Orthopaedic Web Links (OWL)

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Clin Orthop Relat Res (2011) 469:2049–2061 DOI 10.1007/s11999-011-1875-1

BASIC RESEARCH

Orthopaedic Web Links (OWL) A Way to Find Professional Orthopaedic Information on the Internet J. F. M. Clough MD, DPhil, FRCS(C), C. J. H. Veillette MD, MSc, FRCS(C)

Received: 2 June 2010 / Accepted: 14 March 2011 / Published online: 1 April 2011  The Association of Bone and Joint Surgeons1 2011

Abstract Background Finding useful high-grade professional orthopaedic information on the Internet is often difficult. Orthopaedic Web Links (OWL) is a searchable database of vetted online orthopaedic resources. OWL uses a subject directory (OWL Directory) and a custom search engine (OWL Web) to provide a list of resources. The most effective way to find readily accessible, full text on-subject material suitable for education of an orthopaedic surgeon or trainee has not been defined. Questions/purposes We therefore (1) proposed a method for selecting topics and evaluating searches and (2) compared the search results from an orthopaedic-specific directory (OWL Directory), a custom search engine (OWL Web), and standard Google searches. JFM Clough and CJH Veillette are Board Members, editors, and principals of Orthopaedic Web Links. Each author (JFMC and CJHV) certifies that he has or may receive payments or benefits from a commercial entity (Orthopaedic Web Links Inc) related to this work. Each author certifies that his or her institution approved the reporting of this case and that all investigations were conducted in conformity with ethical principles of research. This study was performed at Kamloops, BC, Canada and University of Toronto, Toronto, ON, Canada.

Electronic supplementary material The online version of this article (doi:10.1007/s11999-011-1875-1) contains supplementary material, which is available to authorized users. J. F. M. Clough (&) Department of Orthopaedic Surgery, University of British Columbia, 198 Waddington Dr., Kamloops, BC V2E 1M4, Canada e-mail: [email protected] C. J. H. Veillette Division of Orthopaedic Surgery, Toronto Western Hospital, Toronto, ON, Canada

Methods A scoring system for evaluation of the search results was developed for standardized comparison. Single words and sets of three words from randomly selected examination questions provided the search strings to compare the three strategies. Results For single keyword searches, the OWL Directory scored highest (16.4/50) of the three methods. For the three keywords searches, OWL Web had the highest mean score (26.0/50), followed by Google (22.8/50), and the OWL Directory (1.0/50). OWL Web searches had higher scores than Google searches, while returning 800 times fewer search results. Conclusion The OWL Directory of orthopaedic subjects on the Internet provides a simple browsable category structure to find information. The OWL Web search engine scored higher than Google and resulted in a greater proportion of valid, on-subject, and accessible resources in the search results.

Introduction There are two basic ways to locate information on the Internet: directories [28, 35] and search engines [36]. Directories are collections of web-site addresses (URLs) organized by subject categories; the value is in selection and categorization of resources. When searching a directory, only the information regarding a web site identified by an editor is included in that directory [35]. Search engines evaluate the content of the whole site using software called ‘‘web crawlers’’ that visit web pages and store their information in an index database. The search results are returned based on specific algorithms that rank the results to provide the ‘‘best’’ results first [36]. Owing to the growth of the Internet and inability of directories to be

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maintained, there has been a transition from directories to search engines during the past decade [31]. Despite the improvements in search algorithms, there still is value in web directories, especially niche directories, provided the content is robust, unique, and well-edited, and the listings are of high quality and relevant to a specific user group. When orthopaedic surgeons attempt to find professionallevel orthopaedic subject matter using standard search engines, it often results in information overload, frustration, and eventual failure [32]. There are three main types of search failure: overload, nonspecific searching, and unavailability (true failure) (Table 1). (Information overload reflects the difficulty in understanding an issue and making decisions because of too much information or information that is too confusing or poorly organized.) Studies that fail to find anything valuable [23] may be declaring Type 3 search failures, but actually are committing Types 1 and 2 search errors. Several studies describing orthopaedic information available on the Internet have used search strategies they expected patients to use and comment on the misinformation patients often find in the search results [5, 18, 23, 26]. However, generalized statements regarding the quality of material that is available on the Internet cannot be made without conducting more sophisticated searches. These misperceptions often result in the Internet being viewed as low yield for professional orthopaedic information. There has been limited research of orthopaedic information on the Internet for professionals. Sinkov et al. [34] reported that 100% of residents and 79% of attending staff regularly use the Internet to obtain orthopaedic information. That study covered few web sites and the search behavior of the participants was not evaluated. Using search engines, such as Google, is a common way of accessing information on the Internet for all areas of everyday life. Although searching for orthopaedic information is alluded to in Table 1. Types of search failure on the Internet Type

Name

Description

1

Overload

Too many undesirable resources are returned; it is difficult to isolate desirable ones even though they are in the search results. Common with simple searches in general search engines.

2

Poor specificity

The desired resources are not in the search results because of failure to create a search string that includes the specific terms in the target page. Common with complex searches.

3

Unavailability

The desired resource is not actually available, accessible, or is too expensive to allow its efficient use. Common with journal articles.

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numerous studies of orthopaedic information on the Internet [6, 10, 14, 17, 18, 21, 23, 24, 26, 31–34], these studies do not investigate the success or failure of searches for professional orthopaedic information. As the web continues to grow, the problem of Type 1 failure (overload) means that automated search engines are increasingly unable to generate useful results to search queries [27]. Editorial staffs at directory sites also cannot keep up with the growth of the Internet [31], and the quality and comprehensiveness of their directories inevitably suffer. OWL [29] contains greater than 15,000 resources categorized into three broad groups based on information type – professional, patient, and commercial. OWL facilitates finding professional orthopaedic resources in two ways: it provides direct links to greater than 8000 resources in more than 700 orthopaedic subject categories (OWL Directory) and also provides a custom search engine (OWL Web) [30] where the sites searched are confined to domains that already have contributed valid orthopaedic resources to the OWL Directory (Appendix 1). To evaluate three available methods to find readily available (free), full text, on-subject resources suitable for education of an orthopaedic surgeon or trainee, we (1) proposed a method for selecting topics, creating search queries, and scoring search results specifically for this purpose, and (2) compared the search results from an orthopaedic-specific directory (OWL Directory), a custom search engine (OWL Web), and standard Google searches.

Methods and Materials We used examination questions to select appropriate professional level orthopaedic subjects and generate corresponding search strings. We devised a scoring system that rewards readily available, on-subject, full-text resources at the appropriate professional level. This score then was applied to the search results from the OWL Directory, OWL Web, and Google (Appendix 1). We randomly identified orthopaedic topics from the 2008 Orthopaedic In-Training Exam (OITE) [1, 25] to prevent selection bias and because of its perceived relevance of timely orthopaedic topics. We used a random number generator to select questions to be converted into orthopaedic topics, one-keyword and three-keyword search strings using a predefined protocol (Appendix 2). We performed searches using three search systems: Google, OWL Directory [29], and OWL Web [30], using a one-keyword search string in all three search systems then repeating with a three-keyword search string. Ten topics (Table 2) were used to conduct searches, resulting in 60 total searches. The first 10 resources returned from a search were scored using the scoring system developed to evaluate

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Table 2. Topics selected for single- and three-keyword searches using Google, OWL Directory, and OWL Web 2008 OITE Question Number

Topic

Search string*

221

Ligament balancing in TKR

Balancing knee extension

63

Pathologic fracture of the femur

Pathologic fracture femur

122

Humeral intramedullary associated

229

Complications associated with IM rod treatment of humeral shaft fractures Driving a vehicle after hip arthroplasty

30

Peroneal nerve recovery

Peroneal nerve recovery

248

Complications of cross-pinning pediatric supracondylar humerus fracture

Supracondylar cross-pinning complication

20

Compression of the lateral plantar nerve

Compression lateral plantar

58

Iliopectineal fascia in the ilioinguinal approach to the pelvis

Ilioinguinal approach iliopectineal

153

Role of exostectomy in insertional Achilles tendinosis

Tendinosis Achilles exostectomy

138

Salvage arthroplasty after intertrochanteric fracture

Intertrochanteric fracture arthroplasty

Arthroplasty hip driving

* The first word in each of the listed search strings was used for the single-word search. Table 3. Scoring system for evaluation of the relevance of a resource

Table 4. Concordance between observers

Description

Score

Scores for Observer B

Scores for Observer A

Commercial site, off-subject, duplicate, or unavailable

0

Patient information

1

0

209

20

Low-grade professional information

2

1

1

9

High-grade professional information (abstract/incomplete)

3

2

1

2

High-grade professional information (full text)

5

3

2

3

5

5

the level of information, availability, and relevance of the resource to the topic in question (Table 3). Resources that provided professional level information regarding the topic and were readily accessible (free/not password protected) in full-text format scored 5. Websites that were unavailable, off-subject, or only advertised goods and services, scored 0. All other scores were intermediate. Duplicate sites, whose content already had been presented by the same search system, also scored 0. We defined a low-grade professional resource as one in which the information was presented for medical students, nurses, or other medical professionals. A high-grade resource was one that was informative to a general orthopaedic surgeon or trainee. Resources scored only if they were judged to be ‘‘on-subject’’ (if they were about the topic) as previously defined (Appendix 2); they did not have to answer the specific OITE question. Both authors independently scored all resources and determined whether the resource was on-subject, what level of information was provided, and the extent of access (Table 3). Where there was a difference between the scores of the two observers, we used the mean score (Appendix 3 - Supplemental materials are available with the online version of CORR). Scores were summed for the first 10 search returns. When less than 10 resources were returned from a search, we used the sum of scores for all the resources returned.

Totals

0

1

218

31

Totals

2

3

5

11

18

3

34

292

2

12

1

7

33

5

43

10

4

93

112

27

55

135

466

We determined concordance between the scores of the observers using the Kappa coefficient with linear weighting [19]. We used the Wilcoxon signed-rank matched-pairs (nonparametric) test [20] to determine the differences between the sums of scores for each of the following searches: Google/OWL Directory (one keyword), Google/ OWL Web (one keyword), OWL Directory/OWL Web (one keyword), Google/OWL Directory (three keywords), Google/OWL Web (three keywords), OWL Directory/ OWL Web (three keywords).

Results Ten of the first 13 randomly chosen OITE questions provided an unequivocal topic and words suitable for searching (Appendix 2). In the three excluded questions, the topic was clear but words to define it (ie, the diagnosis) were not present. The number of observed agreements was 347 of 466 (75%) (Table 4). The Kappa value between the scores assigned by the two observers was 0.65. Disagreement between observers arose through different interpretations regarding whether a resource was on the

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subject and, to a lesser extent, owing to differences in accessibility of the resources to observers with different library access. Simple (one word) searches on OWL Directory and OWL Web produced higher scores compared with Google, whereas the search engines (Google and OWL Web) scored better when three keywords were used. The mean scores for searches conducted on Google, OWL Directory, and OWL Web using one or three keyword searches varied from 1 to 26 of a possible 50 (Fig. 1). Searches using one keyword were less successful on Google. The same searches on OWL Directory and OWL Web found a larger proportion of relevant material with scores that were 2.3 and 1.8 times higher, respectively. The OWL Directory scored similarly (Wilcoxon test W = 22, n = 10, p = 0.27): 16.4/50 for single-word searches and OWL Web scored 13.2/50 (Table 5). When three-keyword search

Fig. 1 A comparison between searches using Google, OWL Directory, and OWL Web is shown. For one-word searches, the OWL directory and OWL web searches score higher than Google. For threeword searches, the OWL Web and Google searches score higher than the OWL Directory

strings were used, OWL Web had the highest mean score (26.0), followed by Google (22.8), and OWL Directory (1.0). In seven of 10 cases, a three-keyword search on OWL Directory failed to return any resources. OWL Web searches had equivalent or higher scores than Google searches, but returned 800 times fewer search results (Table 5).

Discussion Finding high-grade orthopaedic information on the Internet is frustrating and has not been rigorously addressed. Therefore, we proposed an unbiased method for choosing orthopaedic subjects, preparing the search strings, and scoring the results of searches. We then used this method to compare three strategies for finding orthopaedic information, a standard search engine (Google), an orthopaedic directory (OWL Directory), and a custom orthopaedic search engine (OWL Web). Our study is limited in several ways. First, the authors are the editors of Orthopaedic Web Links and have spent time, money, and effort providing this service to the orthopaedic community. To counter inherent bias, we designed a study in which the selection of topics and the keywords available were not under our control. The findings are presented (Appendix 3 - Supplemental materials are available with the online version of CORR) so that the scoring aspect of the study can be scrutinized or repeated by an independent observer. Second, the study considered a relatively small number of orthopaedic topics. Larger numbers might show more differences between the search strategies. Third, the study was performed by the developers, and not by users, although the intent is to examine whether OWL provides its users with a more effective way to find orthopaedic information appropriate to their level of need. There is a considerable amount of research on orthopaedic patient information on the Internet [8], assessing readability [2], and overall content [3, 5, 7, 10, 17, 18, 23, 24, 26], with some elaborate assessment tools [5, 23, 24]. Although there are accounts of the professional-level

Table 5. Mean relevance scores and number of returns for one- and three-keyword searches Search engine

Mean score for one-keyword searches

Mean number of results

Mean score for three-keyword searches

Mean number of results

Google

7.25

9.609,100

22.8à

263,134

OWL Directory

16.4*

31

1.0

1

OWL Web

14.6 

459

26.0§

316

* Difference between OWL Directory and Google: Wilcoxon test W = 45, n = 10, p = 0.0232;  difference between OWL Web and Google: Wilcoxon test W = 36, n = 9, 0.02 \ p \ 0.05; àdifference between Google and OWL Directory: Wilcoxon test W = 55, n = 10, p = 0.0054; § difference between OWL Web and OWL Directory: Wilcoxon test W = 55, n = 10, p = 0.0054.

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orthopaedic resources available on the Internet [6, 9–11, 14, 17, 21, 32, 34], research into patterns of usage [34], and discussion of individual sites [4], this article is the first to propose a scoring method for evaluating search strategies for orthopaedic surgeons. The topics addressed in the OITE are of direct relevance to orthopaedic trainees, educators, and examiners [22]. Performance in OITE has correlated with later performance in qualifying examinations [12, 16]. Thus, topics derived from OITE questions are of interest to orthopaedic surgeons and are appropriately granular; therefore, this source for orthopaedic topics was a good choice for this study. Restricting the searches to one or three keywords is artificial, but justified in this context. Freely constructed searches inevitably would introduce bias. Frustration with the results of searching is produced by overload (Type 1 failure) (Table 1), but is compounded by the flood of inappropriate and duplicate material. Another major concern is the inaccessibility of most journal articles for those who do not have subscriptions or access through a library [13]. Our ‘‘relevance’’ scoring system, therefore, rewards on-subject, full-text, readily available material suitable for use by an orthopaedic surgeon or trainee; it penalizes material found more than once by the same search strategy, and material which is off the subject. Abstracts or incomplete resources do not score as well as full text material. Few orthopaedic websites have been critically examined to determine if they accomplish their goals. Most of the literature describes various resources without any numerical evaluation [4, 6, 9–11, 14, 17, 21, 28, 32, 33]. Sinkov et al. [34] surveyed the proportion of residents and attending surgeons who used certain resources, which is an indirect measure of utility. Our comparison between search strategies showed that simple one-word searches on the OWL Directory scored well, especially when compared with Google, where searches typified Type 1 search failure (Overload, Table 1) with a huge number of returns, with low relevance in the first 10 returns (Fig. 1; Table 5; [Appendix 3—Supplemental materials are available with the online version of CORR]). Using more complex (three-keyword) searches with technical terms, the web searches (OWL Web and Google) scored higher. OWL Directory found no resources seven of 10 times when presented with a three-word search string. This is understandable. The OWL Directory search examines only the contents of the OWL database, an indexed title, a short description of the site, keywords, and category information [34]. For the OWL Directory search to be successful, these metadata associated with the resource, must contain all the three keywords in the search string. By contrast, the OWL Web and Google index can search the entire content of millions of resources so they are more likely to find resources with the three words. Owing to these differences, one would use the different

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search systems in different ways and circumstances. The OWL Directory should be searched to find the appropriate subject category; this category then can be browsed. This is valuable when an orthopaedic surgeon wishes to perform a rapid, simple search and find a small group of trusted resources available in full text, with no duplication. When a more comprehensive list of resources is required, OWL Web provides results with improved quality for simple searches, and a good rate of success for complex searches, with less overload than Google. Starting from the premise that the use of general search engines, such as Google, is frustrating for many orthopaedic surgeons, we evaluated the most effective way to find high-grade professional orthopaedic information on the Internet. We developed a method for evaluating search strategies and used it to show that OWL Directory searches with single keywords had higher relevance scores than similar searches on Google. With more complex three-keyword searches, the custom search engine, OWL Web, provided more relevant search results compared with Google, with less likelihood of overload failure. Acknowledgements We thank J. van der Bauwhede who was a founder/editor of the earliest version of OWL and hosted the site for many years. We also thank C. Oliver who also was an OWL editor and made numerous contributions to the development of the site and R. Sechrest for (nonfinancial) support and advice.

Appendix 1: Features of Orthopaedic Web Links (OWL) Directory and OWL Web The Orthopaedic Web Links (OWL) website is a database site to which users may contribute, subject to editorial validation. OWL was formed in 1996 by the amalgamation of three earlier orthopaedic link collections. The original format of flat file hypertext (HTML) pages proved difficult to maintain. In 2002 the site was converted to a MySQL database-driven directory management software platform [28], running on a custom-designed, Perl-based directory management software platform using a dedicated server. The data displayed primarily consisted of URLs (Universal Resource Locators – Internet Addresses) with the title of the page, authors, and short description of the resource. The database also contains metadata concerning the type of resource, language, ownership, and contact information of the ‘owner’. Searches are conducted over the whole site or within a specific category. Users can conduct searches or view the database without having to sign on and without payment. Registered users can add resources to the site, edit resources which they ‘own’, and submit reviews. Also, they can provide user-generated reviews and ratings of

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resources. The administration panel allows important management functions, such as detection and removal of duplicate and expired links. All user-submitted resources and modification of content must be validated by the editors before the database is updated. Resources are grouped by category according to subject. Custom search engines can be created using Google; the search is confined to certain pages or domains [15]. OWL Web integrates the search box and results of a custom search engine for orthopaedics into the OWL environment. The domain addresses of all resources accepted to the ‘Professional’ resource sections of the OWL Directory are supplied to the OWL Web search engine. As a result, a search on OWL Web produces results only from domains that have previously validated orthopaedic content.

Appendix 2: Conversion of OITE Questions into One-word and Three-word Search Strings The purpose of this process is first to identify orthopaedic topics, and second to obtain a selection of words relating to that topic which could be used in a search string. There are 275 questions in the 2008 OITE. Random numbers between 1 and 275 were generated (Table 6), to ensure that

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the questions were randomly selected. A topic was derived from each question (and correct answer). Then the text of the question and answer was examined for three words which were judged to be the most fruitful search string. These words had to be present in the text of the question and answer. Finally one word (the first word in each of the topics of the search string in Table 2) was selected from the three to use in a single-word search. Topics were excluded if a search string valid for that topic could not be made from the words available. In practice this meant that if the diagnosis was not present in the text of the question and answer the topic was rejected. Three of the first 13 topics were excluded because the text did not contain words that identified the conditions (Table 6). The words selected for the search strings were those judged to be the ones most likely to be found in the target resource, and result in a successful search. For example, topic 3 was ‘‘Outcomes associated with IM nailing of humeral fractures’’. The search string chosen was Humeral Intramedullary Associated. Fracture was not used because the word intramedullary is seldom used alongside humeral except in the context of fracture. Outcome was not used because it did not appear in the text. Once the topics, exclusions, and search strings had been formulated they were not changed. There was no feedback from the results of searching.

Random number

221

63

Number

1

2

Topic

Answer - 2

5. Pathologic fracture in a rachitic femur

4. Pathologic fracture in osteogenesis imperfecta

3. Pathologic fracture of the distal femur through a malignant lesion

2. Pathologic fracture of the distal femur through a benign lesion

1. Traumatic fracture of the distal femur

A 12-year-old girl felt a snap in her Pathologic fractures of the leg while pivoting in a football femur game and now is unable to walk. Examination reveals gross instability above the knee. She is neurovascularly intact. Radiographs and MRI scans are shown in Figures 23a through 23d. Based on these findings, what is the most likely diagnosis?

Answer - 4

5. 10 mm

4. 8 mm

3. 6 mm

2. 4 mm

1. 2 mm

When evaluating a posterior Balancing in TKR stabilized knee for balancing, tightness is encountered in extension; therefore, you choose to remove additional distal femur. What is the maximum acceptable joint line elevation?

OITE question and answer

Table 6. OITE questions used in topic selection and search string construction

Pathologic

Balancing

One-word search

Pathologic, femur, fracture

Balancing, knee, extension

Three-word search

Comment

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Random number

122

56

109

Number

3

4

5

Table 6. continued

123 Topic

A 5-year-old boy has been limping Kohler’s Disease of the on the left side for the past Tarsal Navicular 3 months. His mother says that the limp has recently worsened. Examination shows mild swelling but no erythema over the dorsum of the left foot. Radiographs are shown in Figures 43a and 43b. What is the next most appropriate step in management?

Answer - 2

5. Death from recurrent disease

Humeral

One-word search Humeral, intramedullary associated

Three-word search

Excluded. The diagnosis does not appear in the question or answer. A search for the subject cannot be undertaken without this.

Excluded. The word chordoma does not appear in the question or answer. A search for the subject cannot be undertaken without this word or an equivalent

Comment Clough and Veillette

4. Lymph node metastasis

3. Lung metastases

2. Local Recurrence

1. Disease-free survival

A 50-year-old woman reports Chordoma increasing low back pain and has trouble sitting. Sagittal and transverse MRI scans shown in Figures 22a and 22b reveal the extent of her disease. A biopsy specimen is shown in Figure 22c. What is the most likely oncologic outcome 3 years after surgical treatment?

Answer - 4

5. Greater blood loss

4. Higher need for subsequent surgeries

3. Less shoulder stiffness

2. Lower infection rates

1. Higher union rates

When comparing surgical Outcomes associated with treatments of humeral shaft IM nailing of humeral fractures, intramedullary nailing fractures is associated with which of the following when compared to plating?

OITE question and answer

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Random number

229

30

248

Number

6

7

8

Table 6. continued Topic

Complications of crosspinning supracondylar fractures of the humerus in children

Supracondylar

Peroneal

Arthroplasty

One-word search

Supracondylar, cross-pinning, complication

Peroneal, nerve recovery

Arthroplasty, hip, driving

Three-word search

Comment

Finding Orthopaedic Information on the Internet

Answer - 1

4. Loss of fixation 5. Septic arthritis of the elbow

3. Compartment syndrome

2. Iatrogenic anterior nterosseous nerve injury

1. Iatrogenic ulnar nerver injury

What is the most common complication following closed reduction and medial-lateral cross-pinning of a displaced supracondylar fracture of the humerus in a child?

5. Peroneal Answer - 5

4. Tibial

3. Radial

2. Musculocutaneous

1. Femoral

When repaired within 6 months of Peroneal nerve recovery injury, what nerve has the least capacity for motor recovery?

5. After 12 weeks Answer - 3

4. 10 to 12 weeks

3. 4 to 6 weeks

2. 2 to 3 weeks

1. After 1 week

When is it safe for most patients to Driving a vehicle after return to driving after a total hip THA arthroplasty?

5. Short leg walking cast Answer - 5

4. Bone scan

3. Oral antibiotics

2. Open biopsy

1. Immediate aspiration of the bone

OITE question and answer

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Random number

20

58

53

Number

9

10

11

Table 6. continued

123 Topic

A 5-year-old girl has knee pain, a Staging of Ewing’s sarcoma low grade fever, and a limp. A radiograph and MRI scan are shown in Figures 19a and 19b, and a biopsy specimen is shown in Figure 19c. Molecular genetic analysis identifies an EW8-FLI1 gene rearrangement. In addition to a CT scan of the chest and a bone scan, what other study is indicated for complete tumor staging?

Ilioinguinal

Compression

One-word search

Ilioinguinal, approach iliopectineal

Compression, lateral plantar

Three-word search

Excluded. The word ‘‘Ewings’’ does not occur in the text of the question or answer. A search for the subject cannot be done without this.

Comment Clough and Veillette

5. Lateral femoral cutaneous nerve Answer - 3

4. Femoral nerve

3. Iliopectineal fascia

2. Pectineus

1. Corona mortis

What anatomic structure separates Ilioinguinal approach the lateral muscular to the pelvis compartment from the medial vascular compartment in an ilioinguinal surgical approach?

Answer - 3

5. Insertional Achilles tendonitis

4. Painful heel pad syndrome

2. Plantar fibromatosis 3. Compression of the first branch of the lateral plantar nerve

1. Plantar fasciitis

A 37-year-old female marathon Compression of the runner has had heel pain for the lateral plantar nerve past 6 months. Figure 7 show a clinical photograph of the hindfoot with areas numbered 1 through 3. What is the most likely diagnosis based on maximal tenderness in the area labeled 3?

OITE question and answer

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Random number

153

138

Number

12

13

Table 6. continued Topic

Tendinosis

One-word search

Figure 59 shows the radiograph of a Salvage arthroplasty after Intertrochanteric 78-year-old community intertrochanteric fracture ambulatory man who sustained an intertrochanteric hip fracture that was treated with a sliding hip screw (screw and plate). After 4 weeks in an extended care facility, examination reveals declining function and inability to bear weight. What is the next most appropriate step in management?

Answer - 4

5. Achilles tendon debridement, calcaneal exostectomy, and flexor digitorum longus tendon transfer

4. Achilles tendon debridement, calcaneal exostectomy, and flexor hallucis longus tendon transfer

3. Achilles tendon debridement and ankle fusion

2. isolated calcaneal exostectomy

1. isolated Achilles tendon debridement

A 56-year-old man has insertional Insertional Achilles Achilles tendinosis that is tendinosis unresponsive to nonsurgical management. A lateral radiograph is shown in Figure 66. An MRI scan indicates that the central 60% of the tendon is severely compromised over the distal 3 cm. Treatment should consist of

5. Serum alkaline phosphatase Answer - 3

4. Sentinel lymph node biopsy

3. Bone marrow biopsies

2. MRI of the brain

1. Spinal tap

OITE question and answer

Intertrochanteric, fracture, arthroplasty

Tendinosis, achilles exostectomy

Three-word search

Comment

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Answer - 1

(Reprinted with permission from the American Academy of Orthopaedic Surgeons. 2008 Orthopaedic In-Training Examination. Rosemont, IL: AAOS; 2008.)

5. Revision open reduction and internal fixation with a blade plate

4. Revision open reduction and internal fixation with an intramedullary hip screw

3. Revision open reduction and internal fixation with a sliding hip screw

2. Change to nonweightbearing and repeat radiograph in 6 weeks

1. Total hip arthroplasty

Random number Number

Table 6. continued

OITE question and answer

Topic

One-word search

Three-word search

Comment

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