LaCrosse, WI, United States
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Valentine R.J.,University of Texas Southwestern Medical Center | Jones A.,American Board of Surgery | Biester T.W.,American Board of Surgery | Cogbill T.H.,Gundersen Lutheran Medical Center | And 2 more authors.
Annals of Surgery | Year: 2011

Objective: To assess changes in general surgery workloads and practice patterns in the past decade. Background: Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. Methods: The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. Results: GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. Conclusions: GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access. © 2011 by Lippincott Williams & Wilkins.

Donnenwerth M.P.,Gundersen Lutheran Medical Foundation | Roukis T.S.,Gundersen Lutheran Medical Center
Arthroscopy - Journal of Arthroscopic and Related Surgery | Year: 2012

Purpose: The purpose of this systematic review was to determine patient outcomes after arthroscopic debridement and microfracture for osteochondral lesions (OCLs) of the talar dome. Methods: Infotrieve-PubMed/MEDLINE and Google Scholar were systematically searched for the following terms: microfracture AND ankle OR talus. In addition, we hand-searched common American and European orthopaedic and podiatric surgical journals for relevant manuscripts. Articles considered for inclusion were published in peer-reviewed journals, used the American Orthopaedic Foot & Ankle Society hindfoot scoring system for outcome measurement, and involved arthroscopic debridement and microfracture for OCL of the talar dome. Results: We identified 29 potentially relevant publications, of which 7 met our inclusion criteria. A total of 295 patients (299 ankles) were included in this study. The weighted mean postoperative American Orthopaedic Foot & Ankle Society hindfoot score was 86.8 points, translating to good to excellent outcomes in 80.2% of patients. Conclusions: Many techniques exist for the treatment of OCLs of the talar dome. Good to excellent results can be consistently reached in greater than 80% of patients with arthroscopic debridement and microfracture. However, additional prospective trials should be undertaken to determine differences in outcome between techniques, size and location of the OCL, and other patient quality factors, such as cost and time to return to work. Level of Evidence: Level IV, systematic review of Level II, III, and IV studies. © 2012 Arthroscopy Association of North America.

Borkosky S.L.,Gundersen Lutheran Medical Foundation | Roukis T.S.,Gundersen Lutheran Medical Center
Diabetic Foot and Ankle | Year: 2012

Diabetes mellitus with peripheral sensory neuropathy frequently results in forefoot ulceration. Ulceration at the first ray level tends to be recalcitrant to local wound care modalities and off-loading techniques. If healing does occur, ulcer recurrence is common. When infection develops, partial first ray amputation in an effort to preserve maximum foot length is often performed. However, the survivorship of partial first ray amputations in this patient population and associated re-amputation rate remain unknown. Therefore, in an effort to determine the actual re-amputation rate following any form of partial first ray amputation in patients with diabetes mellitus and peripheral neuropathy, the authors conducted a systematic review. Only studies involving any form of partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy but without critical limb ischemia were included. Our search yielded a total of 24 references with 5 (20.8%) meeting our inclusion criteria involving 435 partial first ray amputations. The weighted mean age of patients was 59 years and the weighted mean follow-up was 26 months. The initial amputation level included the proximal phalanx base 167 (38.4%) times; first metatarsal head resection 96 (22.1%) times; first metatarsal-phalangeal joint disarticulation 53 (12.2%) times; first metatarsal mid-shaft 39 (9%) times; hallux fillet flap 32 (7.4%) times; first metatarsal base 29 (6.7%) times; and partial hallux 19 (4.4%) times. The incidence of re-amputation was 19.8% (86/435). The end stage, most proximal level, following re-amputation was an additional digit 32 (37.2%) times; transmetatarsal 28 (32.6%) times; below-knee 25 (29.1%) times; and LisFranc 1 (1.2%) time. The results of our systematic review reveal that one out of every five patients undergoing any version of a partial first ray amputation will eventually require more proximal re-amputation. These results reveal that partial first ray amputation for patients with diabetes and peripheral sensory neuropathy may not represent a durable, functional, or predictable foot-sparing amputation and that a more proximal amputation, such as a balanced transmetatarsal amputation, as the index amputation may be more beneficial to the patient. However, this remains a matter for conjecture due to the limited data available and, therefore, additional prospective investigations are warranted. © 2012 S.L. Borkosky and T.S. Roukis.

Abicht B.P.,Gundersen Lutheran Medical Center | Roukis T.S.,Gundersen Lutheran Medical Center
Arthroscopy - Journal of Arthroscopic and Related Surgery | Year: 2013

Purpose: To determine the incidence of nonunion after isolated arthroscopic ankle arthrodesis. Methods: Electronic databases and relevant peer-reviewed sources, including OvidSP/Medline ( and Google, were systematically searched for the terms "arthroscopic ankle arthrodesis" AND "nonunion". Additionally, we manually searched common American, British, and European orthopaedic and podiatric scientific literature for relevant articles. Studies were eligible for inclusion only if they included the following: isolated ankle arthrodesis, greater than 20 ankles, minimum mean follow-up of 12-months, a 2-portal anterior arthroscopic approach, fixation with 2 or 3 large-diameter cannulated cancellous screws, and the nonunion rate with no restriction on cause. Results: After considering all the potentially eligible articles, 7 (25.9%) met the inclusion criteria. A total of 244 patients (244 ankles) - 148 (60.7%) male and 96 (39.3%) female patients, with a weighted mean age of 49.2 years - were included. For those studies that specified the exact follow-up, the weighted mean was 24.1 months. A total of 21 nonunions (8.6%) were reported, with 14 (66.7%) being symptomatic and requiring further intervention. Conclusions: The results of this systematic review reveal an acceptable incidence of nonunion of 8.6%. However it is important to recognize that of these nonunions, 66.7% were symptomatic. This supports the belief that regardless of approach, nonunion of an ankle arthrodesis is problematic. In light of this finding, additional prospective studies are warranted to compare directly the incidence of nonunion between open, minimum incision, and arthroscopic approaches with a variety of fixation constructs. Level of Evidence: Level IV, systematic review of level IV studies. © 2013 by the Arthroscopy Association of North America.

Sartin J.S.,Gundersen Lutheran Medical Center
Clinical Medicine and Research | Year: 2010

Infectious diseases have led to illness and death for many famous musicians, from the classical period to the rock 'n' roll era. By the 20th century, as public health improved and orchestral composers began living more settled lives, infections among American and European musicians became less prominent. By mid-century, however, seminal jazz musicians famously pursued lifestyles characterized by drug and alcohol abuse. Among the consequences of this risky lifestyle were tuberculosis, syphilis, and chronic viral hepatitis. More contemporary rock musicians have experienced an epidemic of hepatitis C infection and HIV/AIDS related to intravenous drug use and promiscuity. Musical innovation is thus often accompanied by diseases of neglect and overindulgence, particularly infectious illnesses, although risky behavior and associated infectious illnesses tend to decrease as the style matures. ©2010 Marshfield Clinic.

Eradication of bacterial flora from the foot, especially the nailfolds and toe webspaces, through surgical preparation remains a challenge. All previous studies have involved healthy patients undergoing elective foot and ankle surgery or healthy volunteers. However, the patient with diabetes is considered an immunocompromised host with decreased ability to combat invasive bacterial infections. The use of an efficacious surgical preparation is therefore of paramount importance. The author conducted a prospective study involving patients with diabetes with and without ulceration who underwent the current " best evidence available" surgical preparation (i.e., chlorhexidine gluconate [4%] scrub followed by alcohol impregnated with iodine [1%] solution). Qualitative aerobic cultures before and after completion of this surgical preparation technique were obtained from the hallux nailfold; second, third, and fourth toe webspaces (as one culture); and distal anterior tibia. A total of 120 organisms were cultured before surgical preparation with 64 in the elective group and 56 in the ulcerated group. The most commonly isolated organism was methicillin-resistant Staphylococcus epidermidis, which was identified in 46 pre-preparation cultures (38.3%). This was followed by methicillin-sensitive S. epidermidis (16.7%) and " other" organisms (10.0%). There was a significant reduction for both numbers of organisms identified and positive cultures for the 3 most commonly isolated organisms after surgical preparation. Based on the results of this study, the surgical preparation used here appears to be an efficacious surgical preparation technique for eradicating aerobic bacterial pathogens from the foot in patients with diabetes both with and without ulceration. The high incidence of methicillin-sensitive and methicillin-resistant S. epidermidis found in this patient population is a cause for concern, especially when metallic fixation is intended to be implanted. © 2010 American College of Foot and Ankle Surgeons.

White D.W.,Gundersen Lutheran Medical Center | Suzanne Beard R.,Purdue University | Suzanne Beard R.,Wake forest University | Barton E.S.,Wake forest University
Immunological Reviews | Year: 2012

Nearly all human beings, by the time they reach adolescence, are infected with multiple herpesviruses. At any given time, this family of viruses accounts for 35-40 billion human infections worldwide, making herpesviruses among the most prevalent pathogens known to exist. Compared to most other viruses, herpesviruses are also unique in that infection lasts the life of the host. Remarkably, despite their prevalence and persistence, little is known about how these viruses interact with their hosts, especially during the clinically asymptomatic phase of infection referred to as latency. This review explores data in human and animal systems that reveal the ability of latent herpesviruses to modulate the immune response to self and environmental antigens. From the perspective of the host, there are both potentially detrimental and surprisingly beneficial effects of this lifelong interaction. The realization that latent herpesvirus infection modulates immune responses in asymptomatic hosts forces us to reconsider what constitutes a 'normal' immune system in a healthy individual. © 2011 John Wiley & Sons A/S.

Roukis T.S.,Gundersen Lutheran Medical Center
Journal of Foot and Ankle Surgery | Year: 2010

Autogenous soft tissue interpositional arthroplasty has been proposed as an alternative to arthrodesis and other forms of arthroplasty for treatment of end-stage hallux rigidus because of the perceived safety and efficacy. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the outcomes following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, were also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated autogenous soft tissue interpositional arthroplasty for the treatment of end-stage hallux rigidus, evaluated patients at mean follow-up of 12-months' duration or longer, included pre- and postoperative range of motion of the first metatarsal-phalangeal joint, determined pre- and postoperative outcomes using a scoring system, and documented any complications. Two studies involving a total of 28 autogenous soft tissue interpositional arthroplasties for end-stage hallux rigidus were identified that met the inclusion criteria. There were 12 men (52%) and 11 women (48%) with a mean age of 58.2 years followed for a mean of 21.6 months. Both studies used the AOFAS First Metatarsal-Phalangeal-Hallux Scoring System, which had a mean of 26.0 preoperatively rising to 89.4 postoperatively. First metatarsal-phalangeal joint dorsiflexion had a mean of 16.7° preoperatively rising to 51.1° postoperatively. Complications occurred in 4 (14.3%) feet and no feet required surgical revision. The results of this systematic review demonstrate improvement in patient outcomes and first metatarsal-phalangeal joint dorsiflexion, as well as few complications following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that compare autogenous soft tissue interpositional arthroplasty with other forms of arthroplasty and arthrodesis for end-stage hallux rigidus. © 2010 American College of Foot and Ankle Surgeons.

McLaughlin J.R.,The Kennedy Center for the Hip and Knee Mercy Medical Center | Lee K.R.,Gundersen Lutheran Medical Center
Journal of Arthroplasty | Year: 2011

The purpose of the present study was to evaluate the outcome of primary uncemented total hip arthroplasty in patients younger than 50 years using the Taperloc (Biomet, Warsaw, Ind) femoral component. We evaluated 94 hips in 79 patients at a mean follow-up of 16 years (range, 11-18.5 years). The average age of the patients at the time of surgery was 36 years (range, 20-49 years). Three femoral components had been revised, none for aseptic loosening. Complete clinical and radiographic follow-up was obtained on the 91 hips that had not undergone femoral component revision. The mean Harris hip score increased from 54 points (range, 20-72) before surgery to 93 points (range, 68-100) at the time of this review. Radiographically, 89 stems (98%) were determined to have fixation by bone ingrowth, 2 (2%) demonstrated stable fibrous ingrowth, and no femoral component was loose. Distal femoral osteolysis was identified in 1 hip (1%). These findings indicate that excellent clinical and radiographic results can be achieved in young patients with the Taperloc femoral component at a mean follow-up of 16 years. © 2011 Elsevier Inc.

Roukis T.S.,Gundersen Lutheran Medical Center
Journal of Foot and Ankle Surgery | Year: 2010

Isolated cheilectomy has been proposed for treatment of hallux rigidus due to the perceived safety, efficacy, and ability to revise with repeat cheilectomy, implant or interpositional arthroplasty, or arthrodesis. A systematic review was undertaken to better understand the need for surgical revision after isolated cheilectomy for hallux rigidus. Studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated cheilectomy or involved revision surgery of the first metatarsophalangeal joint after isolated cheilectomy, evaluated patients at mean follow-up ≥ 12 months' duration, and included details of complications. Twenty-three studies, describing 706 cheilectomies, met the inclusion criteria, with 62 (8.8%) undergoing surgical revision in the form of arthrodesis (n = 23), no mention of revision procedure (n = 17), interpositional arthroplasty (n = 13), silicone implant arthroplasty (n = 4), Keller resection arthroplasty (n = 3), or repeat cheilectomy (n = 2). Twelve studies specified the grade of hallux rigidus as: 103 (19.9%) grade 1, 210 (40.6%) grade II, 189 (36.6%) grade III, and 15 (2.9%) grade IV. Six studies indicated the number of cheilectomies that required revision surgery as: 2 (20%) grade I, 8 (14.8%) grade II, 12 (9.1%) grade III, and 5 (55.6%) grade IV. These results make clear the low incidence of revision surgery after cheilectomy for hallux rigidus. Therefore, cheilectomy should be considered a first-line surgical treatment for hallux rigidus. There remains a need for methodologically sound prospective cohort studies that focus on the use of cheilectomy for specific grades of hallux rigidus. © 2010 American College of Foot and Ankle Surgeons.

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