Southern orthopaedic association residents and fellows' conference abstracts, presented in conjunction with soa's fall meeting and sma's section on orthopaedic and trauma surgery.

TIBIOTALOCALCANEAL ARTHRODESIS WITH A RETROGRADE INTRAMEDULLARY NAIL: A PATIENT SERIES USING A MODIFICATION OF THE STANDARD TECHNIQUE. Matt Hammit, MD, and Thorn A. Tarquinio, MD. The University of Mississippi Medical Center, Jackson, Miss.

This is a retrospective study of retrograde intramedullary nailing for tibiotalocalcaneal arthrodesis. This study will describe the surgical approach and retrograde nailing technique used at our institution, which is a modification of the approach and technique originally described for this procedure. Our early results and complications encountered in treating patients with this potentially devastating pathology are presented as well. The preoperative diagnoses were post-traumatic avascular necrosis of the talus with resultant ankle and subtalar degenerative joint disease in 14 patients, severe neuropathic (Charcot) arthropathy in 10 patients, rheumatoid arthritis in one patient, and congenital tibial pseudarthrosis in one patient. 26 procedures were performed on 25 patients from December 1996-January 2001. Complications include one superficial wound eschar, which resolved without treatment; two deep venous thromboses; three patients with painful hardware; and one patient with a stress fracture at the proxima l interlocking screw site. There were no nonunions, amputations, infections, or wound necroses. This study will demonstrate that tibiotalocalcaneal arthrodesis with a retrograde intramedullary nail is an effective salvage procedure for patients with extensive ankle and subtalar joint disease; and that the common complication of wound necrosis can potentially be avoided by an alternative surgical exposure.

A COMPARISON OF WEAR DEBRIS INDUCED OSTEOLYSIS ALONG A CEMENTED AND CEMENTLESS INTERFACE: AN ANIMAL MODEL IN THE RABBIT. Jason A. Bergandi, MD. Pennsylvania State University Musculoskeletal Research Laboratory, Hershey, Pa.

By compromising bone structure, periprosthetic osteolysis may increase the risk of fracture and/or aseptic loosening of components leading to revision surgery. Our purpose was to develop a reproducible rabbit model of periprosthetic osteolysis and observe the effects of implant type and fixation on the latency to onset and size of the osteolytic lesions. Thirty-seven New Zealand white rabbits (71 knees) underwent knee arthrotomy and placement of cylindrical intramedullary stainless steel or polymethylmethacrylate (PMMA) implants. Each knee contained both a metallic and PMMA implant in either the femur or tibia that communicated with a common synovial space. A suspension of polyethylene particles (size [less than] 4.5 mm and concentration of 1-5 x 106 particles/ml) was injected into each knee at two-week intervals for ten weeks to induce osteolysis. Serial radiographs were taken at 4, 8, 14, 18, and 22 weeks postoperatively to document the progression of osteolysis. Statistical analysis was performed utilizing a two-tailed, unpaired t test and a Mantel-Cox test with the level of significance set a P [less than] .05. Radiographic analysis revealed that 96.9% of the stainless steel implants had evidence of osteolysis by 22 weeks compared to 22.9% of the PMMA implants. The earliest onset of lesions in the metal implant group occurred at 4 weeks compared to 14 weeks in the PMMA group. We also found the area and volume of the osteolytic lesions to be significantly larger in the metal implants when compared to the implants composed of PMMA. Onset of osteolysis around metal implants occurred in a significantly shorter period of time and more frequently when compared to implants composed of PMMA. Also, the area and volume of the osteolytic lesions around the metal implants was found to be significantly larger than those of the PMMA. We concluded that relative material effects on osteoclast induced bone resorption and differences in ease of transport of particulate debris along metallic compared to PMMA surfaces may accoun t for observed differences in frequency and severity of osteolytic lesions.

LONG TERM FOLLOW-UP FOR ANTEGRADE DRILLING FOR OSTEOCHONDRITIS DESSICANS OF THE KNEE. Rena R. Amro, MD, Wudbhav Sanakar, BS, Theodore Ganley, MD, and John Gregg, MD. The Children's Hospital of Philadelphia, The University of Pennsylvania Health System, Philadelphia, Pa.

The purpose of this study is to review the long-term results of 70 knees with osteochondritis dessicans of the femoral condyles or patella that failed a conservative program and were treated with antegrade drilling. To our knowledge, this study represents the largest reported series using this technique. Between 1986 and 2001, 66 patients had antegrade drilling of 70 lesions of the femoral condyles or patella after failing conservative treatment. Postoperative evaluation included rating by the International Knee Documentation Committee (IKDC) form for osteochondritis dessicans as well as radiographic evaluation. In this group of patients, the average age at the time of surgery was 15 years. Forty-one patients had open physes and twenty-six were skeletally mature. The average follow-up was 30 months. These lesions were drilled in 49 medial femoral condyle lesions, 9 lateral femoral condyle lesions, 7 trochlea lesions, and 9 patella lesions. According to the criteria of the IKDC form, 36 were normal, 29 nearly normal, and 5 abnormal. In the skeletally mature patients, 8 had normal results, 17 had nearly normal results, and 2 had abnormal results. In the skeletally immature population, 27 had normal results, 12 had nearly normal results and 3 had abnormal results. Lesions that were drilled in the patella or trochlea had lower scores than lesions drilled in the lateral or medical femoral condyles. In both groups, IKDC scores were lower in patients who had other surgical procedures on the knee subsequent to the drilling of the osteochondritis dessicans lesion. After failure of conservative therapy, antegrade drilling is an effective treatment for osteochondritis dessicans of the knee that occurs in skeletally immature patients. In comparison, this procedure is not as successful in skeletally mature patients. Consequently, other surgical methods should be considered for skeletally mature patients with osteochondritis dessicans lesions. Further studies need to be completed to determine alternative treatment modalities f or skeletally mature patients with osteochondritis dessicans lesions of the knee.

SUCTION INSTRUMENTATION DECREASES INTRAMEDULLARY PRESSURE AND PULMONARY EMOBLISM DURING TOTAL KNEE ARTHROPLASTY. Rena R. Amro, MD, Matthew Kelly, MD, David G. Nazarian, MD, and Robert E. Booth, MD. The Pennsylvania Hospital, The University of Pennsylvania Health System, Philadelphia, Pa.

The risk of pulmonary embolism as a grave consequence of lower extremity total joint arthroplasty is well documented. Increased intramedullary pressure created during femoral instrumentation has been positively correlated with increased marrow particle content embolization. The purpose of this two-part study is to demonstrate that the use of suction devices during femoral canal instrumentation during total knee arthroplasty decreases femoral intramedullary pressure and the amount of marrow content embolized to the pulmonary circulation. Three of six fresh frozen complete cadaveric femurs were instrumented with a standard intramedullary knee alignment guide and three femurs were instrumented with the same alignment rod, which was placed inside of a cannulated suction sleeve connected to wall suction (-22 in Hg). Intramedullary pressure was monitored with specialized transducers attached at multiple sites along the specimens. The second phase of the study included 24 patients who undenvent unilateral cemented t otal knee arthroplasty. Twelve randomly selected patients were instrumented with the standard intramedullary guide and twelve patients were instrumented with the suction adapted guide. Transesophageal echocardiography and a computerized pixel counter were used to record and quantify embolic activity intraoperatively in both groups. The average intramedullary pressures (in Torr) monitored in the cadaveric specimens were 107.8 with the standard equipment and -248.2 with the suction device. The group of 12 patients who underwent femoral preparation with the standard equipment exhibited an average of 89 embolic particles registered upon tourniquet release. The average particle count was 31 when the suction equipment was used. Postoperatively, patients in the standard group exhibited transient confusion. The knee scores were 91 in both groups and then was no notable radiographic difference at an average of 1 year follow up. Although compliance and pressures are different in the cadaver than in vivo, the intramedul lary pressures in the distal femurs were consistently reduced when using the suction device. The device also decreased thc number of embolic particles by 65% during knee arthro-plasty with no increase in operative time. This data supports the use of these devices to decrease femoral pressure and embolic matter in the pulmonary circulation.

CLINICAL OUTCOME EVALUATIONS OF AN ALTERNTIVE THROMBOEMBOLIC DISEASE PROPHYLACTIC PROTOCOL IN TOTAL JOINT REPLACEMENT. Patrick B. Leach, MD, J. Kevin Brooks, MD, Scott S. Corpe, MD, Timothy R. Young, DO, and Thomas L. Bradbury, MD. Medical College of Georgia, Section of Orthopaedic Surgery, Augusta, Ga.

Thromboembolic disease (TED) prevention conventionally uses chemical prophylaxis. Recently, we initiated a TED prophylaxis protocol including a regime of early ambulation, mechanical foot pumps, compression stockings, and enteric-coated aspirin (ECASA). The purpose of this study was to examine the clinical outcomes of this regimen and to compare these results to literature controls. One thousand-sixteen (1,016) consecutive patients who underwent primary or revision THR or TKR from 1995-1999 were treated by our prophylaxis protocol. A retrospective investigation was completed with clinical outcomes noted for fatal and non-fatal PE; DVTs, which were clinically evident as documented by duplex US and/or venography; infection; and hemorrhagic complications. The review of the patient clinical course was limited to the first six weeks postoperatively. Demographic data of the 1,016 cases (594 THR and 422 TKR) showed that THR were performed on 313 female and 256 male patients, and that TKR were performed on 281 female and 166 male patients.

Results disclosed 3 PEs (0.3%) [1 nonfatal and 2 fatal]; 11 DVTs (1.1%), and 8 deep wound infections (0.8%). There were no hemorrhagic complications. These results are comparable to published series of TED prophylaxis using coumadin or heparin derivatives as chemical prophylactics against TED. We suggest that these results support the use of the aforementioned TED prophylaxis protocol as an effective alternative to other protocols. Advantages to this protocol include low cost, ease of administration, no need for laboratory monitoring of coagulation parameters, low risk of bleeding complications and excellent patient compliance.

EVALUATION OF CALCIUM SULFATE AUGMENTATION IN PEDICLE SCREW PULLOUT TESTS. Michael T. Rohmiller, MD, Dugan Schwalm, MS, R. Chris Glattes, MD, Tarek G. Elalayli, MD, and Dan M. Spengler, MD. Vanderbilt University, Department of Orthopaedics and Rehabilitation, Nashville, Tenn.

Lumbar vertebrae implanted with pedicle screws were subjected to axial pullout tests. The force required to cause implant failure was measured and compared for three methods of fixation. To determine the strength of a new calcium sulfate cement in terms of pedicle screw augmentation. The purpose was to evaluate calcium sulfate versus polymethylmethacrylate in terms of pullout strength. PMMA was considered the gold standard in terms of strength for this experiment. Many authors have evaluated the components responsible for ultimate pullout strength of pedicle screws. In these studies, one important variable has been the screw fixation. Since pedicle screw fixation has increased in popularity over recent years, so has the need to augment difficult situations. PMMA has been established as the gold standard in terms of strength of fixation but has the potential for severe complications when applied in spine surgery. Calcium sulfate represents an alternative to PMMA since calcium sulfate lacks the exothermic react ion, is osteoconductive, and is resorbed by the body in thirty to sixty days. Lumbar vertebrae were harvested from five cadavers and implanted with pedicle screws. These screws were either placed in native bone or augmented with either calcium sulfate paste or PMMA. In those pedicles that had augmentation, the material was permitted to set for a minimum of 24 hours. Axial pullout tests were then performed using an MTS testing machine. The screws were pulled out over a distance of up to 6 mm at 0.25 mm/sec. This rate and distance assured failure in each case. The load to failure was recorded for each pedicle. Calcium sulfate augmentation improved pedicle screw pullout strength significantly when compared to native bone (P[less than].0006). This represented an average increase of 170% over the native bone. Likewise PMMA improved the pullout strength significantly over native bone (P[less than].0001) for an average increase of 205%. There were no significant differences between the calcium sulfate and PMMA augme ntations although the PMMA averaged 121% of the strength of calcium sulfate. Although PMMA is considered the gold standard in terms of bone fixation strength, its use around the spine has been limited due to concern over complications. The calcium sulfate hone paste tested in this study demonstrated similar strength to PMMA without the major risks. In addition, the calcium sulfate paste may allow for possible osteoconduction to aid in spinal fusion. Further study is needed to determine the applicability of this calcium sulfate paste in the clinical setting of spine surgery.

WOUND COMPLICATIONS USING A MODIFIED SURGICAL APPROACH TO OPEN REDUCTION OF TIBIAL PLAFOND FRACTURES. Leo Chen, MD, Kevin O'Shea, MD, and John Early, MD. UT Southwestern Medical Center, Dallas, Tex.

Fractures of the tibial plafond are often extremely difficult to manage because joint reduction must be achieved while maintaining the soft tissue envelope. The argument for closed treatment of tibial plateau fractures centers on the risk of wound complications from surgery. With an anterior longitudinal approach, wound complication rates as high as 37% have been reported. By modifying the approach for open reduction, joint visualization is improved and wound complications reduced. Between 1994 and 1999, 65 tibial plafond fractures in 64 patients underwent open reduction and internal fixation using a standard staged protocol except for modification of the surgical approach. Initially, the fractures were stabilized and reduced provisionally with an ankle spanning AO/ASIF external fixator. Once the soft tissue swelling subsided, open reconstruction of all fractures were accessed through combined medial and lateral incisions for joint reduction and internal fixation. All fractures were AO type 43, with 28 type B (2 open) and 37 types C (7 open). Sixty tibial plafond fractures in 59 patients were available for follow up. The complication rate due to the surgical wounds was 7% (5 patients) overall and 11% (4 patients) for AO type 43 C fractures. Complications included wound dehiscence (2), superficial infection (1), and deep infection (2, with one requiring surgical debridement and hardware removal). No amputations, joint infections, or free soft tissue transfers occurred due to the surgical approach. All surgical wounds healed. Historically, wound complications after immediate open reduction and internal fixation of tibial plafond fractures are well documented. However, later studies have revealed that a staged approach to these injuries can reduce the complication rates. After the soft tissues allow, open reduction has been performed with a standard anterior incision. In our study, the use of a combined medial and lateral approac h to open reduction and internal fixation of the tibial plafond is a safe alternative to the anterior approach.

LUMBAR SPINE SURGERY IN OBESE PATIENTS. Paul Fuchs, DO, Allen Goodrich, MD, and Kevin Brooks, MD. Medical College of Georgia, Section of Orthopaedic Surgery, Augusta, Ga.

Lumbar surgery in obese patients is challenging. Our experience with lumbar spine surgery in obese patients has been without any appreciable increase in peri-operative complications compared to a non-obese population. A retrospective study of 60 consecutive patients who underwent lumbar spine with a minimum of 2 years follow-up was conducted. Patients were grouped as obese versus non-obese based on obesity defined as a body mass index (kg/ht) greater than 30. Data reviewed for each group included procedure duration, estimated blood loss, length of hospital stay, complications (perioperative and late) based on matched procedures, and functional assessment. Statistical analyses included paired t tests and descriptive statistics. Of the parameters examined, estimated blood loss and operative time were significantly increased in the obese group compared to the non-obese group. There was no appreciable difference in complications or surgical outcomes between the obese and non-obese groups. The majority of informat ion regarding perioperative data and the obese patient is in the total joint arthroplasty population. The information in the spine literature regarding perioperative outcomes in obese patients undergoing lumbar spine surgery is limited and controversial. In our review, we found increased blood loss and longer operative times in the obese group; however, there was no difference in complication rates or functional outcomes between the two study groups.

PREFABRICATION OF A VASCULARIZED BONE GRAFT USING A CORAL TEMPLATE. Barry S. Callahan, MD, Thomas Dovan, MD, and Roger A. Summerlin, MD. Vanderbilt University Medical Center, Nashville, Tenn.

The purpose of this study was to investigate the potential of creating a vascularized bone graft from an inorganic template. The template used was a 3 x 5 mm cylinder of calcium phospate coral placed in a segment of silicone tubing with a 1 mm hole drilled centrally for placement of a vascular pedicle. Twenty adult Spraque-Dawley rats were divided into two groups (I & II). Each group had the template implanted in the subcutaneous inguinal region, with microsurgical insertion of the superficial epigastric artery into the central hole of the template. In group II, 0.1 cc of bone marrow aspirate was added to the matrix. A non-vascularized control group was not utilized because the main purpose of the study was to explore the potential of creating a vacularized graft. Two animals from each group were sacrificed at six, eight, ten, twelve and fourteen weeks. Gross appearance and pedicle patency were recorded prior to animal termination. All templates were embedded in paraffin, sectioned and stained with hematoxyli n and eosin. The six-week specimens from both groups demonstrated capillary ingrowth with scattered multinucleated giant cells amongst a fibrous stroma. Osteoid formation was present in Group II at eight weeks with mature trabecular bone and marrow elements at 14 weeks. Group I did not show osteoid until ten weeks, however, at 14 weeks had similar trabecular bone and morrow formation as group II. On retrieval, all pedicles had pulsatile flow to the template. This study demonstrates that a vascularized osseous graft can be prefabricated from an inorganic template without the use of any host elements. The addition of autologous bone marrow did decrease the time to osteoid formation, however it did not appear to effect the time to trabecular bone formation. Although we did not show its clinical feasibility, the ability to create a vascularized bone graft has many clinical applications and would help avoid donor site morbidity commonly associated with these types of autografts.

VASCULARIZED FIBULAR GRAFTS FOR MASSIVE SEGMENTAL BONE LOSS IN THE FOREARM. Thomas T. Dovan, MD, and Douglas R. Weikert. Vanderbilt University Medical Center, Nashville, Tenn.

Massive segmental bony defects of the forearm are a challenging problem with long term outcomes typically associated with multiple complications and functional loss. Treatment options include amputation, creation of a one-bone forearm or reconstruction. Reconstruction can be accomplished with vascularized or non-vascularized grafts. Avascular cortical grafts have prolonged healing times secondary to creeping substitution. In addition, there is a greater risk of infection when placed in a relatively avascular bed. Vascularized grafts maintain their size and structure and have the ability to hypertrophy and remodel under stress. Since they are biologic, they do not require resorption prior to incorporation and are more resistant to the potentially poor conditions of the recipient bed. This study is a retrospective review of six cases involving massive ([greater than]6cm) segmental defects of forearm reconstructed with a vascularized diaphyseal fibular autograft. Six patients were treated for diaphyseal segmenta l bone defects in the radius or ulna. The average follow up was 13 months (4-21 months). There were three males and three females, ages ranging from 32-41 years old. All defects were diaphyseal (4 radius, 2 ulna) ranging in size from 9-14 cm. Five patients had primary compression plating of an associated radius or ulna fracture; one was converted to a one-bone forearm. There were four defects secondary to blunt trauma or osteomyelitis, one from a GSW, and one from a pathologic fracture. The fibula was harvested with its periosteal blood supply and the peroneal artery and vein. The donor vessels were the radial artery in five and the ulnar artery in one. The graft was secured with plate fixation. All patients were immobilized postoperatively. Osseous union was confirmed radiographically in all patients. The average time to union was 7.5 months ranging from 4-12 months. There was one fixation failure requiring conversion from simple screw fixation to plate fixation and one infected donor site requiring local wo und care. For patients with a two-bone forearm, pronation averaged 68[degrees] (20-90) and supination averaged 44[degrees] (20-90). All patients were satisfied with their results postoperatively despite having some residual functional limitations. The development of microsurgical techniques has allowed the use of vascularized bone in the management of massive skeletal defects. Vascularized fibular grafts are biomechanically, biologically and anatomically suited for management of massive segmental defects in the forearm. Bony union of the graft allows for the preservation of forearm rotation thus improving functional outcomes and patient satisfaction.

CHANGES IN CAROTID ARTERY BLOOD FLOW DURING ANTERIOR CERVICAL SPINE SURGERY. Matthew E. Pollard, MD, and Tricia Little, MEd. Department of Orthopaedics & Vascular Lab, Atlanta Medical Center, Atlanta, Ga.

Adequate surgical exposure for Anterior Cervical Discectomy and Fusion (ACDF) necessitates prolonged retraction of the carotid artery. The perioperative effects of retraction on carotid artery flow dynamics. Carotid artery blood flow was measured in 15 patients undergoing anterior cervical spine surgery. Duplex ultrasonic measurements of common carotid artery flow velocity were made in 15 patients undergoing ACDF. Measurements were recorded preoperatively, intra-operatively after exposure was obtained and self-retaining retractors placed, intra-operatively at the end of the procedure just prior to release of retraction, postoperatively in the recovery room, and on postoperative day one. Using flow velocity data, the changes in cross sectional area were calculated at each time interval and expressed as a percentage change in area from baseline measurements. The parameters of patient age, pre-existing atherosclerotic vascular disease, and prolonged intra-operative retraction were analyzed to determine if they w ere associated with the observed changes. Vessel cross sectional area decreased an average of 14% with the initial placement of self-retaining retractors, and further decreased to 70% of baseline by the end of the case. Flow remained laminar at all times and flow velocities returned to normal in the recovery room. These changes were more pronounced in the younger patients studied, but were unrelated to mild pre-existing atherosclerotic vascular disease or prolonged retraction. Intra-operative retraction during anterior cervical spine surgery alters common carotid artery flow dynamics by causing a significant reduction in vessel cromss sectional area. These changes are most pronounced in young patients. Atherosclerotic disease is a common finding in patients being evaluated for ACDF.

THE NATURAL HISTORY OF HIP DISLOCATION IN PATIENTS WITH SPINAL MUSCULAR ATROPHY. Scott M. Sporer, MD. Dartmouth Hitchcock Medical Center, Lebanon, NH.

The purpose of this study was to follow a cohort of patients with a diagnosis of type II (independent sitting) or type III (independent standing) spinal muscular atrophy. The natural history of hip disclocation as well as the incidence of pain and functional difficulties (positioning, skin and perineal care) was determined. In addition, the effect of scoliosis and pelvic obliquity on the timing of hip migration was evaluated in both patient groups. Database retrieval of patients diagnosed with Spinal Muscular Atrophy types II and III at Connecticut Children's Medical Center between 1934 and 1998 were included in the study. A minimum of two year follow-up was required. The prevalence of hip dislocation or subluxation was determined utilizing retrospective serial radiographic review. Hips were graded radiographically using Reimer's index of coverage: normal ([less than] 25% uncovered), subluxed (25-75% uncovered) and dislocated ([greater than] 75% uncovered). Pain as well as functional limitations were assessed via phone or by clinical questionnaire. 41 patients (82 hips) with spinal muscular atrophy (24 patients with Type II and 17 patients with Type III) with a mean age at follow up of 18.2 years (range 2-62 years) were identified. 15 hips in 12 type II patients were dislocated; an additional 15 hips in eight additional patients were subluxed. 21 patients had significant (greater than 1 cm) pelvic obliguity. Two of the 25 patients experienced hip pain, one patient had difficulty with seating and no patients had difficulty with perineal care. Two hips in the type III patients were dislocated, 5 hips were subluxed, and five of the patients had significant pelvic obliguity. None of the 17 patients experienced hip pain, had difficulty with seating, or had problems with perineal care. Hip subluxation and/or dislocation with associated pelvic obliquity is very prevalent in patients with type II spinal muscular atrophy, while it is much less common in the ambulatory type III patients. Despite the presence of hip disloca tion, patients will seldom have associated pain or functional problems. Hip dislocation in type II patients tends to occur at an early age and is frequently accompanied by the temporal relationship of pelvic obliquity.

THE INTERNET AS A COMMUNICATION TOOL FOR U.S. ACADEMIC ORTHOPAEDIC SURGERY DEPARTMENTS. Tamara D. Rozental, MD, Jess H. Lonner, MD, and Selene G. Parekh, MD, MBA. Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, Pa; Wharton Business School, Small Business Development Center, University of Pennsylvania, Philadelphia, Pa.

The Internet's appeal as an affordable, accessible medium for information transfer makes it a potentially useful tool for practicing physicians. In the past several years, Internet-based healthcare companies have proliferated and many medical centers have established individual web sites. The purpose of this study was to evaluate U. S. academic orthopaedic surgery departments with respect to Internet visibility and content. We reviewed existing web sites for the 154 departments or divisions of orthopaedic surgery currently accredited for resident education by the Accreditation Council for Graduate Medical Education. Each web site was assessed for its informational value in the categories of clinical services, resident education and physician recruitment. In addition, three commonly employed browsing engines were used to search for individual web sites and determine their ease of accessibility. In the category of clinical services, 65 sites (57.5%) provided faculty listings and 49 (43.4%) provided office telep hone numbers and locations. Only 13 sites provided information on common orthopaedic conditions and five had links to other patient education sites. In the category of resident education, 24 sites (21.2%) had online academic schedules but only two (1.7%) provided access to complete conferences or teaching files. In the category of physician recruitment, 91 provided a description of their residency program and 54 had information on the application process, but only 26 (23%) web pages offered detailed departmental statistics. In terms of accessibility, 53 (46.9%) programs were identified by one of three popular search engines, 17 (15%) were identified by more than one search engine and two (1.7%) were identified by all three. The Internet is severely underutilized by U. S. academic orthopaedic surgery departments as a source of clinical and educational services. In addition, existing orthopaedic web sites are difficult to access using popular search engines. U.S. academic orthopaedic surgery departments are thu s missing a valuable opportunity to promote awareness of their institution and become an educational resource for the community.