In this report, we present the case of an 80-year-old female with pain located over the tip of her cemented tibial stem in a revision hinge total knee arthroplasty with localized osteolysis that looked suspicious for infection. A thorough workup was negative for infection. We postulate that the osteolysis at the end of her tibial stem was initiated by a modulus of elasticity mismatch at the stem tip, which generated a focal area of increased sagittal bone bending and microparticle generation. She was treated with lesional exploration, debridement, synthetic bone grafting, and tibial plating to distribute stress loads away from the tibial stem tip. Histologic analysis identified no organisms or neoplasm. Her pain ultimately resolved, and the patient returned to her customary activities.

Limb salvage is widely practiced as standard of care in most cases of extremity bone sarcoma. Allograft and endoprosthesis reconstructions are the most widely utilized modalities for the reconstruction of large segment defects, however complication rates remain high. Aseptic loosening and infection remain the most common modes of failure. Implant integration, soft-tissue function, and infection prevention are crucial for implant longevity and function. Macro and micro alterations in implant design are reviewed in this manuscript. Tissue engineering principles using nanoparticles, cell-based, and biological augments have been utilized to develop implant coatings that improve osseointegration and decrease infection. Similar techniques have been used to improve the interaction between soft tissues and implants. Tissue engineered constructs (TEC) used in combination with, or in place of, traditional reconstructive techniques may represent the next major advancement in orthopaedic oncology reconstructive science, although preclinical results have yet to achieve durable translation to the bedside.

Background

The Orthopaedic Research and Education Foundation (OREF) is the leading specialty-specific nongovernmental organization providing orthopaedic funding in the United States. As extramural research funding has become increasingly difficult to acquire, one mission of the OREF is to support investigators to generate data needed to secure larger extramural funding from agencies such as the National Institutes of Health (NIH). The objectives of this study were to evaluate the rate of translating OREF faculty-level grants into subsequent NIH funding and to determine if there are identifiable factors that increase the rate of converting an OREF grant into NIH funding.

Methods

This is a retrospective review of OREF grants awarded to full-time faculty orthopaedic surgeons between 1994 and 2014. Grants were analyzed on the basis of award type and were categorized as basic science, clinical, or epidemiological. Sex, individual scholarly productivity, and publication experience were evaluated. All awardees were assessed for subsequent NIH funding using the NIH RePORTER web site.

Results

One hundred and twenty-six faculty-level OREF grants were awarded to 121 individuals. Twenty-seven OREF grant awardees (22%) received NIH funding at a mean of 6.3 years after OREF funding. Nineteen (46%) of 41 Career Development Grant winners later received NIH funding compared with 10 (12%) of 85 other award winners. OREF grants for basic science projects were awarded more often (58%) and were more than 4 times as likely to result in NIH funding than non-basic science projects (odds ratio, 4.70 [95% confidence interval, 1.66 to 13.33]; p = 0.0036). Faculty who later received NIH funding had higher scholarly productivity and publication experience (p < 0.05).

Conclusions

The OREF grant awardee conversion rate of 22% and, particularly, the 46% for Career Development Grant winners compares favorably with the overall NIH funding success rate (18% in 2014). Faculty-level OREF grants appear to achieve their purpose of identifying and supporting researchers who aim to secure subsequent federal funding.

Clinical relevance

The goal of this study is to examine how successful faculty who have obtained OREF grants have been in securing NIH funding later in their careers. Although subsequent accrual of NIH funding is not the only goal of OREF funding, it can be used as an important benchmark to assess the development of orthopaedic clinician-scientists.

Background

The Orthopaedic Research and Education Foundation (OREF) is the leading specialty-specific nongovernmental organization providing orthopaedic funding in the United States. As extramural research funding has become increasingly difficult to acquire, one mission of the OREF is to support investigators to generate data needed to secure larger extramural funding from agencies such as the National Institutes of Health (NIH). The objectives of this study were to evaluate the rate of translating OREF faculty-level grants into subsequent NIH funding and to determine if there are identifiable factors that increase the rate of converting an OREF grant into NIH funding.

Methods

This is a retrospective review of OREF grants awarded to full-time faculty orthopaedic surgeons between 1994 and 2014. Grants were analyzed on the basis of award type and were categorized as basic science, clinical, or epidemiological. Sex, individual scholarly productivity, and publication experience were evaluated. All awardees were assessed for subsequent NIH funding using the NIH RePORTER web site.

Results

One hundred and twenty-six faculty-level OREF grants were awarded to 121 individuals. Twenty-seven OREF grant awardees (22%) received NIH funding at a mean of 6.3 years after OREF funding. Nineteen (46%) of 41 Career Development Grant winners later received NIH funding compared with 10 (12%) of 85 other award winners. OREF grants for basic science projects were awarded more often (58%) and were more than 4 times as likely to result in NIH funding than non-basic science projects (odds ratio, 4.70 [95% confidence interval, 1.66 to 13.33]; p = 0.0036). Faculty who later received NIH funding had higher scholarly productivity and publication experience (p < 0.05).

Conclusions

The OREF grant awardee conversion rate of 22% and, particularly, the 46% for Career Development Grant winners compares favorably with the overall NIH funding success rate (18% in 2014). Faculty-level OREF grants appear to achieve their purpose of identifying and supporting researchers who aim to secure subsequent federal funding.

Clinical relevance

The goal of this study is to examine how successful faculty who have obtained OREF grants have been in securing NIH funding later in their careers. Although subsequent accrual of NIH funding is not the only goal of OREF funding, it can be used as an important benchmark to assess the development of orthopaedic clinician-scientists.

Purpose

Anterior cruciate ligament (ACL) rupture is increasingly common in adolescents. Time between ACL rupture and surgical reconstruction, surgical wait time, is related to concurrent meniscal tear incidence and possibly tear pattern. This study defines the relationship between meniscal tear characteristics and surgical wait time in adolescents with ACL rupture.

Methods

One-hundred and twenty-one consecutive adolescent (median age 16.1 years, range 9-19 years) ACL rupture patients undergoing primary ACL reconstruction were studied. All had documented surgical wait time, preoperative and 6-month post-operative outcome (Lysholm and pedi-IKDC) scores, and intraoperative meniscus tear characteristics. Meniscal tear severity was graded according to the Lawrence and Anderson system: non-surgical: grade 1; reparable: grade 2-3; irreparable: grade 4-5. Significant tears were defined as at least grade 2.

Results

Average age at surgery was 16.1 years. 48.7 % had surgical wait time greater than 6 months. 42.5 % of menisci were torn. With surgical wait time <6 months, there were more lateral than medial tears (48 vs 21 %, p = 0.001). With surgical wait time >6 months, medial tear incidence increased (50 vs 21 %, p < 0.001), there were more significant tears (63 vs 42 %, OR 2.3, p = 0.02), and preoperative Lysholm and pedi-IKDC scores were lower (58 vs 74, p < 0.001; 52 vs 61, p < 0.007). Scores were lower in patients with meniscus tears (63.8 vs 69.3, n.s.; 53.9 vs 60.5, p = .04). Patients with public insurance had risks of surgical wait time greater than 3 months (OR 12.4, p < 0.001) and 6 months (OR 7.8, p < 0.001), and of a significant meniscus tear (OR 2.5, p = 0.03). Six-month post-operative pedi-IKDC scores improved more in meniscus tear patients (28.4 vs 21, p = 0.05).

Conclusions

This study shows a significant increase in medial meniscal tear incidence, decrease in preoperative scores, and worse tear severity with surgical wait time >6 months. Public insurance was a risk factor for longer surgical wait time and meniscus tear.

Implants and their technological advances have been a critical component of musculoskeletal care for almost a century. Modern implants are designed to enhance bone ingrowth, promote soft-tissue healing, and prevent infection. Porous metals and short-stem fixation devices have rendered previously unreconstructable bony deficits reconstructable. Stem cells, growth factors, and novel biocompatible compounds have been designed to promote and enhance soft tissue attachment to implants. Antimicrobial modifications have been engineered onto implants to deter bacterial attachment, and innovative surface modifications and eluting technologies may be in our near future. Yet, given the enormous economic pressures in orthopaedics, marketing claims of innovation often exceed scientific accomplishment. Vigilance is thus required in distinguishing transformational discovery from unsubstantiated claims.

Limb salvage is widely practiced as standard of care in most cases of extremity bone sarcoma. Allograft and endoprosthesis reconstructions are the most widely utilized modalities for the reconstruction of large segment defects, however complication rates remain high. Aseptic loosening and infection remain the most common modes of failure. Implant integration, soft-tissue function, and infection prevention are crucial for implant longevity and function. Macro and micro alterations in implant design are reviewed in this manuscript. Tissue engineering principles using nanoparticles, cell-based, and biological augments have been utilized to develop implant coatings that improve osseointegration and decrease infection. Similar techniques have been used to improve the interaction between soft tissues and implants. Tissue engineered constructs (TEC) used in combination with, or in place of, traditional reconstructive techniques may represent the next major advancement in orthopaedic oncology reconstructive science, although preclinical results have yet to achieve durable translation to the bedside.

Introduction

Although a variety of agencies have attempted to evaluate the academic achievements of orthopaedic surgery academic centers, most use opaque criteria that are difficult to interpret and do not provide clear targets for improvement. This study leverages a weighted algorithm using objective measurements that has been linked to academic achievement to attempt to provide a comprehensive assessment of scholarly accomplishment for orthopaedic surgery academic centers.

Methods

We examined full-time faculty at 138 US orthopaedic surgery academic centers; part-time or volunteer faculty were excluded. Five metrics of academic achievement were assessed: National Institutes of Health funding (2013), number of publications, Hirschberg-index (ie, a metric of impact of publications), leadership positions held in orthopaedic surgery societies, and editorial board positions of top orthopaedic and subspecialty journals. Academic programs were given a score for every category, and the algorithm was used to calculate an overall score of academic achievement for each program.

Results

The five most academically productive programs were Washington University in St. Louis, Hospital for Special Surgery, Mayo Clinic, University of Pennsylvania, and Thomas Jefferson University.

Conclusion

This algorithm may provide faculty with an assessment tool that can establish benchmarks to help focus efforts toward increasing the academic productivity of their respective programs.

BACKGROUND: According to the American Academy of Orthopaedic Surgeons (AAOS) Standards of Professionalism, the responsible testimony of expert witnesses in orthopaedic surgery malpractice lawsuits is important to the public interest. However, these expert witnesses are recruited and compensated without established standards, and their testimony can potentially sway court opinion, with substantial consequences. The objective of this study was to characterize defense and plaintiff expert orthopaedic surgeon witnesses in orthopaedic surgery malpractice litigation. METHODS: Utilizing the WestlawNext legal database, defense and plaintiff expert witnesses involved in orthopaedic surgery malpractice lawsuits from 2013 to 2017 were identified. Each witnesss subspecialty, mean years of experience, involvement in academic or private practice, fellowship training, and scholarly impact, as measured by the Hirsch index (h-index), were determined through a query of professional profiles, the Scopus database, and a PubMed search. Statistical comparisons were made for each parameter among defense and plaintiff expert witnesses. RESULTS: Between 2013 and 2017, 306 expert medical witnesses for orthopaedic cases were identified; 174 (56.9%) testified on behalf of the plaintiff, and 132 (43.1%) testified on behalf of the defense. Orthopaedic surgeons who identified themselves as general orthopaedists comprised the largest share of expert witnesses on both the plaintiff (n = 61) and defense (n = 25) sides. The plaintiff witnesses averaged 36 years of experience versus 31 years for the defense witnesses (p < 0.001); 26% of the plaintiff witnesses held an academic position versus 43% of the defense witnesses (p = 0.013). Defense witnesses exhibited a higher proportion of fellowship training in comparison to plaintiff expert witnesses (80.5% versus 64.5%, respectively, p = 0.003). The h-index for the plaintiff group was 6.6 versus 9.1 for the defense group (p = 0.04). Two witnesses testified for both the plaintiff and defense sides. CONCLUSIONS: Defense expert witnesses held higher rates of academic appointments and exhibited greater scholarly impact than their plaintiff counterparts, with both sides averaging >30 years of experience. These data collectively show that there are differences in characteristics between plaintiff and defense witnesses. Additional study is needed to illuminate the etiology of these differences.

Aneurysmal bone cysts (ABCs) are benign bone lesions arising predominantly in the pediatric population that can cause local pain, swelling, and pathologic fracture. Primary lesions, which constitute roughly two thirds of all ABCs, are thought to be neoplastic in nature, with one third of ABCs arising secondary to other tumors. Diagnosis is made with various imaging modalities, which exhibit characteristic features such as "fluid-fluid levels," although biopsy is critical, as telangiectatic osteosarcoma cannot be excluded based on imaging alone. Currently, the standard of care and most widely employed treatment is intralesional curettage. However, tumor recurrence with curettage alone is common and has driven some to propose a multitude of adjuvants with varying efficacy and risk profiles. Historically, therapies such as en bloc resection or radiation therapy were utilized as an alternative to decrease the recurrence rate, but these therapies imposed high morbidity. As a result, modern techniques now seek to simultaneously reduce morbidity and recurrence, the pursuit of which has produced preliminary study into minimally invasive percutaneous treatments and medical management.