Dr. Sanaz Hariri acknowledged that direct-to-consumer advertising (DTCA), a phenomenon that is largely unknown outside of the United States and New Zeeland, has played an influential role in the delivery of surgical care. Dr. Hariri, with the help of hip and knee arthroplasty surgeons throughout the United States, sought to determine the influence of DTCA on surgeon and patient opinions and behavior. In particular, she was curious to learn the impact of DTCA on surgical decision making. Patients and surgeons alike recorded their opinions of and experiences with DTCA. Dr. Hariri analyzed these data and reported that over 98% of responding surgeons had experienced patients who made some reference to DTCA. Seventy-four percent of surgeons reported DTCA had a negative impact on their practice and patient interactions. Dr. Hariri reported that 77% of responding surgeons believed that DTCA confused or misinformed their patients. She also found that 52% of patient respondents recalled seeing or hearing advertisements related to hip or knee arthroplasty. She reported that people who has experience DTCA were more likely to seek multiple opinions and request a specific brand of implant. Dr. Hariri recommended that efforts focus on improving the quality and accuracy of information contained in consumer-directed advertisements. Dr. Dennis W. Burke commented on Hariri’s work stating that we are approaching a “perfect storm,” the culmination of increasing consumer demand secondary to DTCA, current cost overruns, outcomes-based reimbursement, and budget cuts. It will be interesting to see if the government allows DTCA to continue unregulated, if at all.

Dr. Raymond W. Hwang investigated the incidence of compartment syndrome in the multiply injured upper extremity. Compartment syndrome after distal radius fracture alone is uncommon and is unknown when it is associated with an ipsilateral elbow injury. Dr. Hwang believed that the risk of forearm compartment syndrome associated with an unstable, operatively treated fracture of the distal radius is higher when there is an associated unstable ipsilateral elbow injury. In order to test this hypothesis, he included all patients that sustained an unstable, operatively treated fracture of the distal radius and/or injury to the elbow (proximal radius/ulna fracture, simple elbow dislocation, elbow fracture-dislocation, distal humerus fracture) at two Level One trauma centers over a five year period were identified from a comprehensive database. He compared the incidence of compartment syndrome and acute carpal tunnel syndrome in an isolated distal radius fracture cohort and a simultaneous distal radius fracture-elbow injury cohort. Dr. Hwang found that 9 of 59 patients (15%) sustaining simultaneous ipsilateral distal radius fracture and elbow injury developed forearm compartment syndrome, compared to three of 869 patients (0.3%) with isolated unstable distal radius fractures (p <0.0001). He concluded saying that forearm compartment syndrome is a frequent complication of simultaneous unstable injuries to the elbow and distal radius. He urged the audience to maintain a high suspicion of compartment syndrome in patients with this combination of injuries. He stated that compartment measurements and prophylactic fasciotomies might be considered in some patients in whom a reliable clinical exam is not be possible due to other injuries. Dr. Rodriguez was shocked to learn that patients with both proximal and distal forearm injuries have a 50 times increased risk of developing compartment syndrome. He said that in general he was not one to quote numbers, but this was a number he would remember.

Dr. Gregory J. DeBlasi commented on the increasing popularity of the anterior retroperitoneal approach for anterior lumbar interbody fusion and stated his concern that prior abdominal surgery may increase the risk of major complication. To evaluate his hypothesis of whether history of prior intra-abdominal/ intrapelvic surgery confers an increased risk of approach related complication when undergoing anterior lumbar interbody fusion via a retroperitoneal approach, Dr. DeBlasi conducted a retrospective chart review. He examined the medical records of 104 patients who underwent an infraumbilical retroperitoneal approach to the anterior aspect of the lower lumbar spine from 2004 to 2006. Data collected included age, gender, procedure performed, levels fused, intraoperative blood loss, length of hospital stay, duration of surgery, preoperative diagnosis, blood transfused, intraoperative and postoperative complications, and resolution of complication. He reported a minimum of 1 year follow up. Dr. DeBlasi reported that 26 patients (25%) had an approach related complication, either intraoperatively (11%), during the immediate postoperative period (5%), or within 1 year of surgery (10%). He determined that there was a statistically significant increase of the probability of having a complication when there was a history of abdominal or pelvic surgery (p <.003). He also found in increased in delayed complication reporting that 19% of patients who had a history of abdominal or pelvic surgery had a late complication compared to only 4% who had not had abdominal surgery in the past (p < .007). Dr. DeBlasi concluded that the operation can be performed safely and with an acceptable complication rate with the assistance of a dedicated approach surgeon in addition to the primary spine team, and that prior abdominal or pelvic surgery puts the patients at higher risk for approach related complication. Although the utilization of an approach surgeon in a abdomen with prior surgery is generally thought to increase safety, Dr. Pellegrini commented on the potential hazards of utilizing an approach surgeon saying that this may increase the risk of intraoperative complications being that the primary surgeon would not know exactly how much of each tissue had been mobilized.