Musculoskeletal Medicine Is Underrepresented in the American Medical School Clinical Curriculum.

BACKGROUND: Musculoskeletal (MSK) conditions are common, and their burden on the healthcare system is increasing as the general population ages. It is essential that medical students be well prepared to evaluate and treat MSK disorders in a confident manner as they enter the workforce. Recent studies and the American Association of Medical Colleges have raised concern that medical schools may not give sufficient instruction on this topic. Other authors have shown that preclinical instruction has increased over the past decade; however, it is unclear if required clinical instruction also has followed that trend. QUESTIONS/PURPOSES: The purposes of this study were: (1) to assess the presence and duration of required or selective instruction in a MSK medicine specialty within the clinical years of undergraduate medical education; and (2) to assess the current state of requirements of clinical clerkships or rotations in other surgical and nonsurgical fields for comparison with the initial findings. METHODS: The web sites of all 141 US medical schools were assessed to determine the content of their clinical curricula for the 2014-2015 academic year; five were excluded because they had not yet had a graduating class by the conclusion of the 2014-2015 academic year. Complete information on required rotations was obtained through the schools' web sites for all 136 (100%) medical schools. For selective experience during the surgery clerkships, complete information was available for 130 of the remaining 136 (96%) web sites. RESULTS: Mean (in weeks, ± SD) duration of core clerkships were as follows: internal medicine (10 ± 2), surgery (8 ± 2), pediatrics (7 ± 1), obstetrics/gynecology (6 ± 1), and psychiatry (5 ± 1). Other common required clerkships were: family medicine (required in 96% [131 of 136] of schools, mean duration of 6 ± 2 weeks), neurology (81% [110], 4 ± 1), and emergency medicine (55% [75], 3 ± 1). Required MSK instruction, at a mean of 2 ± 1 weeks, was only present in 15% (20 of 136) of medical schools. In addition, clinical MSK instruction was offered as a selective (eg, students pick from a selection of subspecialties such as orthopaedics, plastics, or urology during a general surgery clerkship) in 34% (44 of 130) of all medical schools. This is less than other non-core specialties: geriatrics/ambulatory care (required in 40% [54 of 136] of schools, mean duration of 3 ± 1 weeks), critical care (30% [41], mean of 3 ± 1 weeks), radiology (26% [35], mean of 3 ± 1 weeks), anesthesiology (23% [31], mean of 2 ± 1 weeks), and other surgical subspecialties (19% [26], mean of 3 ± 1weeks). CONCLUSIONS: Traditional core clerkships continue to be well represented in the clinical years, whereas three newer specialties have gained a larger presence: family medicine, neurology, and emergency medicine; these comprise the "big eight" of clinical clerkships. Given the high prevalence and burden of MSK disorders, required experience in MSK medicine continues to be underrepresented. Further discussion at a national level is needed to determine appropriate representation of MSK medicine specialties during the clinical years.

Erythropoietin Enhanced Recovery After Traumatic Nerve Injury: Myelination and Localized Effects.

PURPOSE: We previously found that administration of erythropoietin (EPO) shortens the course of recovery after experimental crush injury to the mouse sciatic nerve. The course of recovery was more rapid than would be expected if EPO's effects were caused by axonal regeneration, which raised the question of whether recovery was instead the result of promoting remyelination and/or preserving myelin on injured neurons. This study tested the hypothesis that EPO has a direct and local effect on myelination in vivo and in vitro. METHODS: Animals were treated with EPO after standard calibrated sciatic nerve crush injury; immunohistochemical analysis was performed to assay for myelinated axons. Combined in vitro neuron-Schwann cell co-cultures were performed to assess EPO-mediated effects directly on myelination and putative protective effects against oxidative stress. In vivo local administration of EPO in a fibrin glue carrier was used to demonstrate early local effects of EPO treatment well in advance of possible neuroregenerative effects. RESULTS: Systemic Administration of EPO maintained more in vivo myelinated axons at the site of nerve crush injury. In vitro, EPO treatment promoted myelin formation and protected myelin from the effects of nitric oxide exposure in co-cultures of Schwann cells and dorsal root ganglion neurons. In a novel, surgically applicable local treatment using Food and Drug Administration-approved fibrin glue as a vehicle, EPO was as effective as systemic EPO administration at time points earlier than those explainable using standard models of neuroregeneration. CONCLUSIONS: In nerve crush injury, EPO may be exerting a primary influence on myelin status to promote functional recovery. CLINICAL RELEVANCE: Mixed injury to myelin and axons may allow the opportunity for the repurposing of EPO for use as a myeloprotective agent in which injuries spare a requisite number of axons to allow early functional recovery.

Pharmacological Attenuation of Electrical Effects in a Model of Compression Neuropathy.

BACKGROUND: Peripheral nerve compression and entrapment can be debilitating. Using a validated animal model of peripheral nerve compression, we examined the utility of 2 drugs approved for other uses in humans, 4-aminopyridine (4-AP) and erythropoietin (EPO), as treatments for surgically induced ischemia and as adjuvants to surgical decompression. METHODS: Peripheral nerve compression was induced in wild-type mice by placing an inert silicone sleeve around the sciatic nerve. Decompression surgery was performed at 6 weeks with mice receiving 4-AP, EPO, or saline solution either during and after compression or only after decompression. A nerve conduction study and morphometric analyses were performed to compare the extent of the injury and the efficacy of the therapies, and the findings were subjected to statistical analysis. RESULTS: During peripheral nerve compression, there was a progressive decline in nerve conduction velocity compared with that in sham-treatment animals, in which nerve conduction velocity remained normal (∼55 m/s). Mice treated with 4-AP or EPO during the compression phase had significantly smaller declines in nerve conduction velocity and increased plateau nerve conduction velocities compared with untreated controls (animals that received saline solution). Histomorphometric analyses of newly decompressed nerves (i.e., nerves that underwent decompression on the day that the mouse was sacrificed) revealed that both treated groups had significantly greater proportions of large (>5-µm) axons than the untreated controls. Following surgical decompression, all animals recovered to a normal baseline nerve conduction velocity by day 15; however, treatment significantly accelerated improvement (in both the 4-AP and the EPO group), even when it was only started after decompression. Histomorphometric analyses at 7 and 15 days following surgical decompression revealed significantly increased myelin thickness and significantly greater proportions of large axons among the treated animals. CONCLUSIONS: Both the 4-AP and the EPO-treated group demonstrated improvements in tissue architectural and electrodiagnostic measurements, both during and after peripheral nerve compression, compared with untreated mice. CLINICAL RELEVANCE: Peripheral nerve decompression is one of the most commonly performed procedures in orthopaedic surgery. We believe that there is reason for some optimism about the translation of our findings to the clinical setting. Our findings in this murine model suggest that 4-AP and EPO may lessen the effects of nerve entrapment and that the use of these agents after decompression may speed and perhaps otherwise optimize recovery after surgery.

Shoulder arthritis secondary to rotator cuff tear: A reproducible murine model and histopathologic scoring system.

Untreated rotator cuff tears can progress to a distinct form of shoulder arthritis, and the mechanism of this progression is poorly understood. Biomechanical, molecular and genetic factors may be at play, and a reliable animal model is needed to enable further research. The purpose of this study was to create a reproducible model of posttraumatic shoulder arthritis in the mouse, and to develop a scoring system for this model to enable future research on interventions, the role of various gene products, and the development of therapies to alter the natural course of the disease. Forty-five mice underwent operative ligation of the rotator cuff tendons and were followed for 45 weeks following surgery, with free cage activity post-operatively. Mice were sacrificed at various intervals from 2 to 45 weeks post-injury and histopathologic scoring was developed and tested by blinded reviewers using both quantitative computational analysis of coronal sections of the shoulder joint and semi-quantitative grading. The scoring system revealed a progressive, time-dependent set of tissue changes in the shoulder joint with features similar to human cuff tear arthropathy including acetabularization of the acromion and femoralization of the humeral head. This model establishes that osteoarthritis of the shoulder is distinct from osteoarthritis of the knee or hip, with different stages of degeneration and unique histopathologic features. Using the novel grading procedure and quantitative assessments presented here, future research using this model will enable investigators to test established and novel therapies and evaluate the role of inflammatory factors and gene products in shoulder arthritis. This study provides a reproducible mouse model of shoulder arthritis following isolated injury to the rotator cuff which elucidates characteristics of cuff tear arthropathy and provides a scoring system and venue for future research. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:506-514, 2017.

4-Aminopyridine promotes functional recovery and remyelination in acute peripheral nerve injury.

Traumatic peripheral nerve damage is a major medical problem without effective treatment options. In repurposing studies on 4-aminopyridine (4-AP), a potassium channel blocker that provides symptomatic relief in some chronic neurological afflictions, we discovered this agent offers significant promise as a small molecule regenerative agent for acute traumatic nerve injury. We found, in a mouse model of sciatic crush injury, that sustained early 4-AP administration increased the speed and extent of behavioral recovery too rapidly to be explained by axonal regeneration. Further studies demonstrated that 4-AP also enhanced recovery of nerve conduction velocity, promoted remyelination, and increased axonal area post-injury. We additionally found that 4-AP treatment enables distinction between incomplete and complete lesions more rapidly than existing approaches, thereby potentially addressing the critical challenge of more effectively distinguishing injured individuals who may require mutually exclusive treatment approaches. Thus, 4-AP singularly provides both a new potential therapy to promote durable recovery and remyelination in acute peripheral nerve injury and a means of identifying lesions in which this therapy would be most likely to be of value.

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures.

PURPOSE: To determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes. METHODS: Skeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts. RESULTS: Thirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0-18], and 15 ± 7.9° [range 2-27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p>0.05). Patients with at least 20° (n=7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p=0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p=0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p<0.05 for all). CONCLUSION: Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.

Factors predicting patient-reported functional outcome scores after humeral shaft fractures.

PURPOSE: The aim of this study was to determine patient variables that are independent predictors of validated functional outcome scores after humeral diaphyseal fractures. METHODS: Adult patients with humeral shaft fractures were retrospectively recruited from a level 1 trauma centre over an 8-year period. Basic demographic information was obtained along with Disabilities of the Arm, Shoulder and Hand (DASH), Simple Shoulder Test (SST) and Short Form 12 (SF-12) physical component summary (PCS) and mental component summary (MCS). Regression analysis was performed to identify patient factors associated with satisfactory outcomes, defined as DASH<21; SST≥10; PCS≥40; and MCS≥40. Of 95 eligible patients, 77 were recruited. Participants had an average age of 47±20 years. Forty-five patients were treated with surgery and 32 healed non-operatively. The average follow-up was 48±29 months. RESULTS: Satisfactory DASH scores decreased with increase in age (odds ratio (OR) 0.95; P=0.023). Satisfactory SST scores were more likely in patients without a history of psychiatric illness (OR 6.3; P=0.01). Satisfactory SF-12 PCS scores were more likely with no psychiatric history (OR 12; P=0.007) and in patients with private insurance (OR 11.4; P=0.03), but these scores decreased with rising Charlson comorbidity index (CCI; OR 0.50; P=0.023). Satisfactory SF-12 MCS scores increased in the absence of psychiatric history (OR 39; P=0.003), and decreased with rising CCI score (OR 0.54; P=0.035). Analysis of patients younger than 50 years of age (n=38) revealed that the absence of psychiatric history increased the odds of satisfactory DASH scores (OR 10.4; P=0.04). Patients aged ≥50 (n=39) had worse DASH scores with increasing age (OR 0.89; P=0.037), better SST scores with middle-third fractures compared to proximal (OR 7.8; P=0.039), better SF-12 PCS with no psychiatric history (OR 16.1; P=0.018) and worse scores with rising CCI (OR 0.50; P=0.036), while rising CCI decreased the odds of satisfactory SF-12 MCS scores (OR 0.47; P=0.046). Treatment modality, associated fractures and classification as "high energy" mechanism were not associated with outcome. CONCLUSION: Patient age, history of psychiatric illness, insurance type, fracture location and Charlson comorbidity index scores had a statistically significant effect on patient-reported functional outcomes following treatment of humeral shaft fractures, regardless of treatment modality, injury mechanism and associated fractures. The impact of these variables may be age dependent.