompetence, self-awareness issues, recommendations from physical therapists, and degree of confidence as less common considerations affecting their return to sport.

Conclusion: In spite of excellent functional outcomes, extrinsic and intrinsic factors such as competing interests, kinesiophobia, age, and internal stressors and motivators can have a major effect on a patient's decision to return to sport after arthroscopic shoulder stabilization. The qualitative methods used in this study provide a unique patient-derived perspective into postoperative recovery and highlight the necessity to recognize and address subjective and psychosocial factors rather than objective functional outcome scores alone as contributing to a patient's decision to return to play.
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http://dx.doi.org/10.1177/0363546515590222DOI Listing
August 2015

Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study.

JMIR Mhealth Uhealth 2015 Feb 12;3(1):e18. Epub 2015 Feb 12.

Women\'s College Hospital, Department of Surgery, University of Toronto, Toronto, ON, Canada.

Background: Mobile apps are being viewed as a new solution for post-operative monitoring of surgical patients. Mobile phone monitoring of patients in the post-operative period can allow expedited discharge and may allow early detection of complications.

Objective: The objective of the current study was to assess the feasibility of using a mobile app for the monitoring of post-operative quality of recovery at home following surgery in an ambulatory setting.

Methods: We enrolled 65 consecutive patients (n=33, breast reconstruction surgery; n=32, orthopedic surgery) and asked them to use a mobile phone daily to complete a validated quality of recovery scale (QoR-9) and take photographs of the surgical site for the first 30 days post-op. Surgeons were asked to review patient-entered data on each patient in their roster daily. A semistructured questionnaire was administered to patients and surgeons to assess satisfaction and feasibility of the mobile device.

Results: All 65 patients completed the study. The mean number of logins was 23.9 (range 7-30) for the breast patients and 19.3 (range 5-30) for the orthopedic patients. The mean number of logins was higher in the first 14 days compared to the 15-30 days post-op for both breast patients (13.4 vs 10.5; P<.001) and for the orthopedic patients (13.4 vs 6.0; P<.001). The mean score for overall satisfaction with using the mobile device was 3.9 for breast patients and 3.7 for orthopedic patients (scored from 1 (poor) to 4 (excellent)). Surgeons reported on the easy-to-navigate design, the portability to monitor patients outside of hospital, and the ability of the technology to improve time efficiency.

Conclusions: The use of mobile apps for monitoring the quality of recovery in post-operative patients at home was feasible and acceptable to patients and surgeons in the current study. Future large scale studies in varying patient populations are required.
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http://dx.doi.org/10.2196/mhealth.3929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342621PMC
February 2015

Juvenile Osteochondritis Dissecans in a 13-year-old male athlete: A case report.

J Can Chiropr Assoc 2014 Dec;58(4):384-94

Staff Physician, Division of Orthopaedic Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario ; Assistant Professor, Department of Surgery, University of Toronto.

Objective: To present the clinical management of juvenile osteochondritis dissecans (OCD) of the knee and highlight the importance of a timely diagnosis to optimize the time needed for less invasive, non-operative therapy.

Clinical Features: A 13-year-old provincial level male soccer player presenting with recurrent anterior knee pain despite ongoing manual therapy.

Intervention And Outcome: A multidisciplinary, non-operative treatment approach was utilized to promote natural healing of the osteochondral lesion. The plan of management consisted of patient education, activity modification, manual therapy, passive modalities and rehabilitation, while being overseen by an orthopaedic surgeon.

Conclusions: Considering the serious consequences of misdiagnosing osteochondritis dissecans, such as the potential for future joint instability and accelerated joint degeneration, a high degree of suspicion should be considered with young individuals presenting with nonspecific, recurrent knee pain. A narrative review of the literature is provided to allow practitioners to apply current best practices to appropriately manage juvenile OCD and become more cognizant of the common knee differential diagnoses in the young athletic population.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4262807PMC
December 2014

Cases and current concepts in pediatric sports medicine.

J Pediatr Orthop 2014 Oct-Nov;34 Suppl 1:S49-56

*School of Medicine, Univeristy of Utah, Salt Lake City, UT †Southern California Permanente Medical Group, Los Angeles Medical Center, Los Angeles §Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA ‡St. Luke's Health System, Boise, ID ∥Department of Orthopaedics, Penn State College of Medicine, Hershey, PA ¶Rocky Mountain Youth Sports Medicine Institute, Rocky Mountain Hospital for Children, Centennial, CO #Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA **Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN ††Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, ON, Canada ‡‡Children's Orthopaedics of Atlanta, Atlanta, GA.

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http://dx.doi.org/10.1097/BPO.0000000000000287DOI Listing
May 2015

How to assess communication, professionalism, collaboration and the other intrinsic CanMEDS roles in orthopedic residents: use of an objective structured clinical examination (OSCE).

Can J Surg 2014 Aug;57(4):230-6

The Women's College Hospital, The Hospital for Sick Children, and Toronto Western Hospital, Toronto, Ont.

Background: Assessing residents' understanding and application of the 6 intrinsic CanMEDS roles (communicator, professional, manager, collaborator, health advocate, scholar) is challenging for postgraduate medical educators. We hypothesized that an objective structured clinical examination (OSCE) designed to assess multiple intrinsic CanMEDS roles would be sufficiently reliable and valid.

Methods: The OSCE comprised 6 10-minute stations, each testing 2 intrinsic roles using case-based scenarios (with or without the use of standardized patients). Residents were evaluated using 5-point scales and an overall performance rating at each station. Concurrent validity was sought by correlation with in-training evaluation reports (ITERs) from the last 12 months and an ordinal ranking created by program directors (PDs).

Results: Twenty-five residents from postgraduate years (PGY) 0, 3 and 5 participated. The interstation reliability for total test scores (percent) was 0.87, while reliability for each of the communicator, collaborator, manager and professional roles was greater than 0.8. Total test scores, individual station scores and individual CanMEDS role scores all showed a significant effect by PGY level. Analysis of the PD rankings of intrinsic roles demonstrated a high correlation with the OSCE role scores. A correlation was seen between ITER and OSCE for the communicator role, while the ITER medical expert and total scores highly correlated with the communicator, manager and professional OSCE scores.

Conclusion: An OSCE designed to assess the intrinsic CanMEDS roles was sufficiently valid and reliable for regular use in an orthopedic residency program.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119113PMC
http://dx.doi.org/10.1503/cjs.018813DOI Listing
August 2014

Development of a cast application simulator and evaluation of objective measures of performance.

J Bone Joint Surg Am 2014 May;96(9):e76

Division of Orthopaedic Surgery S107, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8. E-mail address for M.L. Murnaghan:

Background: Surgical simulation offers a low-risk learning environment with repetitive practice opportunities for orthopaedic residents. It is increasingly prevalent in many training programs, as acquisition of technical skills in the face of educational demands and reduced work hours becomes more challenging. In addition to surgical skills, orthopaedic residents must also learn the technique of cast application. Deficiencies in casting skill are risk factors for re-displacement of fractures and cast-specific complications. Formal educational models to instruct or to evaluate casting technique have not been well described or tested. The purposes of this study were to develop a cast application simulator and to validate a novel method of evaluating casting skill.

Methods: A module that simulates short arm cast application on a synthetic forearm model was developed. An Objective Structured Assessment of Technical Skill checklist was created with use of Delphi methodology involving nine content experts (five orthopaedic surgeons and four orthopaedic technologists). Nine participants (three medical students, three orthopaedic residents, two orthopaedic fellows, and one orthopaedic technologist) were used to evaluate the reliability and validity of the checklist. Nine de-identified videos of cast application were recorded and were utilized to test the newly developed Objective Structured Assessment of Technical Skill checklist and Modified Global Rating Scale for reliability and validity. Participants were grouped by training level (medical students, orthopaedic residents, and orthopaedic fellows or orthopaedic technologists) and were evaluated twice.

Results: Reliability was high as shown by intraclass correlation. The inter-rater reliability was 0.85 for the Objective Structured Assessment of Technical Skill, 0.81 for the Modified Global Rating Scale performance, and 0.78 for the Modified Global Rating Scale final product; the intra-rater reliability was 0.88 for the Objective Structured Assessment of Technical Skill, 0.85 for the Modified Global Rating Scale performance, and 0.81 for the Modified Global Rating Scale final product. The Objective Structured Assessment of Technical Skill checklist scores were 9.28 points for the medical students, 17.46 points for the orthopaedic residents, and 18.85 points for the orthopaedic fellows or orthopaedic technologists (p < 0.05, F = 6.32). The Modified Global Rating Scale performance and final product scores also reflected the level of training. Post hoc analysis showed a significant difference between the medical students and orthopaedic fellows or orthopaedic technologists for the Objective Structured Assessment of Technical Skill checklist and Modified Global Rating Scale.

Conclusions: This casting simulation model and evaluation instrument is a reliable assessment of casting skill in applying a short arm cast. However, given the inability to stratify all three groups on the basis of the level of training, further work is needed to establish construct validity.
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http://dx.doi.org/10.2106/JBJS.L.01266DOI Listing
May 2014

Drilling techniques for osteochondritis dissecans.

Clin Sports Med 2014 Apr 18;33(2):305-12. Epub 2014 Feb 18.

Division of Sports Medicine, Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.

Although the advanced stages of osteochondritis dissecans remain challenging to treat, most early-stage lesions in skeletally immature patients, if managed appropriately, can be stimulated to heal. For stable lesions that do not demonstrate adequate healing with nonoperative measures, such as activity modification, weight-bearing protection, or bracing, drilling of the subchondral bone has emerged as the gold standard of management. Several techniques of drilling exist, including transarticular drilling, retroarticular drilling, and notch drilling. Although each technique has been shown to be effective in small retrospective studies, higher-powered prospective comparative studies are needed to better elucidate their relative advantages and disadvantages.
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http://dx.doi.org/10.1016/j.csm.2013.11.007DOI Listing
April 2014

The sizing of hamstring grafts for anterior cruciate reconstruction: intra- and inter-observer reliability.

Knee Surg Sports Traumatol Arthrosc 2015 Apr;23(4):1197-200

Purpose: The objective of this study was to establish the intra- and inter-observer reliability of hamstring graft measurement using cylindrical sizing tubes.

Methods: Hamstring tendons (gracilis and semitendinosus) were harvested from ten cadavers by a single surgeon and whip stitched together to create ten 4-strand hamstring grafts. Ten sports medicine surgeons and fellows sized each graft independently using either hollow cylindrical sizers or block sizers in 0.5-mm increments—the sizing technique used was applied consistently to each graft. Surgeons moved sequentially from graft to graft and measured each hamstring graft twice. Surgeons were asked to state the measured proximal (femoral) and distal (tibial) diameter of each graft, as well as the diameter of the tibial and femoral tunnels that they would drill if performing an anterior cruciate ligament (ACL) reconstruction using that graft. Reliability was established using intra-class correlation coefficients.

Results: Overall, both the inter-observer and intra-observer agreement were >0.9, demonstrating excellent reliability. The inter-observer reliability for drill sizes was also excellent (>0.9). Excellent correlation was seen between cylindrical sizing, and drill sizes (>0.9).

Conclusions: Sizing of hamstring grafts by multiple surgeons demonstrated excellent intra-observer and intra-observer reliability, potentially validating clinical studies exploring ACL reconstruction outcomes by hamstring graft diameter when standard techniques are used.

Level Of Evidence: III.
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http://dx.doi.org/10.1007/s00167-014-2945-1DOI Listing
April 2015

Preoperative femoral nerve block in hip arthroscopic surgery: a retrospective review of 108 consecutive cases.

Am J Sports Med 2014 Jan 27;42(1):144-9. Epub 2013 Nov 27.

Andrew P. Dold, University of Toronto, Division of Orthopaedic Surgery, 100 College Street, Room 302, Toronto, ON M5G 1L5, Canada.

Background: The utility of a femoral nerve block as an adjunct for pain management has been recognized for various surgical techniques but has yet to be examined in the preoperative setting as an adjunct to general anesthesia for improved postoperative pain control in hip arthroscopic surgery.

Purpose: To evaluate the safety and efficacy of a preoperative femoral nerve block for postoperative pain control in patients undergoing hip arthroscopic surgery.

Study Design: Cohort study; Level of evidence, 3.

Methods: A retrospective chart review of 108 consecutive hip arthroscopic surgery cases (in 103 patients) was carried out. All patients underwent arthroscopic surgery under a general anesthetic with or without a preoperative femoral nerve block. Groups were compared with respect to patient sex, age, and body mass index (BMI); physical status classification according to the American Society of Anesthesiologists (ASA); procedure performed; operative time; total intraoperative morphine-equivalent dose; pain scores (0-10 scale) recorded at 0, 15, 30, 45, and 60 minutes postoperatively in the post-anesthesia care unit (PACU); total morphine-equivalent dose in the PACU; presence of nausea or vomiting in the PACU; time to discharge from the PACU; oxycodone consumption in the surgical day care unit (SDCU); and maximal patient-reported pain score in the SDCU.

Results: Twelve cases were excluded from the analysis for a total of 96 cases (in 92 patients). Forty patients had general anesthesia alone (group A), and 56 patients had a preoperative femoral nerve block before the induction of general anesthesia (group B). There was no significant difference between the groups with regard to sex, age, weight, height, BMI, ASA classification, or type of procedure performed. Patients who received a femoral nerve block also received a significantly lower total intraoperative morphine-equivalent dose than did those patients who did not receive a block. Postoperative patient-reported pain scores were lower at all time points for the femoral nerve block group; however, a statistical significance was seen only at the 60-minute postoperative time point. Patients who did not receive a block had significantly higher morphine-equivalent doses in the PACU. There was no difference in the rates of nausea and vomiting and time to discharge from the PACU between the 2 groups. Oxycodone consumption in the SDCU was similar between the groups, but the femoral nerve block group had significantly lower maximal patient-reported pain scores in the SDCU. Two patients in the general anesthesia group were admitted to the hospital postoperatively because of inadequate postoperative pain control. No complications were noted in any patient with regard to the femoral nerve block.

Conclusion: A preoperative femoral nerve block is a relatively safe procedure that may decrease the requirement for intraoperative morphine while providing effective postoperative pain control in patients undergoing hip arthroscopic surgery.
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http://dx.doi.org/10.1177/0363546513510392DOI Listing
January 2014

Assessing competence of orthopaedic residents: the reliability and validity of an objective structured clinical examination after a sports medicine rotation.

J Bone Joint Surg Am 2013 Nov;95(22):e177

Women's College Hospital, Toronto Western and Sunnybrook Hospital, University of Toronto Orthopaedics Sports Medicine, 76 Grenville Street, Toronto, ON M5S 1B1, Canada. E-mail address for T. Dwyer:

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http://dx.doi.org/10.2106/JBJS.M.00148DOI Listing
November 2013

A qualitative investigation of the decision to return to sport after anterior cruciate ligament reconstruction: to play or not to play.

Am J Sports Med 2014 Feb 6;42(2):336-42. Epub 2013 Nov 6.

Vehniah K. Tjong, Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Room 508A, Toronto, ON M5T 1P5, Canada.

Background: Primary anterior cruciate ligament (ACL) reconstruction is known to have excellent outcomes, but many patients do not return to their preinjury level of sport participation. Previous studies have used subjective outcome scores to evaluate this discrepancy, but none to date has used qualitative, in-depth patient interviews.

Purpose: To understand the factors influencing a patient's decision to return to his or her preinjury level of sport after ACL reconstruction.

Hypothesis: Extrinsic and intrinsic factors may affect one's decision to return to sport after primary ACL reconstruction despite good functional knee scores.

Study Design: Case series; Level of evidence, 4.

Methods: An experienced interviewer conducted qualitative, semistructured interviews of 31 patients, aged 18 to 40 years, who had undergone primary ACL reconstruction surgery. All participated in sport before injury and had a minimum 2-year follow-up with no further surgeries or knee injuries. Qualitative analysis was then performed to derive codes, categories, and themes. An assessment of preinjury and current sport participation by type, level of competition, and Marx activity score, along with patient-reported knee function, was also conducted.

Results: Patient interviews revealed 3 overarching themes: fear, lifestyle changes, and innate personality traits. Elements of these factors were shown to largely influence the decision to return to the preinjury sport both in those patients who had returned and those who had not returned to sport. Less common factors included the surgeon's advice not to return, depressed mood, and persistent knee pain.

Conclusion: Patients who did not return to their preinjury level of sport after primary ACL reconstruction despite having good knee function were largely influenced by fear, shifts in priority, and individual personalities. This study highlights the importance for treating physicians to recognize and address psychological factors and lifestyle changes that largely contribute to a patient's postoperative decision to return to sport. Results from this study will allow surgeons and health care professionals to educate patients contemplating surgery and to better understand the recovery process not only from sport-related surgeries but other surgical interventions with the goal of returning to activity.
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http://dx.doi.org/10.1177/0363546513508762DOI Listing
February 2014

Remembering our roots: eponyms in sports medicine.

Am J Sports Med 2013 Jul 21;41(7):1703-11. Epub 2012 Dec 21.

Department of Orthopaedic Surgery, Sports Medicine Center for the Developing Athlete, New York-Presbyterian Medical Center, Columbia University, New York, New York, USA.

For as long as athletes have been competing, injuries from competition have resulted. Sports medicine has a rich and storied history with significant contributors from many different countries and civilizations. Over time, we have honored the contributions of important figures in sports medicine with the use of eponyms. However, the continued use of eponyms in medicine has been called into question by a number of authors. They cite inaccuracies in definition and context, lack of descriptive value, and the possible celebration of unsavory characters. However, eponyms are pervasive in the medical literature. They bring color and character and allow us to honor those who came before us. Furthermore, eponyms can hide some distressing aspects of a disease. This review of eponyms in sports medicine provides an opportunity to celebrate our predecessors, recognize the international flavor of sports medicine, and promote accurate use of eponyms for the future.
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http://dx.doi.org/10.1177/0363546512470620DOI Listing
July 2013

Waking up the next morning: surgeons' emotional reactions to adverse events.

Med Educ 2012 Dec;46(12):1179-88

Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.

Context: The adverse patient event is an inherent component of surgical practice, but many surgeons are unprepared for the profound emotional responses these events can evoke. This study explored surgeons' reactions to adverse events and their impact on subsequent judgement and decision making.

Methods: Using a constructivist grounded theory approach, we conducted 20 semi-structured, 60-minute interviews with surgeons across subspecialties, experience levels, and sexes to explore surgeons' recollections of reactions to adverse events. Further interviews were conducted with six general surgeons to explore more immediate reactions after 28 adverse events. Data coding was both inductive, developing a new framework based on emergent themes, and deductive, using an existing framework for care providers' reactions to adverse events.

Results: Surgeons expressed feeling unique and alone in the depths of their reactions to adverse events and consistently described four phases of response, each containing cognitive and emotive components, following such events. The initial phase (the kick) involved feelings of failure ('Am I good enough?') experienced with a significant physiological response. This was shortly followed by a second phase (the fall), during which the surgeon experienced a sense of chaos and assessed the extent of his or her contribution to the event ('Was it my fault?'). During the third phase (the recovery), the surgeon reflected on the adverse event ('What can I learn?') and experienced a sense of 'moving on'. In the fourth phase (the long-term impact), the surgeon experienced the prolonged and cumulative effects of these reactions on his or her own personal and professional identities. Surgeons also described an effect on their clinical judgement, both for the case in question (minimisation) and future cases (overcompensation).

Conclusions: Surgeons progress through a series of four phases following adverse events that are potentially caused by or directly linked to surgeon error. The framework provided by this study has implications for teaching, surgeon wellness and surgeon error.
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http://dx.doi.org/10.1111/medu.12058DOI Listing
December 2012

Percutaneous curettage and suction for pediatric extremity aneurysmal bone cysts: is it adequate?

J Pediatr Orthop 2012 Dec;32(8):842-7

The Hospital for Sick Children, Division of Orthopaedic Surgery, Toronto, ON, Canada.

Background: The purpose of our study was to evaluate the effectiveness of treating extremity aneurysmal bone cysts (ABC) by percutaneous curettage compared with open intralesional excision.

Methods: A retrospective review of 17 patients with histologically proven primary ABCs and no evidence of a secondary lesion treated either by percutaneous curettage or open intralesional excision with at least 24-month follow-up was undertaken. The percutaneous curettage group was uniformly treated on an outpatient basis using angled curettes under image guidance followed by intralesional evacuation. The primary outcome was radiographic healing using the Neer/Cole 4-grade classification. Complications were noted.

Results: Seventeen patients with a mean age of 11.7 years (range, 1.7 to 17.5) were evaluated. Nine patients underwent percutaneous curettage and 8 had an open intralesional excision. The 2 treatment groups were comparable with regard to age, sex, number of procedures, morphologic type of ABC, and follow-up period. At follow-up, the proportion of patients with satisfactory healing (Neer/Cole grades I and II) were similar among the 2 groups (P = 0.74). In the percutaneous curettage group, 2 cases recurred necessitating repeat procedures, whereas 1 case recurred in the open intralesional excision group and was successfully treated percutaneously.

Conclusions: Percutaneous curettage is a safe and minimally invasive alternative for extremity ABCs that can be performed as an outpatient procedure. Not all ABCs require wide exposure and an open intralesional excision.

Level Of Evidence: III.
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http://dx.doi.org/10.1097/BPO.0b013e31825d3619DOI Listing
December 2012

"First, do no harm": balancing competing priorities in surgical practice.

Acad Med 2012 Oct;87(10):1368-74

University of Toronto Faculty of Medicine, Department of Surgery, Wilson Centre, University Health Network and University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada.

Purpose: To explore surgeons' perceptions of the factors that influence their intraoperative decision making, and implications for professional self-regulation and patient safety.

Method: Semistructured interviews were conducted with 39 academic surgeons from various specialties at four hospitals associated with the University of Toronto Faculty of Medicine. Purposive and theoretical sampling was performed until saturation was achieved. Thematic analysis of the transcripts was conducted using a constructivist grounded-theory approach and was iteratively elaborated and refined as data collection progressed. A preexisting theoretical professionalism framework was particularly useful in describing the emergent themes; thus, the analysis was both inductive and deductive.

Results: Several factors that surgeons described as influencing their decision making are widely accepted ("avowed," or in patients' best interests). Some are considered reasonable for managing multiple priorities external to the patient but are not discussed openly ("unavowed," e.g., teaching pressures). Others are actively denied and consider the surgeon's best interests rather than the patient's ("disavowed," e.g., reputation). Surgeons acknowledged tension in balancing avowed factors with unavowed and disavowed factors; when directly asked, they found it difficult to acknowledge that unavowed and disavowed factors could lead to patient harm.

Conclusions: Some factors that are not directly related to the patient enter into surgeons' intraoperative decision making. Although these are probably reasonable to consider within "real-world" practice, they are not sanctioned in current patient care constructs or taught to trainees. Acknowledging unavowed and disavowed factors as sources of pressure in practice may foster critical self-reflection and transparency when discussing surgical errors.
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http://dx.doi.org/10.1097/ACM.0b013e3182677587DOI Listing
October 2012

Ischioplasty for Femoroischial Impingement: A Case Report.

JBJS Case Connect 2012 Jul-Sep;2(3):e51

Division of Orthopaedic Surgery, Hospital for Sick Children, 555 University Avenue, S107, Toronto, ON M5G 1X8, Canada. E-mail address for M.L. Murnaghan: E-mail address for S. Hopyan: E-mail address for S.P. Kelley:

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http://dx.doi.org/10.2106/JBJS.CC.K.00177DOI Listing
December 2017

Imaging of osteochondritis dissecans.

Orthop Clin North Am 2012 Apr 21;43(2):201-11, v-vi. Epub 2012 Feb 21.

Department of Medical Imaging, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Toronto, Ontario M5G 1X5, Canada.

Osteochondritis dissecans (OCD) is a localized process that affects the subchondral bone and can progress to the overlying articular cartilage. The cause of this lesion remains elusive. With the vague clinical symptoms and signs of OCD, imaging plays a vital role in making the diagnosis and helping with the prognosis of OCD lesions. This article reviews current imaging modalities for the assessment of OCD including conventional radiography, nuclear medicine, computed tomography (CT), CT arthrography, magnetic resonance (MR) and MR arthrography. The role of imaging in evaluating healing of the OCD and articular congruity after surgical and nonsurgical management is discussed.
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http://dx.doi.org/10.1016/j.ocl.2012.01.001DOI Listing
April 2012