Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors.

Background: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence: Level IV.

Postoperative Chest X-Rays After Open Reduction Internal Fixation of Clavicle Fractures May Not Be Cost-Effective or Necessary.

OBJECTIVES: To assess the use of chest x-rays after open-reduction internal fixation of clavicle fractures. Particularly in detection of acute postoperative pneumothorax and cost-effectiveness of obtaining routine chest x-rays postoperatively. DESIGN: A retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Two hundred thirty-six patients who underwent ORIF from 2013 to 2020 between the ages of 12 and 93. INTERVENTION: Chest x-ray performed postoperatively. MAIN OUTCOME MEASUREMENT: Presence of acute postoperative pneumothorax. RESULTS: Of the 236 patients who underwent surgery, 189 (80%) patients received a CXR postoperatively and 7 (3%) patients experienced respiratory symptoms. All patients who had respiratory symptoms received a postoperative CXR. Those who did not receive a CXR postoperatively did not experience any respiratory complications. Two patients in the cohort had a postoperative pneumothorax, which was present preoperatively and unchanged in size postoperatively. Both of these patients were managed with general anesthesia and endotracheal intubation for surgery. The most common finding on CXR postoperatively was atelectasis. The cost of a portable CXR can be upward of $594 when including technology, personnel fees, and radiologic interpretation. CONCLUSION: Postoperative chest x-rays after clavicle open reduction and internal fixation did not detect any acute postoperative pneumothorax in asymptomatic patients. It is not cost-effective to routinely get chest x-rays in patients after open-reduction internal fixation of clavicle fractures. In our study, of the 189 chest x-rays performed, only 7 patients experienced postoperative respiratory symptoms. Our health care system as a total could have saved upward of $108,108 in total for these patients because they may have been considered nonreimbursable by an insurance provider. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short cephalomedullary nail toggle: a closer examination.

OBJECTIVES: In patients with wide femoral canals, an undersized short nail may not provide adequate stability, leading to toggling of the nail around the distal interlocking screw and subsequent loss of reduction. The purpose of this study was to identify risk factors associated with nail toggle and to examine whether increased nail toggle is associated with increased varus collapse. DESIGN: Retrospective cohort study. SETTING: Level 1 and level 3 trauma center. PATIENTS/PARTICIPANTS: Seventy-one patients with intertrochanteric femur fractures treated with short cephalomedullary nails (CMN) from October 2013 to December 2017. INTERVENTION: Short CMN. MAIN OUTCOME MEASUREMENTS: Nail toggle and varus collapse were measured on intraoperative and final follow-up radiographs. Risk factors for nail toggle including demographics, fracture classification, quality of reduction, Dorr type, nail/canal diameter ratio, lag screw engaging the lateral cortex, and tip-apex distance (TAD) were recorded. RESULTS: On multivariate regression analysis, shorter TAD (P = .005) and smaller nail/canal ratio (P < .001) were associated with increased nail toggle. Seven patients (10%) sustained nail toggle >4 degrees. They had a smaller nail/canal ratio (0.54 vs 0.74, P < .001), more commonly Dorr C (57% vs 14%, P = .025), lower incidence of lag screw engaging the lateral cortex (29% vs 73%, P = .026), shorter TAD (13.4 mm vs 18.5 mm, P = .042), and greater varus collapse (6.2 degrees vs 1.3 degrees, P < .001) compared to patients with nail toggle < 4 degrees. CONCLUSIONS: Lower percentage nail fill of the canal and shorter TAD are risk factors for increased nail toggle in short CMNs. Increased nail toggle is associated with increased varus collapse.Level of evidence: Therapeutic Level III.

Ankle Motion and Offloading in Short Leg Cast and Low and High Fracture Boots.

BACKGROUND: Short leg casts (SLCs) and fracture boots are used to treat foot and ankle injuries, but the decision to use one device over the other is often subjective. This study compared the impact of SLCs and low and high fracture boots on ankle motion and offloading. METHODS: Twenty healthy adults were prospectively studied. High-speed dynamic radiography was utilized to determine tibiotalar range of motion in the sagittal plane during nonweightbearing (NWB) and weightbearing (WB) gait in a shoe (control), SLC, and low and high fracture boots. Sensors captured peak plantar surface forces to determine ankle offloading. RESULTS: In NWB, the low fracture boot (2.2 ± 2.0 degrees), high fracture boot (2.3 ± 1.6 degrees), and SLC (2.3 ± 1.5 degrees) had significantly less motion compared with the control (3.6 ± 2.1 degrees; P ≤ .026). During WB, the SLC (3.4 ± 1.4 degrees) and high fracture boot (4.8 ± 2.0 degrees) had less motion compared with the low fracture boot (7.8 ± 3.4 degrees; P < .001). Finally, the SLC (172.6% ± 48.3% body weight [BW]) and low fracture (165.1% ± 36.2% BW) and high fracture (154.5% ± 32.9% BW) boots were associated with less peak plantar surface force compared with the control (195.0% ± 43.8% BW; P ≤ .087). CONCLUSION: The SLC and high fracture boot immobilized the ankle in NWB and offloaded and immobilized the ankle in WB. The low fracture boot also immobilized the ankle in NWB, but in WB, the low fracture boot only offloaded the ankle and did not immobilize it. CLINICAL RELEVANCE: The low fracture boot may be more suited for NWB or possibly immobilizing the foot in WB.

Cost-Effectiveness of Operative Versus Nonoperative Treatment of Displaced Midshaft Clavicle Fractures: A Decision Analysis.

BACKGROUND: While previous studies have shown higher union rates and a quicker return to work with operative treatment of substantially displaced clavicle fractures, there is disagreement whether operative treatment results in improved clinical outcomes. Patients who undergo operative treatment sometimes require additional surgery for implant removal. Nonoperative treatment may fail so that delayed surgical intervention is ultimately required. The duration for which the clinical benefits of operative treatment remain superior to those of nonoperative treatment has not been well established in the literature. Considering these uncertainties, surgeons are faced with a difficult decision regarding whether operative treatment of a midshaft clavicle fracture will be cost-effective. The purpose of this study was to identify the most cost-effective strategy by considering these uncertain parameters with use of decision-analysis techniques. METHODS: An expected-value decision tree was built to estimate the quality-adjusted life years (QALYs) and costs for operative and nonoperative treatment of substantially displaced midshaft clavicle fractures. Values for parameters in the decision model were derived from the literature. Medical costs were obtained from the Medicare database. A Markov model was used to calculate the QALYs for the duration of life expectancy. The decision model was used to analyze the duration for which the clinical results of operative treatment were superior to those of nonoperative treatment during the first 5 years after the operation and during a lifetime. Sensitivity analysis was performed to determine which parameters have the most influence on cost-effectiveness. RESULTS: Operative treatment was more cost-effective than nonoperative treatment in 54% and 68% of the Monte Carlo trials in the 5-year and lifetime analyses, respectively. The cost per QALY with operative management was <$38,000 and <$8,000 in the 5-year and lifetime analyses, respectively. This is below the willingness-to-pay threshold of $50,000 per QALY. For operative treatment to remain cost-effective, its clinical benefits must persist for at least 3 years. CONCLUSIONS: Operative treatment is more cost-effective than nonoperative treatment for substantially displaced midshaft clavicle fractures. The clinical benefits derived with operative treatment must persist for at least 3 years for operative treatment to remain cost-effective. This research should not be used to conclude that all clavicle fractures should be treated surgically. It is best that such a decision is made through a patient-surgeon shared decision-making process. LEVEL OF EVIDENCE: Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Short-term Medical Complications Following Short Versus Long Cephalomedullary Nails.

The purpose of this retrospective cohort study was to evaluate whether there is an increased rate of short-term medical complications following short vs long cephalomedullary nails for the treatment of intertrochanteric hip fractures. A total of 899 patients treated surgically with cephalomedullary nails from January 1, 2005, to September 1, 2014, were included. Patients who received short nails (n=334) were older and had a higher incidence of coronary artery disease and diabetes mellitus compared with patients who received long nails (n=565). The incidences of 30-day medical complications, including myocardial infarction, stroke, deep venous thrombosis, pulmonary embolism, blood transfusion, non-surgical site infection, surgical site infection, and mortality, were recorded. The orthopedic complications of periprosthetic fracture of the ipsilateral hip and implant failure through the latest outpatient follow-up were recorded. No significant difference was found between nails for any studied medical complication (63.5% short vs 66.0% long, P=.4393) or mortality (6.9% short vs 5.3% long, P=.3322). There was also no significant difference in the incidence of orthopedic complications (P=.70). Longer operating room time was associated with superficial surgical site infection. [Orthopedics. 2018; 41(5):e636-e642.].

Characterization of the inflammatory response to four commercial bone graft substitutes using a murine biocompatibility model.

Bone grafting is utilized in nearly all orthopedic subspecialties and in most anatomic regions. Bone graft substitutes have the potential to offer similar efficacy as autogenous grafts without the morbidity of harvest. Several studies have noted the efficacy of new-generation bone substitute products, but few studies have evaluated their safety. This study characterizes and quantifies the inflammatory reaction to four different commercially available bone graft substitutes, which were examined using the in vivo murine air pouch biocompatibility model. One coralline hydroxyapatite product was chosen as an example of a purely osteoconductive material. Three demineralized bone matrix products were chosen to represent products that are both osteoconductive and osteoinductive. Samples were implanted in a murine air pouch and harvested after 14 days in situ. Pouch fluid was extracted, mRNA isolated, and reverse transcription polymerase chain reactions carried out to detect interleukin-1 gene expression as a marker for inflammation. In addition, multiple histological characteristics were examined to quantify cellular responses to the implanted materials. All bone graft substitutes induced a significant inflammatory response compared with negative controls. Histology and polymerase chain reaction data indicated that the level of inflammatory reaction was elevated in materials with a higher demineralized bone matrix to carrier proportion. The hydroxyapatite product generated a low inflammatory reaction. In conclusion, this study used an in vivo model of biocompatibility to demonstrate that a significant inflammatory reaction occurs when using implanted bone graft substitutes. When choosing a bone grafting method, surgeons should consider both the efficacy and safety of methods and materials used. Further studies are necessary to determine the ideal bone graft material to maximize efficacy while minimizing morbidity.

A reliable radiographic measurement technique for extra-articular scapular fractures.

BACKGROUND: Currently, neither well-defined nor standardized measurement techniques exist for assessing deformity of extra-articular scapular fractures. To properly evaluate these injuries, compare observations across studies, and make clinical decisions, a validated measurement protocol for evaluating scapular fractures is needed. QUESTIONS/PURPOSES: We describe techniques to quantitatively characterize extra-articular scapular fracture deformity; evaluate the reliability of these characterizations in plain film radiographs and CT scans; and determine potential differences in the characterization of the deformity between the two imaging modalities. PATIENTS AND METHODS: We evaluated injury radiographs and three-dimensional CT images of 45 patients with extra-articular scapular fracture. Techniques for measuring medial/lateral displacement, angulation, translation, glenopolar angle, and glenoid version were established and utilized in two trials, performed 6 weeks apart, by three observers. We determined descriptive statistics for each measurement parameter. RESULTS: Interobserver reliability based upon interclass correlation coefficients ranged from 0.36 to 0.76 for radiographs and from 0.48 to 0.87 for three-dimensional CT. Intraobserver reliability using Pearson r coefficient ranged from 0.60 to 0.75 for radiographs and 0.64 to 0.89 for three-dimensional CT. Both individual and pooled measurements for angulation and glenopolar angle were higher on three-dimensional CT versus radiographs. CONCLUSIONS: Our data suggest three-dimensional CT is more reliable than plain radiography in the assessment of scapula fracture displacement. Therefore, we believe this modality should be utilized if fracture deformity warrants surgical consideration and to adequately compare data across studies. LEVEL OF EVIDENCE: Level IV, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Surgical management of multiple painful rib nonunions in patient with a history of severe shoulder girdle trauma: a case report and literature review.

The authors report painful nonunions after multiple rib fractures in a 50-year-old man who sustained a displaced scapula fracture and multiple ipsilateral rib fractures. The rib nonunions were reconstructed after an 11-month trial of nonoperative management, which was unsuccessful. The nonunions healed and symptoms completely resolved.