The Geographic Movement Patterns and Career and Personal Interests of Orthopaedic Surgery Residents in the United States.

BACKGROUND: Orthopaedic surgery continues to be a highly desired residency specialty for graduating medical students in the United States. The geographic preferences and trajectories of orthopaedic surgery applicants are not well understood. OBJECTIVE: The primary objective of this study was to determine the geographic movement patterns of orthopaedic residents from university through residency. A secondary objective was to trend the career and personal interests of orthopaedic residents. METHODS: One hundred eighty-seven orthopaedic surgery programs and 3672 residents were identified through the Electronic Residency Application Service website and Google searches and included for study. Program provided information, including the residents' medical school, undergraduate institution, career interests, and personal interests was then gathered. All data were recorded between the dates of March 25, 2020, and April 2, 2020. RESULTS: A minority of orthopaedic residents (46.2%; n = 1,569/3,398) were training in the same geographic region of their medical school; however, analysis revealed a statistically significant strength of association for home region over a different US census bureau region (χ2 = 127.4, df = 8, Cramer's V = 0.2, P < 0.001). The average distance between orthopaedic residents' medical school and residency program was 666 miles. Male residents were more interested in arthroplasty, spine, and sports, whereas female residents were more interested in hand and pediatrics. The residents leading interests were in arthroplasty (24.4%), sports (21.7%), and trauma (21.3%). CONCLUSION: Orthopaedic surgery residents are more likely to train in a geographical region that is different from their medical school or undergraduate institution. The reported career interests of male and female orthopaedic residents showed significant differences, but personal interests seem to be similar between genders.

Website evaluation for shoulder and elbow fellowships in the United States: an evaluation of accessibility and content.

HYPOTHESIS AND/OR BACKGROUND: When examining the access and content related to shoulder and elbow fellowship websites, only 64% of programs had individual websites in a query performed 5 years earlier. The purpose of this study was to re-evaluate content about individual programs listed on the American Shoulder and Elbow Surgeons (ASES) website and on individual program websites and compare the results to prior data. METHODS: The ASES website was accessed to determine both the number of ASES-recognized shoulder and elbow fellowships and the number of direct links to fellowship program websites. A Google search was also performed to determine the ease of access to fellowship program websites. Each website was then evaluated for content in regard to their recruitment and educational program. RESULTS: The ASES website includes contact information and a brief description for 29 programs with 40 reported positions. When trying to identify links to program websites, there were functioning links to 6 programs (21%) and absent/nonfunctioning links for the remaining 23 (79%). Through a Google search, there were functioning links to 22 (76%) and absent/nonfunctioning links for 7 (24%) programs. All 29 program websites had faculty listing and program contact info whereas 28 (97%) had a description of their program. In terms of educational content, 17 (59%) included description of operative cases and 18 (62%) had descriptions of rotations/curriculum. DISCUSSION AND/OR CONCLUSION: Individual shoulder and elbow fellowship program websites provide varied content and accessibility. In the intervening 5 years, there has been minimal improvement in the accessibility of individual fellowship websites from the ASES website.

Can Sural Fasciocutaneous Flaps Be Effective in Patients Older Than 65?

BACKGROUND: Many studies have evaluated the reverse sural fasciocutaneous flap for coverage of wounds on the distal lower extremity, and many of these have focused on younger, healthy patients. However, to our knowledge, there has been no dedicated study focusing on older patients. We believe there is a generalized concern about performing these procedures in older patients because of microvascular changes associated with aging. QUESTIONS/PURPOSES: (1) What is the likelihood of flap survival in a small series of patients older than 64 years who underwent reverse sural artery fasciocutaneous flap for coverage of lower extremity wounds? (2) What additional procedures did patients undergo after treatment with this flap? METHODS: From 2009 to 2018, we identified 16 patients, 64 years or older, who underwent a retrograde sural fasciocutaneous flap. Patients were a mean (range) age of 71.5 years (64 to 87). The average size of the flaps was 30 cm (range 12 to 64 cm). The reverse sural artery flap was indicated when the skin could not be closed primarily and there was not a suitable vascularized bed of tissue for a split-thickness skin graft. All patients underwent a wide-based pedicle (3 cm to 4 cm), reverse sural artery fasciocutaneous flap with all but one completed in a "flap delay" manner, between 2 to 7 days, and without the use of microsurgery or doppler. Thirteen flaps were done to cover wounds that occurred over fractures while three were performed to cover chronic wounds. We performed a retrospective review of the electronic health record to ascertain patient comorbidities, age, timing of coverage, and size of the wound. RESULTS: In all, 94% of flaps (15 of 16) survived with 100% viability. One flap had 30% skin necrosis at the distal tip. The flap ultimately healed with in-office wound care, and epithelization occurred over the intact fascia. A total of five additional procedures were performed in five patients. Although the flap ultimately healed, an 87-year-old patient with partial flap necrosis ultimately elected for below-knee amputation for a persistent tibial infected nonunion. Another patient, despite a healed flap, eventually underwent a below-knee amputation 3 years later for a chronic osteomyelitis present before undergoing the reverse sural flap. One patient developed a pseudomonal infection of their Gustillo-Anderson IIIB open tibia fracture, resulting in a surgical procedure for débridement, after which the flap healed. Two patients underwent underlying hardware removal to relieve wound tension and allow for complete flap healing. No patients underwent further coverage procedures. CONCLUSIONS: In this small series, we found fewer complications than have been observed in prior studies, despite our series consisting solely of higher-risk, older patients. We believe this may have been attributable to the period of delay before placing the flap, which has been previously associated with higher flap survival and which allows for an extra recipient-site débridement. We believe this procedure can be performed by appropriately trained orthopaedic surgeons because it does not need microsurgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Sural Versus Perforator Flaps for Distal Medial Leg Wounds.

Soft tissue coverage of distal medial ankle wounds is a challenging problem in orthopedic surgery because of the limited local tissues and prominent instrumentation. Traditionally, these wounds required free tissue transfer to achieve suitable coverage and subsequent bony union. To better respect the reconstructive ladder and to avoid the inherent difficulty of free flap coverage, rotational flaps have been used to cover these wounds. Both sural fasciocutaneous flaps and rotational fasciocutaneous perforator (propeller) flaps have been described for distal medial soft tissue coverage. The authors performed a retrospective chart review of patients who underwent distal medial leg coverage with the use of either sural flaps or rotational fasciocutaneous perforator flaps. The authors identified 14 patients by Current Procedural Terminology code who met the study criteria. The average age and degree of medical comorbidities were comparable in the 2 groups. The authors reviewed their medical records to evaluate fracture healing, flap size, complications, and return to normal shoe wear. All 7 sural flaps healed without incident, with underlying fracture healing. Of the 7 perforator flaps, 6 healed without incident, with underlying fracture healing. One perforator-based flap was complicated by superficial tip necrosis and went on to heal with local wound care. All patients returned to normal shoe wear. Both sural artery rotational flaps and posterior tibial artery-based rotational flaps are viable options for coverage of the distal medial leg. Coverage can be achieved reliably without microsurgery, anticoagulation, or monitoring in the intensive care unit.

The internet as a source of information for De Quervain's tendinitis.

BACKGROUND: Many individuals are turning to the Internet for information about various health conditions, and in our study we evaluated the quality and readability of information on the internet about De Quervain's tendinitis. METHODS: We chose the search terms "De Quervain's Tendinitis," "De Quervain's Tenosynovitis," and "De Quervain's Syndrome," and entered them into the search engines "Google," "Bing," and "Yahoo" and compiled the search results. The websites were then evaluated and assigned a quality score, a Flesch-Kincaid (FK) reading level, and a subjective quality score. They were then grouped according to the search term used, search engine used, and the order (priority) returned by the search engines. ANOVA analysis and pairwise comparisons of quality and readability among groups, as well as correlation analysis were performed. RESULTS: The FK readability average was 10.3, above the recommended level. The search term De Quervain's tenosynovitis returned the highest objective quality results. There was no statistical difference found between the different search engines. The first 10 results from the searches were of higher quality than results 11-20, and there was a positive correlation between objective and subjective quality scores but no correlation between readability and objective quality. CONCLUSIONS: We concluded that quality information about De Quervain's tendinitis is available on the internet and is most likely to be found using the search term De Quervain's tenosynovitis and in the first 10 results of an internet search. However, most information is written above the recommended 6th grade reading level.

Imaging and management of thumb carpometacarpal joint osteoarthritis.

Primary osteoarthritis (OA) involving the thumb carpometacarpal (CMC) joint is a common and frequently debilitating disease. Clinical examination and radiographs are usually sufficient for diagnosis; however, familiarity with the cross-sectional anatomy is useful for diagnosis of this condition. The most widely used classification system for the radiographic staging of thumb carpometacarpal joint OA was first presented by Eaton and Littler, ranging from mild (stages I and II) to severe (stage IV) disease. If conservative treatment fails, surgical treatment is considered. A variety of surgical techniques have been developed and implemented for the management of this pervasive and disabling condition. The purpose of this article is to review the anatomy of the basal joints of the thumb, pathophysiology, preoperative imaging, and various surgical techniques that are utilized in the treatment of OA of the basal joints of the thumb with emphasis on normal postoperative radiographic findings and possible postoperative complications.

Simultaneous soft tissue coverage of both medial and lateral ankle wounds: Sural and rotational flap coverage after revision fixation in an infected diabetic ankle fracture.

AIMS: To describe a case of simultaneous medial and lateral soft tissue coverage for exposed orthopaedic implants in the setting of revision fixation of a non-united ankle fracture. This was achieved using a sural flap as well as a propeller flap. METHODS: Case report. RESULTS: Both the sural and posterior tibial artery based rotational propeller flap healed without incident. The underlying fracture healed successfully and the patient returned to normal shoe wear. CONCLUSIONS: The sural flap in conjunction with the posterior tibial artery based rotational flap is effective in providing simultaneous medial and lateral soft tissue coverage to the ankle.

The OTA open fracture classification: a study of reliability and agreement.

OBJECTIVES: To determine the reliability of the Orthopaedic Trauma Association (OTA) Open Fracture Classification. DESIGN: Video-based reliability study. SETTING: Orthopedic meetings and grand rounds. PATIENTS/PARTICIPANTS: Orthopedic surgeons. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Interobserver reliability assessment classification. RESULTS: The results demonstrate the system to have high reliability and much improvement compared with published Gustilo-Anderson classification reliability studies. Overall interrater reliability (κ) values were highest for arterial injury, with near perfect agreement across all raters and within each value. Skin injury, bone loss, and contamination demonstrated moderate to substantial levels of agreement. Muscle injury had the most disagreement between raters but still demonstrating a fair level of interrater agreement, which is a level of agreement superior to the literature related to the Gustilo-Anderson classification. Levels of agreement were similar between attending surgeons and residents for all categories. CONCLUSIONS: This study, which included a diverse multicenter multinational cohort of orthopaedic surgeons and residents, of the OTA Open Fracture Classification demonstrated moderate to excellent interobserver reliability.

Imaging and treatment of scaphoid fractures and their complications.

The scaphoid is the most commonly fractured carpal bone, with frequent complications that are predisposed by its anatomical location, anatomical configuration (shape and length), and vascular supply. The most common mechanism of injury is a fall onto an outstretched hand. Imaging plays a significant role in the initial evaluation and treatment of scaphoid fractures and their complications. Radiography should be the first imaging modality in the initial evaluation and follow-up of scaphoid fractures. Computed tomography with its superb spatial resolution enables better visualization and characterization of the fracture line, and the amount of displacement and angulation of the fracture fragments. Using the metal reduction artifact with computed tomography allows good follow-up of scaphoid fractures despite surgical hardware. Magnetic resonance imaging without contrast is the imaging modality of choice for depiction of radiographically occult scaphoid fracture, bone contusion, and associated soft tissue injury; contrast-enhanced imaging aids assessment of scaphoid fracture nonunion, osteonecrosis, fracture healing after bone grafting, and revitalization of the necrotic bone after bone grafting. Proper identification and classification of scaphoid fracture and its complications is necessary for appropriate treatment. This article describes the normal anatomy, mechanism of injury, and classification of stable and unstable fractures, together with the imaging and treatment algorithm of scaphoid fractures and their complications with an emphasis on magnetic resonance imaging.

Distal Radius Fracture Hematoma Block with Combined Lidocaine and Bupivacaine can induce Seizures while within Therapeutic Window: A Case Report.

INTRODUCTION: Hematoma blocks are effective pain management modalities for closed reduction of distal radius fractures. Complications of hematoma blocks are associated with systemic reaction to anesthetic used. CASE REPORT: We present a case report of an elderly patient who received a hematoma block of lidocaine and bupivacaine for a distal radius fracture and subsequently developed a generalized tonic clonic seizure. The dose of both lidocaine and bupivacaine were well within the suggested dose limit. The episode was self limiting and patient had the cast applied. CONCLUSIONS: We conclude that hematoma blocks with a combination of anesthetics may decrease the threshold to neurologic complications, especially in elderly patients. Precautions and ready treatment measures should be made available while performing closed reduction.

Antibiotic-impregnated cement spacer for bone defects of the forearm and hand.

Management of bone loss, particularly in the face of open or contaminated wounds, presents a reconstructive challenge. Polymethylmethacrylate impregnated with antibiotics has been used successfully in the treatment of infected total joint arthroplasty and open fractures. The cement delivers high-dose local concentrations of antibiotics while filling a space. This article presents our use of an antibiotic-impregnated cement spacer for bone loss in the forearm or hand in the face of open or infected wounds. The cement spacer fills a potential space, prevents the involution of the surrounding soft tissue, and delivers appropriate antibiotics. When the spacer is removed, the remaining sheath serves to hold and contain the cancellous bone graft.

The accuracy of distal posterior interosseous and anterior interosseous nerve injection.

PURPOSE: To standardize a technique of delivering a local anesthetic to the posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN) by using the anatomic landmarks of the wrist and to evaluate the accuracy of the technique in a cadaver model. METHODS: Techniques for PIN and AIN injection and for PIN injection alone are described. Techniques were tested in a fresh frozen cadaver model by using methylene blue injections. Stained nerves were dissected under loupe magnification. Digital photographic images were taken of each nerve. Staining was quantified by calculating the mean density and area stained. RESULTS: For both techniques methylene blue was delivered accurately to the PIN in 100% of the samples. Methylene blue was delivered accurately to the AIN in 100% of samples in which it was injected. CONCLUSIONS: These techniques saturated successfully the PIN and AIN and may be useful as diagnostic and therapeutic tools for chronic wrist pain and in evaluating presurgically the effectiveness of partial wrist denervation.