Health Literacy Awareness Among Orthopaedic Surgery Residents: A COERG Survey.

Musculoskeletal health literacy (HL) is an emerging concept in orthopaedic patient care. Estimated rates of low musculoskeletal HL in patients surpass those of general HL. Studies in other specialties suggest that medical trainees are ill equipped to interact with low HL patients, often with detrimental patient outcomes. The purpose of this study was to (1) establish the current state of HL awareness among orthopaedic surgery trainees, (2) characterize the current state of HL training in orthopaedic surgery programs, and (3) evaluate the desire for formalized HL training among orthopaedic surgery trainees. Methods: This study was endorsed by the Collaborative Orthopaedic Education Research Group board. A 17-item questionnaire was administered anonymously to orthopaedic residents through a secure online platform in the 2020 to 2021 academic year. All participation was voluntary. Results: One hundred ninety-two residents (42%) from 19 orthopaedic programs completed the survey. Most residents felt "somewhat comfortable" with issues related to HL. Most residents reported no specific training in HL issues during residency (77.5%). Of the 43 residents (22.3%) who did receive formal training, most of these individuals felt that the training is effective (N = 42, 97.7%). Role playing/standardized patient encounters were reported as the most effective form of HL training. Residents felt it was somewhat important to receive formal HL training in residency (median = 4.0, interquartile range = 3.0-5.0), and there was a modest desire for formalized training (39%). Discussion: This study is the first to characterize orthopaedic resident perceptions of HL issues in practice and training. Residents were somewhat confident in their understanding of HL concepts, and those who received formal training felt it was effective. However, there remains a low rate of formal orthopaedic resident training in HL issues, which may be an area for improvement in orthopaedic training paradigms.

Characteristics of Pyogenic Musculoskeletal Infections in Older Children and Adolescents.

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.].

Pediatric Open Both-Bone Forearm Fracture Stabilized with Titanium and Stainless Steel Stacked Extension Internal Plating: A Case Report.

CASE: A 12-year-old male patient sustained a multisegmental both-bone forearm fracture. Definitive stabilization was ulna intramedullary pinning, with stainless steel plating of the radius followed by a titanium plate stacked atop and extending internal fixation. Currently, 36 months after surgery, he experiences no limitations or complications. All hardware remains in situ. CONCLUSION: We believe this is the first description of different material plates in direct contact, of stacked plates, and of 1 plate extending another's fixation. No adverse effects developed.

Matching in Orthopaedic Surgery.

In 2016, 1,137 fourth year medical students submitted applications for orthopedic surgery residency positions. Students applied to an average of 79 programs, resulting in in a total of 89,846 applications being submitted for 727 first year residency positions. This ratio of 124 applications per position is two SDs above the mean relative to other medical specialties. The average applicant for orthopaedic surgery residency attends 2.4 away rotations, as attending 2 away rotations increases an applicant's odds of matching, and submits 83 applications. This excessive number of applications overburdens programs, subjects applicants to considerable costs, and diminishes the quality of fit between interviewees and programs. Eighty-three percent of program directors use step 1 United States Medical Licensing Examination scores as a screening tool to decrease the number of applications necessary for review. The average matched applicant attended 11.5 interviews, and Step 1 scores, research productivity, and Alpha Omega Alpha (AOA) status can be used to predict the number of applications necessary to obtain 12 interviews. AOA membership has the strongest influence on interview yield. Applicants report spending an average of approximately $7,000 on the interview process, and 72% borrow money to cover these costs. Post-interview contact, although forbidden by the National Resident Matching Program , has been reported by 60% to 64% of applicants.

Obstacles Affecting the Implementation of the O-SCORE for Assessment of Orthopedic Surgical Skills Competency.

OBJECTIVES: There is a need for meaningful and reliable measures of surgical competency in residency education. The goal of the current study is to incorporate the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) into the process of resident evaluation at our institution and to assess the feasibility and effectiveness of its use through a web-based platform. DESIGN: This is a feasibility study that prospectively assesses the implementation of a web-based O-SCORE at our institution. Over a 16-week period, 19 orthopedic surgery residents (PGY2-PGY5) participated in a quality improvement study, which involved collecting 2 feedback forms per week. Each form consisted of a resident form and a linked attending form. At the conclusion of the 16-week trial period, residents and faculty members were asked to complete a survey about their perceptions of the O-SCORE program. SETTING: An academic medical center. PARTICIPANTS: The study included only residents in postgraduate training years (PGY) 2 through 5 (n = 20) and attendings (n = 37). RESULTS: During the 16-week study period, 608 resident surveys were requested for the 19 participating residents, of which 404 surveys (66.5%) were completed. Faculty completed 207 of 326 surveys for an overall compliance rate of 63.5%. The O-SCORE was able to significantly differentiate between all training years (p < 0.0001) with the exception of PGY3 residents when compared to PGY4 residents. Overall, residents and faculty found the program valuable and feasible. Resident and faculty perception of the value of the O-SCORE correlated with compliance rate of the O-SCORE surveys. CONCLUSIONS: This study demonstrates that implementation of an immediate feedback program utilizing an electronic platform is achievable and offers reproducible construct validity. However, issues affecting compliance among both residents and faculty physicians must temper optimism for the program and should be systematically addressed to allow for successful implementation.

Effectiveness of a Low Fidelity Cast Removal Module in Orthopaedic Surgical Simulation.

OBJECTIVE: The purpose of this study is to determine if an educational model during a surgical skills laboratory results in a significant reduction in cast saw blade temperatures generated during cast removal. DESIGN: As part of an orthopedic resident surgical skills laboratory an Institutional Review Board-approved study was performed. A total of 17 study subjects applied a short arm cast. Everyone removed 1 short arm cast with temperatures recorded on the saw blade. Following cast removal, an educational session was conducted on proper cast removal and blade cooling techniques. Everyone then removed a second cast. Blade temperatures were recorded. To assess reproducibility, the 5 PGY-1 orthopedic residents removed a short arm cast 3 months later. SETTING: Carolinas Medical Center, Charlotte, NC, tertiary care center PARTICIPANTS: A total of 17 study subjects with minimal casting experience (5 PGY-1 orthopedic residents and 12 senior medical students) applied a short arm cast. RESULTS: Following the educational session there was a significant reduction in mean and mean maximum blade temperatures (p < 0.05). During the second round of cast removal assessment of blade temperatures and specific techniques to cool the blade were observed among all participants. At 3 months' time, the mean and mean maximum blade temperatures remained significantly lower than before the educational session (p < 0.05). CONCLUSIONS: The intervention in this study reduced the maximum blade temperatures to levels below the threshold known to cause burns. This simple, low cost, and easily reproducible model can easily be disseminated across institutions and simulation laboratories.

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

BACKGROUND: The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period. METHODS: This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated. RESULTS: There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%). CONCLUSIONS: Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates. LEVEL OF EVIDENCE: Level IV-therapeutic.

Effectiveness of a Low-Cost Drilling Module in Orthopaedic Surgical Simulation.

INTRODUCTION: Financial pressures and resident work hour regulations have led to adjunct means of resident education such as surgical simulation. The purpose of this study is to determine the effectiveness of a hands-on training session in orthopaedic drilling technique educational model during a surgical simulation on reducing drill plunging depth and to determine the effectiveness of senior residents teaching a hands-on training session in orthopaedic drilling technique. METHODS: A total of 13 participants (5 orthopaedic interns and 8 medical students) drilled until they penetrated the far cortex of a synthetic bone model and the plunging depth (PD) was measured. They were then randomized and underwent an education session with an attending orthopaedic surgeon or a senior resident. Next, the subjects drilled again with the PD being calculated. The preeducational and posteducational session were compared to determine if there was any improvement in PD and if there was a difference between educators. The cost of the model was also determined. RESULTS: The mean maximum PD and mean PD before the education session was 1.58 (1.40-2.10) and 1.50cm (1.36-1.76), respectively. Following the educational session, the mean maximum PD and mean PD were 0.53 (0.42-0.75) and 0.50cm (0.40-0.72), respectively. These were both significantly lower than before the education session (p <0.05). After the educational session taught by the attending versus the session taught by the resident, the mean maximum PD was 0.59 (0.42-0.75) and 0.49cm. (0.45-0.75), respectively (p = 0.44). After the educational session taught by the attending versus the session taught by the resident, the mean PD was 0.54 (0.40-0.72) and 0.47cm. (0.40-0.65), respectively (p = 0.44). The cost of the station per participant was $5.44. CONCLUSION: This study demonstrated a significant reduction in drilling PD with use of a low-cost training model and a formal didactic and skills session on proper drilling technique that can effectively be led by senior residents.

Adolescent Distal Humerus Fractures: ORIF Versus CRPP.

BACKGROUND: Although supracondylar humerus fractures are common in young children, the incidence in adolescents is much lower. As a result, there is a paucity of literature to guide treatment. The purpose of this study was to review the treatment and outcomes for a consecutive series of distal humerus fractures in adolescents and to compare outcomes between patients treated with percutaneous skeletal fixation and those treated with open reduction and fixation. METHODS: A retrospective review of patients 10 to 17 years of age who underwent surgical treatment for a distal humerus fracture from 2005 to 2014 was performed. Patients with medial epicondyle fractures and those with insufficient follow-up to document union or return of motion were excluded. Medical records were reviewed to collect demographic data as well as operative approach and method of fixation. Clinical outcomes included range of motion, time to maximum motion, and complications [nerve dysfunction, heterotopic ossification (HO), need for secondary surgery]. Radiographs were reviewed to determine time to union as well as coronal and sagittal alignment. RESULTS: One hundred eighteen adolescents with displaced distal humerus fractures were identified. Eighty-one met inclusion criteria. Forty-four of these were classified as extra-articular [Orthopaedic Trauma Association (OTA) 13-A], and 37 were intra-articular fractures (10 OTA 13-B and 27 OTA 13-C).Although not statistically significant, closed treatment with percutaneous fixation of extra-articular fractures resulted in greater flexion-extension arc of motion at final follow-up (128 vs. 119 degrees, P=0.17) and demonstrated more rapid return of motion (2.8 vs. 3.9 mo, P=0.05) when compared with open treatment despite a longer duration of immobilization and less formal physical therapy. Complications such as HO (P=0.05), nerve dysfunction (P=0.02), and secondary surgery (P=0.001) were more common in the open treatment group.Closed treatment with percutaneous fixation of intra-articular fractures was performed in younger patients of similar size (12.8 vs. 14.4 y, P<0.01; 154 vs. 142 lbs, P=0.5). There were no significant differences between groups in regard to outcomes or complications. There were trends toward increased frequency of HO, nerve dysfunction, and secondary surgery in the open treatment group.Patients with intra-articular fractures were older (14.2 vs. 11.5 y, P<0.001) and heavier (144 vs. 94 lbs, P<0.001) than patients with extra-articular fractures and were more likely to be treated open (74% vs. 11%, P<0.001). Extra-articular fractures demonstrated a greater total arc of motion (126 vs. 118 degrees, P=0.04) at final follow-up despite longer duration of immobilization (23 vs. 15 d, P=0.002), and less physical therapy (27% vs. 73%, P<0.001). Radiographic carrying angle (16.6 vs. 22.3 degrees, P=0.08) and anterior humeral line (95% vs. 81%, P=0.07) trended toward more anatomic alignment in the extra-articular group. Secondary surgery was more common after intra-articular fracture (24% vs. 7%, P=0.03). CONCLUSIONS: Closed reduction and pinning of extra-articular distal humerus fractures in adolescents resulted in predictable clinical and radiographic outcomes and allowed for earlier return of motion and fewer complications when compared with open treatment. Intra-articular distal humerus fractures occur more frequently in older adolescents and are more likely to require open reduction and internal fixation to obtain joint congruity. Patients with intra-articular injuries should be cautioned that regaining full elbow motion may be more difficult, and there is an increased risk for complications and need for additional surgery. Closed reduction and percutaneous fixation of intra-articular injuries appears to be a reasonable option in select patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

A Comprehensive, High-Quality Orthopedic Intern Surgical Skills Program.

OBJECTIVES: To design and implement a month-long, low-cost, comprehensive surgical skills curriculum built to address the needs of orthopedic surgery interns with high satisfaction among both interns and faculty. DESIGN: The study design was retrospective and descriptive. SETTING: The study was conducted at tertiary care referral center with a medium sized orthopedic residency surgery program (5 residents/year). PARTICIPANTS: Totally 5 orthopedic surgery residents and 16 orthopedic surgery faculty participated. RESULTS: A general mission was established-to orient the resident to the postgraduate year 1 and prepare them for success in residency. The basic tenets of the American Board of Orthopaedic Surgeons surgical skills program framework were built. Curricular additions included anatomic study, surgical approaches, joint-specific physical examination, radiographic interpretation, preoperative planning, reduction techniques, basic emergency and operating room procedures, cadaveric procedure practice, and introduction to arthroplasty. The program was held in August during protected time for intern participants. In total, 16 orthopedic surgeons instructed 85% of the educational sessions. One faculty member did most of the preparation and organization to facilitate the program. The program ran for a cumulative 89 hours, including 14.5 hours working with cadaveric specimens. The program cost a total of $8100. The average module received a 4.15 rating on a 5-point scale, with 4 representing "good" and 5 representing "excellent." CONCLUSIONS: The program was appropriately timed and addressed topics relevant to the intern without sacrificing clinical experience or burdening inpatient services with interns' absence. The program received high satisfaction ratings from both the interns as well as the faculty. Additionally, the program fostered early relationships between interns and faculty-an unforeseen benefit. In the future, our program plans to better integrate validated learning metrics and improve instruction pertaining to both fluoroscopic examination and arthrocentesis.

Although inconvenient, baclofen pumps do not complicate scoliosis surgery in patients with cerebral palsy.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To compare patients with operative cerebral palsy with and without an intrathecal baclofen pump (ITB) to determine whether an ITB increases the complexity of scoliosis surgery and/or increases the risk of wound complications. SUMMARY OF BACKGROUND DATA: Options for baclofen pump placement include before, during, or after scoliosis surgery. There is some concern that prior placement of an ITB and catheter can further complicate cerebral palsy scoliosis surgery and increase the risk for wound complications. METHODS: Prospectively collected cases from a multicenter cerebral palsy scoliosis database were reviewed for patients who underwent posterior spinal instrumentation and fusion for a major coronal deformity. These patients were then divided on the basis of whether they had ITB at the time of initial scoliosis surgery. The 2 groups were compared to determine differences in demographics, operative parameters, radiographical outcomes, and rates of wound complications. RESULTS: Of 187 patients identified, 32 had an ITB previously placed (ITB group) and 155 did not (non-ITB group). Both groups were similar in regard to age, sex, Gross Motor Function Classification Scale score, and preoperative Cobb magnitude. When comparing operative parameters, there were no differences in the total operating room time (ITB = 375 ± 127 min, non-ITB = 423 ± 178 min; P = 0.149) or total estimated blood loss (ITB = 2323 ± 1489 mL, non-ITB = 2081 ± 1572 mL; P = 0.424). Postoperatively, the 2 groups had similar correction rates (71% vs. 67%, P = 0.303). As for perioperative wound complications, there were no differences in rates (P = 0.546) between the ITB (16%) and non-ITB group (15%). CONCLUSION: Although it may be inconvenient for the surgeon, ITBs do not increase the complexity of surgery or the risk for wound complications. When counseling patients and their caregivers on the timing of pump placement, it does not seem to compromise the care of the patient if the baclofen pump is placed first. Further study is needed to evaluate the safety of pump placement during or after scoliosis surgery. LEVEL OF EVIDENCE: 4.

Biomechanical Testing of Unstable Slipped Capital Femoral Epiphysis Screw Fixation: Worth the Risk of a Second Screw?

BACKGROUND: In a prior biomechanical study, 2-screw fixation of anatomically reduced slipped capital femoral epiphysis (SCFE) demonstrated marginally greater stability than single-screw fixation. However, the authors judged the benefits of a second screw to be minimal compared with the additional complication risk. A similar evaluation of fixation stability in unstable moderately displaced SCFE is performed. METHODS: SCFE model: Transverse periosteal incision and epiphyseal separation from the metaphysis by leveraging in 25-month-old porcine femurs. Four groups were evaluated: pinned (3.5 mm cortex screws; Synthes, Monument, CO) with no displacement (1 screw=group N1; 2 screws=group N2) or with moderate posterior-inferior displacement of 50% of the epiphyseal diameter (1 screw=group D1; 2 screws=group D2). Biomechanical testing: Cyclical shear forces (40 to 200 N, 1 Hz) were applied along the physeal plane. Maximum load increased by 100 N every 500 cycles until failure (epiphyseal translation greater than one third the epiphyseal diameter). Force cycles (the sum of the maximum cycle loads) and number of cycles to failure were reported. RESULTS: A sample from each D1 and D2 had fixation problems (D1, D2: n=4; N1, N2: n=5). One D1 failed through the femoral neck; all others failed through the epiphysis. The data showed nonsignificant trends of greater force cycles for nondisplaced over displaced (P=0.13) and for 2 screws over 1 (P=0.19). Number of cycles to failure showed similar trends, with no significant differences between nondisplaced and displaced (P=0.10) and screw number (P=0.13). Force cycles were significantly greater in the N2 group than in the D1 group. CONCLUSIONS: A trend toward higher force cycles to failure in nondisplaced and 2-screw groups was observed. Higher force cycles correspond to greater physeal stability and thus decreased risk for subsequent displacement. Within displacement groups, adding a second screw did not significantly increase stability. Reduction of displaced SCFE also did not significantly increase stability. Only the D1 and N2 groups were significantly different. CLINICAL RELEVANCE: Nondisplaced SCFE does not require 2 screws. In situ fixation of displaced SCFE might be optimized with 2 screws.

The perfused, pulseless supracondylar humeral fracture: intermediate-term follow-up of vascular status and function.

BACKGROUND: This study provides intermediate-term follow-up data on the vascular status of a cohort of children with a perfused, pulseless supracondylar humeral fracture who were managed with closed reduction, percutaneous pinning, and observation. METHODS: Pediatric patients who sustained a perfused, pulseless supracondylar humeral fracture in the period from 2007 to 2011 and who had at least six months of clinical follow-up were identified and returned for evaluation. The primary outcome was vascular status as indicated by palpation of the radial pulse, the wrist brachial index, and arterial patency on duplex ultrasound. Secondary outcomes included functional parameters assessed with the Pediatric Outcomes Data Collection Instrument (PODCI), arm circumference, arm length, elbow motion, neurologic findings, muscle endurance, grip strength, and intolerance to cold. RESULTS: Follow-up data were obtained for twenty of thirty-six patients with a Gartland type-III fracture who had been managed with closed reduction and percutaneous pinning. Five patients had a return of a palpable pulse in the operating room after closed reduction and percutaneous pinning. All twenty had a palpable radial pulse at the time of the latest follow-up, and all nerve palsies resolved. Duplex ultrasound performed at the time of follow-up showed that fourteen patients had a patent brachial artery, five had brachial artery occlusion with large collateral vessels, and one had severe arterial stenosis. All fourteen patients with a patent brachial artery, two of the five with an occluded brachial artery, and the patient with a stenotic brachial artery had a normal wrist brachial index. Three patients with an occluded brachial artery had an abnormal wrist brachial index (0.73, 0.71, and 0.80). No differences between the injured and uninjured sides were observed with regard to arm circumference, arm length, elbow motion, muscle endurance, or grip strength. Thirteen of the twenty patients had higher functioning in all domains of the PODCI questionnaire compared with the general population. Two patients (one with an occluded artery and one with a patent artery) had lower values on the global functioning score. CONCLUSIONS: After an average of twenty months of follow-up, children with a perfused, pulseless supracondylar humeral fracture that had been treated with closed reduction, percutaneous pinning, and observation demonstrated a palpable distal radial pulse, normal growth of the arm, and good/excellent functional outcomes, although five of the twenty patients had an occluded brachial artery. LEVEL OF EVIDENCE: Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of intraoperative red blood cell salvage and autotransfusion in the treatment of acetabular fractures.

OBJECTIVES: To determine if cell saver (CS) use in patients with acetabular fractures reduces the volume or rate of allogeneic blood transfused intraoperatively and postoperatively and if this translated to a decrease in blood-related charges to the patient. DESIGN: Retrospective review. SETTING: Level 1 trauma center. PATIENTS: One hundred eighty-six patients with operatively treated acetabular fractures. INTERVENTION: All patients underwent open reduction internal fixation of their acetabular fracture. The decision to use CS was at the surgeon's discretion. MAIN OUTCOME MEASUREMENTS: The volume and rate of intraoperative and postoperative allogeneic blood transfused and blood-related charges were evaluated. RESULTS: CS was used in 60 cases (32%), and the average volume of blood autotransfused was 345 mL. No differences were observed in the rates (58.3% vs 48%, P = 0.1883) or the mean volumes (770 vs 518 mL, P = 0.0537) of intraoperative and postoperative allogeneic blood transfusions between the CS and the non-CS groups. Total blood-related charges in the CS group were significantly higher than that in the nonCS group ($1958 vs $694, P < 0.0001). Subanalyses based on fracture pattern, injury severity score, body mass index, days to surgery, and estimated blood loss were performed. In each subanalyses, no differences were observed in intraoperative and postoperative transfusion rates and volumes, and total blood-related charges were higher in the CS groups. CONCLUSIONS: In the routine use of CS in acetabular surgery, there was no reduction in the volume or rate of allogeneic blood transfused intraoperatively or postoperatively. However, blood-related charges were significantly increased.