Search

COVID-19 has affected surgical practice globally. Treating neurosurgical patients with the restrictions imposed by the pandemic is challenging in institutions with shared patient areas. The present study was performed to assess the changing patterns of neurosurgical cases, the efficacy of repeated testing before surgery, and the prevalence of COVID-19 in asymptomatic neurosurgical inpatients.Cases of non-trauma-related neurosurgical patients treated at the Postgraduate Institute of Medical Education and Research (PGIMER) before and during the COVID-19 pandemic were reviewed. During the pandemic, all patients underwent a nasopharyngeal swab reverse transcription-polymerase chain reaction test to detect COVID-19 at admission. Patients who needed immediate intervention were surgically treated following a single COVID-19 test, while stable patients who initially tested negative for COVID-19 were subjected to repeated testing at least 5 days after the first test and within 48 hours prior to the planned surgery. The COVID-19 positivity rate was compared with the local period prevalence. The number of patients who tested positive at the second test, following a negative first test, was used to determine the probable number of people who could have become infected during the surgical procedure without second testing.Of the total 1769 non-trauma-related neurosurgical patients included in this study, a mean of 337.2 patients underwent surgery per month before COVID-19, while a mean of 184.2 patients (54.6% of pre-COVID-19 capacity) underwent surgery per month during the pandemic period, when COVID-19 cases were on the rise in India. There was a significant increase in the proportion of patients undergoing surgery for a ruptured aneurysm, stroke, hydrocephalus, and cerebellar tumors, while the number of patients seeking surgery for chronic benign diseases declined. At the first COVID-19 test, 4 patients (0.48%) tested were found to have the disease, a proportion 3.7 times greater than that found in the local community. An additional 5 patients tested positive at the time of the second COVID-19 test, resulting in an overall inpatient period prevalence of 1%, in contrast to a 0.2% national cumulative caseload. It is possible that COVID-19 was prevented in approximately 67.4 people every month by using double testing.COVID-19 has changed the pattern of neurosurgical procedures, with acute cases dominating the practice. Despite the fact that the pandemic has not yet reached its peak in India, COVID-19 has been detected 3.7 times more often in asymptomatic neurosurgical inpatients than in the local community, even with single testing. Double testing displays an incremental value by disclosing COVID-19 overall in 1 in 100 inpatients and thus averting its spread through neurosurgical services.

Background Preliminary data suggest that Coronavirus Disease-2019 (COVID-19) is associated with hypercoagulability and neurovascular events, but data on outcomes is limited. Objective To report the clinical course and outcomes of a case series of COVID-19 patients with a variety of cerebrovascular events. Methods We performed a multicentric, retrospective chart review at our three academic tertiary care hospitals, and identified all COVID-19 patients with cerebrovascular events requiring neuro-intensive care and/or neurosurgical consultation. Results We identified 26 patients between March 1 and May 24, 2020, of whom 12 (46%) died. The most common event was a large-vessel occlusion (LVO) in 15 patients (58%), among whom 8 died (8/15, 53%). A total of 9 LVO patients underwent mechanical thrombectomy, of whom 5 died (5/9, 56%). A total of 7 patients (27%) presented with intracranial hemorrhage. Of the remaining patients, 2 had small-vessel occlusions, 1 had cerebral venous sinus thrombosis, and another had a vertebral artery dissection. Acute Respiratory Distress Syndrome occurred in 8 patients, of whom 7 died. Mortalities had a higher D-dimer on admission (mean 20 963 ng/mL) than survivors (mean 3172 ng/mL). Admission Glasgow Coma Scale (GCS) score was poor among mortalities (median 7), whereas survivors had a favorable GCS at presentation (median 14) and at discharge (median 14). Conclusion COVID-19 may be associated with hemorrhage as well as ischemia, and prognosis appears poorer than expected-particularly among LVO cases, where outcome remained poor despite mechanical thrombectomy. However, a favorable neurological condition on admission and lower D-dimer may indicate a better outcome.

No currently available literature evaluates the effect of Achilles tendon repair on professional baseball players in the Major League Baseball (MLB).The purpose of this study was to determine the impact of Achilles tendon rupture and repair on MLB players in terms of return to play and batting/fielding performance metrics.Achilles tendon rupture data were retrospectively collected using information from the MLB disabled list, injury reports, MLB game summaries, player profiles, and publicly available news articles. Four pair-matched control MLB position players were selected for each of the players who underwent advanced analysis. Baseline characteristics were compared between injured players and controls using Fisher's exact or Student'sOverall, the incidence of Achilles tendon rupture reported in MLB has increased substantially since 1996. Rate of return to play in MLB after Achilles tendon rupture and repair is 62% for position players (non-pitchers) who suffer the injury. There was no association of injury with any player metric. Compared with injury to the non-power side, injury to the power side was associated with fewer plate appearances, fewer triples, an increase in percentage of at-bats with strikeouts, and decreased speed score.The incidence of Achilles tendon rupture in MLB has increased substantially since 1996. While comparison suggests that overall Achilles tendon injury does not have an effect on MLB player statistics in the years following surgical repair, subset analysis of injury to the rear (power-generating) leg may lead to a decline in those statistics which denote a player's speed and running ability.

Although metal-on-metal (MoM) bearing surfaces provide low rates of volumetric wear and increased stability, evidence suggests that certain MoM hip arthroplasties have high rates of complication and failure. Some evidence indicates that women have higher rates of failure compared with men; however, the orthopaedic literature as a whole has poorly reported such complications stratified by gender.This systematic review aimed to: (1) compare the rate of adverse local tissue reaction (ALTR); (2) dislocation; (3) aseptic loosening; and (4) revision between men and women undergoing primary MoM hip resurfacing arthroplasty (HRA).Systematic MEDLINE and EMBASE searches identified all level I to III articles published in peer-reviewed journals, reporting on the outcomes of interest, for MoM HRA. Articles were limited to those with 2-year followup that reported outcomes by gender. Ten articles met inclusion criteria. Study quality was evaluated using the Modified Coleman Methodology Score; the overall quality was poor. Heterogeneity and bias were analyzed using a Mantel-Haenszel statistical method.Women demonstrated an increased odds of developing ALTR (odds ratio [OR], 5.70 [2.71-11.98]; p0.001), dislocation (OR, 3.04 [1.2-7.5], p=0.02), aseptic loosening (OR, 3.18 [2.21-4.58], p0.001), and revision (OR, 2.50 [2.25-2.78], p0.001) after primary MoM HRA.A systematic review of the currently available literature reveals a higher rate of complications (ALTR, dislocation, aseptic loosening, and revision) after MoM HRA in women compared with men. Although femoral head size has been frequently implicated as a prime factor in the higher rate of complication in women, further research is necessary to specifically probe this relationship. Retrospective studies of data available (eg, registry data) should be undertaken, and moving forward studies should report outcomes by gender (particularly complications).Level III, therapeutic study.

How much does the Addiction-Like Eating Behavior Scale add to the debate regarding food versus eating addictions?

W e thank Dr. Wyland and appreciate his interest in our study. We would like to respond to the concerns raised in his letter to the editor [2]. We agree with Dr. Wyland that reporting the outcome in five separate subscales (symptoms; pain; function, daily living; function, sports and recreational activities; quality of life), enhances interpretation. However, as stated by Roos and colleagues [7], even though it makes it impossible to closely monitor the stages of rehabilitation, the calculation of a total KOOS score can show an improvement. Due to the fact that our objective was to report the general patient-relevant outcome at a minimum of 6 months postoperatively (and not to optimize rehabilitation), we decided to report a single score in this initial retrospective case series. Dr. Wyland noted that ‘‘the grading system described by Mitsou et al. and previously by Tegner actually evaluated the success of ACL reconstruction, not knee osteoarthritis treatments.’’ Due to lack of a specific patient-reported outcome score for treatment evaluation of subchondral bone marrow edema lesions, we decided to use the Tegner-Lysholm Score which, as correctly stated by Dr. Wyland, was initially developed and validated for ACL injuries. The rationale behind our decision lies in the fact that in up to 80% of ACL-ruptured knees, bone marrow edema lesions are present [3, 4]. We also feel that the critique by Bengsston and colleagues [1] on the sensitivity of the Tegner Lysholm Score regarding ACL injuries and other lower extremity conditions corroborates as opposed to discredits our choice. The grading of the score allows a more critical analysis of the outcome [1]. Dr. Wyland also correctly noted that ‘‘... there was no discussion of surgical revisions in evaluating clinical failure or surgeon learning curve, which one would expect to influence failure rates.’’ Within the confines of manuscript length, we reported the followup data that was available for this retrospective study; none of the patients had revisions. However, three patients were lost to followup. Also, the minimum followup to be included in this (RE: Chatterjee D, McGee A, Strauss E, Youm T, Jazrawi L. Subchondral calcium phosphate is ineffective for bone marrow edema lesions in adults with advanced osteoarthritis. Clin Orthop Relat Res. 2015;473:2334–2342). Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. D. Chatterjee MD (&), A. McGee MD, E. Strauss MD, T. Youm MD, L. Jazrawi MD Orthopaedic Surgery, NYU Langone Medical Center, 333 East 38th Street 4th Floor, New York, NY 10016, USA e-mail: Dipal.Chatterjee@nyumc.org; dipal.chatterjee@gmail.com Reply to Letter to the Editor Published online: 24 September 2015 The Association of Bone and Joint Surgeons1 2015

The recent publication by Aly et al. [1] further confirms our conclusion that ultrasound-guided percutaneous tenotomy of the long head of the biceps tendon is feasible. Our paper was accepted for publication in April 2014 [2], and the Aly et al. paper was accepted for publication in June 2014. Since we had no previous knowledge of their study, we could not reference it in our paper. However, they describe a similar technique and results to ours using an arthroscopic hook blade, with a deep to superficial approach in the cadavers, which successfully resulted in complete tendon transection and no evidence of iatrogenic injury. We are the first to describe this procedure successfully performed on a live subject. Both the Aly et al. and the Levy et al. [3] studies show that the use of size 11 blade scalpels, banana blades, and retractable serrated blades results in incomplete transections of the tendons, as well as iatrogenic lesions of the cartilage, supraspinatus tendon, and subscapularis tendon. This further supports our conclusion that hook blades are the ideal instruments to obtain successful results of complete tendon transection, without iatrogenic injury. We concur that future long-term comparative studies of US-guided percutaneous tenotomy procedures are necessary to determine the efficacy of the procedure.

W e would like to support the interesting conclusions from a systematic review recently presented by Schlatterer and colleagues [1]. Their study addresses treatment for Grade IIIB tibial fractures and points to negative pressure wound therapy as an option that is changing the way many traumatologists think about the treatment of these difficult-to-manage wounds. As Schlatterer and colleagues point out, some clinicians support wound closure or stable muscle flap coverage within 72 hours to limit complications. The authors, however, found evidence to suggest that negative pressure wound therapy can be performed safely beyond 72 hours without increasing the risk of infection. These complex wounds can cause terrible morbidity and constitute a public health problem for many centers [2]. Through the years, researchers have devised a hierarchy of procedures within a hypothetical reconstructive ladder to guide the surgical treatment of wounds. This traditional reconstructive ladder, in its various iterations, subsequently has become a paradigm that helps to inform the choice of closure method across an array of defects. Currently, the increased availability of negative pressure wound therapy has illuminated its key benefits, including faster granulation tissue formation, less periwound edema, decreased closure time, less-frequent dressing changes, control of bacterial proliferation, and potential cost reduction. Although Janis et al. [3] have now incorporated negative pressure wound therapy as a new step in the traditional reconstructive ladder, we are advocating a different approach. In our experience, a descent in the usual reconstructive ladder (that is, from flaps to skin grafts or primary closure) is feasible if neoadjuvant negative pressure wound therapy is applied in the course of treating some complex wounds. This downscaled approach was taken in 106 patients with complex wounds seen between February 2011 and August 2014. All patients were initially subjected to negative pressure wound therapy via VAC system (Kinetic Concepts Inc, San Antonio, TX, USA). In 90 patients whose wounds were measured, the average wound area was 87 cm. (RE: Schlatterer DR, Hirschfeld AG, Webb LX. Negative pressure wound therapy in grade IIIB tibial fractures: Fewer infections and fewer flap procedures? Clin Orthop Relat Res. 2015;473:1802–1811). The authors certify that they, or any member of their immediate families, have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. J. A. Farina Jr MD, PhD (&), C. E. F. de Almeida MD, PhD, E. G. S. C. Marques MD, J. L. G. Jorge MD, R. V. K. S. Lima MD Division of Plastic Surgery of Department of Surgery and Anatomy, Ribeirao Preto Medical School of University of Sao Paulo-Brazil, Av. Bandeirantes, 3900 Monte Alegre, Ribeirao Preto, Sao Paulo 14049-900, Brazil e-mail: jafarinajr@fmrp.usp.br Letter to the Editor Published online: 21 August 2015 The Association of Bone and Joint Surgeons1 2015

Sir, We read with interest the article by Loupakis et al (2013) entitled ‘Histopathologic evaluation of liver metastases from colorectal cancer in patients treated with FOLFOXIRI plus bevacizumab' published in the June 2013 issue of the British Journal of Cancer. This paper clearly underlines the positive impact of FOLFOXIRI plus bevacizumab, on the extent of both tumour regression and necrosis, in resected liver metastases from colorectal cancer (CRC). The authors conclude that the addition of bevacizumab leads to a high ‘histopathologic activity' as compared to FOLFOXIRI or XELOXIRI alone. These data are important as pathologic response is considered as a new outcome end point by some authors, representing a prognostic parameter and a marker of sensitivity to preoperative treatments (Rubbia-Brandt et al, 2007; Blazer et al, 2008). Indeed, the higher the histopathologic response, the longer the survival (Rubbia-Brandt et al, 2007; Blazer et al, 2008). In this setting, we would like to mention several points that may be clinically relevant. First of all, pathologic complete response (pCR) was defined, in the study by Loupakis et al (2013), as the absence of tumour cells replaced by fibrosis and/or necrosis. This pCR definition corresponds to the grade 0 of the classification proposed by Blazer et al (2008), which is based exclusively on the percentage of residual tumour cells whatever the type of regression. However, in the Tumour Regression Grade (TRG) classification as proposed by Rubbia-Brandt et al (2007), fibrosis, but not necrosis, is considered as a characteristic feature of cellular response. According to these authors, the necrosis seen in CRC liver metastases is linked to spontaneous evolution of the tumour, involving insufficient vascular supply, and not to the treatment itself, thus excluding this characteristic from the TRG. In contrast, Li Chang et al (2012) recently showed a particular type of necrosis, so-called ‘infarct-like necrosis' (ILN), characterised by large confluent areas of eosinophilic cytoplasmic remnants, located centrally within a lesion and surrounded by a rim of fibrosis with foamy macrophages (Li Chang et al, 2012). This necrosis is morphologically different from the so-called ‘dirty necrosis', usually seen in CRC, containing nuclear debris in a patchy distribution. In this study, ILN was only seen in preoperatively treated CRC liver metastases and never observed in untreated patients who underwent primary resection of CRC liver metastases. In addition, Li Chang et al (2012) also noticed that ILN was significantly associated with chemotherapy plus bevacizumab treatment, although this feature was not specific and was also encountered with chemotherapy alone. Moreover, progression-free survival and overall survival were longer in patients with CRC whose liver metastases showed ILN as compared with CRC patients whose metastases lacked this feature. Besides the well-designed work by Loupakis et al (2013), several studies concerning preoperative treatment of liver metastases have already reported a higher percentage of necrotic areas in tumours treated with bevacizumab (Klinger et al, 2010; Wicherts et al, 2011). However, the precise type of necrosis involved in tumour response was not reported. Our team recently confirmed the previous findings of Li Chang et al (2012), but on a larger population of bevacizumab-treated patients and in the setting of first-line metastatic treatment. We retrospectively reviewed archival liver CRC metastases from 91 patients who underwent secondary resection after preoperative treatment. On the basis of tumour availability, three group of patients with liver metastases were identified: a control group of chemonaive metastases (n=29), a group with metastases treated with chemotherapy (CT) alone (n=31) and a group with metastases treated with CT and bevacizumab (n=31). The frequency of ILN was statistically different among the three groups (P

Reply: Comment on ‘Allergy and acute leukaemia in children with Down syndrome: a population study. Report from the Mexican Inter-Institutional Group for the Identification of the Causes of Childhood Leukaemia (MIGICCL)’ – A reality or myth or two viewpoints about the association between allergies and acute leukaemia in Down syndrome children

Sir, We thank you for the response and valuable comments (Dieckmann, 2014). We appreciate your contribution by pointing out that, besides experimental data (Nuver et al, 2010), there is growing clinical evidence of acute cardiovascular toxicity of chemotherapy in TC patients, which is most likely based on vascular wall damage. Previous studies have suggested not only chronic atherosclerotic effects of chemotherapy for TC, but also more acute effects of thrombo-embolic origin (Dieckmann et al, 2010). The increased von Willebrand factor found in patients directly after chemotherapy contributes to the idea of acute vascular toxicity of chemotherapy (Dieckmann et al, 2011). It is indeed important for clinicians treating patients with TC, to appreciate the acute as well as the more chronic vascular effects of cisplatin-based chemotherapy.

Reply: Comment on ‘A derived neutrophil to lymphocyte ratio predicts clinical outcome in stage II and III colon cancer patients’

On behalf of my coauthors, I thank Singh et al. for their comments regarding our study [2]. We agree they have raised valid questions. We believe that traction or tethering effect on the nerve roots due to spinal cord shift occurring after spinal canal decompression is the cause of postoperative C5 palsy [4]. The rationale for choosing this technique is to preserve ligamentous attachments and bony posterior elements as much as possible to control posterior shift of spinal cord after suitable decompression, instead of excessive decompression. The mean improvement ratio of neurologic function (Japanese Orthopaedic Association score) was 59% at last followup in this study. Because we did not have a control group for this study, it is unclear whether the suitable decompression of hemilaminectomy decreases the degree of cord function compared to excessive decompression of laminectomy. It is true that the hemilaminectomy approach may provide a relatively narrow exposure of the spinal canal, but does more decompression lead to a better clinical result? The surgical results for multilevel continuous/mixed cervical ossification of posterior longitudinal ligament involves various aspects, including neurological function and complications (especially C5 palsy and kyphosis) at short- and long-term followup. Previous studies [1, 3] reported that unilateral fixation had comparable efficacy to bilateral fixation in lumbar spinal fusion. Unilateral fixation is one of the remarkable novel ideas of this technique. We performed contralateral fixation because it was convenient to perform bone grafting on this side, and there was sufficient bone graft bed to afford adequate stabilization of the cervical spine. Because the cervical spine was not unstable, we tried unilateral fixation after multilevel hemilaminectomy and found it was enough for stabilization of the cervical spine. Our last followup indicated a spinal fusion rate of 100%. There were no instances of pseudoarthrosis, rod breakage, or pullout of screws. Fixation on both sides may be more rigid, but unilateral fixation can be acceptable if the approach stabilizes the cervical spine. Future research studying the long-term biomechanical outcomes of unilateral fixation is necessary. Thank you for highlighting some interesting issues relevant to this surgical technique.

Background: A phase III trial was conducted to determine whether neoadjuvant chemotherapy (NACT) before radical surgery (RS) improves overall survival. Methods: Patients with stage IB2, IIA2, or IIB squamous cell carcinoma of the uterine cervix were randomly assigned to receive either BOMP (bleomycin 7 mg days 1–5, vincristine 0.7 mg m−2 day 5, mitomycin 7 mg m−2 day 5, cisplatin 14 mg m−2 days 1–5, every 3 weeks for 2 to 4 cycles) plus RS (NACT group) or RS alone (RS group). Patients with pathological high-risk factors received postoperative radiotherapy (RT). The primary end point was overall survival. Results: A total of 134 patients were randomly assigned to treatment. This study was prematurely terminated at the first planned interim analysis because overall survival in the NACT group was inferior to that in the RS group. Patients who received postoperative RT were significantly lower in the NACT group (58%) than in the RS group (80% P=0.015). The 5-year overall survival was 70.0% in the NACT group and 74.4% in the RS group (P=0.85). Conclusion: Neoadjuvant chemotherapy with BOMP regimen before RS did not improve overall survival, but reduced the number of patients who received postoperative RT.

To the Editor: We read the article “Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures” by Matre et al. [3] with great interest, and we congratulate the authors for their valuable contribution to the orthopaedic literature. A fracture registration system database including more than 17,000 primary operations for hip fractures is a golden opportunity. The choice of implant for stable AO 31A1 fractures is a sliding hip screw and this is textbook knowledge [1, 2] that was confirmed by this article [3]. Another generally accepted piece of textbook knowledge is that the two disadvantages of intramedullary nails are local pain and fracture about the implant [2]. Matre et al. also confirmed this by reporting the two major reasons for increased reoperations for intramedullary nails other than sliding hip screws were local pain from the implant and fracture around the implant (with p values of 0.043 and 0.027, respectively; Table 4 [3]). Another statistically significant difference was the risk of implant removal (p = 0.028), which was lower for sliding hip screws. In their article, Matre et al. discussed the limitations of their database, and stated that they did not have the radiographs of the patients in their register. However, we believe analyzing the reasons for reoperations by depending on the radiographic images and file records (at least the failures of osteosynthesis, nonunions, cutouts, fractures around implants, and pain) would be important. In Table 4 [3], it shows there were 249 reoperations, including 189 sliding hip screws and 60 intramedullary nails. If the authors are able to review the x-rays and file records of a reasonable number of patients, perhaps as the subject of a new article, they might discuss the tip apex distance, position of the lag screw, reasons for the observed failures, pain, infection, and other reasons leading to reoperations, which we believe would be valuable contributions to the literature, and in particular would help us to distinguish implant-related from surgeon-related causes of reoperations.

I appreciate and agree with the comments shared by Rohman and Boddice regarding the expanding library of useful orthopaedic applications. In fact, since the initial publication of “Smartphone apps for Orthopaedic Surgeons” in July 2011 [3], much has changed in the realm of available orthopaedic apps. A followup study specifically examining iPad apps [4] and another review of orthopaedic apps [1] were published. I and others are continuing to examine the role that mobile technology will play in the lives of orthopaedic surgeons and patients. Rohman and Boddice identified an important concept: that the world of apps is in a state of constant change. With this in mind I launched www.TopOrthoApps.com in December 2011 to serve as a continuously updated resource of orthopaedic mobile apps. The site currently includes more than 200 apps for iPhone, iPad, and Android devices, a substantial increase from the 74 apps identified for my original article just 18 months ago. The website includes a listing of peer-reviewed apps and current literature on the topic of orthopaedic applications. In addition, the recent release of the “Top Ortho” app from the iTunes App Store (https://itunes.apple.com/us/app/toportho/id553738826?mt=8) now allows users to read reviews and download apps directly from their mobile devices. I also appreciate the authors’ mention of many newer apps and general surgical and anatomy apps that were not included in the initial review. To expand on their list, it is worth mentioning new educational resource apps such as AAOS eBooks, a plethora of online journals (Spine, Journal of Hand Surgery, JBJS Image Quiz, Journal of Orthopaedic Trauma, etc), TraumaLine, and EBSS.Live from AO. There also exist new reference and decision-management apps, such as OrthoRef, Septic Hip, SLIC, and eSplint. Newer apps have been released that focus on patient information and education, including the “Decide” series (SpineDecide, HandDecide, FootDecide, KneeDecide, etc) and DrawMD Orthopedics. Some publications [5, 7, 8, 11–13, 15] have started validating particular apps, which to this point have focused mostly on goniometer-based devices for angular measurements (ie, simple gait or function analysis measures). Finally, the number of nonEnglish apps has been increasing and currently includes apps such as OmbroCotov, OrtoClas, and TumorOsseo (Portuguese). With the prevalence and use of clinical apps on the rise, concerns have increased regarding app validation [6, 10], the risk of decreased hand hygiene [2, 14], confidentiality [9], and physician distraction [16]. Ultimately it is the responsibility of the physician to make decisions based on appropriate medical information and to ensure the safety of his or her patients. I encourage all providers to consider how apps influence their own practice and to remain diligent about ensuring patient safety and care.

To the Editor We read with interest the article by Shi et al. [9] published in your journal that addresses the controversial topic of percutaneous vertebroplasty (PVP) using meta-analysis of selected literature. The authors’ conclusion [9] appears to contradict Recommendation 8 of the American Academy of Orthopaedic Surgeons (AAOS) “Clinical Practice Guideline (CPG) on the Treatment of Symptomatic Osteoporotic Spinal Compression Fractures” [2]. We would like to address the differences between their analysis and that done by the AAOS CPG Workgroup. Although the meta-analysis process was similar in both reviews, some methodologic aspects differ. AAOS established a priori content based inclusion and exclusion criteria for study selection [2]. It is unclear how Shi et al. determined which articles to include. The AAOS Workgroup excluded three studies that they included [1, 4, 8] for poor study design description and for not being the best available evidence. A study is not the best available evidence if there are at least two studies of higher quality that measure the same outcomes; high quality studies are unlikely to be overturned by future evidence. Three studies in the current review [5, 7, 11] were published after the AAOS CPG was completed, but would not have changed our recommendation. Only three studies were mutually included [3, 6, 10]. Both reviews show no difference between sham treatments and PVP [2, 9]. There is disagreement in outcomes between nonoperative therapy and PVP, a comparison not made in randomized controlled studies because of inherent bias. The AAOS considered the magnitude of treatment effects by using statistical significance in the context of minimal clinically important improvements (MCII). The MCII is the smallest change that is important to patients; it controls for statistically significant treatment effects that are too small to matter. Shi et al. appear to incorporate only statistics. They rely heavily on the results of PVP that measure subjective outcomes and, in their conclusion, diminish the validity of comparing PVP with nonoperative treatment [9]. The meta-analysis by Shi et al. offers a different conclusion on the benefits of PVP than does the AAOS guideline. The methodology used by the AAOS is substantially more rigorous and transparent. Additional studies used in the Shi et al. analysis either do not meet our inclusion criteria standards or their weakened quality would exclude them in the AAOS analysis. We believe the AAOS’s use of MCII is preferred over the use of straight statistical comparisons used by Shi et al. PVP versus sham surgery is the gold standard of comparisons, and these results are not contradicted. It is understandable that physicians would want to validate a procedure that they believe works. For this to occur, high-quality studies using appropriate outcome measures will have to show a difference greater than the MCII.

We appreciate the thoughtful comments of Dr. Berger regarding our recent publication [1]. He focused on the following methodologic points: randomization methods, concealment of allocations, and masking (blinding). Overall, we are in agreement with the position that every action should be taken to minimize susceptibility to bias by using the most appropriate methods for conducting randomized controlled trials. However, we are concerned that theoretical judgments were proposed by Dr. Berger without detailed review of the actual studies being evaluated. Specifically, he argues that “in point of fact, it is unlikely that any of the studies were properly randomized, or enjoyed the benefits of allocation concealment”. In addition, he stated “it is unlikely that even the one study [2] that claimed masking could have been truly masked”. We should start by examining the specific methods used in the excellent study by Brushoj et al. [2] as an example. With respect to randomization, each subject was randomly divided into a group performing the prevention training program or a group performing the placebo training program using a stochastic computer-generated method. With respect to allocation concealment, group assignment was performed (according to personal registration number) by the head nurse who maintained the allocation sequence and who otherwise did not participate in the study. With respect to masking, the subjects and program instructors did not know which of the training programs was being tested. All subjects with knee or shin pain were examined by one of the authors who was blinded to training group allocation. Data were entered in a blinded manner from coded collection forms. In light of these actual methods, we are interested in comments and direction from Dr. Berger on how to better design, conduct, and report randomization, allocation concealment, and masking in future orthopaedic prevention studies.

Dr. Ali raises important and valid points. The medical profession should lead quality improvement efforts in health care, and the primary vehicles for change in our healthcare delivery system will be healthcare professionals. Expecting the dissemination of cost and quality reports to correct the information asymmetry in healthcare markets in a manner that equips patients to independently make informed value-conscious medical decisions is unrealistic and overly simplified. However, this was not the premise underlying our recommendation for public reporting of cost and quality information [4]. In the text of our article, we state that “The policy goals of reporting quality and cost information in orthopaedic surgery are to equip stakeholders, including healthcare purchasers, payers, and patients, with information to evaluate the relative value of musculoskeletal care. Correlating surgical outcomes with the costs associated with the delivery of surgical care holds the potential of yielding the measure of value desired” [4]. The underlying assumption is that the availability of cost and quality information will equip a multitude of actors to make more informed decisions, to increase provider accountability, and to incentivize performance improvement, more effectively than they can in the absence of such information. If appropriately implemented and applied, the provision and use of publicly available cost and quality information should gradually make it impossible for “failing providers” to provide care, and should equip patients to recognize what substandard care would be. Thus to the point raised concerning the possibility that “failing providers are left for those unable to exercise choice, for example, those in lower socioeconomic classes or the elderly”, the goal of public reporting in health care is to not allow such providers to practice without accountability and reprimand for delivery of substandard care. However to stimulate change in the medical profession requires the development of a standard of care that patients must learn to expect and evaluate through access to information and provision of feedback. This is reportedly the preference of patients particularly in the case of elective procedures, where studies [1] including that of the Dartmouth Center for Informed Choice [6] have shown that patients facing elective procedures—such as elective orthopaedic procedures—benefit greatly from understanding their options, risks, and benefits. In the current evolution toward a patient-centered care model, patients’ personal preferences and values, lifestyles, and family and social circumstances are considered in the decision-making regarding individual options for treatment. This has been identified as one of the important factors constituting high-quality health care [1]. Patients prefer participation in the decision-making process, and when informed often make different choices than patients who are not fully informed [3]. Thus the goal of access to healthcare information is not to oblige patient choice without appropriate support, but rather to involve and educate patients toward exercising a choice that reflects their preferences and values. Regarding the responsibilities of the patient consumer and the healthcare professional, it is overly simplistic to designate public reporting and the practice of quality control as the exclusive responsibility of one or the other. As was alluded to in the text of our article [4], the list of actors certainly includes patients, approximately 55% of whom are younger than 65 years with benefits through employment-based insurance, 30% of whom receive Medicare and Medicaid, and the remainder who represent a segment of the uninsured in the United States [2]. A large segment of these patients would benefit from access to information, and have been active users of existing online vehicles of health information. A 2009 Pew Research study [5] showed that 61% of all US adults sought web-based health information. Approximately 59% of this population were in the 50- to 64-year-old age group, 27% were 65 years old or older, and approximately 44% of this population were in a household annual income bracket of less than $30,000. Furthermore for patients either not capable or not interested in engaging in shared, value-conscious healthcare decisions, the proposed concept of accountability under public reporting would incentivize physicians, health plans, and purchasers to consider this information and guide patients accordingly, as their value-based reimbursement rates become driven by public reports of patient satisfaction. However in addition to patients, the list of stakeholders also includes payers, who will use this information to derive provider payment rates and allocations. It includes purchasers who will consider the information in designing new benefit plans (eg, tiered provider networks, consumer-directed health plans, and global payment models, etc). It also includes healthcare professionals ranging from physicians, nurses, and case managers to hospital administrators and management support staff, who will need this information to perform effective monitoring and evaluation, accurate benchmarking, and continuous quality improvement. Thus, rather than dividing the “professional provider” and the “patient consumer” into two separate groups, this interdependent group of actors requires shared participation of all entities to achieve the intended goals. Finally, regarding the final statement “quality control (being) the responsibility of the medical profession, not of patients”, one could argue that the indication for public reporting and greater patient involvement arose in response to the historical lack of professional oversight in health care. This has been revealed through an extensive body of evidence that highlighted inconsistent and unexplained variations in practice, overuse and underuse of services, insufficient monitoring of safety, outcomes, and the management of healthcare finances and resources. It would be unreasonable to assume that a surge of effective self-regulation will spontaneously arise without an organized shift in the paradigm of healthcare delivery for patients, providers, and purchasers. We believe that public reporting is a necessary building block for value-based health care. Alone, it is not sufficient to provoke the transformational changes we seek to promote in our healthcare system. Bending the cost curve and achieving meaningful quality improvement, we believe, is not obtainable without this critical information.

We appreciate the opportunity to reply to the comments of Drs Wolf, Leithner, and Clar. Their comments regarding our study [1] are centered on the concept of applying risk stratification for patients being treated for an infected THA during the early postoperative period. They state that our study does not account for patient-related risk factors in its analysis and that we overlooked two studies [2, 3] that might have contributed insight into this element of the analysis. As is known, the success or failure of any medical intervention in general, and the treatment of periprosthetic joint infections in particular, are predicated on many factors. The concept of Bayes’ theorem and a priori risk are highlighted in this clinical scenario and are mentioned in our article. We believe strongly that risk stratification has an extremely important role in deciding a treatment regimen. What Wolf et al. fail to mention is that these are just concepts. Even for common orthopaedic procedures such as THA, the elements that lead to meaningful risk stratification are not fully understood or implemented, and moreover, in complex clinical scenarios such as with a periprosthetic joint infection, these elements and their application become even more challenging. The two studies referenced by Wolf et al. [2, 3] serve to highlight the lack of information on this concept in the literature. The study by McPherson et al. [3] reports on a staging system for patients with chronic infection who have had a resection arthroplasty as the first stage of a two-stage procedure. McPherson et al. report that the staging system they used correlated with the ultimate ability to successfully reimplant a prosthesis. Although this study provides insight into the specific clinical scenario of patients with a resection arthroplasty after a chronic infection awaiting a second-stage reimplantation, this does not in apply to the hypothetical clinical scenario of our patient 3 weeks after THA. In addition, although elements of this staging system might be useful for acute postoperative infections, the study by McPherson et al. [3] cannot be applied to fundamentally different clinical scenarios. In the study by DeMan et al. [2], no elements of risk stratification are provided, but rather this is a study reporting on the results of a specific algorithmic approach to infection. In addition and similar to the study by McPherson et al., DeMan et al. do not report on the outcomes of acute postoperative infection, but rather a combination of acute and chronic infections they treated. They also report the use of antibiotic cement for fixation of the femoral and acetabular components in approximately half of their cohort. The use of antibiotic cement for the single-stage approaches is mentioned specifically in our study with reported infection control rates. In addition, we discussed the concept of single- and two-stage exchanges being performed using cementless components. The study by De Man et al. does not apply to the clinical scenario presented by an acute postoperative infection. Although we fundamentally agree with Wolf et al. in their desire to use risk stratification in the analysis of different treatment algorithms, there are no published data that establish these parameters. We agree that prospective studies are warranted to better answer this question.

We thank Dr. Lang for further clarification regarding our article. We are happy to address her concerns. First, regarding the issue of inclusion of the article by Paterson et al. [4], we acknowledged in a response to a previous Letter-to-the-Editor [3], that the existence of “temporary brittle bone disease” as a variant of osteogenesis imperfecta (OI) has been challenged and in some ways shown to be nonscientific. However, all authors of the original paper [2] were unaware of the court ruling from the United Kingdom related to the study by Paterson et al. [4], and we welcome the clarification provided by Dr. Lang. This point is even more relevant in light of the fact that the MOOSE group (Meta-analysis of Observational Studies in Epidemiology) state in their guidelines that because observational studies are vulnerable to bias, confounding, and chance, readers should consider explanations for the observations other than the conclusions of the authors [5]. However, even had we known a priori about the court ruling, the study by Paterson et al. [4] still would have met our search criteria and our inclusion and exclusion criteria. As such, strict observation of systematic review technique would dictate that it be included as the article has not been retracted from its originally published journal. However, we would have made note of the controversy and indicated that his ‘disease’ has been challenged, and that Dr. Paterson has been banished from medical practice. We by no means support the existence of “temporary brittle bone disease” or the work of Dr. Paterson; we simply reported the results of our systematic review. Exclusion of the article would have made our study a selective, not a systematic review because we would have excluded an article that met inclusion and exclusion criteria simply because we did not agree with the authors or their findings. Furthermore, we do not believe that inclusion of the article discredits our entire study. In our article, reference to the work by Paterson et al. [4] regarding temporary brittle bone disease [4] is made only sparingly in the article. Furthermore, of the 914 cases we pooled in our study, the article by Paterson et al. contributed only 39 cases (less than 5%). The omission of their article (based on the facts provided) would not have changed our main conclusion: various bone disorders (primarily OI, rather than temporary brittle bone disease) might be mistaken for child abuse. The main result of our study [2] which would have been affected is the following: “Pooling the studies in which confirmed cases of metaphyseal dysplasia/OI were present, there was an 18.7% (162 of 866) rate of initial misdiagnosis of CAN [child abuse and neglect] or bone disease.” Through exclusion of the article by Paterson et al., that sentence should now read: “Pooling the studies in which confirmed cases of metaphyseal dysplasia/OI were present, there was a 15.7% (130 of 827) rate of initial misdiagnosis of CAN or bone disease.” The purpose our study was simply to note that bone disease (particularly OI) can be mistaken for child abuse and neglect, and should be in the mind of the clinician. The exclusion of the work by Paterson et al. does not change that conclusion. Second, Dr. Lang proposed that we did not correctly cite the data in the 1980 study by Horan and Beighton [1]. The cited article was a review of notes and radiographs of patients with reported bone disease. Dr. Lang stated that we incorrectly presented the information by including 13 children (six in the bone disease category and the remaining seven in the child abuse and neglect category). Dr. Lang believes that the exact data included 15 patients. The actual text of the article reports on 13 cases (representing 15 patients, two of the cases represented two siblings which we treated as a ‘case’). We should have clarified this in our manuscript using the word “cases” as opposed to patients, but our analysis remains the same. On page 246 of the article in Table 1, 13 cases (representing 15 patients) are listed with complete data regarding their initial diagnosis and final diagnosis [1]. From this table, there are six cases in the bone disease category, and seven in the child abuse category. We should have clarified this in our manuscript, but believe that data should still be reported as 13 cases – with our subsequent proportions accurate. Regardless, this once again does not change our conclusion. Finally, Dr. Lang takes issue that we state in our article [2] that: “In many instances, a physician’s own instincts make the diagnosis.” She isolates this statement out of the context of the paragraph. The entire paragraph reads, “The limitations of our study and the literature are not trivial. First, there is no gold standard test for diagnose [sic] CAN; it remains a synthesis of history, physical examination, and radiographic findings. In many instances, a physician’s instincts make the diagnosis. Therefore, any study of CAN is fraught with the danger of misclassification.” This statement is placed in the limitation section of our study as a limitation [2]. This is not our recommendation. We even state in the following sentence that since physicians incorrectly rely on instincts (not a gold standard test), child abuse and neglect are fraught with misclassification. We do not believe, as Dr. Lang states, that the results of our study are inherently incorrect. Our study still reports on 827 cases of metaphyseal dysplasia/OI of which 130 were misdiagnosed as CAN [2]. These data are simply from the systematic review we performed, and we are reporting the results of this review. Exclusion of the 39 cases of Paterson et al. [4] does not inherently change the conclusions of our study as they represent a minimal percentage of our total cases. Furthermore, our use of the patients from the Horan and Beighton [1] study as 13 cases as opposed to 15 patients does not change the results of our study, and represents how the authors reported their data. Our study simply summarizes the literature present regarding bone disease and child abuse and neglect.

We thank Dr. Partridge and his colleagues for their letter. They commented, ”…the distinction between patients with infection and without infection must be questioned as a large proportion of patients deemed to be correctly diagnosed as having aseptic loosening did not have specimens sent for culture.” As we explained [4], before institution of a standard protocol, some patients with aseptic loosening may not have been adequately investigated to rule out periprosthetic joint infection (PJI). The latter explains why intraoperative culture specimens were not sent for some patients. Although their point is valid, it does not detract from the message of the paper. At worst, sending culture specimens for the aseptic cases might have increased the number of “misdiagnosed” aseptic cases adding strength to the message of the article. However, the number of optimal culture specimens is not known. In the recent AAOS Guidelines for Diagnosis of PJI for which a comprehensive literature search was done, Della Valle et al. were not able to address this issue based on evidence [3]. Dr. Partridge and his colleagues also commented, “There is also the likelihood that a proportion of the patients assigned to Group 1 (prosthetic joint infection) on the grounds of definite prosthetic joint infection at the time of subsequent rerevision actually had infection after their revision surgery rather than representing falsely diagnosed aseptic loosening.” We were cognizant regarding the possibility that some of the subsequent infections might have been de novo PJIs and not missed aseptic cases, as we stated in our article. Although plausible, the latter is unlikely as these patients did have abnormal serology, and in some cases synovial cell count, at the time of their index revision. There currently are no definite diagnostic criteria for PJI [1]. We are unaware of any validated criteria specifying the number of culture specimens required to be positive for the case to qualify as PJI, nor is there a definite criterion that specifies the importance of isolation of organisms from broth. Diagnosis of PJI is based on a combination of criteria that may need to be varied on an individual basis. As reported previously, in as much as 7% of PJI cases one is not able to isolate the infecting organism (culture negative cases) [2]. Thus, reliance on isolation of an organism (positive culture) is not accepted as the gold standard for diagnosis of PJI. We disagree with the last comment in the third paragraph that isolation of an organism from a single culture represents contamination. For example, for a patient with abnormal serology and abnormal synovial cell count parameters in whom an organism is isolated from a single culture–even broth, would the latter result not be considered significant? Within the confines of manuscript length, we discussed the details pertinent to transport and processing of culture specimens. We recognize that variations in processing culture specimens might have existed but also acknowledge that this is not unique to this cohort or our institution. We agree that management of patients with PJI requires a team effort. As a center that treats approximately 300 patients with PJI per year, we rely on the expertise of our colleagues from infectious disease, microbiology, pharmacy, rehabilitation, and other disciplines to optimize the care of these patients.

Dr. Beck rightly points out that Figure 1 [3] suggests that a cam-type hip can be diagnosed from an AP radiograph. In the original version of the figure, the CT image in three orthogonal views was included beneath the radiograph, to show that the diagnosis was a three-dimensional one. This original figure is appended (Fig. 1) by way of reassurance that an AP radiograph is not relied on for this diagnosis. Dr. Beck therefore can be assured that cam hips were not misdiagnosed. Fig. 1 Plain radiographs of normal, cam, and pincer-type hips are shown, with CT images of 3d, axial, sagittal and coronal reconstructions below. The green normal hip has alpha and centre-edge angles in the normal range. The red cam hip has a large alpha angle ... If the 3-D method of Beaule et al. [1] is used to describe a cam on the femoral side, I have yet to find a case with an acetabulum that is deeper than normal, thus being able to act as a pincer as described by Ganz et al. [4] in a seminal and widely cited article. Therefore I agree with the conclusion that Dr. Beck draws from the data presented [3]: the acetabulum in pincer hips does appear to be distinctly different from the acetabulum in cam hips. Dr. Beck describes exactly what was observed: there are two separate methods of impingement. However, in a later paper that also is cited widely, Beck et al. stated that the majority of cases are of ‘mixed’ type [2]. Although I agree that most cases have evidence of impingement on the femoral and acetabular sides, I do not agree that the mechanism is ever mixed, and wonder if this important point might have been ‘lost in translation’. I continue to look for the first reported case of coxa profunda with a cam on the femur, or of a cam hip with an acetabulum that is even of average depth. This issue is clinically relevant: the acetabulum of the cam hip is shallow - not deep, therefore “rim trimming” of the acetabular iliac eminence in these hips runs the risk of causing iatrogenic acetabular insufficiency, leading to rapidly progressive hip damage.

We thank Descatha et al. for their interest in our article [3] and their comments. A systematic review and meta-analysis uses a systematic approach to identify evidence from multiple studies to attain an accurate and unbiased estimate of the association between interventions or exposures and events that could be widely applicable to a larger population [4]. By combining patient data from multiple studies appropriately, meta-analyses allow for larger sample sizes and therefore statistical power to determine treatment effects [1, 4]. However, systematic reviews are not without limitations. All reviews are retrospective and observational and therefore are subject to random error and systematic bias [1]. Systematic reviews, when conducted properly, can provide a high level of evidence, improve the precision of the analysis by increasing the sample size, and help to explain differences in study results attributable to heterogeneity [2]. Ultimately, a meta-analysis depends on the quality of the primary studies included in the analysis [2]. We believe that we performed a quality meta-analysis [3], confirmed by high scores on the Oxman and Guyatt index [5], a validated scoring system for the quality of meta-analyses and systematic reviews. Drs. Descatha, Huard, and Duval suggest that by combining studies that used different cross-sectional area cutoffs for positive diagnosis of carpal tunnel syndrome, our results may artificially influence the sensitivity and specificity of the sample. All meta-analyses carry this risk, and our study is no different. We agree that obtaining the raw data from all studies included in the analysis would have yielded more accurate results. However, as obtaining the raw data from every study is not possible, including only studies for which we were able to obtain raw data would introduce substantial selection bias. They also suggested that separate analyses should have been performed at each cross-sectional area cutoff value, however, this would decrease the sample size for each value and add more confusion to an already potentially confusing analysis. We thank Drs. Descatha, Huard, and Duval for observing our failure to include the likelihood ratios in the manuscript and have included a table detailing the ratios (Table 1). Table 1 Studies included in the meta-analysis [3] and reported likelihood positive and negative ratios We respectfully disagree that the specific transducer and ultrasound equipment used in each study is an important factor in the sensitivity and specificity of ultrasound as a diagnostic tool. We found no literature to support the advantage or disadvantage of one transducer over another. We did identify substantial heterogeneity in the criteria used for electrodiagnostic testing and clinical findings in the diagnosis of carpal tunnel syndrome. This heterogeneity, however, mirrors clinical reality where different institutions and physicians use varying criteria. We sincerely thank Descatha et al. for their thoughtful comments and hope we have addressed their concerns.

We thank Drs. Ng and Ellis for their well-taken comments to our article “The Cam-type Deformity of the Proximal Femur Arises in Childhood in Response to Vigorous Sporting Activity” [3]. We agree with their comment that although there is an exponentially increasing number of varied treatment methods in recent years, little is known regarding the etiology of cam-type morphology. In the past, cam-type morphologic features were presumed to arise primarily from a mild or silent capital slip [1, 5]. However, the typical horizontal orientation of the growth plate with extension of the epiphysis onto the neck [4] contradicts this hypothesis in the majority of patients with cam-type impingement. To the best of our knowledge, our study showed for the first time that high-level sports activities (basketball) during childhood and early adolescence might be one important factor determining the final shape of the proximal femur in Caucasians. That means that playing basketball at a high level by this age group represents a risk for the development of a cam-type deformity. Our study however does not provide any confirmation for the hypothesis of Ng and Ellis [2] that high axial loading of the hip is the driving factor in the elite basketball player. Our study simply describes morphologic findings and differences between highly active athletes and a control group during and shortly after the growth period. In contrast to the suspicion of Ng and Ellis that adolescent activities, particularly in flexion-internal rotation, might protect against cam morphologic features, we rather suspect hip activities with vigorous loading during flexion and internal rotation of the hip might be responsible for abnormal growth and an aspherically shaped femur. However it was beyond the scope of our study to define the actual forces and specific damage mechanism leading to cam-type morphology.

To the editor, We read the Level I study by Tarwala and colleagues [11] with great interest. The study compared the operative tourniquet group to cementation tourniquet group in patients undergoing TKA. The authors found no difference in surgical time, postoperative pain, motion of the knee, blood loss, and complications between the two groups. The authors also indicated in their conclusion that they prefer to use the tourniquet only during cementing in TKA. Although the authors mentioned that there were no previous studies comparing the effects of tourniquet used only during cementing, we found two studies on the same topic published before the current study [4, 7]. Kvederas and colleagues [4] compared three groups undergoing TKA in a Level II study. In the first group, the tourniquet was inflated before incision and deflated after hardening of the cement. In the second group, the tourniquet was inflated just prior to cementing and was released after its hardening. In the third group, it was inflated before incision and deflated after closure of the incision. In contrast to Tarwala et al., these authors found higher estimated blood loss with the second group (the group that used the tourniquet only during cementation). The second study by Mittal and colleagues [7] noted higher transfusion rates with the short tourniquet group (cementation tourniquet). The authors had to abandon the study due to unacceptably high transfusion rates in the cementation-only tourniquet group. As both of these studies were not cited by the authors, their findings, which are in contrast to the present study, were not compared in the Discussion section. The authors failed to perform a power analysis at the initiation of the study because similar studies were not available in literature. The timing of deflation of the tourniquet remains unclear in the current study. In the Methods section, it is stated that the tourniquet was released in all patients at the completion of cementation of the patella and the knee held in extension with compression of the patella for the subsequent 10 minutes it took for the cement polymerize. If the tourniquet was released after complete polymerization of the cement, the mean tourniquet time in the cementation tourniquet group of 9 minutes (range = 7 minutes to 14 minutes) is less than the time it took for the cement to polymerize completely. If the tourniquet was released just after implantation, but before complete curing of the cement, blood that would flow after the tourniquet’s deflation would be mixed with cement at the crucial phase of cement polymerization and weaken the interface for cementation. It has been shown that hyperemia following tourniquet deflation peaks at 5 minutes after deflation [5]. Therefore, it would not provide a bloodless bone for cementation, defeating the purpose of using tourniquet only during cementation. Additionally, certain discrepancies were found in the references cited in the text and their actual contribution. In the Introduction, the authors compared randomized controlled trials featuring patients undergoing TKA with or without tourniquet that show no statistical difference in blood loss or less blood loss when no tourniquet is used. The authors provided three additional studies [2, 6, 13] in their References section. However, none of these three papers have studied blood loss with or without tourniquet in TKA. Yang and colleagues [13] investigated the effectiveness and safety of tranexamic acid in reducing postoperative blood loss in TKA, but not of the tourniquet alone. A study by Vandenbussche and colleagues [12] has been quoted as showing no difference or less blood loss without tourniquet. However, the study reports higher blood loss without the use of a tourniquet. Similarly, a study by Kato et al. [3] has been cited as a reference for wound complications following tourniquet use. However, the original study purpose was to detect emboli during the tourniquet inflation phase and to identify the composition of the echogenic material. In the Discussion section, the authors cited two meta-analyses [1, 10] as references for the absence of differences in pain with or without the use of tourniquet. However, both of these articles failed to assess pain as a part of their meta-analysis. Also, no difference in swelling of the knee has been shown as a finding of both these meta-analysis when they have not assessed the same. In fact, both of these studies discussed increased swelling of the extremity with tourniquet use in their Introduction. Alcelik and colleagues used a reference by Silver et al. [8] to cite the increased swelling post-tourniquet use. A study by Tai and colleagues [9] has been mentioned as reference for a study showing that increased drainage has been correlated to tourniquet pressure more than 225-mm of Mercury. However, this study compared the tourniquet and non-tourniquet group with respect to blood loss, soft tissue damage, pain, swelling rehabilitation, and hospital stay. It does not address the correlation between tourniquet pressure and drainage. In fact, Tai et al. [9] did not use a drain in their study in order to avoid excessive blood loss.

I appreciate the interest and comments from Drs. Zhou ZhiJie and Fan ShunWu regarding the article, New Equations for Predicting Postoperative Risk in Patients with Hip Fracture [7] and two previous studies [8, 9]. In several studies, the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system correlated with the incidence of postoperative morbidity and mortality and the severity of potential postoperative complications [8, 9]. It also correlated with the length and cost of hospitalization [9]. However, the correlation coefficients in the studies were low. I recognize the correlation coefficient less than 0.2 means weak correlation. Moreover, the E-PASS score is a poor predictor of complications in patients requiring liver resection although the mortality is effectively predicted [1]. Therefore, the predictive ability of the E-PASS scores was confirmed [7]. First, equations were established to predict the morbidity and mortality rates in candidates for hip fracture surgery using the E-PASS system, and then the equations were compared with the Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity (POSSUM) systems. POSSUM systems are the best available for assessing outcomes by risk adjustment analysis in various types of surgery [4, 6, 10], and their usefulness for hip fracture surgery also has been reported [2, 3]. Hirose et al. [7] showed the E-PASS more correctly predicted the actual morbidity and mortality rates than the POSSUM system. The observed to estimated ratios for morbidity and mortality as a risk-adjusted quality measure were 1.06 and 0.71 calculated by the developed equations, respectively. The predicted rates for inhospital and 30-day morbidity and mortality calculated by POSSUM systems were overestimated by 2.6-fold to 6.7-fold compared with those by E-PASS. Based on these results, it was concluded that the E-PASS score was effective and reproducible as an audit tool to predict the postoperative course of patients considered for hip fracture surgery. The E-PASS scoring system is comprised of a preoperative risk score (PRS), a surgical stress score (SSS), and a comprehensive risk score (CRS) that is determined by the PRS and SSS. In hip fracture surgery, the E-PASS scores have some inconsequential parameters such as the extent of the skin incision, which means a laparotomy and/or thoracotomy for calculating the SSS, because this scoring system was developed originally for gastrointestinal surgery [5]. Therefore, additional studies are being done to modify the E-PASS scores to evaluate more accurately the postoperative course for hip fracture. As few scoring systems are still practical to predict postoperative risk in patients with hip fractures, I recommend the E-PASS system and presume their predictive values will be evaluated in many institutions.

Comment on ‘Prevalence of the metabolic syndrome and cardiovascular disease risk in chemotherapy-treated testicular germ cell tumour survivors’

Comment: childhood leukaemia and power lines – the Geocap study: is proximity an appropriate MF exposure surrogate?

Around 1 in 10 of all cancer cases occur in adults of reproductive age. Cancer and its treatments can cause long-term effects, such as loss of fertility, which can lead to poor emotional adjustment. Unmet information needs are associated with higher levels of anxiety. US research suggests that many oncologists do not discuss fertility. Very little research exists about fertility information provision in the United Kingdom. This study aimed to explore current knowledge, practice and attitudes among oncologists in the United Kingdom regarding fertility preservation in patients of child-bearing age.A national online survey of 100 oncologists conducted online via medeconnect, a company which has exclusive access to the doctors.net.uk membership of GMC registered doctors.Oncologists saw fertility preservation (FP) as mainly a women's issue, and yet only felt knowledgeable about sperm storage, not other methods of FP; 87% expressed a need for more information. Most reported discussing the impact of treatment on fertility with patients, but only 38% reported routinely providing patients with written information, and 1/3 reported they did not usually refer patients who had questions about fertility to a specialist fertility service. Twenty-three per cent had never consulted any FP guidelines. The main barriers to initiating discussions about FP were lack of time, lack of knowledge, perceived poor success rates of FP options, poor patient prognosis and, to a lesser extent, if the patient already had children, was single, or could not afford FP treatment.The findings from this study suggest a deficiency in UK oncologist's knowledge about FP options and highlights that the provision of information to patients about FP may be sub-optimal. Oncologists may benefit from further education, and further research is required to establish if patients perceive a need for further information about FP options.

Reply: Comment on 'Stage-dependent alterations of the serum cytokine pattern in colorectal carcinoma'

We read the letter from Tao et al. with great interest. We very much appreciate their comments. In our study [4], we highlighted the fact that surgical technique is the key to achieve ideal nail positioning, ensure stable fixation, and prevent major complications. We agree with the importance of keeping the instrument insertion line (guide wire, reamer, and the nail) coaxial to the femoral canal line. Following the surgical technique guidance is the safest way to achieve that. In our practice, we always try to use the recommended entry point for the PFNA II according to the manufacturer’s suggested surgical technique; the entry point recommended by Synthes is at the tip of the greater trochanter or slightly lateral to it [6]. The decreased mediolateral angle of the PFNA II (5° compared with 6° for the PFNA) and its flattened lateral surface allow for that slightly more lateral entry point. To date, in our department, the PFNA-II has been used in more than 300 cases of unstable intertrochanteric fractures and no varus reduction of the proximal head-neck fragment or a wedge opening effect between the head-neck fragment and the shaft fragment has occurred. It is true that there are numerous cases where defining the exact position of the awl at the tip of the greater trochanter is not reliable [1, 2]. We agree that potential problems such as a stiff spine, soft tissue mass about the hip, operative drapes, or laterally oriented operating trajectory of the side-standing surgeon could arise, as Tao et al. noted. We still consider the greater trochanter entry point to be adequate for those cases. There also are cases with extension of the fracture line around the tip of the greater trochanter or with substantial comminution at the suggested entry point. In the latter cases we suggest a deeper awl insertion bypassing the fracture line and introduction of the guide wire under careful fluoroscopy in the AP and lateral views. Tao et al., in their letter, are in accordance with Streubel et al. [5] who suggested that the trochanteric tip represents the ideal starting point in only the minority of cases and an entry point 3 mm medial to the tip is the most suitable for the majority of the trochanteric nails. Nevertheless, the above suggestions are contrary not only to the manufacturer’s surgical technique, but also to the pioneering studies that introduced the PFNA II for Asian patients [3, 7]. We do not argue with the experience of Tao et al., as we do not have a medial entry point experience. However, we do stress the fact that the suggested entry point is at the tip of the greater trochanter and this specific approach was used in our published series. We thank Tao et al. for adding their experience. Adherence to the suggested surgical techniques should not discourage surgeons from trying to improve on or question some of details.

The posterior tension band complex, as articulated so clearly by Dr. Yoshihara, in my opinion makes an important contribution to the etiology of proximal junctional kyphosis (PJK). However, my hesitation in attributing the posterior tension band as the most important risk factor is largely owing to the lack of supportive data in the current literature. This lack of data lies partially in the difficulty of measuring the preservation of the posterior structures and lack of consistency with which the data often are presented. For example, if the dissection of the posterior muscular attachments to transverse processes of the upper thoracic vertebrae plays a pivotal role in the development of PJK, studies should consistently show upper instrumented vertebrae of T1–T6 having a higher incidence of PJK [1]. More recent literature comparing PJK rates in those with upper thoracic (T1–T3) versus lower thoracic (T10–T12) instrumented vertebrae [4, 8] have determined that upper instrumented vertebrae in the lower thoracic spine had a higher PJK rate. In addition, some studies [4–8] have failed to show a difference in PJK rates between different upper instrumented vertebrae. The etiology of PJK is clearly multifactorial and therefore, studies should focus on conducting multivariate analyses when identifying risk factors associated with the development of PJK. We did not investigate the posterior soft tissue integrity. As mentioned by Dr. Yoshihara, the difficulty in including this as a risk factor lies in the inability to reliably quantify the extent of soft tissue dissection and facet capsule disruption at the time of the index operation. One point mentioned by Dr. Yoshihara is that pedicle screw instrumentation damages the supraadjacent facet capsule owing to the footprint of the screw head. Although I agree this is theoretically possible, this has not been supported consistently in the literature [2, 4, 7, 10]. If this were true, one would expect constructs using hooks at the upper instrumented vertebrae to have lower rates of PJK. In fact, reports are inconsistent when it comes to instrumentation type at the upper instrumented vertebrae and PJK, with one report [2] showing a difference and others [4, 7, 10] showing no difference whether a pedicle screw or a hook is used at the upper instrumented vertebrae. As our understanding of the etiology of PJK improves, the spectrum of pathologic features encompassing PJK is becoming more transparent. Earlier studies have described PJK to be a pure radiographic finding [1, 6] while more recent studies [4, 5] suggest differences in Scoliosis Research Society outcomes scores between those with and without PJK. In studies such as those referenced by Dr. Yoshihara [2, 3, 9], no differences in health-related quality of life questionnaires were noted between patients with and without PJK and therefore, the amount of increase in PJK angle noted may be of questionable clinical importance (if it is attributed solely to the posterior approach). This shows the necessity in distinguishing purely radiographic PJK versus progressive PJK causing pain versus catastrophic PJK which often can present with myelopathy and spinal cord impingement. Studies that focus on differences between these subsets of patients with PJK will be useful in determining clinically important risk factors since it is entirely plausible that the inclusion of less severe cases of PJK with more severe cases in a study cohort can have an umbrella effect and dilute otherwise important findings. At the recent Hibbs Society Meeting held during the 2012 Annual Scoliosis Research Society Meeting in Chicago, Illinois, USA, a group of surgeons met with interest on the topic of PJK. It is clear that our understanding of PJK has improved since it was first described [1] but much work remains in understanding the cause and optimal method for treating severe cases. I believe these questions will be answered in future studies and will help us tailor methods for the prevention of PJK.

We thank Dr. Moyad for his constructive criticism and service to the Haitian people. His positive experience providing care in the wake of this natural disaster is testament to the power of volunteerism in resource-poor countries. After the earthquake, many medical and surgical volunteers sacrificed to provide the highest quality care to disaster casualties. These stories and tremendous worldwide response should give all of us hope regarding our international capacity for relief. Nevertheless, the intention of the publication was to provide our readership with a perspective that has remained largely elusive. Although many publications regarding the orthopaedic response to the Haiti earthquake document the quantity of procedures performed and the personal stories of the volunteers, there are few systematic documentations of the failures. Our systematic method of data collection and analysis has many weaknesses highlighted in the publication, but it provides an important window into potential ways in which we can improve and devise measures of disaster care. Many of the anecdotes associated with poor-quality care, we believe, were preventable with training. From our interviews, for example, we discovered that ill-prepared physicians such as ophthalmologists and pediatricians were performing orthopaedic surgeries without adequate training. In addition, to address Dr. Moyad’s specific point regarding fasciotomies, there is documentation to suggest that this procedure should be reconsidered in the acute muscle-crush compartment syndromes commonly found in earthquake zones. The muscle in these limbs usually is already dead and in these resource-poor settings, when damage-control orthopaedics is necessary, there is limited time for repeated operations that risk limb-threatening infection [2]. Although we will never know the specific nature of every injury treated, there clearly is room for debate and greater need for better documentation and further study of disaster response. A substantial report from the Pan American Health Organization (PAHO) discusses the overall lack of organization and chaotic pattern of the relief effort [1]. The foreword of the report states that the response, “included a number of wholly unprepared or even incompetent health actors who bypassed the overburdened coordination mechanisms”. For these reasons, the PAHO report highlights the need for accreditation and training in disaster response, a matter about which we disagree with Dr. Moyad. Regardless of the outcome, training courses provide volunteers with the opportunity to share stories, exchange knowledge, build expert opinion, and prepare for a variety of patient-care possibilities. We hope that formal training courses are cultivated to continue to improve the care provided to patients most in need.

We greatly appreciate the letter from Drs. Unglaub, Leclere, Hahn, and Wolfe regarding our article, Peripheral triangular fibrocartilage complex tears cause ulnocarpal instability: a biomechanical pilot study [1]. Regarding the surgically created lesion of the peripheral triangular fibrocartilage, we transected the insertion of the articular disc from the ulnar styloid with a Number 11 scalpel blade. This was done using arthroscopic observation from the 6R portal. Transection of the disc was confirmed during the same arthroscopy by inserting a probe at the base of the styloid. Arthroscopic images showing creation of the tear and confirmation of the tear are shown below (Fig. 1). A video showing the latter is available with the online version of CORR®. Fig. 1A–D Arthroscopic images show (A–B) creation and (C–D) confirmation of tear of the peripheral triangular fibrocartilage.

Drs Wettstein and Mouhsine are correct to point out the benefits of advanced axial imaging for total hip replacement planning. It is especially helpful in assessing the rotational anatomy of the femur and acetabulum which may help individualize the best component alignment. They also are correct to point out that determination of the actual rotational version of the femur requires scanning the distal femur. The purpose of my study [1] was not to determine anteversion of the arthritic hip or postoperative version of the surgically treated hip since such studies have been reported. Rather, the purpose of my study was to compare preoperative version with the final postoperative version in the same patient. The methodology used was a fluoroscopic technique at the time of surgery, the interpretations of which are subjective and therefore the data were checked with a different methodology. Given similar findings, I presumed the study methods were valid. Two MRI series were used, one with a group of patients with no arthritis (scanned for other medical reasons) and another with patients who underwent MRI as part of the planning for hip replacement, which did include the knee, as Wettstein and Mouhsine suggested. Unfortunately, they missed the main point of the study which showed that version of the anatomic femoral head did not predict version of the prosthetic femoral head using a canal filling broach-only bone ingrowth stem. In fact, on average, the total hip femoral head is more anteverted than the native femoral head, 18.9° (femoral head) versus 27.0° (prosthesis). The range of postoperative version was wide, 0° to 42°, so there were outliers with extremes of retroversion and anteversion. This has implications for polyethylene wear and joint stability. Briefly, as the technique is presented in detail in the paper, a neutral femoral position is determined and marked, and the preoperative proximal femur version is compared with the postreplacement proximal femur. The end points for both of these determinations are subjective, based on change in shape of the image, leaving the conclusions open to criticism regarding the validity of the observation. As the shape of the femoral canal determines the position of a canal-filling stem, a comparison of the canal shape (and therefore version) of the neck can be compared with the head, using axial imaging, either CT or MRI, and the neck version should differ from the head version in the same direction if the study methods are valid. Both scan series showed the same findings, namely that the neck version was more than the head version, which would lead to the canal-filling stem having more anteversion on average compared with the femoral head. The magnitude of the differences was interesting: the average difference for the fluoro-surgical series between preoperative and postoperative images was 6.1°, whereas the MRI series differences of 15.4° for the nonarthritic group and 11.2° for the arthritic group were in the same ballpark as that of the surgical group. Therefore, the conclusions of my study were valid, namely that the postoperative femoral stem is, on average, more anteverted than the preoperative femoral head when using a canal-filling broach-only stem, and the surgeon needs to be aware of this fact to keep the appropriate relationship between the acetabulum and femur to avoid impingement and excessive polyethylene wear. The increased use of axial imaging for total hip planning is a good idea because it would indicate when a specialized implant is needed or when a change from routine component placement is warranted.

We thank Dr Fang for his careful review and consideration of our manuscript [1]. For the benefit of patients every debate is welcome in the development of surgical techniques. Dr Fang questioned whether the technique addresses the hindfoot. The technique we describe reduces from the subtalar joint to the medial cuneiform first metatarsal joint. Therefore, the hindfoot also is corrected. As described in the article, the hindfoot of these patients was in valgus preoperatively and was corrected by the technique. We showed the AP and lateral views of the cases so the reader could view the correction we obtained. We have data for the measurements of all patients (data were not shown). Lateral measurements are much more a reflection of the correction with this technique than the AP angles. If the subtalar joint appears corrected on the lateral view, it will be corrected on the AP view and we reported the subtalar joint was adequately corrected. The second concern regarding degeneration of the adjacent joints also deserves our attention. Wunschel [2] suggested degenerative disease would occur in adjacent joints whenever there is a limitation of movement produced by an arthrodesis (although he did not report on such occurrence in his full article) and we agree. Our patients are being followed every 6 months and none has had complaints of pain or any sign of arthritis up to the last followup (ranging from 2.5 to 7.5 years). The transference of pain to the forefoot also was not observed. A study on the followup of our patients in which the issue of arthritic lesions will be addressed is underway. The third observation regarding hardware points out a “too long screw” observed on the lateral radiograph. As described in our paper, no local complications occurred including skin problems. The long screw observed on the image was observed by our team, but we believed it unnecessary to remove as the patient had no complaints. A second intervention to correct the length of a screw can be a bigger problem in an aligned and pain-free foot. One patient had pain in the plantar surface of the foot, in that case bilaterally, and had the plates removed with resolution of the pain (and a corrected deformity). However, we cannot attribute this pain solely to presumed impingement with soft tissues. Regarding the insertions of the tendons, the description of the technique shows that the periosteum was retracted together with the tendon insertions. Clearly, the insertions of the plantar tendons are contiguous with the periosteum and they are replaced after the plates are fixed and the wound is closed. Therefore, tendon function is not impaired by the procedure. In this deformity the posterior tibial tendon usually is not working properly. The details regarding function, such as balance, will be discussed in a followup report of these patients. We are pleased to have the opportunity to further describe details regarding the surgical technique we proposed.

We thank Dr. Koh and colleagues for their well-taken comments to our article, “The Effect of Long-term Alendronate Treatment on Cortical Thickness of the Proximal Femur” [7]. Our results interestingly showed that the majority of patients treated with alendronate at a minimum of 5 years had stable or decreased cortical thickness. This finding is contradictory to the results from Lenart et al. [3]. Although the method used to calculate a cortical thickness ratio from dual energy x-ray absorptiometry images in our study is similar to that of the plain radiographs used by Lenart et al., a so-called normalized cortical thickness, some differences must be underscored between their study and ours regarding the methodology and patient population. First, Lenart et al. [3] reported the normalized cortical thickness in only patients with subtrochanteric fractures, whereas we included only patients without a history of fractures around the lower extremities. Thus, our findings may not be applicable to those with atypical femoral insufficiency fractures. As we discussed in the original article [7], our study strongly supports the concept that patients with atypical femoral insufficiency fractures had thickened femoral cortices at the onset of bisphosphonate therapy. Second, we determined the cortical thickness ratio only at the subtrochanteric region, whereas Lenart et al. [3] measured femoral cortices just distal to the fracture site, which may not always be synonymous with the subtrochanteric area. Thus, the average value of the normalized cortical thickness from their study may differ from ours. Third, the mean ages of patients in their study were much older (70 and 83 years in patients with and without x-ray pattern for atypical femoral insufficiency fracture, respectively) than our patients (62 and 63 years in patients with and without history of long-term bisphosphonate therapy, respectively). It is possible that patients of different ages may respond to alendronate treatment differently. In addition, we do not have rigorous detail available regarding the adherence and compliance of patients with long-term bisphosphonate treatment in our study. However, the bone mineral density responses in our patients with long-term alendronate therapy were consistent with a compliant population based on previous reports [1, 5]. The majority of patients with atypical femoral insufficiency fractures have enlarged femoral cortices. In addition, they also have localized femoral thickening that may represent a true stress fracture [1–3]. We speculate that a stress fracture occurs at an area of abnormal stress concentration, such as at the lateral aspect of the femur attributable to anterolateral femoral bowing. As prolonged bisphosphonate therapy may lead to inhibition of the fracture healing process and deposition of poor-quality bony tissue [4], these stress fractures can propagate to simple transverse or short oblique fractures with beaking. Nevertheless, we agree with Koh and colleagues that the American Society for Bone and Mineral Research criteria [6] to define atypical femoral insufficiency fractures needs further refinement. As we gain a greater understanding of the pathophysiology, we will be able to better define the critical elements of this unique disorder.

We thank Drs. Van Tongel and De Wilde for their interest in and comments regarding our article [1]. In the Methods section, they questioned the following statements: “it is unclear what they mean when they say it is already more lateralized. If they mean the center of rotation, then this is not correct. The center of rotation does not change by enlarging the diameter of the glenosphere.” We wrote: “The disc of cancellous bone graft thickness was adjusted according to the size of the sphere. A 10-mm graft was used for a 36-mm sphere and a 7-mm graft for a 42-mm sphere since it is already more lateralized than the 36 mm.” We refer to the humerus and not the center of rotation. As mentioned by Drs. Van Tongel and De Wilde, using a 10-mm autograft and a 36-mm glenosphere [10 + 18 = 28 mm] or a 7-mm autograft and a 42-mm glenosphere [7 + 21 = 28 mm] leads to the same humeral lateralization. This choice in the surgical technique is based on our experience: using a 42-mm glenosphere and a too-thick autograft (10 or 12 mm, for instance), in a patient without glenoid bone loss might cause difficulty at the time of reducing the humerus, which is dislocated posteriorly for glenoid exposure. Our goal with the BIO-RSA technique is to obtain the same humeral lateralization (28 mm), regardless of the size of the sphere. Drs. Van Tongel and De Wilde also stated that we “did not describe if there was a difference between the prevalence of scapular notching between the group with a 36-mm glenosphere and the group with a 42-mm glenosphere. This would be interesting to know because using a larger hemisphere on the same position of the baseplate means that there is more prosthetic overhang.” In our series, one of the 10 patients (10%) with a 42-mm glenosphere had scapular notching, whereas scapular notching occurred in eight of the 29 patients (28%) with a 36-mm glenosphere. Using Fisher’s Exact Test, we did not find a significant difference in the proportion of patients with notching in the two groups (p = 0.39). This probably is attributable to the small number of patients in our series. Almost three times more notching occurred in our patients with the 36-mm glenosphere. Thus, our observations seem to confirm that when a large glenosphere (42 mm) is used with the same diameter autograft (29 mm), the incidence of inferior scapular notching is less. As mentioned, this construct increases prosthetic overhang and could explain these findings. We agree that prosthetic overhang probably reduces inferior scapular impingement and presumably notching [3, 5]. However, with the numbers available in our series, we were unable to confirm these findings. We hope to confirm your results in a larger series of BIO-RSA in the future. We believe decreasing the risk of inferior scapular notching is not the only benefit of the BIO-RSA [1, 6]. Other problems encountered with the Grammont (medialized) reverse prosthesis are limited shoulder rotation (specifically in internal rotation, with few patients being able to pass their hand in the back), prosthetic instability (more frequent when the prosthesis is implanted through the deltopectoral approach), and loss of shoulder contour [2]. By effectively creating a scapula with a long neck, the BIO-RSA also decreases the rate of anterior, posterior, and superior scapular notching (allowing greater clearance for the humeral cup around the glenoid sphere), and therefore, improving shoulder mobility in elevation, abduction, and external and internal rotation. In addition, by lateralizing the humerus, the BIO-RSA improves shoulder stability (because of improved tension of the deltoid and the remaining cuff) and shoulder contour. Finally, in contrast to metallic increased offset, BIO-RSA offers the advantage of maintaining the joint center of rotation at the prosthesis-glenoid interface, thereby minimizing torque on the glenoid component [4].

We appreciate your interest in our study. In this study, we did not focus on lumbar extensor strength. Our interventions were consisted of trunk extensor, flexor, and rotator muscles strength. Isolated lumbar extensor strengthening machine MedX (MedX Holdings Inc., Ocala, FL, USA) was used to compare superficial muscles of trunk and deep spinal muscles strength between baseline and post-intervention. You pointed out the similarities between lumbar stabilization and dynamic lumbar strengthening exercises. In exercise method of the two groups, the posture was somewhat similar on the picture. But in the text, we described that "before each exercise, the physical therapist gave detailed verbal explanation and visual instructions, regarding the start and end positions." All exercises were conducted according to the following specific principles: "breathe in and out, gently and slowly draw in your lower abdomen below your umbilicus without moving your upper stomach, back or pelvis". In addition, the group of lumbar stabilization exercises subjects practiced 'abdominal hollowing maneuver' with a therapist providing verbal instruction and tactile feedback until they were able to perform the maneuver in a satisfactory manner [1,2]. We thought that lumbar stabilization exercises should include strengthening deep lumbar muscles as well as neuromuscular control and endurance of these muscles. Conventional lumbar dynamic strengthening exercises were practiced to activate the erector spinae and rectus abdominis muscles. You mentioned that the floor and ball based exercises had little evidence in conditioning effect of lumbar extensor muscles. However, floor- and ball-based exercises are commonly referred to as lumbar stability exercises in many studies [3,4]. I would like to answer your question as follows: 1) Can exercises other than isolated lumbar extension (ILEX) condition the lumbar extensors (e.g., improve ILEX strength) in symptomatic participants, 2) Does ILEX provide greater improvements in ILEX strength, pain and disability than other exercises in symptomatic participants? At present, there is no study that has compared specific isolated lumbar extension training and lumbar stabilization exercise directly. Therefore, it is difficult to say which exercise method is more effective. In my opinion, lumbar extensor strengthening exercise is the most appropriate exercise for chronic LBP. That is why the study of Nachemson and Linch [5] showed that strengthening exercise on lumbar extensor increased the muscle activity, but increased loading of compression on the low back affects injury of tissue. It can cause pain and deteriorate the symptom. Some researchers demonstrated that traditional exercise methods on the deficiencies of stabilizer muscles can make an incorrect compensation. It also has effect on changes of proper muscle coordination pattern and recurrence [6,7]. However, the pathogenic mechanism of back pain is not ensuring. In addition, the effect of exercise treatment showed various results according to the study. Generally, clinical guidelines recommend exercise treatment rather than rest. Today, exercise programs designed to improve lumbar stability and core strengthening are popular to increase athletic performance and treat pain. Movement patterns that were altered by faulty strength and flexibility, fatigue from poor endurance, and abnormal neural control would eventually cause tissue damage. Tissue damage would lead to decreased stability of spinal structures, increased challenges to the already inefficient muscles and the perpetuation of a degenerative cascade. Spinal stability could be compromised by motor control errors or poor muscular endurance of inter segmental muscles and allow for overloading of passive tissues. Patients with back pain also seem to over-activate superficial global muscles whereas control and activation of the deep spinal muscles is impaired. Thus, core stability exercises have strong theoretical basis for prevention of different musculoskeletal conditions and the treatment of spinal disorders [8]. Although a great deal of research has shown that exercises in general are effective treatment for lower back pain, much more research is needed that specifically addresses if lumbar stabilization exercises are more effective than other types of exercise in treating back pain. 3) Whether there is indeed any relationship between improved ILEX strength as a result of exercise interventions and changes in pain and disability. I think that improvement of ILEX strength is contributing to the decrease of pain and disability. The optimal treatment for chronic low back pain is to provide ILEX training and superficial global muscles of trunk and deep spinal muscle strength exercises considering of individual physical characteristics.

The intermix between obstetrics and orthopaedic trauma has been an interest of mine dating back several years. My father is an obstetrician-gynecologist and I spent years working with him. Thus it is natural that I continue research involving pregnancy and orthopaedic trauma. I was thrilled I had the opportunity to work with Dr. Carol Copeland, an expert in this area, during my Trauma Fellowship at the R.A. Cowley Shock Trauma Center. The concept of my collaboration with Dr. Carol Copeland, which began in 2001, focused on pelvic fractures in women of childbearing age and was a direct continuation of her research [2–4]. She developed an extensive questionnaire in 1993 which served as a basis for her articles and our subsequent study. Together, we developed a full research protocol on “Childbirth After Pelvic Fractures”, but I was not able to complete the study during or immediately after my fellowship. I first submitted the “Childbirth After Pelvic Fractures” grant to the Ruth Jackson Orthopaedic Society in 2005. In December 2005, I was notified I did not receive the grant, but they stated there was similar grant by Dr. Vallier and perhaps we should talk. I approached Dr. Vallier, sending her my research protocol, grant proposal, and forms. She agreed to collaborate. I submitted the grant in 2006 successfully to the Foundation for Orthopaedic Trauma ($15,000 received) and the Ruth Jackson Orthopaedic Society/Zimmer Research Grant ($29,948 received). Being the Grant Principle Investigator, I communicated with the other sites’ PIs (Dr. Vallier was the site PI for MetroHealth Medical Center) on numerous occasions, providing extensive details regarding how to complete the study and all spreadsheets and forms to be used. A subcontract was signed with each participating center. As indicated in the article by my coauthor and me published in CORR [1], all patients involved in that study were to be sent the study invitation letter, consent form, HIPAA form, patient information form, SF12, and release form for the obstetrician (as shown in Appendix 1 of the article published in CORR [1]). The study centers then were to send the forms to the obstetrician for completion. In addition, there was an xray and injury form to be completed by the investigators for each patient. I requested the data be sent to me in early January 2009 for submission to the Orthopaedic Trauma Association (OTA). The other two involved centers had extensive data sheets with more than 70 points, as they followed the study protocol. I received a spreadsheet with only 17 data parameters from Dr. Vallier. (Editor’s Note: This spreadsheet was sent to me.) I found it difficult to write an abstract, but did so with the limiting factor being the Metro Health Medical Center data. The abstract was accepted for podium presentation for the 2009 annual meeting of the OTA. More data from Metro Health Medical Center were needed to complete a scholarly paper. On numerous occasions, I asked, through multiple avenues of communication, to obtain the additional data with the intent of including Dr. Vallier as an author for the article published in CORR [1]. Dr. Vallier stated she was not informed the article had been submitted for publication, but I have e-mails confirming otherwise. As I did not receive the complete data from Dr. Vallier, we could not include her patients in the CORR article. In March 2010, I was reviewing a blinded article for the Journal of Orthopaedic Trauma on pelvic injury and its association with sexual dysfunction in women. I was surprised to find a 10-item questionnaire, of which all 10 items were part of my 18-item questionnaire published as Appendix 2 in our article in CORR [1]. The questionnaire Dr. Vallier provided in her article contained the same context and descriptive choices for the 10 items. Dr. Vallier signed a subcontract with the University of Texas Southwestern (where I was completing the research project) indicating in the statement of work that she agreed to complete the study, following our protocol and using the specified forms. In addition, the submission of articles regarding any patients in this study requires permission from the study PI (me) and also acknowledgment of the monies received. Because a grant cannot be submitted without the patient forms and without the collaborating PIs viewing the grant application, the forms in question were received by Dr. Vallier in 2006. That would be more than enough time for Dr. Vallier to let me know that she had the same questions. I questioned her, but she did not provide a direct answer to my question, “How could you have my data sheets since 2006 and not know the questions were the same/quite similar?” I want to thank the editor for the opportunity to provide information regarding this research. These situations can be regretful when completing research to seek the best possible care and information for our patients.