Improving the Patient Experience During Care in the Orthopedic Cast Room.

Patients regularly have casts, splints, and wounds that require attention in the clinic. Patients commonly experience anxiety and pain during such visits. We hypothesized that aromatherapy and music would improve these patients' pain and anxiety when compared with no exposure. Patients in the orthopedic cast room were randomly exposed to no experience, music, or aromatherapy. Postprocedural surveys using an abbreviated form of the Spielberger State-Trait Anxiety Inventory (5 items; 4-point Likert scale) and a visual analog scale (0 to 10) were used to collect patient perceptions that were then compared using Spearman rank correlation calculations, t tests, and ordinal regression. Correlation results for the anxiety inventory were not different for patients with music or aromatherapy exposure vs no exposure; however, lower anxiety inventory scores were correlated with lower pain scores for upset, frightened, nervous, and confused measures. Mean reported pain scores were statistically lower for patients exposed to music (3.0) or aromatherapy (3.9) compared with patients who had no exposure (5.1; P=.004). These results support our hypothesis that exposure to music or aromatherapy improves pain. Although neither music nor aromatherapy resulted in significantly lower scores on the anxiety inventory items, the attention to patients' pain could have an indirect effect on their anxiety. [Orthopedics. 2024;47(2):e90-e92.].

Resident Perceptions of Virtual Reality Versus Dry Lab Simulation for Advanced Shoulder Arthroscopy Resident Training.

INTRODUCTION: Surgical training using simulation can fill gaps in traditional surgical residency learning. We hypothesize that arthroscopy training conducted on a virtual reality simulator will be preferred by orthopaedic surgery residents over a traditional dry lab simulation model. METHODS: 38 orthopaedic surgery residents at a single U.S. residency program were randomized to train for a shoulder arthroscopy procedure using either a virtual reality simulator or a table-top dry lab simulator. Training and learning preferences were then asked of the resident participants. RESULTS: Junior residents were likely to report training preference for the virtual reality simulator compared to senior residents [15/24 (62.5%) v. 8/14 (57.1%); P = .043]. Simulator preference was not influenced by subspecialty interest, prior arthroscopy experience, or simulator experience. Virtual reality simulation was associated with positive attitude towards arthroscopy and high chance of reporting learning gains on general arthroscopic understanding. Senior residents were 4.7 times more likely than juniors to report learning gains via staff discussion pre- and post-operatively. A majority of residents [34/38 (89.5%)] reported, however, wanting more simulation for training surgical skills. CONCLUSION: Simulation is a desired and potentially valuable adjunct to training orthopaedic residents in arthroscopy. Training needs do evolve; and junior arthroscopists may benefit more from virtual reality platforms for general skills. Senior residents preferred dry lab simulation, possibly because it allowed for handling of actual instruments and implants.

Bad to the bone. Not all bone tumors are cancer: Case of long bone osteomyelitis.

Long bone osteomyelitis could mimic bony tumor in clinical presentation and imaging studies. We present a case of a 47-year man who presented with leg pain, weight loss and night sweats that initially was thought to be related to osteosarcoma, later suffered a pathologic fracture from Staphylococcus aureus osteomyelitis. This case highlights the importance of source control of infection and careful clinical evaluation including radiographic and pathologic findings that can help physicians to differentiate between competing diagnoses.

Motorized Intramedullary Nail Lengthening in the Older Population.

Limb lengthening has not been widely employed in the elderly population due to concerns that outcomes will be inferior. The purpose of this multicenter, retrospective case-control series was to report the bone healing outcomes and complications of lower limb lengthening in older patients (≥60 years) using magnetic intramedullary lengthening nail (MILN). Our hypothesis was that healing parameters including consolidation days, the consolidation index, maturation days, and the maturation index, as well as the number of adverse events reported in the older population, would be no different to those of the general adult population. We retrospectively reviewed charts and radiographs from patients ≥60 years of age with limb-length discrepancies who underwent femoral or tibial lengthening using a MILN. Parameters were compared among the age categories "≤19 years," "20-39 years," "40-59 years," or "≥60 years" and propensity-matched cohorts for the age groups 20-59 years and ≥60 years. Complications were reported as percentages for each age category. In the study period, 354 MILN were placed in 257 patients. Sixteen nails were placed in patients 60 years of age or older (mean 65 ± 5 years; range 60-72 years). Comparisons of healing parameters showed no difference between those aged 60+ and the younger cohort. Complication percentages were not statistically significant (p = 0.816). Limb lengthening with MILN may therefore be considered a safe and feasible option for a generally healthy elderly population.

Musculoskeletal Conditions and Secondary Cardiovascular Morbidity Increase Veterans' Rehabilitation and Orthopaedic Service Utilization.

Background Musculoskeletal conditions often affect patients' mobility and ability to participate in health behaviors such as exercise, potentially affecting their systemic health. The purpose of this research is to determine how frequently cardiac-related comorbidities present in a veteran population with musculoskeletal service-connected disability and how this affects musculoskeletal health care utilization.  Methodology A retrospective cohort of Iraq and Afghanistan Veterans who received a Veterans Affairs (VA) disability determination for service-connected musculoskeletal disability were categorized according to the diagnosis of cardiac comorbidity including diabetes mellitus, hyperlipidemia, hypertension, and obesity, and atherosclerosis disease documented by ICD-9 codes in the VA administrative data. Among veterans with musculoskeletal service-connected disability, logistic regression was modeled to determine if musculoskeletal clinic utilization was associated with also having a cardiac comorbid condition.  Results Veterans with musculoskeletal disability had a comorbid cardiac disorder 43% of the time. Post-traumatic arthritis was the only musculoskeletal condition positively associated with comorbid cardiac conditions. Veterans with comorbid cardiac diagnoses had 26-37% higher odds of receiving care by physical and occupational therapy, physical medicine, and orthopaedic surgery clinics compared to veterans without comorbid cardiac disease. Conclusions Veterans in this cohort with musculoskeletal service-connected disability, plus cardiac conditions had greater clinic use for musculoskeletal and rehabilitation services compared to those without cardiac conditions. These results have implications for the rehabilitation and other health service needs of a new generation of veterans.

Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis.

Aim: In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS). Background: Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal. Technique: Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones. Conclusion: Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication. Clinical significance: The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS. How to cite this article: Elhessy AH, Rivera JC, Shu HT, et al. Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis. Strategies Trauma Limb Reconstr 2022;17(2):123-130.

Using the articularis genu to test peri-articular muscle health during knee osteoarthritis.

Knee osteoarthritis (OA) involves peri-articular sarcopenia. The infrapatellar articularis genu (AG) links to the quadriceps femoris (QF) and can be sampled from discarded tissue during arthroplasty. We predict disuse-mediated changes in AG myofiber type ratio and atrophy similar to reports on the QF during OA. OA AGs (n = 40) were preserved and grouped by poor (≤ 85°; n = 11), fair (90°-110°; n = 19), and good (≥ 115°; n = 10) range of motion (ROM). Immunolabeling of slow and fast myosin heavy chains in AG sections allowed comparing distribution and cross-sectional area (CSA) of type-I (T1) and type-II (T2) myofibers between groups and associating to ROM. T1/T2 ratios in fair and poor ROM groups was consistent with those published in OA QF. Increasing mean ± SD T2 percentages from good (43.31 ± 11.76), to fair (50.96 ± 5.85), and poor (60.02 ± 8.29) ROM groups was significant between poor versus fair (p = 0.018) and good (p < 0.0001) in association with ROM deficits (r = - 0.729; p < 0.0001). T1 and T2 CSA decreased with worsening ROM, which associates with lower symptom scores (r = 0.3198; p = 0.0472). In-depth evaluation of the OA AG as a surrogate for the OA QF relative to serum and/or synovial fluid biomarkers of sarcopenia could refine diagnostics of peri-articular muscle health to guide individualized strength rehabilitation after surgery.

The VA vascular injury study: A glimpse at quality of care in Veterans with traumatic vascular injury repair.

OBJECTIVE: The high number of limb injuries among Post-9/11 Veterans and their long-term care pose significant challenges to clinicians. Current follow-up for extremity arterial vascular injury (EVI) is based on guideline-concordant care for treatment of peripheral vascular disease (GCC-PVD), including anticoagulant/antiplatelet or statin therapy and duplex ultrasound. No best practices exist for arterial EVI. Our goal was to determine correlates of GCC-PVD and other care among Post-9/11 Veterans with combat-related arterial EVI. MATERIALS AND METHODS: We identified Post-9/11 Veterans with arterial EVI who underwent initial limb salvage repair or ligation (e.g., for single-vessel injury) attempt per DoD Trauma Registry validated by chart abstraction. Veterans Health Administration (VHA) data characterized the cohort in the first five years of VHA care. Models predicted (a) GCC-PVD, (b) pain clinic use, (c) mental/behavioral health care, (d) long-term opioid use, and (e) time to complication, controlling for injury severity and type, mental health parameters, and demographics. RESULTS: The 490-Veteran cohort with validated arterial injury was 77% White averaging 25.2 years at injury (range: 18-56). Mechanism of injury was primarily explosive (63%). Veterans had Injury Severity Scores classified as mild (60%), moderate (25%) and severe (15%). Approximately 25% received at least one component of VHA GCC-PVD including 8% arterial ultrasounds, 5% statins, and 11% anticoagulants/antiplatelets; 77% had mental/behavioral healthcare. GCC-PVD, as well as PTSD and substance use disorders, were associated with receipt of mental/behavioral health care. Complications affected 46% of the cohort and were more common among those prescribed 90+ days of opioids or receiving GCC-PVD. CONCLUSION: Despite injury severity (40% moderate/severe), only 25% of cohort patients received VHA GCC-PVD, and nearly half had complications from their arterial injury. Receiving GCC-PVD appeared to potentiate receiving care for mental and behavioral disorders. IMPACT: The treatment gap in Veterans with arterial EVI may be due to lack of appropriate guidelines, lack of vascular specialists in VHA or accessing care outside the VHA. Focused study of care options and their outcomes will help define optimal care processes for combat Veterans with arterial EVI.

Early Advanced Weight-Bearing After Periarticular Fractures: A Randomized Trial Comparing Antigravity Treadmill Therapy Versus Standard of Care.

SUMMARY: In current clinical practice, weight-bearing is typically restricted for up to 12 weeks after definitive fixation of lower extremity periarticular fractures. However, muscle atrophy resulting from restricting weight-bearing has a deleterious effect on bone healing and overall limb function. Antigravity treadmill therapy may improve recovery by allowing patients to safely load the limb during therapy, thereby reducing the negative consequences of prolonged non-weight-bearing while avoiding complications associated with premature return to full weight-bearing. This article describes a multicenter randomized controlled trial comparing outcomes after a 10-week antigravity treadmill therapy program versus standard of care in adult patients with periarticular fractures of the knee and distal tibia. The primary hypothesis is that, compared with patients receiving standard of care, patients receiving antigravity treadmill therapy will report better function 6 months after definitive treatment.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After Traumatic Orthopaedic Lower Extremity Injury (CBPT-Trauma).

SUMMARY: Physical and psychological impairment resulting from traumatic injuries is often significant and affects employment and functional independence. Extremity trauma has been shown to negatively affect long-term self-reported physical function, the ability to work, and participation in recreational activities and contributes to increased rates of anxiety and/or depression. High pain levels early in the recovery process and psychosocial factors play a prominent role in recovery after traumatic lower extremity injury. Cognitive-behavioral therapy pain programs have been shown to mitigate these effects. However, patient access issues related to financial and transportation constraints and the competing demands of treatment focused on the physical sequelae of traumatic injury limit patient participation in this treatment modality. This article describes a telephone-delivered cognitive-behavioral-based physical therapy (CBPT-Trauma) program and design of a multicenter trial to determine its effectiveness after lower extremity trauma. Three hundred twenty-five patients from 7 Level 1 trauma centers were randomized to CBPT-Trauma or an education program after hospital discharge. The primary hypothesis is that compared with patients who receive an education program, patients who receive the CBPT-Trauma program will have improved physical function, pain, and physical and mental health at 12 months after hospital discharge.

The Military Orthopedics Tracking Injuries and Outcomes Network: A Solution for Improving Musculoskeletal Care in the Military Health System.

INTRODUCTION: Musculoskeletal injuries are an endemic amongst U.S. Military Service Members and significantly strain the Department of Defense's Military Health System. The Military Health System aims to provide Service Members, military retirees, and their families the right care at the right time. The Military Orthopedics Tracking Injuries and Outcomes Network (MOTION) captures the data that can optimize musculoskeletal care within the Military Health System. This report provides MOTION structural framework and highlights how it can be used to optimize musculoskeletal care. MATERIALS AND METHODS: MOTION established an internet-based data capture system, the MOTION Musculoskeletal Data Portal. All adult Military Health System patients who undergo orthopedic surgery are eligible for entry into the database. All data are collected as routine standard of care, with patients and orthopedic surgeons inputting validated global and condition-specific patient reported outcomes and operative case data, respectively. Patients have the option to consent to allow their standard of care data to be utilized within an institutional review board approved observational research study. MOTION data can be merged with other existing data systems (e.g., electronic medical record) to develop a comprehensive dataset of relevant information. In pursuit of enhancing musculoskeletal injury patient outcomes MOTION aims to: (1) identify factors which predict favorable outcomes; (2) develop models which inform the surgeon and military commanders if patients are behind, on, or ahead of schedule for their targeted return-to-duty/activity; and (3) develop predictive models to better inform patients and surgeons of the likelihood of a positive outcome for various treatment options to enhance patient counseling and expectation management. RESULTS: This is a protocol article describing the intent and methodology for MOTION; thus, to date, there are no results to report. CONCLUSIONS: MOTION was established to capture the data that are necessary to improve military medical readiness and optimize medical resource utilization through the systematic evaluation of short- and long-term musculoskeletal injury patient outcomes. The systematic enhancement of musculoskeletal injury care through data analyses aligns with the National Defense Authorization Act (2017) and Defense Health Agency's Quadruple Aim, which emphasizes optimizing healthcare delivery and Service Member medical readiness. This transformative approach to musculoskeletal care can be applied across disciplines within the Military Health System.

Shoulder Arthroscopy Simulator Training Improves Surgical Procedure Performance: A Controlled Laboratory Study.

BACKGROUND: Previous simulation studies evaluated either dry lab (DL) or virtual reality (VR) simulation, correlating simulator training with the performance of arthroscopic tasks. However, these studies did not compare simulation training with specific surgical procedures. PURPOSE/HYPOTHESIS: To determine the effectiveness of a shoulder arthroscopy simulator program in improving performance during arthroscopic anterior labral repair. It was hypothesized that both DL and VR simulation methods would improve procedure performance; however, VR simulation would be more effective based on the validated Arthroscopic Surgery Skill Evaluation Tool (ASSET) Global Rating Scale. STUDY DESIGN: Controlled laboratory study. METHODS: Enrolled in the study were 38 orthopaedic residents at a single institution, postgraduate years (PGYs) 1 to 5. Each resident completed a pretest shoulder stabilization procedure on a cadaveric model and was then randomized into 1 of 2 groups: VR or DL simulation. Participants then underwent a 4-week arthroscopy simulation program and completed a posttest. Sports medicine-trained orthopaedic surgeons graded the participants on completeness of the surgical repair at the time of the procedure, and a single, blinded orthopaedic surgeon, using the ASSET Global Rating Scale, graded participants' arthroscopy skills. The procedure step and ASSET grades were compared between simulator groups and between PGYs using paired t tests. RESULTS: There was no significant difference between the groups in pretest performance in either the procedural steps or ASSET scores. Overall procedural step scores improved after combining both types of simulator training (P = .0424) but not in the individual simulation groups. The ASSET scores improved across both DL (P = .0045) and VR (P = .0003), with no significant difference between the groups. CONCLUSION: A 4-week simulation program can improve arthroscopic skills and performance during a specific surgical procedure. This study provides additional evidence regarding the benefits of simulator training in orthopaedic surgery for both novice and experienced arthroscopic surgeons. There was no statistically significant difference between the VR and DL models, which disproved the authors' hypothesis that the VR simulator would be the more effective simulation tool. CLINICAL RELEVANCE: There may be a role for simulator training in the teaching of arthroscopic skills and learning of specific surgical procedures.

What Is a Cytokine Storm and Should It Matter to Me?

The recent COVID-19 pandemic has brought attention to cytokines and the phenomenon of cytokine storm into mainstream discussions. In this disease specifically, a cytokine storm overwhelming immune response contributes to the pathophysiology and mortality of the COVID-19 infection. Analogous perturbed immune reactions are experienced in polytrauma patients, compromising local tissue healing while threatening multiple organ systems. The expanding field of osteoimmunology should contribute to the orthopaedic community's understanding of how the immune system response, whether normal or pathologic, affects the whole body outcome of our patients.

Intramedullary Antibiotic Depot Does Not Preclude Successful Intramedullary Lengthening or Compression.

SUMMARY: The challenging problem of long bone infection and limb length difference cannot be addressed using only an antibiotic-coated nonmagnetic static nail. The combined use of resorbable calcium sulfate and magnetic lengthening nails offers a possible solution to this dilemma, as well as for infected nonunions that require compression. We present a combined technique to treat or prevent infection using femoral or tibial intramedullary antibiotic delivery with an absorbable calcium sulfate depot and concomitant internal lengthening or compression using a nail. Adequate débridement is required in cases of established infection and is a prerequisite for this technique.

Early Fasciotomy and Limb Salvage and Complications in Military Lower Extremity Vascular Injury.

BACKGROUND: Military guidelines endorse early fasciotomy after revascularization of lower extremity injuries to prevent compartment syndrome, but the real-world impact is unknown. We assessed the association between fasciotomy and amputation and limb complications among lower extremitys with vascular injury. METHODS: A retrospectively collected lower extremity injury database was queried for limbs undergoing attempted salvage with vascular procedure (2004-2012). Limbs were categorized as having undergone fasciotomy or not. Injury and treatment characteristics were collected, as were intervention timing data when available. The primary outcome measure was amputation. Multivariate models examined the impact of fasciotomy on limb outcomes. RESULTS: Inclusion criteria were met by 515 limbs, 335 (65%) with fasciotomy (median 7.7 h postinjury). Of 212 limbs, 174 (84%) with timing data had fasciotomy within 30 min of initial surgery. Compartment syndrome and suspicion of elevated pressure was documented in 127 limbs (25%; 122 had fasciotomy). Tourniquet and shunt use, fracture, multiple arterial and combined arteriovenous injuries, popliteal involvement, and graft reconstruction were more common in fasciotomy limbs. Isolated venous injury and vascular ligation were more common in nonfasciotomy limbs. Fasciotomy timing was not associated with amputation. Controlling for limb injury severity, fasciotomy was not associated with amputation but was associated with limb infection, motor dysfunction, and contracture. Sixty-three percent of fasciotomies were open for >7 d, and 43% had multiple closure procedures. Fasciotomy revision (17%) was not associated with increased amputation or complications. CONCLUSIONS: Fasciotomy after military lower extremity vascular injury is predominantly performed early, frequently without documented compartment pressure elevation. Early fasciotomy is generally performed in severely injured limbs with a subsequent high rate of limb complications.

Prescriptions for opioids and opioid-included polypharmacy: An analysis of the National Hospital Ambulatory Medical Care Survey.

OBJECTIVE: Opioid-associated complications are compounded by other concomitant drugs that affect the central nervous system (CNS). This analysis aims to describe opioid and CNS polypharmacy from a representative sample of emergency department (ED) encounters to identify patient- and facility-level characteristics associated with these prescription outcomes. DESIGN: Generalized linear regression multivariable modeling was used to test for associations between the prescrip-tion outcomes and individual and group level predictors. SETTING: Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for ED encounters from 2006-2015 were analyzed. PARTICIPANTS: Survey entrants who received ED care within the above timeframe were analyzed. MAIN OUTCOMES: The primary outcomes were dichotomous variables of an opioid or CNS polypharmacy prescription. RESULTS: Twenty-five percent of encounters resulted in an opioid prescription plus another CNS medication prescription. Diagnoses of a blood disorder, musculoskeletal disorder or gastrointestinal disorder were associated with opioid prescription. Fifty-five percent of the presenting pain level treated with an opioid was reported as severe while 11 percent of opioid prescriptions were given to patients reporting no pain or mild pain. Non-Hispanic blacks had the lowest odds of receiving an opioid or CNS polypharmacy prescription compared to Non-Hispanic whites. Hospitals located within areas of increasing levels of poverty had decreasing odds of dispensing opioids following an ED encounter. CONCLUSION: Opioid prescriptions resulted from one-quarter of ED encounters despite the acute care setting of the ED and included 11 percent frequency of prescription for patients reporting no pain or mild pain.

Developing a Novel Scoring System to Objectively Track Orthopaedic Resident Educational Performance and Progression.

OBJECTIVE: Objectively determining orthopedic resident competence remains difficult and lacks standardization across residency programs. We sought to develop a scoring system to measure resident educational activity to stratify participation and performance in particular aspects of training and the effect of these measures on board certification. DESIGN: A weighted scoring system (Average Resident Score, ARS) was developed using the number of logged cases, clinic notes dictated, OITE PGY percentile, case minimums met, and scholarly activity completed each academic year (AY), with clinical activity being more heavily weighted. The Resident Effectiveness Score (RES), a z-score showing the number of standard deviations from the mean, was determined using the ARS. The RES effect on the Accreditation Council for Graduate Medical Education (ACGME) Milestones and American Board of Orthopedic Surgery (ABOS) Part 1 percentile score was determined using a Spearman correlation. SETTING: Large academic orthopedic residency. PARTICIPANTS: Thirty one orthopedic residents graduating between 2011 and 2016 were included. RESULTS: The RES did not differ between classes in the same AY, nor change significantly for individual residents during their training. Milestone z-scores increased as residents progressed in their education. The RES correlated with each Milestone competency subscore. The PGY5 OITE score and achieving ACGME minimums correlated with passing ABOS Part 1 (28/31 1st time pass), but the RES did not predict passing the board examination. CONCLUSIONS: This study demonstrates a scoring system encompassing multiple facets of resident education to track resident activity and progress. The RES can be tailored to an individual program's goals and aims and help program directors identify residents not maximizing educational opportunities compared to their peers. Monitoring this score may allow tailoring of educational efforts to individual resident needs. This RES may also allow residents to measure their performance and educational accomplishments and adjust their focus to obtain competence and board certification.

Pharmacological Mitigation of Fibrosis in a Porcine Model of Volumetric Muscle Loss Injury.

Volumetric muscle loss (VML) resulting from extremity trauma presents functional deficits and fibrosis, ultimately manifesting disability. The extensive fibrotic accumulation is expected to interfere with neural, trophic, vascular, and mechanical connectivity of any possible regenerative medicine approaches. Our objective was to quantify the muscle properties and stiffness following injury and investigate if the fibrotic deposition could be mitigated using an antifibrotic agent; we hypothesized that antifibrotic treatment would prevent the overwhelming fibrotic response. Yorkshire Cross pigs (n = 10) were randomized to sham or a nontreated ∼20% VML injury. Immediately following surgery, injured animals were further randomized to nintedanib (Ofev; 300 mg/day) or no treatment for 30 days. Longitudinal analysis of muscle function via peroneal nerve stimulation, compartment volume, and quantitative muscle stiffness using shearwave elastography were conducted. Terminally comprehensive histopathologic, biochemical, and genetic investigations were conducted on the skeletal muscle and fibrosis. Through 4 weeks post-VML, nontreated muscles presented a significant deficit (23%) in maximal torque compared to the sham operated (p < 0.01). The stiffness in the VML defect area increased significantly (7-fold) in the VML-nontreated leg than the VML antifibrotic-treated legs by 4 weeks postinjury, which was coupled with the nontreated muscle having ∼40% more hydroxyproline per mg of tissue than those receiving antifibrotic treatment (p = 0.01). This work indicates that VML injury progressively induces fibrosis and muscle stiffness. Antifibrotic treatment can mitigate the pathologic development of fibrosis. Future work should evaluate optimal timing and duration of treatments combined with regenerative medicine approaches in efforts to improve function. Impact statement This work primarily evaluated the effect of a clinically available antifibrotic therapy (nintedanib) on the development of fibrosis after volumetric muscle loss (VML) injury in a large animal model. As a primary outcome measure of fibrosis, skeletal muscle stiffness was repeatedly measured in vivo and noninvasively using a quantitative ultrasound device with shearwave elastography capability. The most salient finding of the study is that the antifibrotic nintedanib significantly reduced the development of VML injury-induced fibrous tissue deposition and stiffness.

Analysis of References Used in Orthopaedic Self-Assessment Exams.

Orthopaedic surgery board certification and maintenance of certification requires success on standardized tests and ongoing continuing medical education. This study aims to identify the most impactful resources for preparation for and maintenance of board certification. Questions included in the Orthopaedic Self-Assessment Exams (SAEs) from 2009 to 2014 were examined with the type and age of reference materials cited for each question. There were 4479 total citations. There were 289 journals and 95 textbooks identified. The Journal of Bone and Joint Surgery (15% of citations), Journal of the American Academy of Orthopaedic Surgeons (11%), and Clinical Orthopaedic and Related Research (6%) were the most frequently cited journals. The average age of cited articles was 8.2 years. These data demonstrate that certain orthopaedic journals are consistently the most commonly cited references for SAEs and could also be expected to be the highest yield references for knowledge acquisition and exam preparation. (Journal of Surgical Orthopaedic Advances 27(2):92-97, 2018).

Orthopaedic Resident Surgical Case Log Disparities Observed in the Next Accreditation System.

INTRODUCTION: With the institution of the Next Accreditation System (NAS), case log procedures fundamentally changed. Unless multiple entries are made, only one procedure per case is credited for procedure counts. We hypothesized that the NAS caused notable changes in national procedure data. METHODS: Accreditation Council for Graduate Medical Education Orthopaedic Surgery Case Logs National Data Reports from 2008 to 2016 were analyzed to calculate differences in case log data before and after NAS implementation. RESULTS: In the first academic year post-NAS, the average total procedures decreased by 36%. Total procedures increased the following 2 years but still represent a decrease of >30% from pre-NAS data. An average of 580 fewer total procedures per resident were reported in the 3 years post-NAS (P = 0.001). Regression analysis showed notable decreases in credited procedures in all but two categories. CONCLUSIONS: The decrease in logged procedures with the NAS may be related to new guidance, resident logging habits, an actual decrease in surgical experience, or unknown causes, or combinations of these factors. A new baseline of case data may be emerging post-NAS. To ensure the highest quality education, NAS case logs warrant continued study to determine how the data should be used in residency education and accreditation decisions.