Orthopedics Commons^™

Risk Factors For Wound Complications After Ankle Fracture Surgery., Adam G Miller, Andrew Margules, Steven M Raikin

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: The overall rate of complications after ankle fracture fixation varies between 5% and 40% depending on the population investigated, and wound complications have been reported to occur in 1.4% to 18.8% of patients. Large studies have focused on complications in terms of readmission, but few studies have examined risk factors for wound-related issues in the outpatient setting in a large number of patients. A review was performed to identify risk factors for wound complications tracked in the hospital and outpatient setting.

METHODS: Four hundred and seventy-eight patients underwent open reduction and internal fixation of an ankle fracture between 2003 …

Ulnar Tunnel Syndrome., Abdo Bachoura, Sidney M Jacoby

Department of Orthopaedic Surgery Faculty Papers

Ulnar tunnel syndrome could be broadly defined as a compressive neuropathy of the ulnar nerve at the level of the wrist. The ulnar tunnel, or Guyon's canal, has a complex and variable anatomy. Various factors may precipitate the onset of ulnar tunnel syndrome. Patient presentation depends on the anatomic zone of ulnar nerve compression: zone I compression, motor and sensory signs and symptoms; zone II compression, isolated motor deficits; and zone III compression; purely sensory deficits. Conservative treatment such as activity modification may be helpful, but often, surgical exploration of the ulnar tunnel with subsequent ulnar nerve decompression is indicated.

Low Rate Of Infection Control In Enterococcal Periprosthetic Joint Infections., Mohammad R Rasouli, Mohan S Tripathi, Robert Kenyon, Nathan Wetters, Craig J Della Valle, Javad Parvizi

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: Enterococcal periprosthetic joint infections (PJIs) are rare after joint arthroplasty. These cases are usually reported in series of PJIs caused by other pathogens. Because few studies have focused only on enterococcal PJIs, management and control of infection of these cases have not yet been well defined.

QUESTIONS/PURPOSES: We asked (1) what is the proportion of enterococcal PJI in our institutes; and (2) what is the rate of infection control in these cases?

METHODS: We respectively identified 22 and 14 joints with monomicrobial and polymicrobial PJI, respectively, caused by enterococcus. The diagnosis of PJI was made based on the presence …

A Prospective Analysis Of Glove Perforation In Primary And Revision Total Hip And Total Knee Arthroplasty., Aaron H Carter, Md, David S Casper, Md, Javad Parvizi, Md, Mathew Austin, Md

Department of Orthopaedic Surgery Faculty Papers

Literature in regard to glove perforation rates in revision total joint arthroplasty (TJA) is scarce. Our purpose was to determine the incidence of perforation in revision TJA. Gloves from all scrubbed personnel were tested based on the American Society for Testing and Materials. A total of 3863 gloves were collected from 58 primary and 36 revision arthroplasty cases. Surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time. …

The Impact Of Epidural Steroid Injections On The Outcomes Of Patients Treated For Lumbar Disc Herniation: A Subgroup Analysis Of The Sport Trial., Kristen Radcliff, Alan Hilibrand, Jon D Lurie, Tor D Tosteson, Lawrence Delasotta, Jeffrey Rihn, Wenyan Zhao, Alexander Vaccaro, Todd J Albert, James N Weinstein

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: The Spine Patient Outcomes Research Trial (SPORT) is a prospective, multicenter study of operative versus nonoperative treatment of lumbar intervertebral disc herniation. It has been suggested that epidural steroid injections may help improve patient outcomes and lower the rate of crossover to surgical treatment.

METHODS: One hundred and fifty-four patients included in the intervertebral disc herniation arm of the SPORT who had received an epidural steroid injection during the first three months of the study and no injection prior to the study (the ESI group) were compared with 453 patients who had not received an injection during the first …

Does The Load-Sharing Classification Predict Ligamentous Injury, Neurological Injury, And The Need For Surgery In Patients With Thoracolumbar Burst Fractures?: Clinical Article., Kristen Radcliff, Christopher K Kepler, Todd A Rubin, Motasem Maaieh, Alan S Hilibrand, James Harrop, Jeffrey A Rihn, Todd J Albert, Alexander R Vaccaro

Department of Orthopaedic Surgery Faculty Papers

OBJECT: The load-sharing score (LSS) of vertebral body comminution is predictive of results after short-segment posterior instrumentation of thoracolumbar burst fractures. Some authors have posited that an LSS > 6 is predictive of neurological injury, ligamentous injury, and the need for surgical intervention. However, the authors of the present study hypothesized that the LSS does not predict ligamentous or neurological injury.

METHODS: The prospectively collected spinal cord injury database from a single institution was queried for thoracolumbar burst fractures. Study inclusion criteria were acute (< 24 hours) burst fractures between T-10 and L-2 with preoperative CT and MRI. Flexion-distraction injuries and pathological fractures were excluded. Four experienced spine surgeons determined the LSS and posterior ligamentous complex (PLC) integrity. Neurological status was assessed from a review of the medical records.

RESULTS: Forty-four patients were included in the study. There were 4 patients for whom all observers …

Minimal Invasive Decompression For Lumbar Spinal Stenosis., Victor Popov, David G Anderson

Department of Orthopaedic Surgery Faculty Papers

Lumbar spinal stenosis is a common condition in elderly patients and may lead to progressive back and leg pain, muscular weakness, sensory disturbance, and/or problems with ambulation. Multiple studies suggest that surgical decompression is an effective therapy for patients with symptomatic lumbar stenosis. Although traditional lumbar decompression is a time-honored procedure, minimally invasive procedures are now available which can achieve the goals of decompression with less bleeding, smaller incisions, and quicker patient recovery. This paper will review the technique of performing ipsilateral and bilateral decompressions using a tubular retractor system and microscope.

Minimal Invasive Decompression For Lumbar Spinal Stenosis., Victor Popov, David G Anderson

Department of Orthopaedic Surgery Faculty Papers

Lumbar spinal stenosis is a common condition in elderly patients and may lead to progressive back and leg pain, muscular weakness, sensory disturbance, and/or problems with ambulation. Multiple studies suggest that surgical decompression is an effective therapy for patients with symptomatic lumbar stenosis. Although traditional lumbar decompression is a time-honored procedure, minimally invasive procedures are now available which can achieve the goals of decompression with less bleeding, smaller incisions, and quicker patient recovery. This paper will review the technique of performing ipsilateral and bilateral decompressions using a tubular retractor system and microscope.

Early Versus Delayed Decompression For Traumatic Cervical Spinal Cord Injury: Results Of The Surgical Timing In Acute Spinal Cord Injury Study (Stascis)., Michael G Fehlings, Alex R. Vaccaro, Jefferson R Wilson, Anoushka Singh, David W Cadotte, James Harrop, Bizhan Aarabi, Christopher Shaffrey, Marcel Dvorak, Charles Fisher, Paul Arnold, Eric M Massicotte, Stephen Lewis, Raja Rampersaud

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: There is convincing preclinical evidence that early decompression in the setting of spinal cord injury (SCI) improves neurologic outcomes. However, the effect of early surgical decompression in patients with acute SCI remains uncertain. Our objective was to evaluate the relative effectiveness of early (injury) versus late (≥ 24 hours after injury) decompressive surgery after traumatic cervical SCI.

METHODS: We performed a multicenter, international, prospective cohort study (Surgical Timing In Acute Spinal Cord Injury Study: STASCIS) in adults aged 16-80 with cervical SCI. Enrolment occurred between 2002 and 2009 at 6 North American centers. The primary outcome was ordinal change …

Molecular Diagnostics In Periprosthetic Joint Infection., Javad Parvizi, Lesley Walinchus, Bahar Adeli

Department of Orthopaedic Surgery Faculty Papers

Periprosthetic joint infection (PJI) is a significant and costly challenge to the orthopedic community. The lack of a gold standard for diagnosis remains the biggest obstacle in the detection and subsequent treatment of PJI. Molecular markers in the serum and joint fluid aspirate hold immense promise to enhance the development of a firm diagnostic criterion. The primary goal is one marker with high sensitivity and specificity. Here, we review our current research efforts in the field of molecular markers: C-reactive protein, erythrocyte sedimentation rate, white blood cells, and leukocyte esterase. Each marker has been studied to determine its sensitivity, specificity, …

An Organ Culture System To Model Early Degenerative Changes Of The Intervertebral Disc., Ravi K Ponnappan, Dessislava Z Markova, Paul Jd Antonio, Hallie B Murray, Alexander R Vaccaro, Irving M Shapiro, D Greg Anderson, Todd J Albert, Makarand V Risbud

Department of Orthopaedic Surgery Faculty Papers

ABSTRACT: INTRODUCTION: Back pain, a significant source of morbidity in our society, is related to the degenerative changes of the intervertebral disc. At present, the treatment of disc disease consists of therapies that are aimed at symptomatic relief. This shortcoming stems in large part from our lack of understanding of the biochemical and molecular events that drive the disease process. The goal of this study is to develop a model of early disc degeneration using an organ culture. This approach is based on our previous studies that indicate that organ culture closely models molecular events that occur in vivo in …

Duration Of Symptoms Resulting From Lumbar Disc Herniation: Effect On Treatment Outcomes: Analysis Of The Spine Patient Outcomes Research Trial (Sport)., Jeffrey A Rihn, Alan S Hilibrand, Kristen Radcliff, Mark Kurd, Jon Lurie, Emily Blood, Todd J Albert, James N Weinstein

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: The purpose of the present study was to determine if the duration of symptoms affects outcomes following the treatment of intervertebral lumbar disc herniation.

METHODS: An as-treated analysis was performed on patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) for the treatment of intervertebral lumbar disc herniation. Randomized and observational cohorts were combined. A comparison was made between patients who had had symptoms for six months or less (n = 927) and those who had had symptoms for more than six months (n = 265). Primary and secondary outcomes were measured at baseline and at regular follow-up …

Femoroacetabular Impingement: Saving The Joint, Ronald Huang, Javad Parvizi

Department of Orthopaedic Surgery Faculty Papers

Many factors have been linked to the development of osteoarthritis (OA) of the hip, but often, cases are still considered “idiopathic.” Femoroacetabular impingement (FAI) has been suggested as a possible etiologic factor for the otherwise “idiopathic” cases. It is theorized that the subtle morphologic abnormalities seen at the head-neck junction and acetabulum in FAI may lead to labral tears, chondral damage, and subsequent progression of OA. Prevalence of FAI has been suggested to be as high as 14% in the general population. It often presents in young active patients that subject their hip joint to repetitive micro trauma associated with …

Potent Inhibition Of Heterotopic Ossification By Nuclear Retinoic Acid Receptor-Γ Agonists., Kengo Shimono, Wei-En Tung, Christine Macolino, Amber Hsu-Tsai Chi, Johanna H Didizian, Christina Mundy, Roshantha A Chandraratna, Yuji Mishina, Motomi Enomoto-Iwamoto, Maurizio Pacifici, Masahiro Iwamoto

Department of Orthopaedic Surgery Faculty Papers

Heterotopic ossification consists of ectopic bone formation within soft tissues after surgery or trauma. It can have debilitating consequences, but there is no definitive cure. Here we show that heterotopic ossification was essentially prevented in mice receiving a nuclear retinoic acid receptor-γ (RAR-γ) agonist. Side effects were minimal, and there was no significant rebound effect. To uncover the mechanisms of these responses, we treated mouse mesenchymal stem cells with an RAR-γ agonist and transplanted them into nude mice. Whereas control cells formed ectopic bone masses, cells that had been pretreated with the RAR-γ agonist did not, suggesting that they had …

Neurologic Improvement After Thoracic, Thoracolumbar, And Lumbar Spinal Cord (Conus Medullaris) Injuries, James S. Harrop, Md, Swetha Naroji, Mitchell G. Maltenfort, Phd, John K. Ratliff, Md, Stavropoula L. Tjoumakaris, Brian Frank, D. Greg Anderson, M.D., Todd Albert, Md, Alexander R. Vaccaro, Md, Phd

Department of Orthopaedic Surgery Faculty Papers

Study Design. Retrospective. Objective. With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord.

Summary of Background Data. Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients …

The Infected Hip: A Treatment Algorithm, Bahar Adeli, Javad Parvizi Md

Department of Orthopaedic Surgery Faculty Papers

The management of periprosthetic joint infection following total joint arthroplasty is presently a major challenge to orthopedic surgeons. Despite various treatment options available, the two-stage revision procedure is most often chosen in North America because of a high success rate, especially in cases involving resistant organisms. Sometimes the use of antibiotics alone, irrigation with debridement, or a one-stage exchange may be a more appropriate treatment option. Various factors such as the status of a patient’s immune system, time of onset of the infection, as well as susceptibility of causative microorganism should be considered as they play an important role in …

Limitations Of The Knee Society Score In Evaluating Outcomes Following Revision Total Knee Arthroplasty., Elie Ghanem, Ian Pawasarat, Adam Lindsay, Lauren May, Khalid Azzam, Ashish Joshi, Javad Parvizi

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: Traditionally, the results of revision total knee arthroplasty have been determined with use of surgeon-based measures such as the Knee Society rating system. Recently, outcome and quality-of-life measures have shifted toward a greater emphasis on patient-based evaluation. The aim of our study was to determine the validity and responsiveness of the Knee Society rating system compared with the Short Form-36 health survey (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a four-question 4-point Likert scale satisfaction questionnaire following revision total knee arthroplasty.

METHODS: A total of 152 patients underwent revision total knee arthroplasty at our institution, between …

Use Of Orthogonal Or Parallel Plating Techniques To Treat Distal Humerus Fractures., Joshua M. Abzug, Phani K. Dantuluri

Department of Orthopaedic Surgery Faculty Papers

Distal humerus fractures continue to be a complex fracture to treat. This article describes two surgical techniques that can be used to tackle these difficult fractures: Parallel plating and orthogonal plating. Both techniques have yielded excellent outcomes after open reduction and internal fixation; yet each has its own set of unique considerations. However, the key to successful treatment of these difficult fractures regardless of technique remains obtaining anatomic reduction with stable fixation and the implementation of early motion.

Current Concepts: Neonatal Brachial Plexus Pals, Joshua M. Abzug, Md, Scott H. Kozin, Md

Department of Orthopaedic Surgery Faculty Papers

Neonatal brachial plexus palsy may be decreasing in incidence; however, conflicting reports exist. Regardless, neonatal brachial plexus palsy has an incidence of 1 to 2 per 1000 live births making this a frequent occurrence. The majority of infants with brachial plexus palsy spontaneously recover in the first 2 months of life and subsequently progress to near complete recovery of motion and strength. However, those infants who do not have substantial recovery by age 3 months will have permanent limited range of motion, less strength, and a decrease in size and girth of the involved extremity. Currently, debate continues about the …

Correlation Of C2 Fractures And Vertebral Artery Injury., Tao Ding, Mitchell Maltenfort, Huilin Yang, Harvey Smith, John Ratliff, Alexander Vaccaro, D Greg Anderson, James Harrop

Department of Orthopaedic Surgery Faculty Papers

STUDY DESIGN: Retrospective review of prospectively collected data.

SUMMARY OF BACKGROUND DATA: Vertebral artery injuries (VAI) occur commonly after cervical spine trauma. No study has yet examined the association between VAI and specific variants of C2 fractures.

OBJECTIVE: To evaluate the incidence of VAI (as defined by magnetic resonance imaging/angiography [MRI/A]) in subtypes of C2 fractures. To define the association between the incidence, morphology, and severity of C2 fractures, based on fracture angulation and comminution, and the occurrence of VAI.

METHODS: Patients admitted to the hospital with C2 fractures between October 2006 and December 2008 to a tertiary care referral …

Acellular Dermal Regeneration Template For Soft Tissue Reconstruction Of The Digits., John S. Taras, Anthony Sapienza, Josh B. Roach, John P. Taras

Department of Orthopaedic Surgery Faculty Papers

PURPOSE: Trauma to the digits often leaves soft tissue defects with exposed bone, joint, and/or tendon that require soft tissue replacement. The objective of this study was to evaluate the effectiveness of acellular dermal regeneration template combined with full-thickness skin grafting for soft tissue reconstruction in digital injuries with soft tissue defects.

METHODS: Acellular dermal regeneration template was used to reconstruct digital injuries with exposed bone, joint, tendon, and/or hardware not amenable to treatment with healing by secondary intention, rotation flaps, or primary skin grafts. Acellular dermal regeneration template was applied to 21 digits in 17 patients. Nineteen digits had …

Mast Cells And Hypoxia Drive Tissue Metaplasia And Heterotopic Ossification In Idiopathic Arthrofibrosis After Total Knee Arthroplasty., Theresa A Freeman, Javad Parvizi, Craig J Dela Valle, Marla J Steinbeck

Department of Orthopaedic Surgery Faculty Papers

ABSTRACT: BACKGROUND: Idiopathic arthrofibrosis occurs in 3-4% of patients who undergo total knee arthroplasty (TKA). However, little is known about the cellular or molecular changes involved in the onset or progression of this condition. To classify the histomorphologic changes and evaluate potential contributing factors, periarticular tissues from the knees of patients with arthrofibrosis were analyzed for fibroblast and mast cell proliferation, heterotopic ossification, cellular apoptosis, hypoxia and oxidative stress. RESULTS: The arthrofibrotic tissue was composed of dense fibroblastic regions, with limited vascularity along the outer edges. Within the fibrotic regions, elevated numbers of chymase/fibroblast growth factor (FGF)-expressing mast cells were …

Reactive Oxygen And Nitrogen Species Induce Protein And Dna Modifications Driving Arthrofibrosis Following Total Knee Arthroplasty., Theresa A Freeman, Javad Parvizi, Craig J Della Valle, Marla J Steinbeck

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: Arthrofibrosis, occurring in 3%-4% of patients following total knee arthroplasty (TKA), is a challenging condition for which there is no defined cause. The hypothesis for this study was that disregulated production of reactive oxygen species (ROS) and nitrogen species (RNS) mediates matrix protein and DNA modifications, which result in excessive fibroblastic proliferation.

RESULTS: We found increased numbers of macrophages and lymphocytes, along with elevated amounts of myeloperoxidase (MPO) in arthrofibrotic tissues when compared to control tissues. MPO expression, an enzyme that generates ROS/RNS, is usually limited to neutrophils and some macrophages, but was found by immunohistochemistry to be expressed …

The Otto Aufranc Award Identification Of A 4 Mb Region On Chromosome 17q21 Linked To Developmental Dysplasia Of The Hip In One 18-Member, Multigeneration Family, George Feldman, Chelsea Dalsey, Kasia Fertala, David Azimi, Paolo Fortina, Marcella Devoto, Maurizio Pacifici, Javad Parvizi

Department of Orthopaedic Surgery Faculty Papers

Developmental dysplasia of the hip (DDH) is a disabling condition of the hip that, depending on geography, can afflict between 20-80% of patients with end-stage arthritis of the hip. Despite its prevalence, the etiology of this disease remains unknown. DDH is a complex disorder with both environmental and genetic causes.. Based on the literature, the candidate genes for the disease are HOXB9, collagen type I α1, and DLX 3. The purpose of our study was to map and characterize the gene or genes responsible for this disorder by family linkage analysis. We recruited one 18-member, multigeneration affected family to provide …

Shoulder Arthroscopy Positioning: Lateral Decubitus Versus Beach Chair., Christina M. Peruto, Md, Michael G. Ciccotti, Md, Steven B. Cohen, Md

Department of Orthopaedic Surgery Faculty Papers

Since the introduction of the beach chair position for shoulder arthroscopy, orthopaedic surgeons have debated whether the beach chair or lateral decubitus is superior. Most surgeons use the same patient position to perform all of their arthroscopic shoulder procedures, regardless of the pathology. Each position has its advantages and disadvantages. The evidence regarding the efficiency, efficacy, and risks of the lateral decubitus and the beach chair positions for shoulder arthroscopy does not show one position to be superior. This review presents a comparison of these positions with regard to setup, surgical visualization, access, and patient risk.

Reactive Oxygen And Nitrogen Species Induce Protein And Dna Modifications Driving Arthrofibrosis Following Total Knee Arthroplasty., Theresa A Freeman, Javad Parvizi, Craig J Della Valle, Marla J Steinbeck

Department of Orthopaedic Surgery Faculty Papers

BACKGROUND: Arthrofibrosis, occurring in 3%-4% of patients following total knee arthroplasty (TKA), is a challenging condition for which there is no defined cause. The hypothesis for this study was that disregulated production of reactive oxygen species (ROS) and nitrogen species (RNS) mediates matrix protein and DNA modifications, which result in excessive fibroblastic proliferation. RESULTS: We found increased numbers of macrophages and lymphocytes, along with elevated amounts of myeloperoxidase (MPO) in arthrofibrotic tissues when compared to control tissues. MPO expression, an enzyme that generates ROS/RNS, is usually limited to neutrophils and some macrophages, but was found by immunohistochemistry to be expressed …

Isolated Polyethylene Exchange Versus Acetabular Revision For Polyethylene Wear, Camilo Restrepo, Elie Ghanem, Carrie Houssock, Mathew Austin, Javad Parvizi, William J. Hozack

Department of Orthopaedic Surgery Faculty Papers

Polyethylene wear and osteolysis are not uncommon in THA mid- and long-term. In asymptomatic patients the dilemma faced by the orthopaedic surgeon is whether to revise the cup and risk damage to the supporting columns and even pelvic discontinuity or to perform isolated polyethylene exchange and risk a high rate of postoperative recurrent instability and dislocation that will necessitate further surgery. We retrospectively reviewed 62 patients (67 hips) who underwent revision arthroplasty for polywear and osteolysis. Thirty-six hips had isolated polyethylene exchange, while 31 had full acetabular revision. The minimum followup was 2 years (mean, 2.8 years; range, 2-5 years). …

An Approach To The Failed Ankle Arthrodesis, Steven M. Raikin, Venkat Rampuri

Department of Orthopaedic Surgery Faculty Papers

Ankle arthrodesis remains the gold standard of surgical treatment for advanced ankle joint arthritis. Failure can occur as a result of infection, nonunion or malunion, resulting in pain and poor function. This paper offers a systematic approach to preventing, and managing these problems should they occur. Revision arthrodesis performed with a detailed understanding of the appropriate alignment and mechanics of the ankle joint, combined with meticulous attention to understanding and reversing the cause of the failure can result in successful salvage and restoration of function.

Hemorrhage Into An Occult Spinal Ependymoma After Epidural Anesthesia, Peter G. Campbell, John K. Birknes, Ashwini D. Sharan, James S. Harrop, Alexander R. Vaccaro, John K. Ratliff

Department of Orthopaedic Surgery Faculty Papers

Summary of Background Data: Five cases of hemorrhage into a spinal neoplasm after spinal or epidural anesthesia are reported in the literature. Presentation ranges from severe low back pain to acute cauda equina syndrome.

Methods: A case study of a patient who hemorrhaged into an intradural, extramedullary spinal cord mass was performed. A detailed literature review is also provided.

Results: A 27 year old female underwent epidural anesthesia for Cesarean section delivery. She presented with a 3 week history of increasing low back pain with bilateral radiculopathy. Imaging studies revealed a large hemorrhagic intradural mass compressing the lower conus medullaris …

Anthony Frederick Depalma, Md: Educator, Researcher And Clinical Care Doctor., Phillip J. Marone

Department of Orthopaedic Surgery Faculty Papers

My first meeting with Dr. DePalma was in 1957 as an intern in his office on the 6th floor of the Curtis Clinic. He and I spoke for a while about the residency and he looked at me and said “you know you are going to be 33 years old before you make a plug nickel.” I replied, “well I don’t make any money now, so what is the difference?” He laughed and I got the residency. In the next two years, I spent many hours in the operating room with Dr. DePalma and learned quickly how skilled a surgeon …