Orthopedics

Neither psoriatic arthritis (PsA) nor cutaneous psoriasis (PsC) is an independent predictor of poor postoperative pain or function following a total hip arthroplasty, according to the results of a case-control study by Dr. Lisa A. Mandl and her colleagues.

The study’s participants underwent surgery between May 1, 2007, and Dec. 31, 2010, in a center that performs more than 4,300 THAs annually. All subjects lived for at least 2 years after their operations. The researchers compared pre- and postoperative data from patients in the following three categories: those with PsA, those with PsC without evidence of inflammatory arthritis, and those with osteoarthritis (OA). Patients with OA comprised the control group, which excluded any patient who self-reported a history of PsA, rheumatoid arthritis, lupus erythematosus, or any other systematic rheumatic disease, or who had documentation of skin psoriasis. The researchers acquired postoperative self-report data from 47 PsA patients, 106 PsC patients, and 864 OA patients. Seventeen percent of patients submitted information on their status at 1 year, 69% at 2 years, and 14% at 3-5 years.

The primary outcomes of interest were postoperative pain and function, which were assessed via the Hip Osteoarthritis Outcome Score (HOOS), from which the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was derived.

There were no statistically significant differences in postoperative WOMAC pain or function scores between the three groups of patients (P = .78 and .96, respectively). The mean pain scores were 14.9, 6.1, and 15.8 for patients with PsA, PsC, and OA, respectively. These patients’ mean function scores were 16.3, 19.6, and 18.8 for the PsA, PsC and OA groups, respectively.

Overall levels of satisfaction with the surgery were similar among the three groups (P = .54). Ninety-three percent of the PsA patients, 79% of the PsC patients, and 84% of the OA patients were “very satisfied” with their total hip arthroplasty. Between 1% and 3% of each group reported being “very dissatisfied” with their surgery. The researchers found that extent of skin disease was not associated with worse postoperative pain or function.

“Further work needs to be done to better understand the interplay of disease activity and quality of life on the outcomes of [total hip arthroplasty] in PsA and PsC,” they wrote.

Read the report in Arthritis & Rheumatology (doi: 10.1002/art.39431).

[email protected]

Neither psoriatic arthritis (PsA) nor cutaneous psoriasis (PsC) is an independent predictor of poor postoperative pain or function following a total hip arthroplasty, according to the results of a case-control study by Dr. Lisa A. Mandl and her colleagues.

The study’s participants underwent surgery between May 1, 2007, and Dec. 31, 2010, in a center that performs more than 4,300 THAs annually. All subjects lived for at least 2 years after their operations. The researchers compared pre- and postoperative data from patients in the following three categories: those with PsA, those with PsC without evidence of inflammatory arthritis, and those with osteoarthritis (OA). Patients with OA comprised the control group, which excluded any patient who self-reported a history of PsA, rheumatoid arthritis, lupus erythematosus, or any other systematic rheumatic disease, or who had documentation of skin psoriasis. The researchers acquired postoperative self-report data from 47 PsA patients, 106 PsC patients, and 864 OA patients. Seventeen percent of patients submitted information on their status at 1 year, 69% at 2 years, and 14% at 3-5 years.

The primary outcomes of interest were postoperative pain and function, which were assessed via the Hip Osteoarthritis Outcome Score (HOOS), from which the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was derived.

There were no statistically significant differences in postoperative WOMAC pain or function scores between the three groups of patients (P = .78 and .96, respectively). The mean pain scores were 14.9, 6.1, and 15.8 for patients with PsA, PsC, and OA, respectively. These patients’ mean function scores were 16.3, 19.6, and 18.8 for the PsA, PsC and OA groups, respectively.

Overall levels of satisfaction with the surgery were similar among the three groups (P = .54). Ninety-three percent of the PsA patients, 79% of the PsC patients, and 84% of the OA patients were “very satisfied” with their total hip arthroplasty. Between 1% and 3% of each group reported being “very dissatisfied” with their surgery. The researchers found that extent of skin disease was not associated with worse postoperative pain or function.

“Further work needs to be done to better understand the interplay of disease activity and quality of life on the outcomes of [total hip arthroplasty] in PsA and PsC,” they wrote.

Read the report in Arthritis & Rheumatology (doi: 10.1002/art.39431).

[email protected]

Neither psoriatic arthritis (PsA) nor cutaneous psoriasis (PsC) is an independent predictor of poor postoperative pain or function following a total hip arthroplasty, according to the results of a case-control study by Dr. Lisa A. Mandl and her colleagues.

The study’s participants underwent surgery between May 1, 2007, and Dec. 31, 2010, in a center that performs more than 4,300 THAs annually. All subjects lived for at least 2 years after their operations. The researchers compared pre- and postoperative data from patients in the following three categories: those with PsA, those with PsC without evidence of inflammatory arthritis, and those with osteoarthritis (OA). Patients with OA comprised the control group, which excluded any patient who self-reported a history of PsA, rheumatoid arthritis, lupus erythematosus, or any other systematic rheumatic disease, or who had documentation of skin psoriasis. The researchers acquired postoperative self-report data from 47 PsA patients, 106 PsC patients, and 864 OA patients. Seventeen percent of patients submitted information on their status at 1 year, 69% at 2 years, and 14% at 3-5 years.

The primary outcomes of interest were postoperative pain and function, which were assessed via the Hip Osteoarthritis Outcome Score (HOOS), from which the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was derived.

There were no statistically significant differences in postoperative WOMAC pain or function scores between the three groups of patients (P = .78 and .96, respectively). The mean pain scores were 14.9, 6.1, and 15.8 for patients with PsA, PsC, and OA, respectively. These patients’ mean function scores were 16.3, 19.6, and 18.8 for the PsA, PsC and OA groups, respectively.

Overall levels of satisfaction with the surgery were similar among the three groups (P = .54). Ninety-three percent of the PsA patients, 79% of the PsC patients, and 84% of the OA patients were “very satisfied” with their total hip arthroplasty. Between 1% and 3% of each group reported being “very dissatisfied” with their surgery. The researchers found that extent of skin disease was not associated with worse postoperative pain or function.

“Further work needs to be done to better understand the interplay of disease activity and quality of life on the outcomes of [total hip arthroplasty] in PsA and PsC,” they wrote.

Read the report in Arthritis & Rheumatology (doi: 10.1002/art.39431).

[email protected]

SAN DIEGO – Rough materials used for orthopedic implants, such as cobalt chromium and titanium, increased bacterial adherence, while smoother materials such as stainless steel did not, results from an image analysis demonstrated.

“In light of these results, it is important to question why we utilize the types of materials we use for various orthopedic procedures,” Dioscaris R. Garcia, Ph.D., said in an interview in advance of the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “There was no one-size-fits-all material to minimize adherence per the findings of this study, but the findings may suggest that having a smoother surface may minimize the ability of bacterial pathogens to adhere to the surface.”

He characterized the topic of bacterial adherence to orthopedic implants as “an issue of great interest due to how little is known about the biological implications of the materials utilized. The most researched of these materials is titanium, which is touted for its biocompatibility. This study aims to provide a base and a glimpse into how the most commonly utilized orthopedic-relevant materials interact with some of the most commonly encountered pathogens.”

For the study, Dr. Garcia, a molecular pharmacologist at Rhode Island Hospital in Providence, Dr. Alan H. Daniels, an orthopedic surgeon at the hospital, and their associates used scanning electron microscopy and confocal laser scanning microscopy to evaluate the adherence pattern, density, and propagation of six commonly encountered bacterial pathogens (methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, coagulase-negative Staphylococcus epidermidis, multidrug-resistant Acinetobacter baumannii, Propionibacterium acnes, and vancomycin-resistant Enterococcus faecalis) on five commonly used spinal implant materials (titanium, titanium alloy, stainless steel, cobalt chromium, and polyetherether ketone). The samples were fixed and dehydrated via ethanol dehydration gradient and critical point drying.

The researchers found that some pathogens, such as vancomycin-resistant E. faecalis and multidrug-resistant A. baumannii, were more likely to adhere to more textured materials such as cobalt chromium and titanium, compared with smoother materials such as stainless steel. “Additionally, the findings suggest that the microtopography of these materials may be the driving force behind the adherence of pathogens on the materials themselves,” Dr. Garcia said. Compared with smoother, polished materials, he explained, the rougher materials were more likely to harbor dense proliferation of bacterial pathogens, which could be characterized as biofilms.

“This study has been successful in providing a platform for future studies to build upon and expand to study additional parameters and statistical tools to give further insight into additional driving forces behind adherence and means for improvement of material design,” Dr. Garcia concluded.

Dr. Christopher T. Born, head of the Diane N. Weiss Center for Orthopedic Trauma Research at Rhode Island Hospital, was the study’s principal investigator. The study was supported by Stryker Corp.*

*Correction, 9/19/2015: Dr. Born is a consultant for Stryker. He also has stock ownership in Biointraface, does consulting for the company, and is a member of its board.

[email protected]

SAN DIEGO – Rough materials used for orthopedic implants, such as cobalt chromium and titanium, increased bacterial adherence, while smoother materials such as stainless steel did not, results from an image analysis demonstrated.

“In light of these results, it is important to question why we utilize the types of materials we use for various orthopedic procedures,” Dioscaris R. Garcia, Ph.D., said in an interview in advance of the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “There was no one-size-fits-all material to minimize adherence per the findings of this study, but the findings may suggest that having a smoother surface may minimize the ability of bacterial pathogens to adhere to the surface.”

He characterized the topic of bacterial adherence to orthopedic implants as “an issue of great interest due to how little is known about the biological implications of the materials utilized. The most researched of these materials is titanium, which is touted for its biocompatibility. This study aims to provide a base and a glimpse into how the most commonly utilized orthopedic-relevant materials interact with some of the most commonly encountered pathogens.”

For the study, Dr. Garcia, a molecular pharmacologist at Rhode Island Hospital in Providence, Dr. Alan H. Daniels, an orthopedic surgeon at the hospital, and their associates used scanning electron microscopy and confocal laser scanning microscopy to evaluate the adherence pattern, density, and propagation of six commonly encountered bacterial pathogens (methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, coagulase-negative Staphylococcus epidermidis, multidrug-resistant Acinetobacter baumannii, Propionibacterium acnes, and vancomycin-resistant Enterococcus faecalis) on five commonly used spinal implant materials (titanium, titanium alloy, stainless steel, cobalt chromium, and polyetherether ketone). The samples were fixed and dehydrated via ethanol dehydration gradient and critical point drying.

The researchers found that some pathogens, such as vancomycin-resistant E. faecalis and multidrug-resistant A. baumannii, were more likely to adhere to more textured materials such as cobalt chromium and titanium, compared with smoother materials such as stainless steel. “Additionally, the findings suggest that the microtopography of these materials may be the driving force behind the adherence of pathogens on the materials themselves,” Dr. Garcia said. Compared with smoother, polished materials, he explained, the rougher materials were more likely to harbor dense proliferation of bacterial pathogens, which could be characterized as biofilms.

“This study has been successful in providing a platform for future studies to build upon and expand to study additional parameters and statistical tools to give further insight into additional driving forces behind adherence and means for improvement of material design,” Dr. Garcia concluded.

Dr. Christopher T. Born, head of the Diane N. Weiss Center for Orthopedic Trauma Research at Rhode Island Hospital, was the study’s principal investigator. The study was supported by Stryker Corp.*

*Correction, 9/19/2015: Dr. Born is a consultant for Stryker. He also has stock ownership in Biointraface, does consulting for the company, and is a member of its board.

[email protected]

SAN DIEGO – Rough materials used for orthopedic implants, such as cobalt chromium and titanium, increased bacterial adherence, while smoother materials such as stainless steel did not, results from an image analysis demonstrated.

“In light of these results, it is important to question why we utilize the types of materials we use for various orthopedic procedures,” Dioscaris R. Garcia, Ph.D., said in an interview in advance of the annual Interscience Conference on Antimicrobial Agents and Chemotherapy. “There was no one-size-fits-all material to minimize adherence per the findings of this study, but the findings may suggest that having a smoother surface may minimize the ability of bacterial pathogens to adhere to the surface.”

He characterized the topic of bacterial adherence to orthopedic implants as “an issue of great interest due to how little is known about the biological implications of the materials utilized. The most researched of these materials is titanium, which is touted for its biocompatibility. This study aims to provide a base and a glimpse into how the most commonly utilized orthopedic-relevant materials interact with some of the most commonly encountered pathogens.”

For the study, Dr. Garcia, a molecular pharmacologist at Rhode Island Hospital in Providence, Dr. Alan H. Daniels, an orthopedic surgeon at the hospital, and their associates used scanning electron microscopy and confocal laser scanning microscopy to evaluate the adherence pattern, density, and propagation of six commonly encountered bacterial pathogens (methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus, coagulase-negative Staphylococcus epidermidis, multidrug-resistant Acinetobacter baumannii, Propionibacterium acnes, and vancomycin-resistant Enterococcus faecalis) on five commonly used spinal implant materials (titanium, titanium alloy, stainless steel, cobalt chromium, and polyetherether ketone). The samples were fixed and dehydrated via ethanol dehydration gradient and critical point drying.

The researchers found that some pathogens, such as vancomycin-resistant E. faecalis and multidrug-resistant A. baumannii, were more likely to adhere to more textured materials such as cobalt chromium and titanium, compared with smoother materials such as stainless steel. “Additionally, the findings suggest that the microtopography of these materials may be the driving force behind the adherence of pathogens on the materials themselves,” Dr. Garcia said. Compared with smoother, polished materials, he explained, the rougher materials were more likely to harbor dense proliferation of bacterial pathogens, which could be characterized as biofilms.

“This study has been successful in providing a platform for future studies to build upon and expand to study additional parameters and statistical tools to give further insight into additional driving forces behind adherence and means for improvement of material design,” Dr. Garcia concluded.

Dr. Christopher T. Born, head of the Diane N. Weiss Center for Orthopedic Trauma Research at Rhode Island Hospital, was the study’s principal investigator. The study was supported by Stryker Corp.*

*Correction, 9/19/2015: Dr. Born is a consultant for Stryker. He also has stock ownership in Biointraface, does consulting for the company, and is a member of its board.

[email protected]

Analyzing the Guidelines: It Can't All Be Level I

The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.

The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.

An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.

We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.

Analyzing the Guidelines: It Can't All Be Level I

The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.

The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.

An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.

We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.

Analyzing the Guidelines: It Can't All Be Level I

The demand for total joint arthroplasty continues to rise, resulting in a steady increase in the number of primary total hip and knee replacements every year. Unfortunately, as these numbers rise, so will the number of periprosthetic joint infections (PJIs). The economic burden and patient morbidity associated with PJI has resulted in the creation of multiple orthopedic societies and committees focused on formulating “best practice” guidelines in order to reduce the rates of PJI as much as possible.

The new guidelines for surgical site infection (SSI) prevention by the Centers for Disease Control and Prevention (CDC) recently forced the orthopedic community to critically analyze the current literature. Dr. Javad Parvizi’s editorial elegantly notes that many areas of infection prevention and treatment are not well evaluated, and many of our day-to-day practices are based on low levels of evidence. Level I studies continue to be a costly and time-consuming challenge due to the already very low SSI rate, and, in order to show an improvement in this rate, thousands of patients are required for study. This makes a multicenter approach necessary to ensure adequate power, and a multicenter study often requires significant resources and funding outlets. These requirements have resulted in many of our practice recommendations being based on retrospective reviews, which have inherent methodological limitations. The retrospective nature of these studies lacks the experimental design necessary to confidently make treatment recommendations; however, they do allow us to look at what strategies have been tried, and in essence, how well they worked. Although level III and IV studies do not allow us to compare treatments head to head, they do give us some insights into viable treatment strategies and should not be completely disregarded. The results of retrospective studies allow us to design prospective experiments based on what we have observed as successful treatment modalities in particular patient cohorts.

An alternative approach for evaluating new and existing treatment strategies is through basic science translational research. Future advancements in PJI diagnosis and treatment will likely be founded upon translational research efforts from clinician scientists testing treatment protocols both on the benchtop and in animal models. The most glaring knowledge gaps in PJI should be identified through the combined efforts of the CDC, the Musculoskeletal Infection Society, the American Academy of Orthopaedic Surgeons, and the Orthopaedic Research Society. Coordinated efforts should be made and strategies executed to systematically fund translational projects that answer these questions. Translational studies will be able to safely and methodically evaluate new and even established treatment protocols for PJI in a cost-effective manner.

We have made great strides in the prevention and treatment of PJI over the past 2 decades. When working together as a cohesive profession, we will undoubtedly continue to advance our knowledge base and improve treatment recommendations for our patients.

According to a new study, total knee arthroplasty is highly effective in reducing clinically relevant knee pain to a greater extent than other subjective health-related quality-of-life indicies in patients with rheumatoid arthritis, although this improvement is less marked as compared to outcomes in patients with osteoarthritis. These study findings were published online ahead of print July 20 in Arthritis & Rheumatology.

The study included patients with rheumatologist-diagnosed arthritis undergoing primary total knee arthroplasty during 1999 to 2012. Indices of pain knee, and health-related quality of life were obtained in 3 consecutive 6-month intervals: preoperative, perioperative, and postoperative. Descriptive statistics and 1-way analysis of variance were used to compare total knee arthroplasty outcomes by diagnosis. Effect sizes and standardized response means were calculated between baseline and recovery.

Of the participating 18,897 patients, 834 people with rheumatoid arthritis, and 315 people with osteoarthritis had undergone index total knee arthroplasty at mean ages 65 and 68. Post total knee arthroplasty, significant improvements were observed for most domains of pain, function, and health-related quality of life within both disease groups, with greater impact in osteoarthritis. Based on the standardized response means, the maximum improvement was shown in index knee pain.

The Health Assessment Questionnaire II and the Short Form 36 physical component summary were the most responsive health-related quality of life indices in detecting post-total knee arthroplasty improvement in rheumatoid arthritis. A diagnosis of rheumatoid arthritis, lower income, and preoperative anxiety were independently associated with a lower degree of improvement in index knee pain following total knee arthroplasty.

Senior author Kaleb D. Michaud, PhD, Associate Professor in the Division of Rheumatology and Immunology at the University of Nebraska Medical Center in Omaha, and colleagues said that total knee replacement can serve as a “time machine” by which patients can return to a less disabled lifestyle, before the arthritic process catches up.

“A new knee can give osteoarthritis patients 10 to 20 years of painless use, whereas rheumatoid arthritis continues to affect the joint soon afterward,” the researchers said. “It’s an important and effective treatment, but patients with rheumatoid arthritis shouldn’t expect the same, often dramatic results experienced by their osteoarthritis counterparts,” Dr. Michaud said.

According to a new study, total knee arthroplasty is highly effective in reducing clinically relevant knee pain to a greater extent than other subjective health-related quality-of-life indicies in patients with rheumatoid arthritis, although this improvement is less marked as compared to outcomes in patients with osteoarthritis. These study findings were published online ahead of print July 20 in Arthritis & Rheumatology.

The study included patients with rheumatologist-diagnosed arthritis undergoing primary total knee arthroplasty during 1999 to 2012. Indices of pain knee, and health-related quality of life were obtained in 3 consecutive 6-month intervals: preoperative, perioperative, and postoperative. Descriptive statistics and 1-way analysis of variance were used to compare total knee arthroplasty outcomes by diagnosis. Effect sizes and standardized response means were calculated between baseline and recovery.

Of the participating 18,897 patients, 834 people with rheumatoid arthritis, and 315 people with osteoarthritis had undergone index total knee arthroplasty at mean ages 65 and 68. Post total knee arthroplasty, significant improvements were observed for most domains of pain, function, and health-related quality of life within both disease groups, with greater impact in osteoarthritis. Based on the standardized response means, the maximum improvement was shown in index knee pain.

The Health Assessment Questionnaire II and the Short Form 36 physical component summary were the most responsive health-related quality of life indices in detecting post-total knee arthroplasty improvement in rheumatoid arthritis. A diagnosis of rheumatoid arthritis, lower income, and preoperative anxiety were independently associated with a lower degree of improvement in index knee pain following total knee arthroplasty.

Senior author Kaleb D. Michaud, PhD, Associate Professor in the Division of Rheumatology and Immunology at the University of Nebraska Medical Center in Omaha, and colleagues said that total knee replacement can serve as a “time machine” by which patients can return to a less disabled lifestyle, before the arthritic process catches up.

“A new knee can give osteoarthritis patients 10 to 20 years of painless use, whereas rheumatoid arthritis continues to affect the joint soon afterward,” the researchers said. “It’s an important and effective treatment, but patients with rheumatoid arthritis shouldn’t expect the same, often dramatic results experienced by their osteoarthritis counterparts,” Dr. Michaud said.

According to a new study, total knee arthroplasty is highly effective in reducing clinically relevant knee pain to a greater extent than other subjective health-related quality-of-life indicies in patients with rheumatoid arthritis, although this improvement is less marked as compared to outcomes in patients with osteoarthritis. These study findings were published online ahead of print July 20 in Arthritis & Rheumatology.

The study included patients with rheumatologist-diagnosed arthritis undergoing primary total knee arthroplasty during 1999 to 2012. Indices of pain knee, and health-related quality of life were obtained in 3 consecutive 6-month intervals: preoperative, perioperative, and postoperative. Descriptive statistics and 1-way analysis of variance were used to compare total knee arthroplasty outcomes by diagnosis. Effect sizes and standardized response means were calculated between baseline and recovery.

Of the participating 18,897 patients, 834 people with rheumatoid arthritis, and 315 people with osteoarthritis had undergone index total knee arthroplasty at mean ages 65 and 68. Post total knee arthroplasty, significant improvements were observed for most domains of pain, function, and health-related quality of life within both disease groups, with greater impact in osteoarthritis. Based on the standardized response means, the maximum improvement was shown in index knee pain.

The Health Assessment Questionnaire II and the Short Form 36 physical component summary were the most responsive health-related quality of life indices in detecting post-total knee arthroplasty improvement in rheumatoid arthritis. A diagnosis of rheumatoid arthritis, lower income, and preoperative anxiety were independently associated with a lower degree of improvement in index knee pain following total knee arthroplasty.

Senior author Kaleb D. Michaud, PhD, Associate Professor in the Division of Rheumatology and Immunology at the University of Nebraska Medical Center in Omaha, and colleagues said that total knee replacement can serve as a “time machine” by which patients can return to a less disabled lifestyle, before the arthritic process catches up.

“A new knee can give osteoarthritis patients 10 to 20 years of painless use, whereas rheumatoid arthritis continues to affect the joint soon afterward,” the researchers said. “It’s an important and effective treatment, but patients with rheumatoid arthritis shouldn’t expect the same, often dramatic results experienced by their osteoarthritis counterparts,” Dr. Michaud said.

Postmenopausal women with kidney or bladder stones are not at increased risk for osteoporosis, but they do have about a 15% increased risk of another painful stone, according to a study published online ahead of print May 19 in the Journal of Bone and Mineral Research.

Researchers examined data on approximately 150,000 postmenopausal women and found, despite the 2 conditions being clearly associated in men, the same did not hold true for women. “We know in men that if you have a kidney stone, you are more likely to have osteoporosis,” said Laura D. Carbone, MD, MS, Division Chief Chief of Rheumatology in the Department of Medicine at the Medical College of Georgia at Georgia Regents University in Augusta. What Dr. Carbone and colleagues found was that “unlike what has been reported in men, a woman having a kidney stone is not a risk factor for osteoporosis. However, having one urinary tract stone does put women at increased risk for a second stone.”

Data came from participants in the National Institutes of Health Women’s Health Initiative. Out of more than 150,000 women followed in the Women’s Health Initiative, 9,856 women reported urinary tract stones at the start of or over the course of the study. The women were followed for about 8 years, on average.

Dr. Carbone and colleagues looked at the data several different ways, adjusting for factors that could also influence outcome, such as physical inactivity. Investigators only looked at whether urinary tract stones increased the risk of osteoporosis, not the reverse. In unadjusted models there was a significant association of urinary tract stones with incident total fractures (hazard ratio, 1.10) However, in covariate adjusted analyses, urinary tract stones were not significantly related to changes in bone mineral density at any skeletal site or to incident fractures.

The Osteoporotic Fractures in Men study, which looked at nearly 6,000 men with a mean age of 73.7 to determine risk factors for osteoporosis, identified urinary tract stones are a risk factor.

One link between the seemingly disparate conditions of stones and weak bones is an excess of calcium in the urine, which tends to be more common in men, Dr. Carbone said. Sodium and calcium share a common transport mechanism in the kidney, the researchers pointed out, and sodium affects reabsorption of calcium by that organ. When sodium levels are high, more calcium in eliminated in the urine. “Overactivity of the parathyroid glands, which regulate levels of calcium in the blood, is associated with both urinary tract stones and fractures of the vertebra in the spine,” the researchers said.

Some treatments for osteoporosis, including calcium supplementation, can increase the risk of stones. Conversely, individuals who’ve already experienced a urinary tract stone might avoid calcium to help avoid another a subsequent stone and inadvertently increase their osteoporosis risk, the researchers wrote.

“Women with a stone likely should work with their physician to reduce their increased risk of a subsequent stone,” the physicians said, noting that low water and fluid intake, and a high-salt, high-calorie diet are common stone risks.

Postmenopausal women with kidney or bladder stones are not at increased risk for osteoporosis, but they do have about a 15% increased risk of another painful stone, according to a study published online ahead of print May 19 in the Journal of Bone and Mineral Research.

Researchers examined data on approximately 150,000 postmenopausal women and found, despite the 2 conditions being clearly associated in men, the same did not hold true for women. “We know in men that if you have a kidney stone, you are more likely to have osteoporosis,” said Laura D. Carbone, MD, MS, Division Chief Chief of Rheumatology in the Department of Medicine at the Medical College of Georgia at Georgia Regents University in Augusta. What Dr. Carbone and colleagues found was that “unlike what has been reported in men, a woman having a kidney stone is not a risk factor for osteoporosis. However, having one urinary tract stone does put women at increased risk for a second stone.”

Data came from participants in the National Institutes of Health Women’s Health Initiative. Out of more than 150,000 women followed in the Women’s Health Initiative, 9,856 women reported urinary tract stones at the start of or over the course of the study. The women were followed for about 8 years, on average.

Dr. Carbone and colleagues looked at the data several different ways, adjusting for factors that could also influence outcome, such as physical inactivity. Investigators only looked at whether urinary tract stones increased the risk of osteoporosis, not the reverse. In unadjusted models there was a significant association of urinary tract stones with incident total fractures (hazard ratio, 1.10) However, in covariate adjusted analyses, urinary tract stones were not significantly related to changes in bone mineral density at any skeletal site or to incident fractures.

The Osteoporotic Fractures in Men study, which looked at nearly 6,000 men with a mean age of 73.7 to determine risk factors for osteoporosis, identified urinary tract stones are a risk factor.

One link between the seemingly disparate conditions of stones and weak bones is an excess of calcium in the urine, which tends to be more common in men, Dr. Carbone said. Sodium and calcium share a common transport mechanism in the kidney, the researchers pointed out, and sodium affects reabsorption of calcium by that organ. When sodium levels are high, more calcium in eliminated in the urine. “Overactivity of the parathyroid glands, which regulate levels of calcium in the blood, is associated with both urinary tract stones and fractures of the vertebra in the spine,” the researchers said.

Some treatments for osteoporosis, including calcium supplementation, can increase the risk of stones. Conversely, individuals who’ve already experienced a urinary tract stone might avoid calcium to help avoid another a subsequent stone and inadvertently increase their osteoporosis risk, the researchers wrote.

“Women with a stone likely should work with their physician to reduce their increased risk of a subsequent stone,” the physicians said, noting that low water and fluid intake, and a high-salt, high-calorie diet are common stone risks.

Postmenopausal women with kidney or bladder stones are not at increased risk for osteoporosis, but they do have about a 15% increased risk of another painful stone, according to a study published online ahead of print May 19 in the Journal of Bone and Mineral Research.

Researchers examined data on approximately 150,000 postmenopausal women and found, despite the 2 conditions being clearly associated in men, the same did not hold true for women. “We know in men that if you have a kidney stone, you are more likely to have osteoporosis,” said Laura D. Carbone, MD, MS, Division Chief Chief of Rheumatology in the Department of Medicine at the Medical College of Georgia at Georgia Regents University in Augusta. What Dr. Carbone and colleagues found was that “unlike what has been reported in men, a woman having a kidney stone is not a risk factor for osteoporosis. However, having one urinary tract stone does put women at increased risk for a second stone.”

Data came from participants in the National Institutes of Health Women’s Health Initiative. Out of more than 150,000 women followed in the Women’s Health Initiative, 9,856 women reported urinary tract stones at the start of or over the course of the study. The women were followed for about 8 years, on average.

Dr. Carbone and colleagues looked at the data several different ways, adjusting for factors that could also influence outcome, such as physical inactivity. Investigators only looked at whether urinary tract stones increased the risk of osteoporosis, not the reverse. In unadjusted models there was a significant association of urinary tract stones with incident total fractures (hazard ratio, 1.10) However, in covariate adjusted analyses, urinary tract stones were not significantly related to changes in bone mineral density at any skeletal site or to incident fractures.

The Osteoporotic Fractures in Men study, which looked at nearly 6,000 men with a mean age of 73.7 to determine risk factors for osteoporosis, identified urinary tract stones are a risk factor.

One link between the seemingly disparate conditions of stones and weak bones is an excess of calcium in the urine, which tends to be more common in men, Dr. Carbone said. Sodium and calcium share a common transport mechanism in the kidney, the researchers pointed out, and sodium affects reabsorption of calcium by that organ. When sodium levels are high, more calcium in eliminated in the urine. “Overactivity of the parathyroid glands, which regulate levels of calcium in the blood, is associated with both urinary tract stones and fractures of the vertebra in the spine,” the researchers said.

Some treatments for osteoporosis, including calcium supplementation, can increase the risk of stones. Conversely, individuals who’ve already experienced a urinary tract stone might avoid calcium to help avoid another a subsequent stone and inadvertently increase their osteoporosis risk, the researchers wrote.

“Women with a stone likely should work with their physician to reduce their increased risk of a subsequent stone,” the physicians said, noting that low water and fluid intake, and a high-salt, high-calorie diet are common stone risks.

Total knee replacements can effectively treat degeneration caused by Blount disease, according to a study published online ahead of print July 11 in the Journal of Arthroplasty.

Middle-aged patients with Blount disease who underwent joint replacements on 1 or both knees were found to have stable knees, excellent range of motion, and no need for pain medications, according to the study conducted at Loyola University Medical Center in Illinois.

“With proper attention paid to technical details, patients with Blount or Blount-like deformity can undergo successful total knee arthroplasty,” said Harold Rees, MD, Assistant Professor of Reconstructive Surgery and Joint Replacement at Loyola University Chicago Stritch School of Medicine in Maywood, Illinois, and colleagues.

For the study, Dr. Rees and colleagues reviewed the records of 5 patients with Blount disease. Three patients had replacements on both knees and 2 patients had replacements on 1 knee. Four patients were African American and 4 were male. All were obese. The average age at the time of the knee replacements was 49.9. Patients were followed-up an average of 75.2 months after their knee replacements.

Mean proximal tibial metaphyseal-diaphyseal angle was 20.75 degrees. Each patient had substantial posteromedial tibial bony defects and 6 knees required extensive medial releases. Two knees required increased constraint at index procedure. One patient underwent bilateral revision surgery with rotating hinge prostheses.

The researchers used a scoring system, devised by the Knee Society, that combines clinical, functional, and satisfaction scores. The mean Knee Society score was 212.5, out of a maximum possible score of 255. Patients also were rated on the Western Ontario and McMaster Universities Osteoarthritis Index.

“The main purpose was to highlight surgical considerations in performing total knee arthroplasty in patients with Blount disease or Blount-like deformity. Despite a challenging patient population in which to perform total knee arthroplasty, we show that it can be done with a low risk of complication and reasonable medium-term results,” said the study authors. “Surgeons should be prepared to address posteromedial tibial bony defects and consider constrained arthroplasty at the index procedure,” they said.

Total knee replacements can effectively treat degeneration caused by Blount disease, according to a study published online ahead of print July 11 in the Journal of Arthroplasty.

Middle-aged patients with Blount disease who underwent joint replacements on 1 or both knees were found to have stable knees, excellent range of motion, and no need for pain medications, according to the study conducted at Loyola University Medical Center in Illinois.

“With proper attention paid to technical details, patients with Blount or Blount-like deformity can undergo successful total knee arthroplasty,” said Harold Rees, MD, Assistant Professor of Reconstructive Surgery and Joint Replacement at Loyola University Chicago Stritch School of Medicine in Maywood, Illinois, and colleagues.

For the study, Dr. Rees and colleagues reviewed the records of 5 patients with Blount disease. Three patients had replacements on both knees and 2 patients had replacements on 1 knee. Four patients were African American and 4 were male. All were obese. The average age at the time of the knee replacements was 49.9. Patients were followed-up an average of 75.2 months after their knee replacements.

Mean proximal tibial metaphyseal-diaphyseal angle was 20.75 degrees. Each patient had substantial posteromedial tibial bony defects and 6 knees required extensive medial releases. Two knees required increased constraint at index procedure. One patient underwent bilateral revision surgery with rotating hinge prostheses.

The researchers used a scoring system, devised by the Knee Society, that combines clinical, functional, and satisfaction scores. The mean Knee Society score was 212.5, out of a maximum possible score of 255. Patients also were rated on the Western Ontario and McMaster Universities Osteoarthritis Index.

“The main purpose was to highlight surgical considerations in performing total knee arthroplasty in patients with Blount disease or Blount-like deformity. Despite a challenging patient population in which to perform total knee arthroplasty, we show that it can be done with a low risk of complication and reasonable medium-term results,” said the study authors. “Surgeons should be prepared to address posteromedial tibial bony defects and consider constrained arthroplasty at the index procedure,” they said.

Total knee replacements can effectively treat degeneration caused by Blount disease, according to a study published online ahead of print July 11 in the Journal of Arthroplasty.

Middle-aged patients with Blount disease who underwent joint replacements on 1 or both knees were found to have stable knees, excellent range of motion, and no need for pain medications, according to the study conducted at Loyola University Medical Center in Illinois.

“With proper attention paid to technical details, patients with Blount or Blount-like deformity can undergo successful total knee arthroplasty,” said Harold Rees, MD, Assistant Professor of Reconstructive Surgery and Joint Replacement at Loyola University Chicago Stritch School of Medicine in Maywood, Illinois, and colleagues.

For the study, Dr. Rees and colleagues reviewed the records of 5 patients with Blount disease. Three patients had replacements on both knees and 2 patients had replacements on 1 knee. Four patients were African American and 4 were male. All were obese. The average age at the time of the knee replacements was 49.9. Patients were followed-up an average of 75.2 months after their knee replacements.

Mean proximal tibial metaphyseal-diaphyseal angle was 20.75 degrees. Each patient had substantial posteromedial tibial bony defects and 6 knees required extensive medial releases. Two knees required increased constraint at index procedure. One patient underwent bilateral revision surgery with rotating hinge prostheses.

The researchers used a scoring system, devised by the Knee Society, that combines clinical, functional, and satisfaction scores. The mean Knee Society score was 212.5, out of a maximum possible score of 255. Patients also were rated on the Western Ontario and McMaster Universities Osteoarthritis Index.

“The main purpose was to highlight surgical considerations in performing total knee arthroplasty in patients with Blount disease or Blount-like deformity. Despite a challenging patient population in which to perform total knee arthroplasty, we show that it can be done with a low risk of complication and reasonable medium-term results,” said the study authors. “Surgeons should be prepared to address posteromedial tibial bony defects and consider constrained arthroplasty at the index procedure,” they said.

Applying for a residency program can be a stressful process for medical students. It is a combination of applying for a job in the “real world” and applying to a college or medical school. In certain fields of medicine or surgery, there may be over 600 residency applications for 40 to 80 interviewee slots. Different specialties, as well as programs within a given specialty, take a different number of residents per year. This can vary from 1 to over 20 available spots, depending on the field of medicine or surgery as well as the specific program. Orthopedic surgery residencies, for example, can match between 2 and 12 residents each year. During the 2013–2014 academic year at our institution, there were over 600 applications received for approximately 50 interview slots for a class of 5 orthopedic surgery residents. Nationally, according to publicly available 2013 National Resident Matching Program (NRMP) data, a total of 1038 applicants (833 US medical school seniors) applied for 693 spots in orthopedic surgery, of which 692 were filled, indicating that orthopedic surgery remains one of the most desired fields among medical school seniors.¹ Looking at the statistics provided by the NRMP data, orthopedic applicants remain some of the most competitive, with proportionally higher board scores, publication numbers, and grades, among other factors.¹

Each individual program has its own method for sifting through the applications. At some institutions, the individual “in charge” of the selection committee may look through all applications initially, narrow them down, and then distribute them to the other members of the selection committee to determine the final interviewee list. At other institutions, the initial group of applications may be divided and distributed to the committee members so that each member reviews the applications and ultimately decides upon the interview candidates.

The Electronic Residency Application Service (ERAS) application includes the applicant’s name, birth city, current place of residence, education history, standardized test scores, grades achieved during medical school, letters of recommendation, personal statement, extracurricular activities, volunteer activities, research experience, and languages spoken, along with several other pieces of data, all intended to be able to give the committee a better understanding of the applicant. Interestingly, however, the application also includes a photograph of the applicant.

Countless authors have demonstrated that we make assumptions and reach conclusions without even being aware that this is occurring. This is the theory of “unconscious bias.”^2-5 Unconscious bias applies to how we perceive other people, and occurs when subconscious beliefs or unrecognized stereotypes about specific characteristics, including gender, ethnicity, religion, socioeconomic status, age, and sexual orientation, result in an automatic and unconscious reaction and/or behavior.⁶ Unconscious bias has the ability to affect everything from how health care is delivered to how employees are hired.^7-12 We are all biased, and becoming aware of our biases will help us mitigate them in the workplace.

Title VII of the Civil Rights Act of 1964 requires that employers rely solely on job-related qualifications, and not physical characteristics, in their interviewing and hiring process. The US Equal Employment Opportunity Commission (EEOC), the federal agency that enforces Title VII, includes asking for photographs during the application stage on its list of prohibited practices for employers.¹³ It is our belief that including a photograph in the ERAS application, prior to the selection of interview candidates, may produce unconscious bias in the decision for granting (or not granting) an interview, and this component of the application should be eliminated.

Using a wide spectrum of cultural backgrounds in employers, Dion and colleagues¹⁴ demonstrated that the “what is beautiful is good” bias is present in all cultures when prospective employees are closely matched in qualification. Attractive individuals are thought to have better professional lives and stable marital relationships and personalities, according to previous studies.¹⁴ There has been much research aimed at determining if physical attractiveness is a factor in hiring, and the evidence suggests that the more attractive the applicant is, the greater the chances of being hired.¹⁵ Specifically, Watkins and Johnston¹⁵ have found that attractive people are thought to have better personalities than less attractive people, and that a photograph can influence the hiring decision process.

Bradley Ruffle at Ben-Gurion University and Ze’ev Shtudiner at Ariel University looked at what happens when job hunters include photographs with their curricula vitae (CV), as is the norm in much of Europe and Asia.¹⁶ For over 2500 job postings, they sent 2 identical résumés: one with a photograph and one without a photograph. An equal number of male and female applicants were sent to each posting, as were an equal number of attractive and plain-looking photographs; applications without photographs were also sent as a control group. For men, the results were as expected: CVs of “attractive” men were more likely to elicit a response from the employer (19.7%) compared with those of no-picture men (13.7%) and plain-looking men (9.2%). Interestingly, men who were viewed as “plain-looking” were better off not including a photograph. For the female applicants, however, the results were unexpected: CVs of women without a picture elicited the highest response rate (16.6%), while CVs of “plain-looking” women (13.6%) and of “attractive” women (12.8%) were less likely to receive a response.¹⁶

It is an unfortunate reality that personal preference, bias, and, in some cases, discriminatory hiring practices all factor into the selection process.¹⁷ This is why, as described above, the EEOC includes asking for photographs during the application stage on its list of prohibited practices for employers.¹³ The EEOC website also states: “If needed for identification purposes, a photograph may be obtained after an offer of employment is made and accepted.”¹³ In the residency application scenario, once an applicant has been granted an interview, a photograph can be taken on the day of the interview. With so many interviewees, this may help the interviewers to remember the interviewee. At this point in the process, the applicant has already been granted the interview. The bias associated with merely looking at a photograph is thus eliminated. This is in accordance with Title VII and is clearly different than including a photograph in the initial application, which directly violates Title VII.

Reviewers of applicants may have an unconscious bias due to the applicant’s attractiveness, race, sex, ethnicity, etc. Other, subtler forms of bias may also be present. Without realizing it, people may judge the quality of the photograph, or even what the applicant was wearing in the photograph. In orthopedic surgery, for example, there may be bias in the “size” of the applicant regardless of sex. Reviewers may unconsciously think how is he/she going to hold the leg, cut a rod, reduce a hip, etc. Without even realizing it, this may sway the person reviewing the application to choose one applicant over another. This may occur regardless of the applicant’s actual qualifications as based on the previously described factors, including test scores, grades during medical school, letters of recommendation, personal statement, extracurricular activities, volunteer activities, and research experience.

Unconscious bias is present in everyone. In an ideal world, one would be able to eliminate all sources of unconscious bias in the application process. Bias due to attending an Ivy League school versus a state school, bias due to where the applicant is from, bias due to who wrote the letter of recommendation, along with various other sources of unconscious bias, would be able to be eliminated. Unfortunately, this is not possible. What is possible, however, is to remove the photograph from the application process and to comply with Title VII of the Civil Rights Act of 1964.

Applying for a residency program can be a stressful process for medical students. It is a combination of applying for a job in the “real world” and applying to a college or medical school. In certain fields of medicine or surgery, there may be over 600 residency applications for 40 to 80 interviewee slots. Different specialties, as well as programs within a given specialty, take a different number of residents per year. This can vary from 1 to over 20 available spots, depending on the field of medicine or surgery as well as the specific program. Orthopedic surgery residencies, for example, can match between 2 and 12 residents each year. During the 2013–2014 academic year at our institution, there were over 600 applications received for approximately 50 interview slots for a class of 5 orthopedic surgery residents. Nationally, according to publicly available 2013 National Resident Matching Program (NRMP) data, a total of 1038 applicants (833 US medical school seniors) applied for 693 spots in orthopedic surgery, of which 692 were filled, indicating that orthopedic surgery remains one of the most desired fields among medical school seniors.¹ Looking at the statistics provided by the NRMP data, orthopedic applicants remain some of the most competitive, with proportionally higher board scores, publication numbers, and grades, among other factors.¹

Each individual program has its own method for sifting through the applications. At some institutions, the individual “in charge” of the selection committee may look through all applications initially, narrow them down, and then distribute them to the other members of the selection committee to determine the final interviewee list. At other institutions, the initial group of applications may be divided and distributed to the committee members so that each member reviews the applications and ultimately decides upon the interview candidates.

The Electronic Residency Application Service (ERAS) application includes the applicant’s name, birth city, current place of residence, education history, standardized test scores, grades achieved during medical school, letters of recommendation, personal statement, extracurricular activities, volunteer activities, research experience, and languages spoken, along with several other pieces of data, all intended to be able to give the committee a better understanding of the applicant. Interestingly, however, the application also includes a photograph of the applicant.

Countless authors have demonstrated that we make assumptions and reach conclusions without even being aware that this is occurring. This is the theory of “unconscious bias.”^2-5 Unconscious bias applies to how we perceive other people, and occurs when subconscious beliefs or unrecognized stereotypes about specific characteristics, including gender, ethnicity, religion, socioeconomic status, age, and sexual orientation, result in an automatic and unconscious reaction and/or behavior.⁶ Unconscious bias has the ability to affect everything from how health care is delivered to how employees are hired.^7-12 We are all biased, and becoming aware of our biases will help us mitigate them in the workplace.

Title VII of the Civil Rights Act of 1964 requires that employers rely solely on job-related qualifications, and not physical characteristics, in their interviewing and hiring process. The US Equal Employment Opportunity Commission (EEOC), the federal agency that enforces Title VII, includes asking for photographs during the application stage on its list of prohibited practices for employers.¹³ It is our belief that including a photograph in the ERAS application, prior to the selection of interview candidates, may produce unconscious bias in the decision for granting (or not granting) an interview, and this component of the application should be eliminated.

Using a wide spectrum of cultural backgrounds in employers, Dion and colleagues¹⁴ demonstrated that the “what is beautiful is good” bias is present in all cultures when prospective employees are closely matched in qualification. Attractive individuals are thought to have better professional lives and stable marital relationships and personalities, according to previous studies.¹⁴ There has been much research aimed at determining if physical attractiveness is a factor in hiring, and the evidence suggests that the more attractive the applicant is, the greater the chances of being hired.¹⁵ Specifically, Watkins and Johnston¹⁵ have found that attractive people are thought to have better personalities than less attractive people, and that a photograph can influence the hiring decision process.

Bradley Ruffle at Ben-Gurion University and Ze’ev Shtudiner at Ariel University looked at what happens when job hunters include photographs with their curricula vitae (CV), as is the norm in much of Europe and Asia.¹⁶ For over 2500 job postings, they sent 2 identical résumés: one with a photograph and one without a photograph. An equal number of male and female applicants were sent to each posting, as were an equal number of attractive and plain-looking photographs; applications without photographs were also sent as a control group. For men, the results were as expected: CVs of “attractive” men were more likely to elicit a response from the employer (19.7%) compared with those of no-picture men (13.7%) and plain-looking men (9.2%). Interestingly, men who were viewed as “plain-looking” were better off not including a photograph. For the female applicants, however, the results were unexpected: CVs of women without a picture elicited the highest response rate (16.6%), while CVs of “plain-looking” women (13.6%) and of “attractive” women (12.8%) were less likely to receive a response.¹⁶

It is an unfortunate reality that personal preference, bias, and, in some cases, discriminatory hiring practices all factor into the selection process.¹⁷ This is why, as described above, the EEOC includes asking for photographs during the application stage on its list of prohibited practices for employers.¹³ The EEOC website also states: “If needed for identification purposes, a photograph may be obtained after an offer of employment is made and accepted.”¹³ In the residency application scenario, once an applicant has been granted an interview, a photograph can be taken on the day of the interview. With so many interviewees, this may help the interviewers to remember the interviewee. At this point in the process, the applicant has already been granted the interview. The bias associated with merely looking at a photograph is thus eliminated. This is in accordance with Title VII and is clearly different than including a photograph in the initial application, which directly violates Title VII.

Reviewers of applicants may have an unconscious bias due to the applicant’s attractiveness, race, sex, ethnicity, etc. Other, subtler forms of bias may also be present. Without realizing it, people may judge the quality of the photograph, or even what the applicant was wearing in the photograph. In orthopedic surgery, for example, there may be bias in the “size” of the applicant regardless of sex. Reviewers may unconsciously think how is he/she going to hold the leg, cut a rod, reduce a hip, etc. Without even realizing it, this may sway the person reviewing the application to choose one applicant over another. This may occur regardless of the applicant’s actual qualifications as based on the previously described factors, including test scores, grades during medical school, letters of recommendation, personal statement, extracurricular activities, volunteer activities, and research experience.

Unconscious bias is present in everyone. In an ideal world, one would be able to eliminate all sources of unconscious bias in the application process. Bias due to attending an Ivy League school versus a state school, bias due to where the applicant is from, bias due to who wrote the letter of recommendation, along with various other sources of unconscious bias, would be able to be eliminated. Unfortunately, this is not possible. What is possible, however, is to remove the photograph from the application process and to comply with Title VII of the Civil Rights Act of 1964.

Applying for a residency program can be a stressful process for medical students. It is a combination of applying for a job in the “real world” and applying to a college or medical school. In certain fields of medicine or surgery, there may be over 600 residency applications for 40 to 80 interviewee slots. Different specialties, as well as programs within a given specialty, take a different number of residents per year. This can vary from 1 to over 20 available spots, depending on the field of medicine or surgery as well as the specific program. Orthopedic surgery residencies, for example, can match between 2 and 12 residents each year. During the 2013–2014 academic year at our institution, there were over 600 applications received for approximately 50 interview slots for a class of 5 orthopedic surgery residents. Nationally, according to publicly available 2013 National Resident Matching Program (NRMP) data, a total of 1038 applicants (833 US medical school seniors) applied for 693 spots in orthopedic surgery, of which 692 were filled, indicating that orthopedic surgery remains one of the most desired fields among medical school seniors.¹ Looking at the statistics provided by the NRMP data, orthopedic applicants remain some of the most competitive, with proportionally higher board scores, publication numbers, and grades, among other factors.¹

Each individual program has its own method for sifting through the applications. At some institutions, the individual “in charge” of the selection committee may look through all applications initially, narrow them down, and then distribute them to the other members of the selection committee to determine the final interviewee list. At other institutions, the initial group of applications may be divided and distributed to the committee members so that each member reviews the applications and ultimately decides upon the interview candidates.

The Electronic Residency Application Service (ERAS) application includes the applicant’s name, birth city, current place of residence, education history, standardized test scores, grades achieved during medical school, letters of recommendation, personal statement, extracurricular activities, volunteer activities, research experience, and languages spoken, along with several other pieces of data, all intended to be able to give the committee a better understanding of the applicant. Interestingly, however, the application also includes a photograph of the applicant.

Countless authors have demonstrated that we make assumptions and reach conclusions without even being aware that this is occurring. This is the theory of “unconscious bias.”^2-5 Unconscious bias applies to how we perceive other people, and occurs when subconscious beliefs or unrecognized stereotypes about specific characteristics, including gender, ethnicity, religion, socioeconomic status, age, and sexual orientation, result in an automatic and unconscious reaction and/or behavior.⁶ Unconscious bias has the ability to affect everything from how health care is delivered to how employees are hired.^7-12 We are all biased, and becoming aware of our biases will help us mitigate them in the workplace.

Title VII of the Civil Rights Act of 1964 requires that employers rely solely on job-related qualifications, and not physical characteristics, in their interviewing and hiring process. The US Equal Employment Opportunity Commission (EEOC), the federal agency that enforces Title VII, includes asking for photographs during the application stage on its list of prohibited practices for employers.¹³ It is our belief that including a photograph in the ERAS application, prior to the selection of interview candidates, may produce unconscious bias in the decision for granting (or not granting) an interview, and this component of the application should be eliminated.

Using a wide spectrum of cultural backgrounds in employers, Dion and colleagues¹⁴ demonstrated that the “what is beautiful is good” bias is present in all cultures when prospective employees are closely matched in qualification. Attractive individuals are thought to have better professional lives and stable marital relationships and personalities, according to previous studies.¹⁴ There has been much research aimed at determining if physical attractiveness is a factor in hiring, and the evidence suggests that the more attractive the applicant is, the greater the chances of being hired.¹⁵ Specifically, Watkins and Johnston¹⁵ have found that attractive people are thought to have better personalities than less attractive people, and that a photograph can influence the hiring decision process.

Bradley Ruffle at Ben-Gurion University and Ze’ev Shtudiner at Ariel University looked at what happens when job hunters include photographs with their curricula vitae (CV), as is the norm in much of Europe and Asia.¹⁶ For over 2500 job postings, they sent 2 identical résumés: one with a photograph and one without a photograph. An equal number of male and female applicants were sent to each posting, as were an equal number of attractive and plain-looking photographs; applications without photographs were also sent as a control group. For men, the results were as expected: CVs of “attractive” men were more likely to elicit a response from the employer (19.7%) compared with those of no-picture men (13.7%) and plain-looking men (9.2%). Interestingly, men who were viewed as “plain-looking” were better off not including a photograph. For the female applicants, however, the results were unexpected: CVs of women without a picture elicited the highest response rate (16.6%), while CVs of “plain-looking” women (13.6%) and of “attractive” women (12.8%) were less likely to receive a response.¹⁶

It is an unfortunate reality that personal preference, bias, and, in some cases, discriminatory hiring practices all factor into the selection process.¹⁷ This is why, as described above, the EEOC includes asking for photographs during the application stage on its list of prohibited practices for employers.¹³ The EEOC website also states: “If needed for identification purposes, a photograph may be obtained after an offer of employment is made and accepted.”¹³ In the residency application scenario, once an applicant has been granted an interview, a photograph can be taken on the day of the interview. With so many interviewees, this may help the interviewers to remember the interviewee. At this point in the process, the applicant has already been granted the interview. The bias associated with merely looking at a photograph is thus eliminated. This is in accordance with Title VII and is clearly different than including a photograph in the initial application, which directly violates Title VII.

Reviewers of applicants may have an unconscious bias due to the applicant’s attractiveness, race, sex, ethnicity, etc. Other, subtler forms of bias may also be present. Without realizing it, people may judge the quality of the photograph, or even what the applicant was wearing in the photograph. In orthopedic surgery, for example, there may be bias in the “size” of the applicant regardless of sex. Reviewers may unconsciously think how is he/she going to hold the leg, cut a rod, reduce a hip, etc. Without even realizing it, this may sway the person reviewing the application to choose one applicant over another. This may occur regardless of the applicant’s actual qualifications as based on the previously described factors, including test scores, grades during medical school, letters of recommendation, personal statement, extracurricular activities, volunteer activities, and research experience.

Unconscious bias is present in everyone. In an ideal world, one would be able to eliminate all sources of unconscious bias in the application process. Bias due to attending an Ivy League school versus a state school, bias due to where the applicant is from, bias due to who wrote the letter of recommendation, along with various other sources of unconscious bias, would be able to be eliminated. Unfortunately, this is not possible. What is possible, however, is to remove the photograph from the application process and to comply with Title VII of the Civil Rights Act of 1964.

Osteochondromas are common benign bone tumors composed of a bony protrusion with an overlying cartilage cap.¹ This lesion constitutes 24% to 40% of all benign bone tumors, and the great majority arise from the metaphyseal region of long bones.² The scapula accounts for only 3% to 5% of all osteochondromas; however, this lesion is the most common benign bone tumor to involve the scapula.³

In contrast, cutaneous bronchogenic cyst of the scapula is an exceedingly rare pathology. The bronchogenic cyst is a congenital cystic mass lined by tracheobronchial structures and respiratory epithelium.⁴ These are most commonly located in the thorax, although numerous remote locations have also been described, including cutaneous cysts.⁵ The overall incidence of bronchogenic cysts is thought to be 1 in 42,000 to 1 in 68,000.⁶ There are only 15 case reports of cutaneous bronchogenic cysts in the scapular region.⁷

We report the case of a novel dual lesion of both an osteochondroma and a contiguous cutaneous bronchogenic cyst in the scapula. The patient’s guardian provided written informed consent for print and electronic publication of this case report.

Case Report

A 12-month-old boy presented to our clinic with the complaint of a mass over the left scapula. The mass was first noted incidentally several weeks earlier during bathing. Examination revealed a firm, subcutaneous, nontender mass measuring 1×2 cm located over the spine of the scapula. There were no overlying skin changes, and there was normal function of the ipsilateral upper extremity. Anteroposterior and lateral chest radiographs revealed no abnormality. Magnetic resonance imaging (MRI) showed an exostosis projecting from the scapular spine measuring 2×6×7 mm with an adjacent cystic mass measuring 5×8×9 mm that was thought to represent bursitis (Figure 1). The decision was made to observe the mass. 

The patient returned to clinic at age 31 months with a new complaint of scant drainage of serous fluid from a pinprick-sized hole located just superolateral to the scapular mass. The child’s mother reported daily manual expression of fluid from the mass via the hole, without which the mass would enlarge. There were no local or systemic signs of infection. A repeat MRI again revealed an exostosis with an adjacent cystic mass with interval enlargement of the cyst (Figure 2). At age 4.5 years, the decision was made to proceed with excision of the osteochondroma and adjacent cystic mass.

The mass was approached via a 2-cm incision designed to excise the tract to the skin. Dissection revealed a sinus tract connecting to a well-defined cystic sac. This sac was attached to the underlying exostosis. The exostosis and attached cyst were excised en bloc. The cyst was opened, revealing foul-smelling, cloudy white fluid that was sent for culture; the specimen was sent for pathology.

The fluid culture grew mixed flora, with no Staphylococcus aureus, group A streptococcus, or Pseudomonas aeruginosa identified. The pathologic examination identified bone with a cartilaginous cap, consistent with osteochondroma (Figure 3), as well as a cyst lined by respiratory epithelium with patchy areas of squamous epithelium and surrounding mucus glands, consistent with bronchogenic cyst (Figure 4). Figure 5 shows the contiguous nature of the 2 lesions.

The postoperative course was uneventful. The patient returned to full use of the left upper extremity and had resolution of all drainage. 

Discussion

Osteochondromas are thought to arise from aberrant growth of the epiphyseal growth plate cartilage. A small portion of the physis herniates past the groove of Ranvier and grows parallel to the normal physis with medullary continuity. This can occur idiopathically or, more rarely, secondary to an identified injury to the growth plate.¹

The formation of bronchogenic cysts is most often attributed to anomalous budding of the ventral foregut during fetal development,⁴ hence the alternative designation of these cysts as foregut cysts. An extrathoracic location of the cyst has been postulated to stem from 2 possible events: a preexisting cyst may migrate out of the thorax prior to closure of the sternal plates, or sternal plate closure may itself pinch off the cyst.^8,9 An alternative explanation is in situ metaplastic development of respiratory epithelium.¹⁰ When located near the skin, these cysts often drain clear fluid.¹¹

Scapular osteochondromas are known to cause various pathologies of the shoulder girdle, including snapping scapula syndrome, chest wall deformity, shoulder impingement, and bursa formation.^12-17 This case, however, is the first known finding of a scapular osteochondroma with a contiguous cutaneous bronchogenic cyst. A putative explanation for their co-occurrence is that local disturbances caused by one lesion stimulated the formation of the second. The direct connection between the bronchogenic cyst and the bone, as has been reported in 3 cases,^7,9,18 seems to favor this explanation. Definitive conclusions regarding any causal relationship are beyond the scope of this single case report.

Definitive management of bronchogenic cysts is complete excision, although the diagnosis is often not made until histopathologic examination has been completed.¹⁹ Osteochondromas are managed with observation unless they are symptomatic.² Malignant degeneration is a rare but documented occurrence in both lesions.^2,20

Conclusion

In approaching the pediatric patient with a cystic mass over the scapula, a cutaneous bronchogenic cyst may be included in the differential diagnosis. This lesion can occur in isolation or can be found with another pathology, such as osteochondroma, as reported here.

Osteochondromas are common benign bone tumors composed of a bony protrusion with an overlying cartilage cap.¹ This lesion constitutes 24% to 40% of all benign bone tumors, and the great majority arise from the metaphyseal region of long bones.² The scapula accounts for only 3% to 5% of all osteochondromas; however, this lesion is the most common benign bone tumor to involve the scapula.³

In contrast, cutaneous bronchogenic cyst of the scapula is an exceedingly rare pathology. The bronchogenic cyst is a congenital cystic mass lined by tracheobronchial structures and respiratory epithelium.⁴ These are most commonly located in the thorax, although numerous remote locations have also been described, including cutaneous cysts.⁵ The overall incidence of bronchogenic cysts is thought to be 1 in 42,000 to 1 in 68,000.⁶ There are only 15 case reports of cutaneous bronchogenic cysts in the scapular region.⁷

We report the case of a novel dual lesion of both an osteochondroma and a contiguous cutaneous bronchogenic cyst in the scapula. The patient’s guardian provided written informed consent for print and electronic publication of this case report.

Case Report

A 12-month-old boy presented to our clinic with the complaint of a mass over the left scapula. The mass was first noted incidentally several weeks earlier during bathing. Examination revealed a firm, subcutaneous, nontender mass measuring 1×2 cm located over the spine of the scapula. There were no overlying skin changes, and there was normal function of the ipsilateral upper extremity. Anteroposterior and lateral chest radiographs revealed no abnormality. Magnetic resonance imaging (MRI) showed an exostosis projecting from the scapular spine measuring 2×6×7 mm with an adjacent cystic mass measuring 5×8×9 mm that was thought to represent bursitis (Figure 1). The decision was made to observe the mass. 

The patient returned to clinic at age 31 months with a new complaint of scant drainage of serous fluid from a pinprick-sized hole located just superolateral to the scapular mass. The child’s mother reported daily manual expression of fluid from the mass via the hole, without which the mass would enlarge. There were no local or systemic signs of infection. A repeat MRI again revealed an exostosis with an adjacent cystic mass with interval enlargement of the cyst (Figure 2). At age 4.5 years, the decision was made to proceed with excision of the osteochondroma and adjacent cystic mass.

The mass was approached via a 2-cm incision designed to excise the tract to the skin. Dissection revealed a sinus tract connecting to a well-defined cystic sac. This sac was attached to the underlying exostosis. The exostosis and attached cyst were excised en bloc. The cyst was opened, revealing foul-smelling, cloudy white fluid that was sent for culture; the specimen was sent for pathology.

The fluid culture grew mixed flora, with no Staphylococcus aureus, group A streptococcus, or Pseudomonas aeruginosa identified. The pathologic examination identified bone with a cartilaginous cap, consistent with osteochondroma (Figure 3), as well as a cyst lined by respiratory epithelium with patchy areas of squamous epithelium and surrounding mucus glands, consistent with bronchogenic cyst (Figure 4). Figure 5 shows the contiguous nature of the 2 lesions.

The postoperative course was uneventful. The patient returned to full use of the left upper extremity and had resolution of all drainage. 

Discussion

Osteochondromas are thought to arise from aberrant growth of the epiphyseal growth plate cartilage. A small portion of the physis herniates past the groove of Ranvier and grows parallel to the normal physis with medullary continuity. This can occur idiopathically or, more rarely, secondary to an identified injury to the growth plate.¹

The formation of bronchogenic cysts is most often attributed to anomalous budding of the ventral foregut during fetal development,⁴ hence the alternative designation of these cysts as foregut cysts. An extrathoracic location of the cyst has been postulated to stem from 2 possible events: a preexisting cyst may migrate out of the thorax prior to closure of the sternal plates, or sternal plate closure may itself pinch off the cyst.^8,9 An alternative explanation is in situ metaplastic development of respiratory epithelium.¹⁰ When located near the skin, these cysts often drain clear fluid.¹¹

Scapular osteochondromas are known to cause various pathologies of the shoulder girdle, including snapping scapula syndrome, chest wall deformity, shoulder impingement, and bursa formation.^12-17 This case, however, is the first known finding of a scapular osteochondroma with a contiguous cutaneous bronchogenic cyst. A putative explanation for their co-occurrence is that local disturbances caused by one lesion stimulated the formation of the second. The direct connection between the bronchogenic cyst and the bone, as has been reported in 3 cases,^7,9,18 seems to favor this explanation. Definitive conclusions regarding any causal relationship are beyond the scope of this single case report.

Definitive management of bronchogenic cysts is complete excision, although the diagnosis is often not made until histopathologic examination has been completed.¹⁹ Osteochondromas are managed with observation unless they are symptomatic.² Malignant degeneration is a rare but documented occurrence in both lesions.^2,20

Conclusion

In approaching the pediatric patient with a cystic mass over the scapula, a cutaneous bronchogenic cyst may be included in the differential diagnosis. This lesion can occur in isolation or can be found with another pathology, such as osteochondroma, as reported here.

Osteochondromas are common benign bone tumors composed of a bony protrusion with an overlying cartilage cap.¹ This lesion constitutes 24% to 40% of all benign bone tumors, and the great majority arise from the metaphyseal region of long bones.² The scapula accounts for only 3% to 5% of all osteochondromas; however, this lesion is the most common benign bone tumor to involve the scapula.³

In contrast, cutaneous bronchogenic cyst of the scapula is an exceedingly rare pathology. The bronchogenic cyst is a congenital cystic mass lined by tracheobronchial structures and respiratory epithelium.⁴ These are most commonly located in the thorax, although numerous remote locations have also been described, including cutaneous cysts.⁵ The overall incidence of bronchogenic cysts is thought to be 1 in 42,000 to 1 in 68,000.⁶ There are only 15 case reports of cutaneous bronchogenic cysts in the scapular region.⁷

We report the case of a novel dual lesion of both an osteochondroma and a contiguous cutaneous bronchogenic cyst in the scapula. The patient’s guardian provided written informed consent for print and electronic publication of this case report.

Case Report

A 12-month-old boy presented to our clinic with the complaint of a mass over the left scapula. The mass was first noted incidentally several weeks earlier during bathing. Examination revealed a firm, subcutaneous, nontender mass measuring 1×2 cm located over the spine of the scapula. There were no overlying skin changes, and there was normal function of the ipsilateral upper extremity. Anteroposterior and lateral chest radiographs revealed no abnormality. Magnetic resonance imaging (MRI) showed an exostosis projecting from the scapular spine measuring 2×6×7 mm with an adjacent cystic mass measuring 5×8×9 mm that was thought to represent bursitis (Figure 1). The decision was made to observe the mass. 

The patient returned to clinic at age 31 months with a new complaint of scant drainage of serous fluid from a pinprick-sized hole located just superolateral to the scapular mass. The child’s mother reported daily manual expression of fluid from the mass via the hole, without which the mass would enlarge. There were no local or systemic signs of infection. A repeat MRI again revealed an exostosis with an adjacent cystic mass with interval enlargement of the cyst (Figure 2). At age 4.5 years, the decision was made to proceed with excision of the osteochondroma and adjacent cystic mass.

The mass was approached via a 2-cm incision designed to excise the tract to the skin. Dissection revealed a sinus tract connecting to a well-defined cystic sac. This sac was attached to the underlying exostosis. The exostosis and attached cyst were excised en bloc. The cyst was opened, revealing foul-smelling, cloudy white fluid that was sent for culture; the specimen was sent for pathology.

The fluid culture grew mixed flora, with no Staphylococcus aureus, group A streptococcus, or Pseudomonas aeruginosa identified. The pathologic examination identified bone with a cartilaginous cap, consistent with osteochondroma (Figure 3), as well as a cyst lined by respiratory epithelium with patchy areas of squamous epithelium and surrounding mucus glands, consistent with bronchogenic cyst (Figure 4). Figure 5 shows the contiguous nature of the 2 lesions.

The postoperative course was uneventful. The patient returned to full use of the left upper extremity and had resolution of all drainage. 

Discussion

Osteochondromas are thought to arise from aberrant growth of the epiphyseal growth plate cartilage. A small portion of the physis herniates past the groove of Ranvier and grows parallel to the normal physis with medullary continuity. This can occur idiopathically or, more rarely, secondary to an identified injury to the growth plate.¹

The formation of bronchogenic cysts is most often attributed to anomalous budding of the ventral foregut during fetal development,⁴ hence the alternative designation of these cysts as foregut cysts. An extrathoracic location of the cyst has been postulated to stem from 2 possible events: a preexisting cyst may migrate out of the thorax prior to closure of the sternal plates, or sternal plate closure may itself pinch off the cyst.^8,9 An alternative explanation is in situ metaplastic development of respiratory epithelium.¹⁰ When located near the skin, these cysts often drain clear fluid.¹¹

Scapular osteochondromas are known to cause various pathologies of the shoulder girdle, including snapping scapula syndrome, chest wall deformity, shoulder impingement, and bursa formation.^12-17 This case, however, is the first known finding of a scapular osteochondroma with a contiguous cutaneous bronchogenic cyst. A putative explanation for their co-occurrence is that local disturbances caused by one lesion stimulated the formation of the second. The direct connection between the bronchogenic cyst and the bone, as has been reported in 3 cases,^7,9,18 seems to favor this explanation. Definitive conclusions regarding any causal relationship are beyond the scope of this single case report.

Definitive management of bronchogenic cysts is complete excision, although the diagnosis is often not made until histopathologic examination has been completed.¹⁹ Osteochondromas are managed with observation unless they are symptomatic.² Malignant degeneration is a rare but documented occurrence in both lesions.^2,20

Conclusion

In approaching the pediatric patient with a cystic mass over the scapula, a cutaneous bronchogenic cyst may be included in the differential diagnosis. This lesion can occur in isolation or can be found with another pathology, such as osteochondroma, as reported here.