Loretta Chou, MD

All Publications

• Current Use of Patient-Reported Outcome Measures Ignores Functional Demand. The Journal of the American Academy of Orthopaedic Surgeons Kamal, R. N., Gomez, G., Chakraborty, A., Leversedge, C., Amanatullah, D. F., Chou, L., Gardner, M. J., Hu, S. S., Safran, M., Zhuang, T., Shapiro, L. M. 2024

  Abstract

  Patient-reported outcome measures (PROMs) are used in orthopaedic surgery to measure aspects of musculoskeletal function that are important to patients, such as disability and pain. However, current assessments of function using PROMs do not necessarily consider a patient's functional demands in detail. A patient's functional demands could serve as a confounder to their perception of their functional ability. Hence, functional demands may need to be adjusted for when PROMs are used to measure musculoskeletal function.We conducted a cross-sectional study in which new orthopaedic patients completed a questionnaire regarding demographics, function [Patient-Reported Outcomes Measurement Information System], functional demand (Tegner Activity Level Scale), pain self-efficacy, and symptoms of depression. 169 eligible patients with diverse orthopaedic conditions were enrolled in the study from an orthopaedic clinic, and 19 were excluded for incomplete questionnaires.The mean Patient-Reported Outcomes Measurement Information System score was 36.5 ± 9.1, and the mean Tegner score was 2.6 ± 2.0. In the multivariable regression model, patient-reported function was significantly associated with functional demand (β = 0.17, P < 0.001). Significant associations were observed for pain self-efficacy (β = 0.15, P < 0.001), acuity (β = -0.10, P = 0.004), and age 80 years or older (β = -0.16, P = 0.004). No notable association was observed with depression or age 65 to 79 years.Higher patient-reported physical function is associated with higher levels of functional demand when controlling for psychosocial factors, acuity, and age. Because of its confounding effect on measuring physical function, functional demand should be assessed and included in models using PROMs before and after surgery. For example, payment models using improvements in PROMs, such as the short form of the Hip dysfunction and Osteoarthritis Outcome Score and the Knee injury and Osteoarthritis Outcome Score after joint arthroplasty, should include functional demand in the model when assessing quality of care.Level II.

  View details for DOI 10.5435/JAAOS-D-24-00069

  View details for PubMedID 39186610

• Health Numeracy Is Associated With a Patient's Ability to Interpret Patient-Reported Outcome Measures Data. Orthopedics Schultz, E. A., Eppler, S. L., Gardner, M., Hu, S. S., Chou, L., Safran, M., Amanatullah, D. F., Abrams, G. D., Shapiro, L. M., Kamal, R. N. 2024: 1-6

  Abstract

  Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results.We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results.Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions.Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 202x;4x(x):xx-xx.].

  View details for DOI 10.3928/01477447-20240718-04

  View details for PubMedID 39073043

• Pain Self-Efficacy Can Improve During a Visit With an Orthopedic Surgeon ORTHOPEDICS Lemos, J. L., Gomez, G. I., Tewari, P., Amanatullah, D. F., Chou, L., Gardner, M. J., Hu, S., Safran, M., Kamal, R. N. 2024; 47 (4): e197-e203

  Abstract

  Greater pain self-efficacy (PSE) is associated with reduced pain, fewer limitations, and increased quality of life after treatment for orthopedic conditions. The aims of this study were to (1) assess if PSE improves during a visit with an orthopedic surgeon and (2) identify modifiable visit factors that are associated with an increase in PSE.We performed a prospective observational study of orthopedic clinic visits at a multispecialty clinic from February to May 2022. New patients who presented to one of six orthopedic surgeons were approached for the study. Patients who provided consent completed a pre-visit questionnaire including the Pain Self-Efficacy Questionnaire (PSEQ) and demographic questions. A trained research member recorded the five-item Observing Patient Involvement in Decision Making Instrument (OPTION-5) score, number of questions asked, and visit duration. Immediately after the visit, patients completed a post-visit questionnaire consisting of the PSEQ and Perceived Involvement in Care Scale (PICS).Of 132 patients enrolled, 61 (46%) had improved PSE after the orthopedic visit, with 38 (29%) having improvement above a clinically significant threshold. There were no significant differences between patients with increased PSE and those without increased PSE when comparing the PICS, OPTION-5, questions asked, or visit duration.Almost half of the patients had improvement in PSE during an orthopedic visit. The causal pathway to how to improve PSE and the durability of the improved PSE have implications in strategies to improve patient outcomes in orthopedic surgery, such as communication methods and shared decision-making. Future research can focus on studying different interventions that facilitate improving PSE. [Orthopedics. 2024;47(4):e197-e203.].

  View details for DOI 10.3928/01477447-20240605-01

  View details for Web of Science ID 001274494200007

  View details for PubMedID 38864646

• Health Considerations for Female Orthopaedic Surgeons. The Journal of the American Academy of Orthopaedic Surgeons Chou, L. B., Kha, S. T., Shapiro, L. M. 2023

  Abstract

  The number of female orthopaedic surgeons is increasing. They face unique health concerns, which include cancer risk, pregnancy and fertility problems, musculoskeletal issues, and mental health disorders. In 2010, a survey study showed a 2.9-fold increased prevalence of breast cancer in female orthopaedic surgeons, compared with women in the general US population. A follow-up study 13 years later showed a 3.97-fold higher prevalence of breast cancer in female orthopaedic surgeons compared with matched women in the US general population. Surveys on fertility have also reported that orthopaedic surgery is one of three surgical subspecialty fields with the highest rates of fertility difficulty. In addition, the rate of pregnancy loss in female surgeons was twice the rate compared with that of the general population. There is an increased risk of preterm delivery in female orthopaedic surgeons. Awareness, education, and preventive measures may help reduce these issues and thereby promote the recruitment, retainment, and success of female surgeons in orthopaedic surgery.

  View details for DOI 10.5435/JAAOS-D-23-00221

  View details for PubMedID 37797264

• Reply to Letter to the Editor: Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Chou, L. B., Johnson, B., Shapiro, L. M., Pun, S., Cannada, L. K., Chen, A. F., Valone, L. C., Van Nortwick, S. S., Ladd, A. L., Finlay, A. K. 2023; 7 (9)

  View details for DOI 10.5435/JAAOSGlobal-D-23-00130

  View details for PubMedID 37678820

  View details for PubMedCentralID PMC10484368

• The Environmental Impact of Orthopaedic Surgery. The Journal of bone and joint surgery. American volume Saleh, J. R., Mitchell, A., Kha, S. T., Outterson, R., Choi, A., Allen, L., Chang, T., Ladd, A. L., Goodman, S. B., Fox, P., Chou, L. 2022

  Abstract

  ➤: There are a growing number of opportunities within the field of orthopaedic surgery to address climate change and investigate ways to promote sustainability.➤: Orthopaedic surgeons can take a proactive role in addressing climate change and its impacts within the areas of operating-room waste, carbon emissions from transportation and implant manufacturing, anesthetic gases, and water usage.➤: Future studies are needed to further these initiatives on quantifying and decreasing environmental impact and furthering sustainable use of our resources.

  View details for DOI 10.2106/JBJS.22.00548

  View details for PubMedID 36574633

• Multidisciplinary extremity preservation program improves quality of life for patients with advanced limb threat. Annals of vascular surgery Fereydooni, A., Yawary, F., Sen, S., Chou, L., Murphy, M., Dalman, R. L., Stern, J. R., Chandra, V. 2022

  Abstract

  The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution.Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions.From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P<0.044) and emotional role limitation (OR:8.1; P=0.042), while patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P<0.049). Conversely, patients with a smoking history had less improvement in energy level (OR:0.4; P=0.044) and patients with dialysis-dependence had less improvement in social function (OR:0.2; P=0.034).Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Further study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.

  View details for DOI 10.1016/j.avsg.2022.05.047

  View details for PubMedID 35803456

• Health Literacy and Patient Participation in Shared Decision-Making in Orthopedic Surgery ORTHOPEDICS Mertz, K., Eppler, S., Shah, R., Yao, J., Steffner, R., Safran, M., Hu, S., Chou, L., Amanatullah, D. F., Kamal, R. N. 2022; 45 (4): 227-232

  Abstract

  The influence of health literacy on involvement in decision-making in orthopedic surgery has not been analyzed and could inform processes to engage patients. The goal of this study was to determine the relationship between health literacy and the patient's preferred involvement in decision-making. We conducted a cross-sectional observational study of patients presenting to a multispecialty orthopedic clinic. Patients completed the Literacy in Musculoskeletal Problems (LiMP) survey to evaluate their health literacy and the Control Preferences Scale (CPS) survey to evaluate their preferred level of involvement in decision-making. Statistical analysis was performed with Pearson's correlation and multivariable logistic regression. Thirty-seven percent of patients had limited health literacy (LiMP score <6). Forty-eight percent of patients preferred to share decision-making with their physician equally (CPS score=3), whereas 38% preferred to have a more active role in decision-making (CPS score≤2). There was no statistically significant correlation between health literacy and patient preference for involvement in decision-making (r=0.130; P=.150). Among patients with orthopedic conditions, there is no significant relationship between health literacy and preferred involvement in decision-making. Results from studies in other specialties that suggest that limited health literacy is associated with a preference for less involvement in decision-making are not generalizable to orthopedic surgery. Efforts to engage patients to be informed and participatory in decision-making through the use of decision aids and preference elicitation tools should be directed toward variation in preference for involvement in decision-making, but not toward patient health literacy. [Orthopedics. 2022;45(4):227-232.].

  View details for DOI 10.3928/01477447-20220401-04

  View details for Web of Science ID 000831125900015

  View details for PubMedID 35394383

• Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS Chou, L. B., Johnson, B., Shapiro, L. M., Pun, S., Cannada, L. K., Chen, A. F., Valone, L. C., Van Nortwick, S. S., Ladd, A. L., Finlay, A. K. 2022; 6 (5)

  View details for DOI 10.5435/JAAOSGlobal-D-22-00031

  View details for Web of Science ID 000810990000001

• Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Chou, L. B., Johnson, B., Shapiro, L. M., Pun, S., Cannada, L. K., Chen, A. F., Valone, L. C., Van Nortwick, S. S., Ladd, A. L., Finlay, A. K. 2022; 6 (5)

  Abstract

  INTRODUCTION: Cancer is the second leading cause of death among women in the United States. Previous studies demonstrate a higher prevalence of cancer among female orthopaedic surgeons. This study aimed to provide an updated prevalence of breast and all-cause cancer among female orthopaedic surgeons using a larger and more current study population.METHODS: We distributed surveys to female orthopaedic surgeons in national orthopaedic specialty societies. Six hundred seventy-two survey responses were collected. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) based on gender-specific, race-specific, and age-specific cancer prevalence statistics in the US population. We compared the distribution of breast cancer risk factors with that of women in the 2018 and 2009 California Health Interview Survey.RESULTS: Fifty-one of the 672 surveyed surgeons reported a diagnosis of invasive cancer. Twenty reported breast cancer with a prevalence higher among female orthopaedic surgeons compared with the US female population (SPR: 2.89, 95% CI: 2.16 to 3.81, P < 0.001). The breast cancer prevalence was also higher among orthopaedic surgeons compared with the US female population (SPR: 3.97, 95% CI: 2.43 to 6.14, P = 0.003).DISCUSSION: The increased prevalence of breast and all-cause cancer among a larger and more diverse cohort of female orthopaedic surgeons confirms previous studies and provides an update regarding a concerning public health issue within this specialty.

  View details for DOI e22.00031

  View details for PubMedID 35587823

• A framework to make PROMs relevant to patients: qualitative study of communication preferences of PROMs. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation Lai, C. H., Shapiro, L. M., Amanatullah, D. F., Chou, L. B., Gardner, M. J., Hu, S. S., Safran, M. R., Kamal, R. N. 2021

  Abstract

  PURPOSE: Patient-reported outcome measures are tools for evaluating symptoms, magnitude of limitations, baseline health status, and outcomes from the patient's perspective. Healthcare professional organizations and payers increasingly recommend PROMs for clinical care, but there lacks guidance regarding effective communication of PROMs with orthopedic surgery patients. This qualitative study aimed to identify (1) patient attitudes toward the use and communication of PROMs, and (2) what patients feel are the most relevant or important aspects of PROM results to discuss with their physicians.METHODS: Participants were recruited from a multispeciality orthopedic clinic. Three PROMs: the EuroQol-5 Dimension, the Patient-Specific Functional Scale, and the Patient-Reported Outcome Measurement Information System Physical Function Computer Adaptive Test were shown and a semi-structured interview was conducted to elicit PROMs attitudes and preferences. Interviews were transcribed and inductive-deductively coded. Coded excerpts were aggregated to (1) identify major themes and (2) analyze how themes interacted.RESULT: Three themes emerged: (1) Beliefs toward the purpose of PROMs, (2) PROMs as a reflection of self, and(3) PROMs to facilitate communication and guide healthcare decisions. These themes informed a framework outlining the patient perspective on communicating PROMs during clinical care.CONCLUSION: Patient attitudes toward the use and communication of PROMs start with the incorporation of patient beliefs, which can facilitate or act as a barrier to engagement. Patients should ideally believe that PROMs are an accurate reflection of personal health state before incorporation into care. Clinicians should endeavor to communicate the purpose of a chosen PROM in line with a patient's unique needs and what they feel is most relevant to their own care. Aspects of PROMs results which may be helpful to address include providing context for what scores mean and how they are calculated, and using scores as a way to weigh risks and benefits of treatment and tracking progress over time. Future research can focus on the effect of communication strategies on patient outcomes and engagement in care.

  View details for DOI 10.1007/s11136-021-02972-5

  View details for PubMedID 34510335

• Multidisciplinary Extremity Preservation Program Improves Quality of Life for Patients With Advanced Limb Threat Fereydooni, A., Yawary, F., Sen, S., Chou, L., Dalman, R. L., Murphy, M., Stern, J. R., Chandra, V. MOSBY-ELSEVIER. 2021: E41-E43

  View details for Web of Science ID 000691401100095

• Short-term outcomes following dehydrated micronized allogenic cartilage versus isolated microfracture for treatment of medial talar osteochondral lesions. Foot and ankle surgery : official journal of the European Society of Foot and Ankle Surgeons Allahabadi, S., Johnson, B., Whitney, M., Oji, D., Chou, L., Lau, B. C. 2021

  Abstract

  BACKGROUND: Osteochondral lesions of the talus (OLTs) have been traditionally treated with bone marrow stimulation techniques such as microfracture. However, conventional microfracture results in a biomechanically weaker repair tissue of predominantly type I collagen. Acellular micronized cartilage matrix (MCM) serves as a bioactive scaffold to restore hyaline cartilage. The purpose was to compare short-term outcomes after microfracture with and without augmentation with MCM for medial-sided OLTs.METHODS: A retrospective review was performed between 2010-2019 for medial-sided OLTs undergoing treatment with either microfracture augmented with MCM or isolated microfracture. The MCM was hydrated with either bone marrow aspirate concentrate (BMAC) or platelet-rich plasma (PRP). Outcomes included visual analogue scale (VAS) pain scores, Foot and Ankle Activity Measure (FAAM) scores, return-to-daily activities, and return-to-sport.RESULTS: 48 patients (14 MCM with PRP, 6 MCM with BMAC; 28 isolated microfracture) with average age 35.5 years (range: 13.8-67.2 years) and mean follow-up 4.0±3.4 years (range,.13-10.7) were included. There was no difference in average lesion size between MCM and microfracture groups (64.0±49.4 mm2 versus 57.3±44.2 mm2, P=.63) and a trend toward larger lesion size for BMAC compared to PRP (106.5±59.2 versus 45.9±32.1 mm2, P=.056). There was no difference in time to return-to-activity (83.5±18.8 versus 87.3±49.1 days) or return-to-sports (151.9±62.2 versus 165±99.2 days) with MCM versus isolated microfracture. However, the MCM group had a significantly greater improvement in VAS pain score at final follow-up (4.9±2.2 versus 2.7±2.6, P=.0032) and significantly higher post-operative FAAM-Activities of Daily Living subscale scores (97.2±8.2 versus 79.7±32.8, P=.033).CONCLUSIONS: Augmenting microfracture with MCM hydrated with PRP or BMAC may result in beneficial changes in pain scores and activities of daily living, but similar return-to-activities and return-to-sport times compared to microfracture alone in management of medial OLT.LEVEL OF EVIDENCE: IV.

  View details for DOI 10.1016/j.fas.2021.07.012

  View details for PubMedID 34366249

• Methods for Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons. The Journal of bone and joint surgery. American volume Van Nortwick, S. S., Leonard, D. A., Finlay, A. K., Chou, L., Valone, L. C. 2021

  Abstract

  BACKGROUND: Standard lead aprons and vests do not adequately shield the most common breast cancer site, the upper outer quadrant (UOQ), from intraoperative radiation. The purpose of the present study was to determine if lead sleeves, wings, and/or axillary supplements decreased intraoperative radiation exposure of the UOQ of the breast.METHODS: An anthropomorphic torso phantom (simulating the female surgeon) was placed adjacent to a standard operating room table. Dosimeters were placed bilaterally over the UOQ of the breast. Scatter radiation dose equivalent rates (mrem/hr) were measured during continuous fluoroscopy of a pelvic phantom (simulating the patient). Five protection configurations (no lead; lead vest; and vest with sleeves, wings, and axillary supplements), 2 surgeon positions (facing the table and perpendicular to the table), and 2 C-arm positions (anteroposterior and cross-table lateral projection) were tested. The t test was utilized with a Bonferroni correction for multiple t tests.RESULTS: Lead sleeves and axillary supplements decreased intraoperative radiation exposure to the UOQ of the breast when compared with a well-fitted standard lead vest alone (p < 0.01) across all surgeon and C-arm positions. The addition of wings decreased radiation exposure to a lesser extent than sleeves or axillary supplements, and the difference when compared with the lead vest alone did not reach significance (p = 0.29). Breast radiation exposure in the C-arm cross-table lateral projection was highest across all testing.CONCLUSIONS: The UOQ of the breast is not adequately protected by standard lead vests alone or vests with the addition of wings. Axillary supplements and sleeves improved protection of the breast.CLINICAL RELEVANCE: Modifications of lead protective vests may improve intraoperative breast radiation protection.

  View details for DOI 10.2106/JBJS.20.02024

  View details for PubMedID 34255759

• Opioid use among patients with pain syndromes commonly seeking surgical consultation: A retrospective cohort. Annals of medicine and surgery (2012) Kin, C., Chou, L., Safer, D. L., Morris, A., Ding, Q., Trickey, A., Girod, S. 2021; 69: 102704

  Abstract

  Surgeons often see patients with pain to exclude organic pathology and consider surgical treatment. We examined factors associated with long-term opioid therapy among patients with foot/ankle, anorectal, and temporomandibular joint pain to aid clinical decision making.Using the IBM MarketScan® Research Database, we conducted a retrospective cohort analysis of patients aged 18-64 with a clinical encounter for foot/ankle, anorectal, or temporomandibular joint pain (January 2007-September 2015). Multivariable logistic regression was used to estimate adjusted odds ratios for factors associated with long-term opioid therapy, including age, sex, geographic region, pain condition, psychiatric diagnoses, and surgical procedures in the previous year.The majority of the cohort of 1,500,392 patients were women (61%). Within the year prior to the first clinical encounter for a pain diagnosis, 14% had an encounter for a psychiatric diagnosis, and 11% had undergone a surgical procedure. Long-term opioid therapy was received by 2.7%. After multivariable adjustment, older age (age 50-64 vs. 18-29: aOR 4.47, 95% CI 4.24-4.72, p < 0.001), region (South vs. Northeast, aOR 1.76, 95% CI 1.70-1.81, p < 0.001), recent surgical procedure (aOR 1.83, 95% CI 1.78-1.87, p < 0.001), male sex (aOR 1.14, 95% CI 1.12-1.16, p < 0.001) and recent psychiatric diagnosis (aOR 2.49, 95% CI 2.43-2.54, p < 0.001) were independently associated with long-term opioid therapy.Among patients with foot/ankle, anorectal, or temporomandibular joint pain, the risk of long-term opioid therapy significantly increased with older age, recent psychiatric diagnoses and surgical history. Surgeons should be aware of these risk factors in order to make high quality clinical decisions in consultations with these patients.

  View details for DOI 10.1016/j.amsu.2021.102704

  View details for PubMedID 34466218

  View details for PubMedCentralID PMC8384768

• Does a Question Prompt List Improve Perceived Involvement in Care in Orthopaedic Surgery Compared with the AskShareKnow Questions? A Pragmatic Randomized Controlled Trial. Clinical orthopaedics and related research Mariano, D. J., Liu, A., Eppler, S. L., Gardner, M. J., Hu, S., Safran, M., Chou, L., Amanatullah, D. F., Kamal, R. N. 2020

  Abstract

  BACKGROUND: Most conditions in orthopaedic surgery are preference-sensitive, where treatment choices are based on the patient's values and preferences. One set of tools increasingly used to help align treatment choices with patient preferences are question prompt lists (QPLs), which are comprehensive lists of potential questions that patients can ask their physicians during their encounters. Whether or not a comprehensive orthopaedic-specific question prompt list would increase patient-perceived involvement in care more effectively than might three generic questions (the AskShareKnow questions) remains unknown; learning the answer would be useful, since a three-question list is easier to use compared with the much lengthier QPLs.QUESTION/PURPOSE: Does an orthopaedic-specific question prompt list increase patient-perceived involvement in care compared with the three generic AskShareKnow questions?METHODS: We performed a pragmatic randomized controlled trial of all new patients visiting a multispecialty orthopaedic clinic. A pragmatic design was used to mimic normal clinical care that compared two clinically acceptable interventions. New patients with common orthopaedic conditions were enrolled between August 2019 and November 2019 and were randomized to receive either the intervention QPL handout (orthopaedic-specific QPL with 45 total questions, developed with similar content and length to prior QPLs used in hand surgery, oncology, and palliative care) or a control handout (the AskShareKnow model questions, which are: "What are my options? What are the benefits and harms of those options? How likely are each of those benefits and harms to happen to me?") before their visits. A total of 156 patients were enrolled, with 78 in each group. There were no demographic differences between the study and control groups in terms of key variables. After the visit, patients completed the Perceived Involvement in Care Scale (PICS), a validated instrument designed to evaluate patient-perceived involvement in their care, which served as the primary outcome measure. This instrument is scored from 0 to 13, with higher scores indicating higher perceived involvement.RESULTS: There was no difference in mean PICS scores between the intervention and control groups (QPL 8.3 ± 2.3, control 8.5 ± 2.3, mean difference 0.2 [95% CI -0.53 to 0.93 ]; p = 0.71.CONCLUSION: In patients undergoing orthopaedic surgery, a QPL does not increase patient-perceived involvement in care compared with providing patients the three AskShareKnow questions. Implementation of the three AskShareKnow questions can be a more efficient way to improve patient-perceived involvement in their care compared with a lengthy QPL.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for DOI 10.1097/CORR.0000000000001582

  View details for PubMedID 33239521

• The Importance of Concordance Between Patients and Their Subspecialists ORTHOPEDICS Shah, R. F., Mertz, K., Gil, J. A., Eppler, S. L., Amanatullah, D., Yao, J., Chou, L., Steffner, R., Safran, M., Hu, S. S., Kamal, R. N. 2020; 43 (5): 315-+

  Abstract

  Concordance, the concept of patients having shared demographic/socioeconomic characteristics with their physicians, has been associated with improved patient satisfaction and outcomes in primary care but has not been studied in subspecialty care. The objective of this study was to investigate whether patients value concordance with their specialty physicians. The authors assessed the importance of concordance in subspecialist care in 2 cohorts of participants. The first cohort consisted of patients seeking care at a multispecialty orthopedic clinic. The second cohort consisted of volunteer participants recruited from an online platform. Each participant completed a survey scored on an ordinal scale which characteristics of their physicians they find important for their primary care physician (PCP) and a specialist. The characteristics included age, sex, ethnicity, sexual orientation, primary language spoken, and religion. The difference in concordance scores for PCPs and specialists were compared with paired t tests with a Bonferroni correction. A total of 118 patients were recruited in clinic, and a total of 982 volunteers were recruited online. In the clinic cohort, the level of importance for patient-physician concordance of age, ethnicity, language, and religion was not significantly different between PCPs and specialists. In the volunteer cohort, the level of importance for concordance of age, sex, national origin, language, and religion was not significantly different between PCPs and specialists. The volunteers recruited online had significantly higher concordance scores than the patients recruited in clinic for most variables. Patients find patient-physician concordance as important in specialty care as they do in primary care. This may have similar effects on patient outcomes in specialty care. [Orthopedics. 2020;43(5):315-319.].

  View details for DOI 10.3928/01477447-20200818-01

  View details for Web of Science ID 000608158400032

  View details for PubMedID 32931591

• Radiation Exposure and Case Characteristics in National Sample of Female Orthopaedic Trauma and Arthroplasty Surgeons. The Iowa orthopaedic journal Lai, C. H., Finlay, A., Cannada, L. K., Chen, A. F., Chou, L. B. 2020; 40 (1): 5–11

  Abstract

  Background: The risks of radiation exposure in orthopaedic surgery have become a topic of increasing interest in the setting of widespread fluoroscopy use and concern for an increased prevalence of breast cancer among female orthopaedic surgeons. The aim of this national study of 31 female orthopaedic surgeons was to achieve a deeper understanding of fluoroscopic use in the OR and its associated exposure to radiation, by comparing female orthopaedic trauma and arthroplasty surgeons.Methods: A total of 31 surgeons wore dosimeters for 10 operating days each to track cumulative radiation exposure. Surgeons were not asked to modify their practice in any way, with no requirement that the operating days had to be chosen with the knowledge that fluoroscopy would be used. Participants were also asked to fill out a form at the end of each day, detailing the number of cases that day, the number of hours spent in the OR, and the total amount of time using fluoroscopy.Results: Trauma surgeons received significantly higher radiation doses in the OR (p=0.01) and reported longer use of fluoroscopy (p<0.001). Trauma surgeons also spent more time per day in the OR and had more cases per day compared to arthroplasty surgeons, but this difference was not significant. Radiation dose penetrating through protective equipment remained minimal.Conclusion: Although the female trauma surgeons in the study operated longer and performed more procedures per day, the higher radiation exposure was best explained by the amount of time fluoroscopy is used in the OR. The fluoroscopic times in this study therefore may be a useful self-assessment tool for attending trauma and arthroplasty surgeons. Awareness of these differences will hopefully increase an individual surgeon's mindfulness toward the length of fluoroscopy use in each case, regardless of orthopaedic subspecialty.Level of Evidence: IV.

  View details for PubMedID 32742202

• The Association of Financial Distress With Disability in Orthopaedic Surgery. The Journal of the American Academy of Orthopaedic Surgeons Mertz, K., Eppler, S. L., Thomas, K., Alokozai, A., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. N. 2019; 27 (11): e522–e528

  Abstract

  INTRODUCTION: Increased out-of-pocket costs have led to patients bearing more of the financial burden for their care. Previous work has shown that financial burden and distress can affect outcomes, symptoms, satisfaction, and adherence to treatment. We asked the following questions: (1) Does patients' financial distress correlate with disability in patients with nonacute orthopaedic conditions? (2) Do patient demographic factors affect this correlation?METHODS: We conducted a cross-sectional, observational study of new patients presenting to a multispecialty orthopaedic clinic with a nonacute orthopaedic complication. Patients completed a demographics questionnaire, the InCharge Financial Distress/Financial Well-Being Scale, and the Health Assessment Questionnaire Disability Index. Statistical analysis was done using Pearson's correlation.RESULTS: The mean score for financial distress was 4.10 (SD, 2.09; scale 1 [low distress] to 10 [high distress]; range, 1.13 to 10.0), and the mean disability score was 0.54 (SD, 0.65; scale 0 to 3; range, 0 to 2.75). A moderate positive correlation exists between financial distress and disability (r = 0.43; P < 0.01). Financial distress and disability were highest for poor, uneducated, Medicare patients.CONCLUSIONS: A moderate correlation exists between financial distress and disability in patients with nonacute orthopaedic conditions, particularly in patients with low socioeconomic status. Orthopaedic surgeons may benefit from identifying patients in financial distress and discussing the cost of treatment because of its association with disability and potentially inferior outcomes. Further investigation is needed to test whether decreasing financial distress decreases disability.LEVEL OF EVIDENCE: Level III prospective cohort.

  View details for DOI 10.5435/JAAOS-D-18-00252

  View details for PubMedID 31125323

• Ankle joint contact loads and displacement in syndesmosis injuries repaired with Tightropes compared to screw fixation in a static model. Injury Pang, E. Q., Bedigrew, K. n., Palanca, A. n., Behn, A. W., Hunt, K. J., Chou, L. n. 2019

  Abstract

  The effect of syndesmotic fixation on restoration of pressure mechanics in the setting of a syndesmotic injury is largely unknown. The purpose of this study is to examine the contact mechanics of the tibiotalar joint following syndesmosis fixation with screws versus a flexible fixation device for complete syndesmotic injury.Six matched pairs of cadaveric below knee specimens were dissected and motion capture trackers were fixed to the tibia, fibula, and talus and a pressure sensor was placed in the tibiotalar joint. Each specimen was first tested intact with axial compressive load followed by external rotation while maintaining axial compression. Next, syndesmotic ligaments were sectioned and randomly assigned to repair with either two TightRopes® or two 3.5 mm cortical screws and the protocol was repeated. Mean contact pressure, peak pressure, reduction in contact area, translation of the center of pressure, and relative talar and fibular motion were calculated. Specimens were then cyclically loaded in external rotation and surviving specimens were loaded in external rotation to failure.No differences in pressure measurements were observed between the intact and instrumented states during axial load. Mean contact presure relative to intact testing was increased in the screw group at 5 Nm and 7.5 Nm torque. Likewise, peak pressure was increased in the TightRope group at 7.5 Nm torque. There was no change in center of pressure in the TightRope group at any threshold; however, at every threshold tested there was significant medial and anterior translation in the screw group relative to the intact state.Either screws or TightRope fixation is adequate with AL alone. With lower amounts of torque, the TightRope group appears to have contact and pressure mechanics that more closely match native mechanics.

  View details for DOI 10.1016/j.injury.2019.09.012

  View details for PubMedID 31547966

• Quality Measures in Foot and Ankle Care. The Journal of the American Academy of Orthopaedic Surgeons Xiong, G., Bennett, C. G., Chou, L., Kamal, R. N. 2018

  Abstract

  BACKGROUND: Quality measures may be operationalized in payment models or quality reporting programs to assess foot and ankle surgeons, but if existing measures allow accurate representation of a foot and ankle surgeon's practice is unclear.METHODS: National quality measures databases, clinical guidelines, and MEDLINE/PubMed were systematically reviewed for quality measures relevant to foot and ankle care. Measures meeting internal criteria were categorized by clinical diagnosis, National Quality Strategy priority, and Donabedian domain.RESULTS: Of 12 quality measures and 16 candidate measures, National Quality Strategy priorities most commonly addressed "Effective Clinical Care" (n = 19) and "Communication and Coordination of Care" (n = 6). Donabedian classifications addressed were process (n = 25) and outcome (n = 3). Diabetic foot care was most commonly addressed (n = 18).CONCLUSIONS: Available foot and ankle quality measures are limited in number and scope, which may hinder appropriate assessment of care, analysis of trends, and quality improvement. Additional measures are needed to support the transition to a value-based system.LEVEL OF EVIDENCE: Level I.

  View details for DOI 10.5435/JAAOS-D-17-00733

  View details for PubMedID 30325881

• Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018; 476 (9): 1859–65

  View details for DOI 10.1097/CORR.0000000000000365

  View details for Web of Science ID 000452513200030

• Postoperative Pain After Surgical Treatment of Ankle Fractures: A Prospective Study JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS Chou, L. B., Niu, E. L., Williams, A. A., Duester, R., Anderson, S. E., Harris, A. H. S., Hunt, K. J. 2018; 2 (9)

  View details for DOI 10.5435/JAAOSGlobal-D-18-00021

  View details for Web of Science ID 000461099100002

• Postoperative Pain After Surgical Treatment of Ankle Fractures: A Prospective Study. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews Chou, L. B., Niu, E. L., Williams, A. A., Duester, R., Anderson, S. E., Harris, A. H., Hunt, K. J. 2018; 2 (9): e021

  Abstract

  Background: Postoperative pain after fixation of ankle fractures has a substantial effect on surgical outcome and patient satisfaction. Patients requiring large amounts of narcotics are at higher risk of long-term use of pain medications. Few prospective studies investigate patient pain experience in the management of ankle fractures.Methods: We prospectively evaluated the pain experience in 63 patients undergoing open reduction and internal fixation of ankle. The Short-Form McGill Pain Questionnaire was administered preoperatively and postoperatively (PP) at 3 days (3dPP) and 6 weeks (6wPP). Anticipated postoperative pain (APP) was recorded.Results: No significant differences were found between PP, APP, and 3dPP; however, 6wPP was markedly lower. Significant correlations were found between PP and APP and between preoperative and postoperative Short-Form McGill Pain Questionnaire scores. PP and APP were independent predictors of 3dPP; however, only APP was predictive of 6wPP. Sex, age, and inpatient versus outpatient status were not notable factors. No statistically significant differences were found in pain scores between fracture types.Conclusions: Both preoperative pain severity and anticipated postoperative pain are predictive of postoperative pain levels. Orthopaedic surgeons should place a greater focus on the postoperative management of patient pain and expectations after surgical procedures.

  View details for PubMedID 30465035

• Patient Perceptions Correlate Weakly With Observed Patient Involvement in Decision-making in Orthopaedic Surgery. Clinical orthopaedics and related research Mertz, K., Eppler, S., Yao, J., Amanatullah, D. F., Chou, L., Wood, K. B., Safran, M., Steffner, R., Gardner, M., Kamal, R. 2018

  Abstract

  BACKGROUND: Shared decision-making between patients and physicians involves educating the patient, providing options, eliciting patient preferences, and reaching agreement on a decision. There are different ways to measure shared decision-making, including patient involvement, but there is no consensus on the best approach. In other fields, there have been varying relationships between patient-perceived involvement and observed patient involvement in shared decision-making. The relationship between observed and patient-perceived patient involvement in decision-making has not been studied in orthopaedic surgery.QUESTIONS/PURPOSES: (1) Does patient-perceived involvement correlate with observed measurements of patient involvement in decision-making in orthopaedic surgery? (2) Are patient demographics associated with perceived and observed measurements of patient involvement in decision-making?METHODS: We performed a prospective, observational study to compare observed and perceived patient involvement in new patient consultations for eight orthopaedic surgeons in subspecialties including hand/upper extremity, total joint arthroplasty, spine, sports, trauma, foot and ankle, and tumor. We enrolled 117 English-literate patients 18 years or older over an enrollment period of 2 months. A member of the research team assessed observed patient involvement during a consultation with the Observing Patient Involvement in Decision-Making (OPTION) instrument (scaled 1-100 with higher scores representing greater involvement). After the consultation, we asked patients to complete a questionnaire with demographic information including age, sex, race, education, income, marital status, employment status, and injury type. Patients also completed the Perceived Involvement in Care Scale (PICS), which measures patient-perceived involvement (scaled 1-13 with higher scores representing greater involvement). Both instruments are validated in multiple studies in various specialties and the physicians were blinded to the instruments used. We assessed the correlation between observed and patient-perceived involvement as well as tested the association between patient demographics and patient involvement scores.RESULTS: There was weak correlation between observed involvement (OPTION) and patient-perceived involvement (PICS) (r = 0.37, p < 0.01) in decision-making (mean OPTION, 28.7, SD 7.7; mean PICS, 8.43, SD 2.3). We found a low degree of observed patient involvement despite a moderate to high degree of perceived involvement. No patient demographic factor had a significant association with patient involvement.CONCLUSIONS: Further work is needed to identify the best method for evaluating patient involvement in decision-making in the setting of discordance between observed and patient-perceived measurements. Knowing whether it is necessary for (1) actual observable patient involvement to occur; or (2) a patient to simply believe they are involved in their care can inform physicians on the best way to improve shared decision-making in their practice.LEVEL OF EVIDENCE: Level II, therapeutic study.

  View details for PubMedID 29965894

• Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture. journal of the American Academy of Orthopaedic Surgeons Truntzer, J. N., Triana, B., Harris, A. H., Baker, L., Chou, L., Kamal, R. N. 2017; 25 (6): 449-457

  Abstract

  Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.From the payer's perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.III, Economic Decision Analysis.

  View details for DOI 10.5435/JAAOS-D-16-00553

  View details for PubMedID 28459710

• Association of Short-term Complications With Procedures Through Separate Incisions During Total Ankle Replacement FOOT & ANKLE INTERNATIONAL Criswell, B., Hunt, K., Kim, T., Chou, L., Haskell, A. 2016; 37 (10): 1060–64

  Abstract

  Surgeons disagree about the safety of adding adjuvant procedures requiring separate incisions during total ankle replacement (TAR). This study tested the hypothesis that complication rates for patients in the first year after TAR would be greater when combined with procedures through separate incisions.A retrospective review was performed on a consecutive series of 124 patients who underwent total ankle replacement between 2007 and 2013. Demographics, case-specific data, and postoperative complications over the first year were collected. A chi-square analysis was performed to compare differences in complication rates among patients with and without additional procedures requiring a separate incision. The average patient age was 67±10 years. Fourteen patients (11%) were diabetic and 2 patients (2%) were current smokers. Eighty-seven (70%) had prior trauma leading to arthritis. Ninety-seven (78%) cases used the Scandinavian Total Ankle Replacement (STAR), 16 (13%) Salto Talaris, and 11 (9%) In Bone implants. Ten (8%) cases were revisions. Excluding percutaneous Achilles lengthening, 35 of 124 patients (28%) had a total of 54 adjuvant procedures requiring a separate incision during TAR. These included 9 (7%) calcaneal osteotomies, 8 (6%) medial malleolar fixation, 6 (5%) subtalar fusions, 5 (4%) lateral ligament repair, 4 (3%) open Achilles lengthening, 4 (3%) removal of hardware, 2 (2%) first metatarsal osteotomy, and 8 other procedures.Overall, 32 (26%) of the 124 patients had a complication, including 15 (12%) delayed wound healing, 6 (5%) malleolar fracture, and 11 other complications. At 1 year, 24 (27%) of 89 patients without additional incisions and 8 (23%) of 35 patients with additional incisions, excluding percutaneous Achilles lengthening, had any complication (P = .64).This study did not demonstrate an association between additional procedures requiring a separate incision during TAR and early complications. Overall complication rates were similar to previously reported series of TAR. This study suggests that surgeons can add adjuvant procedures during TAR to improve alignment, stability, or treat adjacent segment arthritis without affecting short-term complication rates. The necessity or utility of these adjuvant procedures requires further study.Level III, comparative series.

  View details for PubMedID 27283155

• Ankle Joint Contact Loads and Displacement With Progressive Syndesmotic Injury FOOT & ANKLE INTERNATIONAL Hunt, K. J., Goeb, Y., Behn, A. W., Criswell, B., Chou, L. 2015; 36 (9): 1095-1103

  Abstract

  Ligamentous injuries to the distal tibiofibular syndesmosis are predictive of long-term ankle dysfunction. Mild and moderate syndesmotic injuries are difficult to stratify, and the impact of syndesmosis injury on the magnitude and distribution of forces within the ankle joint during athletic activities is unknown.Eight below-knee cadaveric specimens were tested in the intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular, anterior deltoid (1 cm), interosseous/transverse (IOL/TL), posterior-inferior tibiofibular, and whole deltoid. In each condition, specimens were loaded in axial compression to 700 N and then externally rotated to 20 N·m torque.During axial loading and external rotation, both the fibula and the talus rotated significantly after each ligament sectioning as compared to the intact condition. After IOL/TL release, a significant increase in posterior translation of the fibula was observed, although no syndesmotic widening was observed. Mean tibiotalar contact pressure increased significantly after IOL/TL release, and the center of pressure shifted posterolaterally, relative to more stable conditions, after IOL/TL release. There were significant increases in mean contact pressure and peak pressure along with a reduction in contact area with axial loading and external rotation as compared to axial loading alone for all 5 conditions.Significant increases in tibiotalar contact pressures occur when external rotation stresses are added to axial loading. Moderate and severe injuries are associated with a significant increase in mean contact pressure combined with a shift in the center of pressure and rotation of the fibula and talus.Considerable changes in ankle joint kinematics and contact mechanics may explain why moderate syndesmosis injuries take longer to heal and are more likely to develop long-term dysfunction and, potentially, ankle arthritis.

  View details for DOI 10.1177/1071100715583456

  View details for Web of Science ID 000360624300016

• Ankle Joint Contact Loads and Displacement With Progressive Syndesmotic Injury. Foot & ankle international Hunt, K. J., Goeb, Y., Behn, A. W., Criswell, B., Chou, L. 2015; 36 (9): 1095-1103

  Abstract

  Ligamentous injuries to the distal tibiofibular syndesmosis are predictive of long-term ankle dysfunction. Mild and moderate syndesmotic injuries are difficult to stratify, and the impact of syndesmosis injury on the magnitude and distribution of forces within the ankle joint during athletic activities is unknown.Eight below-knee cadaveric specimens were tested in the intact state and after sequential sectioning of the following ligaments: anterior-inferior tibiofibular, anterior deltoid (1 cm), interosseous/transverse (IOL/TL), posterior-inferior tibiofibular, and whole deltoid. In each condition, specimens were loaded in axial compression to 700 N and then externally rotated to 20 N·m torque.During axial loading and external rotation, both the fibula and the talus rotated significantly after each ligament sectioning as compared to the intact condition. After IOL/TL release, a significant increase in posterior translation of the fibula was observed, although no syndesmotic widening was observed. Mean tibiotalar contact pressure increased significantly after IOL/TL release, and the center of pressure shifted posterolaterally, relative to more stable conditions, after IOL/TL release. There were significant increases in mean contact pressure and peak pressure along with a reduction in contact area with axial loading and external rotation as compared to axial loading alone for all 5 conditions.Significant increases in tibiotalar contact pressures occur when external rotation stresses are added to axial loading. Moderate and severe injuries are associated with a significant increase in mean contact pressure combined with a shift in the center of pressure and rotation of the fibula and talus.Considerable changes in ankle joint kinematics and contact mechanics may explain why moderate syndesmosis injuries take longer to heal and are more likely to develop long-term dysfunction and, potentially, ankle arthritis.

  View details for DOI 10.1177/1071100715583456

  View details for PubMedID 25948693

• Cancer Prevalence among a Cross-sectional Survey of Female Orthopedic, Urology, and Plastic Surgeons in the United States. Women's health issues : official publication of the Jacobs Institute of Women's Health Chou, L. B., Lerner, L. B., Harris, A. H., Brandon, A. J., Girod, S., Butler, L. M. 2015; 25 (5): 476-481

  Abstract

  Exposure to ionizing radiation from fluoroscopy performed during surgery, although low and within established limits, remains a health concern among surgeons. Estimates of breast cancer prevalence among women across surgery specialties with different patterns of fluoroscopy use are needed to evaluate this concern.Female U.S. surgeons in urology, plastics, and orthopedics were identified using national directories and mailed surveys to collect information on occupational and medical history, including cancer diagnoses. Standardized prevalence ratios (SPRs) and 95% CIs were calculated by dividing the observed number of cancers among female surgeons in each specialty by the expected number, based on the gender-specific, age-specific, and race-specific cancer prevalence statistics in the general U.S.Standard fluoroscopy use more than once per week was common among urologists (54%) and orthopedists (37%); the same frequency of mini fluoroscopy use was only common among orthopedics (31%) and hardly ever used by urologists. Plastic surgeons reported very infrequent use of any fluoroscopy. For orthopedic surgeons, a significantly greater than expected prevalence of any cancer (SPR, 1.85; 95% CI, 1.19-2.76) and breast cancer (SPR, 2.90; 95% CI, 1.66-4.71) were observed. There was no difference between the observed and expected prevalence of any cancer or breast cancer for urology or plastics.Using the first available cancer prevalence data comparing female surgeons across three specialties, we report that orthopedic surgeons have a greater than expected prevalence of cancer that may or may not be owing to occupational exposure to ionizing radiation.

  View details for DOI 10.1016/j.whi.2015.05.005

  View details for PubMedID 26265543

• Locked Versus Nonlocked Plate Fixation for First Metatarsophalangeal Arthrodesis: A Biomechanical Investigation FOOT & ANKLE INTERNATIONAL Hunt, K. J., Barr, C. R., Lindsey, D. P., Chou, L. B. 2012; 33 (11): 984-990

  Abstract

  First metatarsophalangeal (MTP) arthrodesis using dorsal plate fixation is a common procedure for painful conditions of the great toe. Locked plates have become increasingly common for arthrodesis procedures in the foot, including the hallux MTP joint. The biomechanical advantages and disadvantages of these plates are currently unknown. The purpose of this study was to compare locked and nonlocked plates used for first MTP fusion for strength and stiffness.The first ray of nine matched pairs of fresh-frozen cadaveric feet underwent dissection, preparation with cup-and-cone reamers, and fixation of the MTP joint with a compression screw and either a nonlocked or locked stainless steel dorsal plate. Each specimen was loaded in a cantilever fashion to 90 N at a rate of 3 Hz for a total of 250,000 cycles. The amount of plantar MTP gap was recorded using a calibrated extensometer. Load-to-failure testing was performed for all specimens that endured the entire cyclical loading. Stiffness was calculated from the final load-to-failure test.The locked plate group demonstrated significantly less plantar gapping during fatigue endurance testing from cycle 10,000 through 250,000 (p < .05). Mean stiffness was significantly greater in the locked plate group compared with the nonlocked plate group (p = .02). There was no significant difference in load to failure between the two groups (p = .27).Compared with nonlocked plates, locked hallux MTP arthrodesis plates exhibited significantly less plantar gapping after 10,000 cycles of fatigue endurance testing and significantly greater stiffness in load-to-failure testing.As the use of locked plate technology is becoming increasingly common for applications in the foot, a thorough understanding of the biomechanical characteristics of these implants may help optimize their indications and clinical use.

  View details for DOI 10.3113/FAI.2012.0984

  View details for PubMedID 23131445

• The Benefits of Implant Removal from the Foot and Ankle JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Williams, A. A., Witten, D. M., Duester, R., Chou, L. B. 2012; 94A (14): 1316-1320

  Abstract

  Following successful orthopaedic surgical procedures, implant removal is generally not necessary or recommended. However, patients with pain related to implants may benefit from this elective procedure. The foot and ankle may be more symptomatic from retained implants because of weight-bearing activities, shoe wear, and limited soft-tissue cushioning. In such cases, implant removal may provide good and reliable relief of symptoms.A prospective study of sixty-nine patients who underwent elective removal of symptomatic implants from the foot and ankle was undertaken to evaluate the patients' pain experience. The short-form McGill pain questionnaire was administered preoperatively and six weeks postoperatively. Postoperatively, patients were also asked whether they would repeat the procedure and whether they were satisfied with the results.Patients reported significantly less pain following the procedure, with the average rating of pain on the visual analog scale (VAS) decreasing from 3.06 to 0.88 and the average rating of present pain intensity decreasing from 2.03 to 0.58 (p < 0.05 for both). Sixty-five percent of the patients reported no pain on either measure at six weeks postoperatively. Preoperative pain was correlated with postoperative pain (r = 0.24 and p < 0.05 for VAS, and r = 0.16 and p > 0.05 for present pain intensity).With the small sample size, preoperative and postoperative pain did not show a significant difference on the basis of implant location or patient age or sex. Ninety-four percent of patients said they would repeat the procedure under the same circumstances, and 91% of patients were satisfied with the results.Following successful orthopaedic surgical procedures, removal of implants causing symptoms can result in pain relief and a high rate of patient satisfaction.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.J.01756

  View details for Web of Science ID 000306725700010

• The benefits of implant removal from the foot and ankle. The Journal of bone and joint surgery. American volume Williams, A. A., Witten, D. M., Duester, R., Chou, L. B. 2012; 94 (14): 1316-20

  Abstract

  Following successful orthopaedic surgical procedures, implant removal is generally not necessary or recommended. However, patients with pain related to implants may benefit from this elective procedure. The foot and ankle may be more symptomatic from retained implants because of weight-bearing activities, shoe wear, and limited soft-tissue cushioning. In such cases, implant removal may provide good and reliable relief of symptoms.A prospective study of sixty-nine patients who underwent elective removal of symptomatic implants from the foot and ankle was undertaken to evaluate the patients' pain experience. The short-form McGill pain questionnaire was administered preoperatively and six weeks postoperatively. Postoperatively, patients were also asked whether they would repeat the procedure and whether they were satisfied with the results.Patients reported significantly less pain following the procedure, with the average rating of pain on the visual analog scale (VAS) decreasing from 3.06 to 0.88 and the average rating of present pain intensity decreasing from 2.03 to 0.58 (p < 0.05 for both). Sixty-five percent of the patients reported no pain on either measure at six weeks postoperatively. Preoperative pain was correlated with postoperative pain (r = 0.24 and p < 0.05 for VAS, and r = 0.16 and p > 0.05 for present pain intensity).With the small sample size, preoperative and postoperative pain did not show a significant difference on the basis of implant location or patient age or sex. Ninety-four percent of patients said they would repeat the procedure under the same circumstances, and 91% of patients were satisfied with the results.Following successful orthopaedic surgical procedures, removal of implants causing symptoms can result in pain relief and a high rate of patient satisfaction.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.2106/JBJS.J.01756

  View details for PubMedID 22810403

• Increased Breast Cancer Prevalence Among Female Orthopedic Surgeons JOURNAL OF WOMENS HEALTH Chou, L. B., Chandran, S., Harris, A. H., Tung, J., Butler, L. M. 2012; 21 (6): 683-689

  Abstract

  As a result of low-dose ionizing radiation exposure during clinical practice, female orthopaedic surgeons may be at increased risk for breast cancer.The 2009 American Academy of Orthopaedic Surgeons (AAOS) membership directory was used to mail a survey to all female AAOS fellows. Survey responses were collected between June 2009 and June 2010 among 505 (69.7%) of the eligible women. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) by dividing the observed number of cancers among female orthopaedic surgeons by the expected number, based on the gender-specific, age-specific, and race-specific cancer prevalence statistics in the general U.S. population. We compared the distribution of breast cancer risk factors in our study population to that of the women in the 2007 California Health Interview Survey (CHIS, n=30,541).Twenty-four women reported a prior diagnosis of invasive cancer. Female orthopaedic surgeons had a prevalence of cancer that was 85% higher than that of the general U.S. female population (SPR 1.85, 95% CI 1.19-2.76). Orthopaedic surgeons in our study also had a statistically significant 2.9-fold higher prevalence of breast cancer compared to the general U.S. female population (SPR 2.9, 95% CI 1.66-4.71). Survey respondents had a higher prevalence of both protective and predisposing breast cancer factors compared to California women.Our findings confirm that breast cancer prevalence is elevated among female orthopaedic surgeons. Although further research is needed to determine the factors behind this population's hypothesized increased risk, taken together, our results and others suggest that the orthopaedic community consider educating current practitioners of the use of protective shielding and other modifiable breast cancer risk factors.

  View details for DOI 10.1089/jwh.2011.3342

  View details for PubMedID 22432467

• Foot and Ankle Questions on the Orthopaedic In-Training Examination: Analysis of Content, Reference, and Performance ORTHOPEDICS Barr, C. R., Cheng, I., Chou, L. B., Hunt, K. J. 2012; 35 (6): E880-E888

  Abstract

  The purpose of this study was to provide a comprehensive analysis of the Orthopaedic In-Training Examination's (OITE's) questions, question sources, and resident performance over the course of residency training.The authors analyzed all OITE questions pertaining to foot and ankle surgery between 2006 and 2010. Recorded data included the topic and area tested, imaging modality used, tested treatment method, taxonomic classification, cited references, and resident performance scores. Foot- and ankle-related questions made up 13.9% (186/1341) of the OITE questions. Thirteen general topic areas were identified, with the most common being foot and ankle trauma, the pediatric foot, and foot and ankle deformity. Imaging modalities were tested in approximately half of the questions. Knowledge of treatment modalities was required in 58.1% (108/186) of the questions. Recall-type questions were the most common. Trends existed in the recommended references, with 2 journals and 1 textbook being commonly and consistently cited: Foot and Ankle International, The Journal of Bone and Joint Surgery American Volume, and Surgery of the Foot and Ankle, respectively. Resident performance scores increased with each successive level of training.An understanding of the topics and resources used for OITE foot and ankle questions is an important aid in creating or improving residency programs' foot and ankle education curricula. With knowledge of question content, source, and resident performance, education can be optimized toward efficient learning and improved scores on this section of the examination.

  View details for DOI 10.3928/01477447-20120525-28

  View details for PubMedID 22691661

• Supercharged Free Fibula for Complex Ankle Arthrodesis A Case Report ANNALS OF PLASTIC SURGERY Fox, P. M., Chou, L., Lee, G. K. 2012; 68 (4): 342-345

  Abstract

  We report the successful use of a supercharged free fibula for tibial reconstruction and ankle arthrodesis. A 28-year-old woman underwent resection of a giant cell tumor of the distal tibia and reconstruction using a methyl methacrylate cement spacer 12 years prior. The spacer eroded into her ankle joint causing significant pain with ambulation. Therefore, she required ankle arthrodesis but lacked distal tibia bone stock. The ipsilateral fibula was harvested for reconstruction and transferred on its distal blood supply into the bony tibial defect. The proximal blood supply of the fibula flap was then anastomosed to the posterior tibial vessels to supercharge the blood supply. An Ilizarov was placed for external fixation. The combination of a supercharged free fibula and stable external fixation for tibial reconstruction led to timely bony union and ambulation, as well as avoiding the potential complications that can occur with other reconstructive options.

  View details for DOI 10.1097/SAP.0b013e31824189d0

  View details for PubMedID 22421475

• Osteochondral Lesions of the Talus Effect of Defect Size and Plantarflexion Angle on Ankle Joint Stresses AMERICAN JOURNAL OF SPORTS MEDICINE Hunt, K. J., Lee, A. T., Lindsey, D. P., Slikker, W., Chou, L. B. 2012; 40 (4): 895-901

  Abstract

  Osteochondral lesions of the talus (OLTs) are a common cause of ankle pain and disability. Current clinical guidelines favor autogenous or allogenic osteochondral grafting procedures for lesions larger than 10 mm in diameter because of increased failure rates in these larger lesions with arthroscopic debridement, curettage, and microfracture. There are currently no biomechanical data nor level I clinical data supporting this size threshold.The purpose of this study was to determine the effect of OLT defect size on stress concentration, rim stress, and location of peak stress and whether a threshold defect size exists.Descriptive laboratory study.Progressively larger medial OLTs were created (6, 8, 10, and 12 mm) in 8 fresh-frozen cadaveric ankle joints. With a calibrated Tekscan pressure sensor in the tibiotalar joint, an axial load of 686 N was applied, and pressure was recorded in neutral and 15° of plantar flexion with each defect size. Peak stress, contact area, peak and average rim stresses, and location of peak stress were determined.The distance between peak stress and defect rim was significantly decreased with increasing defect size for lesions of 10 mm and larger. Total tibiotalar contact area was significantly decreased with increasing defect size and with ankle plantar flexion. While peak joint stress and peak rim stress were not affected by defect size or plantar flexion, average rim stress was significantly increased by plantar flexion.Reduction in contact area and shift in the location of peak stress with increasing defect size may contribute to articular cartilage degeneration, pain, and defect enlargement in patients with OLTs. There appears to be a threshold of 10 mm after which the distance between the rim of the defect and the peak stress decreases; however, there is no change in peak stress magnitude with increasing defect size.The location of peak stress in the ankle joint becomes closer to the rim of the defect in OLTs at a threshold of 10 mm and greater in diameter. These data may have implications toward OLT size thresholds for surgical decision making in symptomatic lesions (ie, primary osteochondral transplantation procedure vs curettage and debridement). The ultimate goal is to determine whether there is a threshold defect size for primary osteoarticular graft techniques.

  View details for DOI 10.1177/0363546511434404

  View details for PubMedID 22366518

• Current Concepts Review: Intra-Articular Fractures of the Calcaneus FOOT & ANKLE INTERNATIONAL Epstein, N., Chandran, S., Chou, L. 2012; 33 (1): 79-86

  Abstract

  1) Intra-articular fractures of the calcaneus are associated with severe long-term consequences for function and pain. The condition of the soft tissues is of paramount importance when determining the method of treatment,the timing of surgery, and the post-injury rehabilitation.2) Intra-articular fractures are difficult to fully evaluate with plain radiographs. Computed tomography may assist in assessing the fracture pattern and planning for surgery. The likelihood of a good to excellent outcome is increased when an anatomic reduction is obtained.3) The outcome after operative management is difficult to characterize and appears to be influenced by factors related to the fracture, the patient, and the experience of the institution where the patient obtains treatment.All these factors should be factors in the decision to operate, but no single factor reliably determines the most appropriate treatment.4) Open reduction and internal fixation through an extensile approach achieves acceptable results in carefully selected patients. The use of a limited exposure with minimally invasive techniques may decrease the incidence of wound complications. However, this option is technically demanding and the quality of the reduction achieved may be more difficult to obtain and determine intraoperatively. Open fractures should be promptly debrided. The choice of fixation after reduction is based on the surgeons assessment of the soft tissue and the risk of infection.5) Post-traumatic arthritis of the subtalar joint is a common complication. Successful salvage can be achieved with a subtalar arthrodesis. However, these results may be influenced by the institution at which the initial management was rendered.

  View details for DOI 10.3113/FAI.2012.0079

  View details for PubMedID 22381241

• Influence of Stretching and Warm-Up on Achilles Tendon Material Properties FOOT & ANKLE INTERNATIONAL Park, D. Y., Rubenson, J., Carr, A., Mattson, J., Besier, T., Chou, L. B. 2011; 32 (4): 407-413

  Abstract

  Controversy exists on stretching and warm-up in injury prevention. We hypothesized that warm up has a greater effect on Achilles tendon biomechanics than static stretching. This study investigated static stretching and warm-up on Achilles tendon biomechanics in recreational athletes, in vivo.Ten active, healthy subjects, 5 males, 5 females, With a mean age of 22.9 years with no previous Achilles tendon injuries were recruited. Typical stretching and warm-up routines were created. Testing was performed in a randomized cross-over design. A custom-built dynamometer was utilized to perform controlled isometric plantarflexion. A low profile ultrasound probe was utilized to visualize the musculotendinous junction of the medial gastrocnemius. An eight-camera motion capture system was used to capture ankle motion. Custom software calculated Achilles tendon biomechanics.Achilles tendon force production was consistent. No statistically significant differences were detected in stretch, stiffness, and strain between pre-, post-stretching, and post-warm-up interventions.Stretching or warm-up alone, and combined did not demonstrate statistically significant differences. Stretching and warm-up may have an equivalent effect on Achilles tendon biomechanics. Prolonged and more intense protocols may be required for changes to occur.Stretching and warm-up of the Achilles before exercise are commonly practiced. Investigating the effect of stretching and warm-up may shed light on potential injury prevention.

  View details for DOI 10.3113/FAI.2011.0407

  View details for PubMedID 21733444

• Biomechanical Comparison of Blade Plate and Intramedullary Nail Fixation for Tibiocalcaneal Arthrodesis FOOT & ANKLE INTERNATIONAL Lee, A. T., Sundberg, E. B., Lindsey, D. P., Harris, A. H., Chou, L. B. 2010; 31 (2): 164-171

  Abstract

  Tibiocalcaneal arthrodesis is an uncommon salvage procedure used for complex problems of the ankle and hindfoot. A biomechanical evaluation of the fixation constructs of this procedure has not been studied previously. The purpose of this study was to compare intramedullary nail to blade plate fixation in a deformity model in fatigue endurance testing and load to failure.Nine matched pairs of fresh frozen cadaveric legs underwent talectomy followed by fixation with a blade plate and 6.5-mm fully threaded cancellous screw or an ankle arthrodesis intramedullary nail. The specimens were loaded to 270 N at a rate of 3 Hz for a total of 250,000 cycles, followed by loading to failure.Intramedullary nail fixation demonstrated greater mean stiffness throughout the fatigue endurance testing, from cycles 10 through 250,000 (blade plate versus intramedullary nail; cycle 10, 93 +/- 34 N/mm versus 117 +/- 40 N/mm (t = 2.33, p = 0.04); cycle 100, 89 +/- 34 N/mm versus 118 +/- 42 N/mm (t = 3.16, p = 0.01); cycle 1000, 86 +/- 32 N/mm versus 120 +/- 45 N/mm (t = 3.52, p = 0.01); cycle 10,000, 83 +/- 36 N/mm versus 128 +/- 50 N/mm (t = 3.80, p = 0.01); cycle 100,000, 82 +/- 34 N/mm versus 126 +/- 52 N/mm (t = 3.70, p = 0.01); cycle 250,000, 80 +/- 31 N/mm versus 125 +/- 49 N/mm (t = 4.2, p = 0.003). There was no statistically significant difference between the intramedullary nail and blade plate fixation in cycle one or in load to failure; cycle 10, blade plate 70 +/- 38 N/mm and intramedullary nail 67 +/- 20 N/mm (t = 0.60, p = 0.56); load to failure, blade plate 808 +/- 193 N, IMN 1074 +/- 290 N) (p = 0.15).Intramedullary nail fixation was biomechanically superior to blade plate and screw fixation in a tibiocalcaneal arthrodesis construct.The ankle arthrodesis intramedullary nail provides greater stiffness for fixation in tibiocalcaneal arthrodesis, which may improve healing.

  View details for DOI 10.3113/FAI.2010.0164

  View details for PubMedID 20132755

• Prevalence of cancer in female orthopaedic surgeons in the United States. journal of bone and joint surgery. American volume Chou, L. B., Cox, C. A., Tung, J. J., Harris, A. H., Brooks-Terrell, D., Sieh, W. 2010; 92 (1): 240-244

  View details for DOI 10.2106/JBJS.H.01691

  View details for PubMedID 20048119

• Prevalence of Cancer in Female Orthopedic Surgeons in the United States JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Chou, L. B., Cox, C. A., Tung, J. J., Harris, A. H., Brooks-Terrell, D., Sieh, W. 2010; 92A (1): 240-244

  View details for DOI 10.2106/JBJS.H.01691

  View details for Web of Science ID 000273363600031

• Tumors of the Foot and Ankle: Experience with 153 Cases FOOT & ANKLE INTERNATIONAL Chou, L. B., Ho, Y. Y., Malawer, M. M. 2009; 30 (9): 836-841

  Abstract

  Both primary and metastatic tumors in the foot and ankle have been reported as rare. The purpose of this study was to describe 153 cases of foot and ankle tumors from a 20-year experience in a tertiary referral center specializing in orthopaedic oncology. It is the largest reported series of both bone and soft tissue tumors in the foot and ankle.Between 1986 and 2006, a retrospective chart review was performed of a total of 2,660 tumors surgically treated in all anatomic sites by a single surgeon at a musculoskeletal tumor referral center.One hundred fifty-three patients (5.75%) with bone and/or soft tissue tumors of the foot and ankle were treated. There were 84 women and 69 men. The patients' ages ranged from 1 to 84, with a median age of 30 and mean of 33.2. The tissue types included 80 soft tissue and 73 bone tumors. Overall, 60 (39.2%) were malignant, and 93 (60.8%) were benign. The most common diagnosis was giant cell tumor. In addition, giant cell tumor was the most common bone tumor, while pigmented villonodular synovitis and giant cell tumor of the tendon sheath were the most common soft tissue tumors.The incidence of tumors of the foot and ankle in this series of a single surgeon over a 20-year practice was 5.75%. The results of this study reaffirm that awareness, correctly diagnosing, and appropriately treating or referring to an orthopaedic oncologist may help with an improved outcome for patients.

  View details for DOI 10.3113/FAI.2009.0836

  View details for PubMedID 19755066

• Current Concept Review: Perioperative Soft Tissue Management for Foot and Ankle Fractures FOOT & ANKLE INTERNATIONAL Chou, L. B., Lee, D. C. 2009; 30 (1): 84-90

  View details for DOI 10.3113/FAI.2009.0084

  View details for PubMedID 19176194

• Postoperative Pain Following Foot and Ankle Surgery: A Prospective Study FOOT & ANKLE INTERNATIONAL Chou, L. B., Wagner, D., Witten, D. M., Martinez-Diaz, G. J., Brook, N. S., Toussaint, M., Carroll, I. R. 2008; 29 (11): 1063-1068

  Abstract

  Orthopaedic procedures have been reported to have the highest incidence of pain compared to other types of operations. There are limited studies in the literature that investigate postoperative pain.A prospective study of 98 patients undergoing orthopedic foot and ankle operations was undertaken to evaluate their pain experience. A Short-Form McGill Pain Questionnaire (SF-MPQ) was administered preoperatively and postoperatively.The results showed that patients who experienced pain before the operation anticipated feeling higher pain intensity immediately postoperatively. Patients, on average, experienced higher pain intensity 3 days after the operation than anticipated. The postoperative pain intensity at 3 days was the most severe, while postoperative pain intensity at 6 weeks was the least severe. Age, gender and preoperative diagnosis (acute versus chronic) did not have a significant effect on the severity of pain that patients experienced. Six weeks following the operation, the majority of patients felt no pain. In addition, the severity of preoperative pain was highly predictive of their anticipated postoperative pain and 6-week postoperative pain, and both preoperative pain and anticipated pain predict higher immediate postoperative pain.The intensity of patients' preoperative pain was predictive of the anticipated postoperative pain. Patients' preoperative pain and anticipated postoperative pain were independently predictive of the 3-day postoperative pain. The higher pain intensity a patient experienced preoperatively suggested that their postoperative pain severity would be greater. Therefore, surgeons should be aware of these findings when treating postoperative pain after orthopaedic foot and ankle operations.

  View details for DOI 10.3113/FAI.2008.1063

  View details for PubMedID 19026197

• Variation of nerve to flexor hallucis brevis FOOT & ANKLE INTERNATIONAL Chou, L. B., Choi, L. E., Ramachandra, T., Ma, G. 2008; 29 (10): 1042-1044

  Abstract

  Hallopeau's nerve is a branch of the lateral plantar nerve that supplies the flexor hallucis brevis muscle while also forming an anastomosis with the medial plantar nerve. In this study, the presence of this neural anastomosis was determined through dissection of cadaveric specimens.Twenty-six fresh-frozen adult feet (13 matched pairs) were dissected to assess the presence or absence of Hallopeau's nerve.Dissections revealed four out of 26 specimens had this anastomosis.This study confirms this anatomic variation.The clinical significance of these anastomoses remains unknown. These anastomoses are analogous to some in the hand and forearm.

  View details for DOI 10.3113/FAI.2008.1042

  View details for PubMedID 18851823

• Biomechanical comparison of the simple running and cross-stitch epitenon sutures in Achilles tendon repairs FOOT & ANKLE INTERNATIONAL Shepard, M. E., Lindsey, D. P., Chou, L. B. 2008; 29 (5): 513-517

  Abstract

  Augmenting the strength of Achilles tendon repairs may allow for earlier active rehabilitation with less risk of adhesion formation and re-ruptures, leading to quicker and stronger healing. Building upon previous research that has (1) demonstrated strength gains in Achilles repairs upon addition of simple running epitenon sutures, and (2) shown the cross-stitch epitenon suture to be stronger than the simple running stitch in flexor tendons of the hand, this study compares use of these epitenon sutures in the Achilles tendon.Ruptures were simulated in 7 matched pairs of fresh frozen human Achilles tendons and repaired with the two-tailed Krakow locking loop core technique using No. 2 nonabsorbable, braided, polyester suture. From each pair, one specimen was randomly selected to also receive the epitenon cross-stitch, the other receiving the simple running stitch. All epitenon repairs employed 4-0 nylon suture. Repaired tendons were loaded in tension to the point of failure on a Materials Testing Machine (MTS).Tendon repair augmented with the cross-stitch displayed a significant, 53% greater failure strength than those repaired with the simple running stitch. Increases in initial stiffness and resistance to 2-mm gap formation in the cross-stitch specimens were 3.1% and 3.6%, respectively.Gapping resistance and initial stiffness in Achilles tendon repairs were comparable between the cross-stitch and simple running stitch, but the cross-stitch significantly improved failure strength.Greater failure strength may translate clinically to lower rates of re-rupture and earlier mobilization following Achilles tendon repair.

  View details for DOI 10.3113/FAI.2008.0513

  View details for PubMedID 18510906

• Osteoarthritis of the ankle: The role of arthroplasty 73rd Annual Meeting of the American-Academy-of-Orthopaedic-Surgeons Chou, L. B., Coughlin, M. T., Hansen, S., Haskell, A., Lundeen, G., Saltzman, C. L., Mann, R. A. AMER ACAD ORTHOPAEDIC SURGEONS. 2008: 249–59

  Abstract

  Total ankle arthroplasty was developed to reduce pain and retain motion of the ankle joint in patients with osteoarthritis. The ankle joint has unique, complex anatomic and biomechanical characteristics that must be considered in a successful total ankle arthroplasty prosthesis. Initial designs from the 1960s to the 1970s had many failures. Current designs use two or three components, and recent reports on total ankle arthroplasty show consistent good to excellent intermediate clinical results, with up to 90% decreased pain and high patient satisfaction. The follow-up time of these studies is limited, however, and long-term studies with 10- to 15-year follow-ups are needed. Also, a wide variety of complications has been reported, including osteomyelitis and osteolysis. To limit the number of complications and improve clinical outcome of total ankle arthroplasty, careful patient selection and surgeon experience are important.

  View details for PubMedID 18460685

• Secretan's disease of the foot: A case report and review FOOT & ANKLE INTERNATIONAL Abnousi, F., Chou, L. B. 2008; 29 (2): 248-250

  Abstract

  Secretan's disease is a rare disorder that has, to date, only been reported in the hand. After minor trauma, edema and hyperplasia of the hand may result, and pathological evaluation demonstrates thick fibrous tissue. We present the first report of Secretan's disease involving the foot in a 15-year-old athletic teenage girl with a remote history of blunt trauma, and review the relevant literature.

  View details for DOI 10.3113/FAI.2008.0248

  View details for PubMedID 18315985

• Current concepts review: Venous thromboembolic disease in foot and ankle surgery FOOT & ANKLE INTERNATIONAL Mayle, R. E., DiGiovanni, C. W., Lin, S. S., Tabrizi, P., Chou, L. B. 2007; 28 (11): 1207-1216

  View details for DOI 10.3113/FAI.2007.1207

  View details for PubMedID 18021595

• Biomechanical testing of epitenon suture strength in Achilles tendon repairs FOOT & ANKLE INTERNATIONAL Shepard, M. E., Lindsey, D. P., Chou, L. B. 2007; 28 (10): 1074-1077

  Abstract

  Recent evidence that early, active mobilization protocols after Achilles tendon repairs increase recovery speed and strength make operative repair strength critical to positive outcomes after Achilles tendon ruptures. While previous research has focused on core (tendon proper) repair techniques, no previous literature has reported testing of core repairs augmented with epitenon sutures, which have been shown to increase the strength of repairs of flexor tendons of the hand.Five matched pairs of fresh frozen human Achilles tendons were tested with and without the addition of an epitenon suture to the core repair suture. All specimens were repaired using a No. 2 Ethibond Krakow locking loop core suture. The epitenon suture was added to one tendon randomly chosen from each pair, using a 4-0 nylon suture. All specimens were mounted on an MTS testing machine (MTS Systems Corp., Eden Prairie, MN) and loaded to failure, which was defined as a 1-cm gap formation.The addition of epitenon sutures significantly increased the force necessary to produce a 2-mm gap as compared to core sutures alone by 74%, and it increased the average load to failure by 119%. Also, initial tendon stiffness was 173% greater in tendons reinforced with epitenon sutures.This study demonstrates that greater resistance to gap formation, approximation of tissue ends, and tensile strength were achieved by the addition of an epitenon suture. Clinical relevance may improve healing by decreased gap formation at the repair site and a lower risk of adhesion formation.

  View details for DOI 10.3113/FAI.2007.1074

  View details for PubMedID 17923058

• Osteosarcoma of the calcaneus treated with prosthetic replacement with twelve years of followup: A case report FOOT & ANKLE INTERNATIONAL Chou, L. B., Malawer, M. M. 2007; 28 (7): 841-844

  View details for DOI 10.3113/FAI.2006.0841

  View details for PubMedID 17666179

• Treatment of severe, painful pes planovalgus deformity with hindfoot arthrodesis and wedge-shaped tricortical allograft FOOT & ANKLE INTERNATIONAL Chou, L. B., Halligan, B. W. 2007; 28 (5): 569-574

  Abstract

  This study tested the hypothesis that modification of the standard technique of hindfoot arthrodesis with the use of a wedge-shaped tricortical allograft would improve the amount of correction of pes planovalgus deformity. The results were compared to previous reports.Between 1998 and 2005, the senior author (LBC) performed 13 hindfoot arthrodeses on 12 patients using an allograft to improve correction of the deformity for severe, painful pes planovalgus deformity. The average patient age was 55 (range 27 to 77) years. There were seven women and five men. The indications were posterior tibial tendon dysfunction (seven feet), rheumatoid arthritis (three feet), post-traumatic arthritis and deformity (one foot), congenital pes planovalgus (one foot), and tarsal coalition (one foot).Twelve of 13 feet achieved union by 12 weeks postoperatively. There was one nonunion. The average time to fusion was 12 weeks. All 12 patients were satisfied with the results of the operation. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score was 87 points, and the AOFAS Midfoot score was 85 points. Preoperative and postoperative radiographs were compared to evaluate correction of deformity. On lateral weightbearing views, the talo-first metatarsal angle improved from 15 to 6 degrees, and the lateral talocalcaneal angle improved from 48 to 35 degrees. On anteroposterior views, the talo-first metatarsal angle improved from 17 to 7 degrees, the talonavicular coverage decreased from 28 to 13 degrees, and the talocalcaneal angle improved from 23 to 13 degrees.A simple modification of the addition of allograft to a common procedure of hindfoot arthrodesis to treat severe, painful pes planovalgus results is reliable and offers satisfactory correction.

  View details for DOI 10.3113/FAI.2007.0569

  View details for PubMedID 17559763

• Stress fracture as a complication of autogenous bone graft harvest from the distal tibia FOOT & ANKLE INTERNATIONAL Chou, L. B., Mann, R. A., Coughlin, M. J., McPeake, W. T., Mizel, M. S. 2007; 28 (2): 199-201

  Abstract

  Autogenous bone graft from the distal tibia provides cancellous bone graft for foot and ankle operations, and it has osteogenic and osteoconductive properties. The site is in close proximity to the foot and ankle, and published retrospective studies show low morbidity from the procedure.One-hundred autografts were obtained from the distal tibia between 2000 and 2003. In four cases the distal tibial bone graft harvest resulted in a stress fracture. There were three women and one man.The average time of diagnosis of the stress fracture from the operation was 1.8 months. All stress fractures healed with a short course (average 2.4 months) of cast immobilization.This study demonstrated that a stress fracture from the donor site of autogenous bone graft of the distal tibia occurs and can be successfully treated nonoperatively.

  View details for DOI 10.3113/FAI.2007.0199

  View details for PubMedID 17296139

• Surgical treatment of severe hallux valgus: The state of practice among academic foot and ankle surgeons FOOT & ANKLE INTERNATIONAL Pinney, S. J., Song, K. R., Chou, L. B. 2006; 27 (12): 1024-1029

  Abstract

  The purpose of this study was to evaluate the operative procedures used for treatment of severe hallux valgus by academic foot and ankle surgeons practicing in the United States.A patient with severe hallux valgus deformity was developed as a hypothetical case: a 50-year-old woman with a severe deformity (intermetatarsal angle = 20 degrees; hallux valgus angle = 42 degrees). The patient was symptomatic with pain, did not improve with conservative measures, and wanted the deformity corrected. This case was sent to academic foot and ankle surgeons in a survey to determine their preferred operative treatment for this case. The overall response rate was 84% (128 of 153). To be included in the study group each surgeon had to have 1) foot and ankle patients comprising 50% or more of his clinical practice and 2) direct responsibility for teaching orthopaedic residents. One hundred and five respondents met the inclusion criteria and formed the study group; however, three surveys with invalid responses were deleted.Fifty-two percent (54 of 102) of the respondents chose a metatarsal osteotomy, 26% (26 of 102) a first metatarsophalangeal (MTP) joint arthrodesis, and 24% (24 of 102) a Lapidus procedure. Two respondents chose both an arthrodesis and a metatarsal osteotomy. Among the 54 respondents who chose metatarsal osteotomies, 24 used a Ludloff, 16 a proximal crescentic, eight a proximal chevron, two a scarf, two a distal chevron, and two other. In addition, secondary procedures to enhance the correction included a Weil osteotomy in 46% (47 of 102) and an Akin osteotomy in 30% (31 of 102).There was a wide variation in the type of procedure used to correct this severe hallux valgus deformity; approximately 50% of the respondents chose a metatarsal osteotomy, 25% chose a first MTP joint arthrodesis, and 25% a Lapidus procedure.

  View details for PubMedID 17207427

• Stretching for prevention of achilles tendon injuries: A review of the literature FOOT & ANKLE INTERNATIONAL Park, D. Y., Chou, L. 2006; 27 (12): 1086-1095

  Abstract

  Professional and recreational athletes commonly perform pre-exercise stretching to prevent musculoskeletal injuries. Little definitive evidence exists that clearly demonstrates the efficacy of stretching in reducing injury. Achilles tendon injuries are among the most common injuries affecting active individuals in the United States today. Clinicians commonly recommend stretching the Achilles tendon without concrete scientific evidence to support such a claim. Few studies have addressed the effect of stretching in Achilles tendon injuries, and it is unclear if the conclusions made for musculoskeletal injuries can be applied to the Achilles tendon. Biomechanical studies of the Achilles tendon and measurements of the tendon's reflex activity have demonstrated possible mechanisms for the potential benefit of stretching, including load-induced hypertrophy and increased tendon tensile strength. Recent prospective studies have contended that reductions in plantarflexor strength and increases in ankle dorsiflexion range of motion from stretching the Achilles tendon may increase the risk of injury. Studies examining stretching in injury prevention, the biomechanical properties of injuries to the Achilles tendon were compiled and reviewed. Although many theories have been published regarding the potential benefits and limitations of stretching, few studies have been able to definitively demonstrate its utility in injury prevention.

  View details for Web of Science ID 000242832400014

  View details for PubMedID 17207437

• Surgical treatment of mild hallux valgus deformity: The state of practice among academic foot and ankle surgeons FOOT & ANKLE INTERNATIONAL Pinney, S., Song, K., Chou, L. 2006; 27 (11): 970-973

  Abstract

  The purpose of this study was to determine the operative procedure of choice among academic foot and ankle surgeons practicing in the United States for treatment of mild hallux valgus deformity.A hypothetical patient was created: a 60-year-old woman with a mild hallux valgus deformity (first intermetatarsal angle of 11 degrees and hallux valgus angle of 22 degrees). The patient complained of pain around the bunion, nonoperative treatment had failed, and she desired operative correction. The case was sent to academic foot and ankle surgeons to identify their operative treatment of choice. The overall response rate was 83.7% (128 of 153). To be included in the study group each surgeon had 1) foot and ankle patients comprising 50% or more of their clinical practice and 2) direct responsibility for teaching orthopaedic surgery residents. One hundred and three respondents met the inclusion criteria and formed the study group.Eighty-seven percent (90 of 103) reported that they would use a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus. Ten percent (10 of 103) reported that they would also add an Akin osteotomy of the proximal phalanx to enhance correction.Most respondents chose a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus deformity.

  View details for PubMedID 17144962

• Surgical treatment of tarsal navicular stress fractures OPERATIVE TECHNIQUES IN SPORTS MEDICINE Choi, L. E., Chou, L. B. 2006; 14 (4): 248-251

  View details for DOI 10.1053/j.otsm.2006.05.003

  View details for Web of Science ID 000242773500004

• Current concepts review: Lisfranc injuries FOOT & ANKLE INTERNATIONAL Desmond, E. A., Chou, L. B. 2006; 27 (8): 653-660

  View details for PubMedID 16919225

• Surgical Treatment of Post-Radiotherapy Nonunions of the Clavicle BULLETIN OF THE HOSPITAL FOR JOINT DISEASES Wera, G., Mohler, D., Chou, L. 2005; 62 (3-4): 125–30

  Abstract

  Fractures of irradiated bones present special challenges to healing. Nonunions are very common and are challenging surgical problems. We report three radiated nonunions of the clavicle successfully treated with modifications of standard internal fixation techniques.

  View details for Web of Science ID 000216347100010

  View details for PubMedID 16022226

• Synovial sarcoma presenting as posterior tibial tendon dysfunction: A report of two cases and review of the literature FOOT & ANKLE INTERNATIONAL Chou, L. B., Malawer, M. M. 2004; 25 (11): 810-814

  View details for PubMedID 15574241

• Informed consent for ankle fracture surgery: Patient comprehension of verbal and videotaped information FOOT & ANKLE INTERNATIONAL Rossi, M., McClellan, R., Chou, L., Davis, K. 2004; 25 (10): 756-762

  Abstract

  The purpose of our study was to evaluate the effectiveness of using a videotape to give patients information about the risks, benefits, alternatives, and treatment of a common orthopaedic procedure before they sign consent forms.During a 9-month period, 48 patients with isolated closed ankle fractures requiring surgical intervention were randomized into two groups that received either videotaped or conventional verbal information regarding consent for surgery. The study group watched a videotape containing information about the risks, benefits, and treatment alternatives, while the control group obtained this information verbally. To determine comprehension and retention, all patients completed a multiple-choice questionnaire immediately after receiving the information, and 37 patients (77%) were available to complete a questionnaire at an average of 10 weeks later.The videotape group outperformed the verbal consent group by 40.1% on the initial questionnaire (p = .0002) and by 27.2% on the followup questionnaire (p = 0.0139). Patients with educational levels of less than or equal to the 12th grade performed 67.8% better on the initial questionnaire after watching the video than after receiving the information verbally. (p = .0001).Patients who received information about their surgery on a videotape before giving their consent demonstrated a significant increase in comprehension compared to patients who received this information verbally. The benefit was even greater for patients with lower education levels.

  View details for Web of Science ID 000224765300011

  View details for PubMedID 15566709

• Functional evaluation of the Scandinavian Total Ankle Replacement FOOT & ANKLE INTERNATIONAL Dyrby, C., Chou, L. B., Andriacchi, T. P., Mann, R. A. 2004; 25 (6): 377-381

  Abstract

  The purpose of this study was to evaluate the function of the ankle joint during walking before and after Scandinavian Total Ankle Replacement (STAR). Nine patients (six males and three females) with an average age of 65 years, scheduled for unilateral total ankle replacement for osteoarthritis and rheumatoid arthritis, were evaluated both preoperatively and postoperatively in a gait analysis laboratory. Arthroplasty patients showed reduced range of motion at the ankle compared to normal controls. Postoperative arthroplasty subjects had significantly improved external ankle dorsiflexion moment, the moment that affects the plantarflexor muscles, when compared to their preoperative status. The moment in arthroplasty patients was increased, indicating improved function of the ankle joint.

  View details for PubMedID 15215020

• Autologous osteochondral grafting for talar cartilage defects FOOT & ANKLE INTERNATIONAL Al-Shaikh, R. A., Chou, L. B., Mann, J. A., Dreeben, S. M., Prieskorn, D. 2002; 23 (5): 381-389

  Abstract

  The purpose of this study was to evaluate the clinical results of Osteochondral Autograft Transfer System (OATS) for the treatment of symptomatic osteochondral defects of the talus using standardized outcome analysis. Nineteen patients with symptomatic osteochondral defect (OCD) of the talus were treated with autologous osteochondral grafting. There were six men and 13 women. The average age was 32 years (range, 18 to 48 years). The average duration of symptoms prior to surgery was 4.2 years (range, three months to 12 years). All patients had failed nonoperative treatment, and 13 (68%) patients had failed prior excision, curettage and/or drilling of the lesion. The average size of the lesion prior to autografting was 12 mm x 10 mm (range, 10 x 5 mm to 20 x 20 mm). Donor plugs were harvested from the trochlear border of the ipsilateral femoral condyle. Ankle exposure was obtained with a medial malleolar osteotomy in 13 patients, arthrotomy in five patients and lateral malleolar osteotomy in one patient. Clinical evaluations were performed for both the recipient ankle and donor knee using the AOFAS Ankle/Hindfoot Scale and Lysholm knee scale, respectively. The average follow-up time was 16 months (range, 12 to 30 months). The average postoperative AOFAS ankle score was 88 (range, 60 to 100). Most patients had occasional mild pain, but excellent function, range of motion, stability and alignment. The average postoperative ankle score for the 13 patients who failed prior surgery was 91 (range, 84 to 100). The average postoperative Lysholm knee score was 97 (range, 87 to 100). Only two patients had mild knee pain. Postoperative radiographs were available for 13 patients. There was no evidence of graft subsidence and all grafts healed. All malleolar osteotomies united. Seventeen (89%) patients said that they would undergo the procedure again. The results of osteochondral autograft transplant for OCD lesions of the talus demonstrate excellent postoperative ankle scores including improvement of pain and function with minimal knee donor site morbidity. Also, our results indicate that this is an effective salvage procedure following failed previous procedures and for patients with longstanding symptoms.

  View details for PubMedID 12043980

• Pulmonary embolism following operative treatment of ankle fractures: A report of three cases and review of the literature FOOT & ANKLE INTERNATIONAL Wang, F., Wera, G., Knoblich, G. O., Chou, L. B. 2002; 23 (5): 406-410

  Abstract

  The risks of thromboembolism following operative treatment of ankle fractures are deep vein thrombosis (DVT) and pulmonary embolism (PE). These are potentially life-threatening complications. Many orthopedic surgeons fail to appreciate the potential complications of thromboembolic events because of their rare and delayed occurrence in foot and ankle operations. The purpose of this report is to describe the potential for DVT and PE following ankle operations. We present three cases in which patients who underwent operative treatment of ankle fractures subsequently developed PE. We also review the literature on the prevalence of thrombosis, risk factors, methods of prophylaxis, and use of prophylaxis in surgical procedures of the lower extremity.

  View details for Web of Science ID 000175663900006

  View details for PubMedID 12043984

• Intramedullary screw fixation of proximal fifth metatarsal fractures: A biomechanical study FOOT & ANKLE INTERNATIONAL Shah, S. N., Knoblich, G. O., Lindsey, D. P., Kreshak, J., Yerby, S. A., Chou, L. B. 2001; 22 (7): 581-584

  Abstract

  Intramedullary screw fixation is a popular technique for treatment of proximal fifth metatarsal fractures. The purpose of this study was to compare the fixation rigidity of a 5.5 mm partially threaded cannulated titanium screw, with presumed superior endosteal purchase, to a similar 4.5 mm screw. Acute fifth metatarsal fractures were simulated in cadavers, stabilized with intramedullary screws, and loaded to failure in three-point bending. The initial failure loads for the metatarsals fixed with 4.5 mm and 5.5 mm screws were not significantly different (332.4 N vs. 335.2 N, respectively), nor were the ultimate failure loads (849.8 N vs. 702.2 N, respectively). Based upon our results, maximizing screw diameter does not appear to be critical for fixation rigidity and may increase the risk of intraoperative or postoperative fracture.

  View details for Web of Science ID 000170686700009

  View details for PubMedID 11503984

• Lateral planter nerve entrapment in a competitive gymnast CLINICAL JOURNAL OF SPORT MEDICINE Fredericson, M., Standage, S., Chou, L., Matheson, G. 2001; 11 (2): 111-114

  View details for Web of Science ID 000169055800008

  View details for PubMedID 11403110

• Malleolar fractures in athletes OPERATIVE TECHNIQUES IN SPORTS MEDICINE Chou, L. B. 2001; 9 (1): 20-25

  View details for DOI 10.1053/otsm.2001.20808

  View details for Web of Science ID 000167339500005

• Tibiotalocalcaneal arthrodesis FOOT & ANKLE INTERNATIONAL Chou, L. B., Mann, R. A., Yaszay, B., Graves, S. C., McPeake, W. T., Dreeben, S. M., Horton, G. A., Katcherian, D. A., Clanton, T. O., MILLER, R. A., Van Manen, J. W. 2000; 21 (10): 804-808

  Abstract

  The purpose of this multicenter retrospective study of 55 patients (56 ankles) who underwent simultaneous tibiotalocalcaneal arthrodesis with severe disease involving the ankle and subtalar joints was to determine improvement of pain and function. The surgical indications included osteoarthritis, posttraumatic injury, failed previous surgery, talar avascular necrosis, osteoarthritis, and rheumatoid arthritis involving the ankle and subtalar joints. The average age at the time of the operation was 53 years. The average time of follow-up was 26 months after the operation. Fusion was achieved in 48 ankles, with an average time of fusion of 19 weeks. Forty-eight of the 55 patients were satisfied with the procedure. The average leg length discrepancy was 1.4 cm. The average amount of dorsiflexion was 2 degrees and plantar flexion was 5 degrees. Following surgery, 42 patients complained of pain, 40 patients required shoe modification or an orthotic device, and 34 patients had a limp. Fourteen patients described their activity as unlimited. Based on the AOFAS evaluation, the patients scored an average of 66 on the ankle-hind foot scale following surgery. The most common complications were nonunion (8 ankles) and wound infection (6 ankles). This study demonstrates that tibiotalocalcaneal arthrodesis is an effective salvage procedure for patients with disease both involving the ankle and subtalar joints.

  View details for Web of Science ID 000090046800002

  View details for PubMedID 11128009

• Disorders of the first metatarsophalangeal joint - Diagnosis of great-toe pain PHYSICIAN AND SPORTSMEDICINE Chou, L. B. 2000; 28 (7): 32-?

  Abstract

  Disorders of the joint at the base of the hallux are common in active patients. Great-toe sprains (turf toe) can range from mild to severe with associated fractures. Hallux rigidus, a painful flexion deformity, is often seen in athletes who stress the joint repetitively. Heredity may predispose athletes to hallux valgus (bunion) but improper footwear, injury, and hyperpronation can also be implicated. Weight-bearing activities, climbing stairs, or wearing high-heeled shoes will aggravate sesamoiditis. Stress fractures, osteochondral defects, and gout are other causes of toe pain. X-rays are essential for accurate diagnosis. Nonoperative measures can reduce pain, but surgery is an option for recalcitrant cases.

  View details for Web of Science ID 000087959000010

  View details for PubMedID 20086649

• Biplanar chevron osteotomy FOOT & ANKLE INTERNATIONAL Chou, L. E., Mann, R. A., Casillas, M. M. 1998; 19 (9): 579-584

  Abstract

  We retrospectively reviewed the results of using a biplanar chevron osteotomy performed on patients who presented with hallux valgus deformities with an increased distal metatarsal articular angle (DMAA). The study included 17 feet (14 patients) of 12 women and 2 men. The average follow-up was 33 months. The average American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Clinical Rating Score was 91. Ten of the 14 patients (13 of 17 feet) stated that they would choose to undergo the procedure again. The hallux valgus angle was improved from an average of 22 degrees to 18 degrees, the intermetatarsal angle from 11 degrees to 9 degrees, and the DMAA from 16 degrees to 9 degrees. We have demonstrated this procedure to be useful in the treatment of symptomatic bunion deformities with an increased DMAA.

  View details for Web of Science ID 000075995400002

  View details for PubMedID 9763161

• Prosthetic replacement for intramedullary calcaneal osteosarcoma: A case report FOOT & ANKLE INTERNATIONAL Chou, L. B., Malawer, M. M., Kollender, Y., Wellborn, C. C. 1998; 19 (6): 411-415

  View details for Web of Science ID 000074288900012

  View details for PubMedID 9677086

• Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas. journal of bone and joint surgery. American volume Malawer, M. M., Chou, L. B. 1995; 77 (8): 1154-1165

  Abstract

  We evaluated the long-term clinical results and the survival of the prostheses in eighty-two patients who had had a limb-sparing procedure by means of the implantation of a large-segment prosthesis. All patients had had a high-grade bone sarcoma of the distal, middle, or proximal part of the femur; the proximal part of the humerus; the proximal part of the tibia; or the pelvis. The duration of follow-up ranged from two to twelve years (median, three and one-half years). Function was evaluated with the revised 30-point classification system of the Musculoskeletal Tumor Society. The survival of the prostheses was analyzed with regard to several variables with use of Kaplan-Meier survival estimates. Sixty-eight patients were alive at the latest follow-up evaluation. The survival rate of the prostheses was 83 per cent at five years and 67 per cent at ten years. Twelve prostheses were revised, and eleven revisions were successful. The rate of revision was highest (six of thirteen) in the patients who had had a tumor of the proximal part of the tibia. In contrast, only three (10 per cent) of the thirty-one patients who had had a tumor of the distal part of the femur and three (10 per cent) of the twenty-nine who had had a tumor of the proximal part of the humerus had a revision. Eleven patients (13 per cent) had an infection, which necessitated an amputation in six. Five patients (6 per cent) had a local recurrence, and nine patients (11 per cent), including the six already mentioned, ultimately needed an amputation. Patients who had had a tumor of the proximal part of the humerus had the highest functional scores, while those who had had a tumor of the proximal part of the tibia had the lowest scores. Large-segment prostheses were a good reconstructive option for the treatment of high-grade bone sarcomas in our patients. The rates of long-term survival of the prostheses were acceptable and the functional results were good or excellent after this form of treatment at most of the anatomical sites at which they were used.

  View details for PubMedID 7642659

• SURVIVAL AND CLINICAL-RESULTS WITH USE OF LARGE-SEGMENT REPLACEMENTS IN THE TREATMENT OF HIGH-GRADE BONE SARCOMAS JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Malawer, M. M., Chou, L. B. 1995; 77A (8): 1154-1165

  View details for Web of Science ID A1995RQ00900003

• ANALYSIS OF SURGICAL-TREATMENT OF 33 FOOT AND ANKLE TUMORS FOOT & ANKLE INTERNATIONAL Chou, L. B., Malawer, M. M. 1994; 15 (4): 175-181

  Abstract

  Thirty-three patients treated for tumors of the foot and ankle at one cancer institution over a 14-year period were reviewed. There were 15 females and 18 males, with an age range of 1 to 64 years (average 22.6 years). Twenty-one tumors were benign, 11 were malignant, and 1 tumor had metastasized. The most common diagnoses were: fibromatosis (10), aneurysmal bone cyst (4), synovial sarcoma (4), chondrosarcoma (3), and other (12). Surgical procedures included: wide resection (14), local resection (8), curettage and cryosurgery (7), and below-knee amputation (4). Follow-up from surgery was 1 to 13 years (average 7.2 years). There were no local recurrences. Functional results were good-to-excellent in 82% (27/33) of patients. Fifty-five percent (18/33) of the patients were full weightbearing and enjoyed unlimited activity.

  View details for Web of Science ID A1994PA07400004

  View details for PubMedID 7951950