Is Grit Associated with Burnout and Well-being in Orthopaedic Resident and Faculty Physicians? A Multi-institution Longitudinal Study Across Training Levels.

BACKGROUND: Grit has been defined as "perseverance and passion for long-term goals" and is characterized by maintaining focus and motivation toward a challenging ambition despite setbacks. There are limited data on the impact of grit on burnout and psychologic well-being in orthopaedic surgery, as well as on which factors may be associated with these variables. QUESTIONS/PURPOSES: (1) Is grit inversely correlated with burnout in orthopaedic resident and faculty physicians? (2) Is grit positively correlated with psychologic well-being in orthopaedic resident and faculty physicians? (3) Which demographic characteristics are associated with grit in orthopaedic resident and faculty physicians? (4) Which demographic characteristics are associated with burnout and psychologic well-being in orthopaedic resident and faculty physicians? METHODS: This study was an institutional review board-approved interim analysis from the first year of a 5-year longitudinal study of grit, burnout, and psychologic well-being in order to assess baseline relationships between these variables before analyzing how they may change over time. Orthopaedic residents, fellows, and faculty from 14 academic medical centers were enrolled, and 30% (335 of 1129) responded. We analyzed for the potential of response bias and found no important differences between sites in low versus high response rates, nor between early and late responders. Participants completed an email-based survey consisting of the Duckworth Short Grit Scale, Maslach Burnout Inventory-Human Services (Medical Personnel) Survey, and Dupuy Psychological Well-being Index. The Short Grit Scale has been validated with regard to internal consistency, consensual and predictive validity, and test-retest stability. The Psychological Well-being Index has similarly been validated with regard to reliability, test-retest stability, and internal consistency, and the Maslach Burnout Inventory has been validated with regard to internal consistency, reliability, test-retest stability, and convergent validity. The survey also obtained basic demographic information such as survey participants' age, gender, race, ethnicity, marital status, current year of training or year in practice (as applicable), and region of practice. The studied population consisted of 166 faculty, 150 residents, and 19 fellows. Beyond the expected age differences between sub-populations, the fellow population had a higher proportion of women than the faculty and resident populations did. Pearson correlations and standardized ß coefficients were used to assess the relationships of grit, burnout, psychologic well-being, and continuous participant characteristics. RESULTS: We found moderate, negative relationships between grit and emotional exhaustion (r = -0.30; 95% CI -0.38 to -0.21; p < 0.001), depersonalization (r = -0.34; 95% CI -0.44 to -0.23; p < 0.001), and the overall burnout score (r = -0.39; 95% CI -0.48 to -0.31; p < 0.001). The results also showed a positive correlation between grit and personal accomplishment (r = 0.39; 95% CI 0.29 to 0.48; p < 0.001). We also found a moderate, positive relationship between grit and psychologic well-being (r = 0.39; 95% CI 0.30 to 0.49; p < 0.001). Orthopaedic surgeons with 21 years or more of practice had higher grit scores than physicians with 10 to 20 years of practice. Orthopaedic surgeons in practice for 21 years or more also had lower burnout scores than those in practice for 10 to 20 years. Married physicians had higher psychologic well-being than unmarried physicians did. CONCLUSION: Among orthopaedic residents, fellows, and faculty, grit is inversely related to burnout, with lower scores for emotional exhaustion and depersonalization and higher scores for personal accomplishment as grit increases. CLINICAL RELEVANCE: The results suggest that grit could be targeted as an intervention for reducing burnout and promoting psychologic well-being among orthopaedic surgeons. Other research has suggested that grit is influenced by internal characteristics, life experiences, and the external environment, suggesting that there is potential to increase one's grit. Residency programs and faculty development initiatives might consider measuring grit to assess for the risk of burnout, as well as offering curricula or training to promote this psychologic characteristic.

Erratum to: Editorial: Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games?

In the November Editorial, "Editorial: Do Orthopaedic Surgeons Belong on the Sidelines at American Football Games?" a statistic was attributed to a JAMA study (Ref. 10) that should have been attributed to an article from the New York Times (Ref. 16). The sentence in question should read: "We accept that critique, provided that the skeptics acknowledge that the best-case estimate in support of the safety of football would result in a CTE prevalence estimate of 9%, since only another 1200 ex-NFL players have died [16] since this research group [10] began studying football players' brains."

Outcomes After Distal Radius Fracture Treatment With Percutaneous Wire Versus Plate Fixation: Meta-Analysis of Randomized Controlled Trials.

Multiple methods for surgical fixation of distal radius fractures exist, including percutaneous pinning with Kirschner wires and open reduction volar plating. Despite increased costs, the hypothesis of this study was that open reduction and volar plating does not provide improved outcomes over wire fixation. Following Transparent Reporting of Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a meta-analysis of randomized controlled trials was conducted comparing these two methods with regard to clinical outcomes, radiographic parameters, and complications. Seven trials with a total of 858 patients were included. Plating was not favored over pinning with regard to clinical outcomes and radiographic parameters. Pinning was associated with a higher superficial infection risk compared with plating, though the risk of repeat surgery was not different. It was concluded that Kirschner wire fixation, which may be associated with lower costs, is associated with similar clinical and radiographic outcomes when compared with volar plate fixation, although wire fixation is associated with higher superficial infection risk.

Insurance-Mandated Stay Prolongs Hospitalization Following Total Shoulder Arthroplasty.

Medicare currently requires a 3-night hospitalization for a patient to be considered for skilled nursing facility (SNF) placement. The purpose of this study was to analyze the relationship between length of stay and (a) insurance status and (b) readmission rates in Medicare-age patients undergoing primary total shoulder arthroplasty. A retrospective review of 251 primary consecutive total shoulder arthroplasty cases was performed. In patients discharged to SNF, Medicare insurance was associated with a significantly longer hospital stay (p < .001) compared with patients with private insurance. Readmission rates for Medicare and private insurance patients were similar at 30 and 90 days after surgery (p = 1.000). Ninety-five percent of Medicare patients discharged to SNF had a prolonged hospital stay primarily to fulfill the 3-night requirement. These findings call into question the necessity of the current 3-night inpatient hospitalization requirement for facility placement following total shoulder arthroplasty.

Bioabsorbable Pin Fixation in Late Presenting Pediatric Radial Neck Fractures.

BACKGROUND: Current treatment algorithms for pediatric radial neck fractures reserve open treatment for severe residual angulation. There is a paucity of literature guiding treatment for delayed presentation resulting in malunion. Bioabsorbable pins have been used successfully for many other fracture types in the upper extremity. The purpose of this study is to determine whether open reduction, bioabsorbable fixation with an osteotomy when necessary is a reasonable treatment option in delayed pediatric radial neck fractures by assessing pain, range of motion, functional, and radiographic outcomes. METHODS: Radial neck fractures were evaluated in 7 children, 4 to 12 years old, with delayed initial presentation averaging 20 days. Patients presented with an average angular deformity of 63 degrees and translational deformity of 57% (6.1 mm) in the AP plane, all with painful and reduced range of motion. Patients underwent open reduction and fixation with Self-Reinforced Poly-L-Lactic Acid pins after failed closed reduction. Four patients required formal osteotomies. Postoperative follow-up averaged 9.2 months and consisted of radiographic and clinical evaluation with Wong-Baker FACES Visual Analog scale and the Mayo Elbow Performance (MEP) score. RESULTS: Final radiographs demonstrate an improvement in angular deformity by 56 degrees and translational deformity by 51%. Final clinical outcomes demonstrated significantly improved pain-free range of motion with excellent MEP scores in 6 of the 7 patients. One patient developed a radioulnar synostosis, subsequently undergoing synostosis excision with a final MEP score of 80/100. There was no evidence of physeal closure or avascular necrosis and no cases requiring hardware removal or complicated by local inflammatory reactions. CONCLUSIONS: This small series shows encouraging results in the treatment of pediatric radial neck fractures with delayed presentation using open reduction, bioabsorbable fixation, and when necessary an osteotomy. Bioabsorbable fixation may eliminate issues surrounding subsequent hardware removal and pin-site infections. Despite these encouraging results, radioulnar synostosis after open surgery is still a concern. LEVEL OF EVIDENCE: Level IV-case series.

Recent Trends in the Effect of Race and Gender on the Orthopedics Match.

Introduction Orthopedics has a reputation for being competitive but not diverse. Leaders of the orthopedics community have been making efforts to increase the participation of women and minorities in the field by raising awareness and strengthening pipeline programs. We aim to explore the trends in the risk of not matching by comparing the proportions of women and underrepresented populations in the applicant pools versus proportions in residency programs. Simultaneously, we aim to evaluate if women or underrepresented population applicants exhibit a lower likelihood of applying to orthopedics compared to male and White applicants. Methods The study received an IRB exemption. The authors collected Accreditation Council for Graduate Medical Education (ACGME) data books for the years 2015-2016 to 2022-2023 to obtain demographic information on orthopedic residents in training during each of those academic years. The pool of corresponding applicants (for example: residents in training during the 2021-2022 academic year would consist of five classes, made up of applicants from 2016-2017 to 2020-2021) was then tabulated from Electronic Residency Applications Service (ERAS) statistics, which are publicly available on the Association of American Medical Colleges (AAMC) website. The race and gender composition of the applicant pool was compared to that of corresponding enrolled residents to calculate the relative risk (RR) of women not matching compared to men and underrepresented population applicants (Blacks, Hispanics, Asians, and Native Americans) compared to White applicants. ERAS data was subsequently used to calculate the percentages of each demographic applying to all residency programs and orthopedic programs. Results For female applicants into orthopedic residency, they had a similar RR of going unmatched when compared to their male counterparts. In the academic year 2020-2021, there was an exception to this as women had a slightly higher RR of going unmatched. All underrepresented populations had a higher risk of not matching compared to White applicants for all cycles, peaking for residents in training in 2020-2021. The trendline improved for residents in the following year. Throughout the study, women accounted for 46.61% of applicants applying for any residency; however, they only accounted for 16.98% of applicants applying for orthopedic residency. A similar discrepancy is noted among Asian applicants but not Black or Hispanic applicants. Conclusions Underrepresented populations were increasingly less likely to match into orthopedics relative to White applicants until 2021. In the academic year of 2021-2022, there was an improvement in this trend for all studied underrepresented populations. Although the exact explanation for this is unclear, it is associated with the transition to virtual applicant interactions. The female gender did not appear to be a consistent advantage or disadvantage in the match. Women and Asian applicants were less likely to apply to orthopedics than other specialties.

Cyanoacrylate microbial sealant may reduce the prevalence of positive cultures in revision shoulder arthroplasty.

BACKGROUND: Cyanoacrylate-based, microbial sealant is an adhesive skin barrier designed to prevent bacterial contamination in surgical wounds. This type of adhesive barrier could have use in decreasing the incidence of positive cultures and subsequent infection in shoulder arthroplasty. QUESTIONS/PURPOSES: We therefore evaluated whether cyanoacrylate microbial sealant reduced the positive intraoperative culture rates in revision shoulder arthroplasty. METHODS: We retrospectively reviewed 55 patients who underwent revision shoulder arthroplasties. Intraoperative aerobic and anaerobic deep tissue culture results taken during the revisions were compared. Cultures were taken of the deep synovial tissue lining the prosthesis. Patients were divided into two groups: those who underwent standard preparations with adhesive, iodine-barrier drapes (Group SP) and those who had placement of cyanoacrylate microbial sealant in addition to the standard prep (Group MS). RESULTS: The prevalence of cases with positive cultures was 18% (seven of 40) in Group SP compared with 7% (one of 15) in Group MS. The prevalence of positive, anaerobic Propionibacterium acnes cultures was 13% in Group SP compared with 7% in Group MS. The prevalence of infections confirmed at revision surgery was 8% in Group SP versus 0% in Group MS. CONCLUSIONS: Our observations suggest application of a cyanoacrylate microbial sealant may reduce the prevalence of positive cultures and thereby subsequent infections in revision shoulder arthroplasties. LEVEL OF EVIDENCE: Level III, retrospective cohort study. See Guidelines for Authors for a complete description of levels of evidence.

Bupivacaine and triamcinolone may be toxic to human chondrocytes: a pilot study.

BACKGROUND: Intraarticular injections of corticosteroids combined with local anesthetics are commonly used for management of chronic pain symptoms associated with degenerative joint diseases and after arthroscopic procedures. Several studies suggest chondrotoxicity of local anesthetics whereas others report chondroprotective and cytotoxic effects of corticosteroids on cartilage. Given the frequency of use of these agents, it is important to know whether they are in fact toxic. QUESTIONS/PURPOSES: We asked whether (1) bupivacaine and triamcinolone acetonide, alone and combined, were chondrotoxic to chondrocytes in culture; (2) buffering of the reagents diminished toxicity of the bupivacaine and triamcinolone; and (3) the presence of the superficial layer of articular cartilage protects against toxicity. MATERIALS AND METHODS: We obtained cartilage from three patients undergoing arthroplasty. To address triamcinolone acetonide, bupivacaine, and combinatorial toxicity to human chondrocytes, we set up monolayer chondrocyte cultures (n = 8 wells per condition). The question of buffering was addressed by performing the same assays as above, but the reagents were buffered. An MTT assay was used to assess chondrocyte survival in the monolayer. We harvested 21 articular plugs from each of three patients (total 63 plugs) and exposed them to the same reagents as above, including the buffered reagents. A Live/Dead assay was used to determine chondrocyte survival. RESULTS: Triamcinolone acetonide, bupivacaine, and their combination were toxic to human chondrocytes in the monolayer comparisons. The addition of buffering did not mitigate chondrocyte death. With the intact superficial layer in the plug group, bupivacaine was not toxic as compared with for the control group; all the other reagents (triamcinolone, combination bupivacaine/triamcinolone, buffered bupivacaine, buffered triamcinolone, and buffered combination) produced chondrotoxicity. CONCLUSIONS: Triamcinolone induced chondrotoxicity in the articular plug and monolayer culture, whereas bupivacaine induced chondrotoxicity only in monolayer culture. The combined used of triamcinolone and bupivacaine did not show additive chondrocyte death in any arm. Buffering of bupivacaine increased its chondrotoxicity. CLINICAL RELEVANCE: Although not necessarily reflecting in vivo conditions, our data suggest physicians should be cognizant of the potential in vitro chondrotoxicity of bupivacaine and triamcinolone when contemplating intraarticular administration.

Fenestrated cannulae with outflow reduces fluid gain in shoulder arthroscopy.

UNLABELLED: Soft tissue fluid retention is a common problem after arthroscopy, with as much as 2% of patients having complications develop. A fenestrated outflow cannula has been introduced to reduce interstitial swelling. We tested the ability of this outflow cannula design to reduce fluid weight gain. We enrolled 28 patients undergoing shoulder arthroscopy and randomized them into two groups using fenestrated outflow versus conventional cannulae. The conventional group had greater weight gain as a function of the procedure duration than the fenestrated outflow group (slope = 0.542 +/- 1.160 kg/hour versus 0.0144 +/- 0.932 kg/hour). The conventional group also had greater weight gain as a function of fluid volume than the fenestrated outflow group (slope = 0.022 +/- 0.038 kg/L versus 0.002 +/- 0.341 kg/L). Compared with conventional nonoutflow cannulae, fenestrated outflow cannulae with negative pressure reduced weight gain associated with longer arthroscopic surgeries and increased arthroscopic fluid volume. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Biomechanical characteristics of 9 arthroscopic knots.

PURPOSE: To determine the optimal arthroscopic slipknot through comparison of ease of placement, loop security, knot security, and amount of suture material needed using a new suture material. METHODS: Nine commonly used arthroscopic knots (Dines, Field, Nicky, Hu, San Diego, Snyder, Tennessee slider, Triad, and Tuckahoe) were tested by use of modern suture material, FiberWire (Arthrex, Naples, FL), with the Instron materials testing machine (Instron, Norwood, MA) for ease of knot placement (forward and backward sliding), loop security, and knot security. The amount of suture material needed to create the knot was compared by use of the knot weight. Analysis of variance with Kruskal-Wallis analysis and Bonferroni correction (alpha < .01) was used to compare different knots. RESULTS: The Tennessee slider knot sustained the greatest force at failure (269 N), the greatest knot resistance (32 N), and the smallest mass (8.5 mg). The Dines was the only knot superior in all 3 knot placement categories. The Nicky held the most loop force (66 N), and the Tuckahoe had the greatest loop resistance (20 N) (P < .01 for all except mass [P < .05]). CONCLUSIONS: Our study comprehensively presents ease-of-placement and security characteristics of 9 common and new arthroscopic knots using modern FiberWire suture. The Tennessee slider knot showed superior characteristics in knot security and knot mass. The Dines knot was the most ideal knot to place. However, the surgeon will need to review the individual knot characteristics and select the knot most suited to application. CLINICAL RELEVANCE: This study analyzed 9 arthroscopic knots with modern suture material and identified those with superior characteristics.

Chondrotoxicity of Local Anesthetics: Liposomal Bupivacaine Is Less Chondrotoxic than Standard Bupivacaine.

OBJECTIVE: The purpose of this study is to determine whether (1) liposomal bupivacaine is chondrotoxic; (2) the chondrotoxicity of liposomal bupivacaine differs from standard bupivacaine; and (3) chondrotoxic effects are time dependent. MATERIALS AND METHODS: We obtained 72 10 mm articular cartilage plugs from 12 fresh bovine distal femoral knee joints and exposed them to either saline, 0.5% bupivacaine, or liposomal bupivacaine for either 30 or 90 minutes. Twenty-four hours after treatment, chondrocyte viability was measured with the use of a fluorescent live/dead assay. An ANOVA test of variance was performed followed by a Holm-Sidak test to make pairwise comparisons across conditions. Student's t-test was used to compare means. RESULTS: Percent viability of cells exposed to liposomal bupivacaine for 30 minutes was less versus saline control (53.9% ± 21.5% vs. 73.7 ± 18.4%, p=0.035), and this remained significant at 90 minutes (49.1% ± 20.3% vs. 67.2% ± 25.6%, p < 0.001). Liposomal bupivacaine had less chondrotoxic effects when compared with bupivacaine after 90 minutes, with greater viability (49.1% ± 20.3% vs. 21.4% ± 14.0%, p=0.003). Chondrotoxicity was found to be time dependent within the bupivacaine group (percent viability at 30 min: 45.5 ± 18.2%, 90 min: 21.4 ± 14.0%, p=0.001); however, liposomal bupivacaine did not demonstrate a significant time-dependent chondrotoxic relationship (p=0.583). CONCLUSIONS: Bupivacaine and liposomal bupivacaine are both toxic to chondrocytes. Liposomal bupivacaine is less chondrotoxic than standard bupivacaine and does not demonstrate a time-dependent toxicity.

Effectiveness of antimicrobial incise drapes versus cyanoacrylate barrier preparations for surgical sites.

Surgical wound infections are one of the leading causes of morbidity and mortality in surgical patients. We compared the effectiveness of antimicrobial incise drapes versus cyanoacrylate microbial sealant adhesive barrier in preventing skin flora contamination of surgical wounds in an animal model. Staphylococcus aureus in suspension was placed on fresh ovine skin across 60 circular marks of defined area: 20 circles were designated as controls, 20 were covered with antimicrobial incise drapes, and 20 were covered with cyanoacrylate. Incisions were made through the circles; swab cultures were taken, serially diluted after agitation, and cultured on blood agar plates. The number of colony forming units (CFUs) was then counted and compared between the samples from the two drapes. While there were no differences between antimicrobial incise-draped areas (108.3 +/- 90 CFUs) and undraped controls (82.7 +/- 93.3 CFUs), the cyanoacrylate-treated group demonstrated lower wound bed contamination (0.3 +/- 0.6 CFUs) when compared to controls.