Patient Understanding and Perception of Urology Resident Training, Role, and Capabilities.

INTRODUCTION: We sought to identify patient understanding of urology residents and comfort with being cared for by residents. Through this pilot study, we aim to propose educational objectives to improve this knowledge gap and ultimately allow for an improved patient experience. METHODS: A prospective survey was distributed from September 2022 to October 2022. A patient knowledge about residents (KAR) score was calculated by combining correct responses to 5 questions (maximum = 5). Another score evaluating patient opinion of residents was calculated using Likert scale questions (range 3-19; higher scores correlate with positive opinion) denoting patient outlook on residents. RESULTS: A total of 88 surveys were completed. The average ± SD patient age was 62.7 ± 15.2 years. Patients previously seen by a resident had significantly higher KAR scores (3.591 ± 1.210) compared to patients never interacting with a resident or unsure (KAR = 2.381 ± 1.324; P < .0001). Additionally, those with higher levels of education had greater KAR scores (graduate-level KAR = 3.792 ± 1.179; P = .002). No variables were found to have a statistically significant impact on patients' average opinion of residents. CONCLUSIONS: Current patient understanding of the role of a urology resident is suboptimal. Given this knowledge gap, we hope to propose educational approaches to help aid in patient understanding of resident physicians, who play a critical role in their clinical care.

Penile Strangulation: Analysis of Postextrication Follow-Up, Sequelae, and a Review of Literature.

Numerous case reports exist on penile strangulation injuries and extrication methods; however, the care and long-term consequences of penile strangulation injuries have been under-reported. Our aim is to investigate the long-term outcomes and sequalae following penile strangulation injuries. The PubMed Medline database was searched using the keyword string "penile strangulation," "penis strangulation," and "constriction" for all studies reporting outcomes of published penile strangulation injuries. Articles were evaluated for follow-up after strangulation injury, strangulating agent, extricating agent, and sequelae of injury. Fifty-six studies resulted with reports of 100 cases of penile strangulation and extrication from January 2000 to December 2019. The mean patient age was 41 (range: 3-86) years. Twenty-four (24/100) cases reported sequalae following extrication. Follow-up ranged from 2 weeks to 7 years with median follow-up time in the 7- to 12-month grouping. Metal rings comprised 36% (36/100) of strangulation agents and 50% of reported incidents were attributed to sexual activity. To our knowledge, this is the only study focusing on long-term outcomes after penile strangulation. This review provides a summary of 56 studies that document penile strangulation injuries over the last 20 years. Although a wide array of penile strangulation injuries have been documented in the literature, reports lack secondary management and long-term outcomes after removal of the strangulation device. We recommend that providers report long-term penile strangulation outcomes for future urologic evaluations after extrication.

Deafening Silence of Male Infertility.

Think about 6 loved ones of reproductive age in your life. Now imagine that 1 of these 6 individuals is suffering from infertility. Perhaps they feel alone and isolated, unable to discuss their heartbreak with their closest friends, family, and support network. Suffering in silence. In this editorial, we discuss the infertility journey through the lens of the patients, the providers, and the scientists who struggle with infertility each and every day. Our goal is to open a dialogue surrounding infertility, with an emphasis on dismantling the longstanding societal barriers to acknowledging male infertility as a disease. Through education, communication, compassion, and advocacy, together we can all begin to break the deafening silence of male infertility.

The availability of gonadotropin therapy from FDA-approved pharmacies for men with hypogonadism and infertility.

Background: Recent changes to the Biologics Price Competition and Innovation Act of 2009 have created barriers to accessing therapy for men utilizing gonadotropins for hypogonadism and infertility. Aim: In this study we sought to investigate ways to decrease disparities in the treatment of male hypogonadism by increasing access to gonadotropin therapy by identifying 503b outsourcing pharmacies which currently provide gonadotropin therapy. Methods: A review of 503b compounding pharmacies was performed using the online published registry available from the US Food and Drug Administration (FDA). Each pharmacy was contacted regarding their ability to provide gonadotropin therapy. Pharmacies were also queried regarding the impact of FDA-related legal changes and cost considerations. Outcomes: The study outcomes were the number and location of FDA-approved 503b compounding pharmacies supplying human chorionic gonadotrophin (hCG) and/or follicle-stimulating hormone (FSH) for the treatment of male hypogonadism and infertility. Results: The 81 503b-compounding pharmacies approved by the FDA to produce hCG and FSH therapy were identified using the FDA registry. Seventy-five of the 81 pharmacies responded to the survey (response rate 92.6%). Of the contacted pharmacies, 5 provided hCG (6.67%). Of the pharmacies offering compounded hCG, 4 offered FSH. No additional pharmacies offered compounded FSH. Eight pharmacies had previously provided hCG and FSH. Six of the 8 pharmacies that stopped making hCG and FSH cited the 2020 FDA mandate as the reason for halting compounding services. Of the 75 pharmacies that responded, only 1 pharmacy provided the cost for FSH ($287 per 100-IU vial), and 3 pharmacies provided the cost for hCG ($50-$83 per 10 000-IU vial). Clinical Implications: There are few FDA-approved outsourcing pharmacies currently providing male gonadotropin therapy, and increasing awareness of these pharmacies may decrease barriers to care for patients with male hypogonadism and infertility. Strengths and Limitations: The strengths of this article are the clinical utility of the data presented, as this article may serve as a tool for clinicians to increase patient access to therapy. All FDA-approved 503b outsourcing pharmacies were contacted, and 92.6% participated in this project. Limitations of this article were the following: no non-FDA-approved compounding pharmacies such as 503a pharmacies were contacted, participant-reported outcomes were utilized, and only 3 contacted outsourcing pharmacies provided a cost for FSH or hCG, allowing for an unknown degree of cost variability between outsourcing pharmacies. Conclusions: There currently exists limited access to FDA-approved compounded gonadotropin therapies for hypogonadism and male infertility, and these results demonstrate the barriers to hCG and FSH access and the need for additional treatment options for this vulnerable patient population.

A Multilingual Chatbot Can Effectively Engage Arthroplasty Patients Who Have Limited English Proficiency.

BACKGROUND: In the United States, English language proficiency is widely accepted as a key social determinant of health. For patients with limited English proficiency (LEP), language barriers can make the delivery of perioperative instructions challenging. The purpose of this study was to evaluate whether a multilingual chatbot could effectively engage LEP patients and improve their outcome after total joint arthroplasty (TJA). METHODS: We identified 1,282 TJA patients (705 knees, 577 hips) who enrolled in a short message service (SMS) chatbot from 2020-2022. Forty-seven patients enrolled in the chatbot received their messages in a language other than English. A historical control of 68 LEP patients not enrolled in the chatbot was identified. Chi-squared, Fisher's exact test, and t-tests were performed to measure the effect that conversational engagement had on emergency department (ED) visits, hospital readmissions, and reoperations. RESULTS: There was no difference in the conversational engagement between LEP patients and those with English as their primary language (EPL) (12.3 versus 12.2 text responses, P = .959). The LEP cohort who enrolled in the chatbot had fewer readmissions (0% versus 8.3%, P = .013) and a near significant reduction in ED visits (0.9% versus 8.0%, P = .085) compared to those not enrolled. There was no difference in reoperations between the 2 cohorts. CONCLUSION: LEP and EPL patients engaged equally with the multilingual chatbot. LEP patients who enrolled in the chatbot had fewer readmissions and a near significant reduction in ED visits. Multilingual platforms such as this chatbot may provide more equitable care to our frequently encountered LEP patients.

Evaluating the Utility of Using Text Messages to Communicate With Patients During the COVID-19 Pandemic.

INTRODUCTION: We evaluated the use of text messages to communicate information to patients whose surgeries were postponed because of the COVID-19 restriction on elective surgeries. Our hypothesis was that text messaging would be an effective way to convey updates. METHODS: In this observational study, 295 patients received text messaging alerts. Eligibility included patients who had their surgery postponed and had a cell phone that received text messages. Engagement rates were determined using embedded smart links. Patient survey responses were collected. RESULTS: A total of 3,032 texts were delivered. Engagement rates averaged 90%. Survey responses (n = 111) demonstrated that 98.2% of patients liked the text messages and 95.5% said that they felt more connected to their care team; 91.9% of patients agreed that the text updates helped them avoid calling the office. Patients with higher pain levels reported more frustration with their surgery delay (5.3 versus 2.8 on 1 to 10 scale, P value < 0.01). More frustrated patients wished they received more text messages (24.4% versus 4.6%, P value = 0.04) and found the content less helpful (8.2 versus 9.2 on 1 to 10 scale, P value = 0.01). CONCLUSION: Text messaging updates are an efficient way to communicate with patients during the COVID-19 pandemic.

The quadriceps insertion of the medial patellofemoral complex demonstrates the greatest anisometry through flexion.

PURPOSE: A comprehensive understanding of the biomechanical properties of the medial patellofemoral complex (MPFC) is necessary when performing an MPFC reconstruction. How components of the MPFC change over the course of flexion can influence the surgeon's choice of location for graft fixation along the extensor mechanism. The purpose of this study was to (1) determine native MPFC length changes throughout a 90° arc using an anatomically based attachment and using Schöttle's point, and (2) compare native MPFC length changes with different MPFC attachment sites along the extensor mechanism. METHODS: Eight fresh-frozen (n = 8), cadaveric knees were dissected of all soft tissue structures except the MPFC. The distance between the femoral footprint (identified through anatomical landmarks and Schottle's point) and the MPFC was calculated at four attachment sites along the extensor mechanism [midpoint of the patella [MP], the center of the osseous footprint of the MPFC (FC), the superomedial corner of the patella at the quadriceps insertion (SM), and the proximal extent of the MPFC along the quadriceps tendon (QT)] at 0°, 20°, 40°, 60°, and 90° of flexion. RESULTS: Length changes were investigated between the MPFL femoral attachment site and the radiographic surrogate of the MPFL attachment site, Schottle's Point (SP). Paired t tests at each of the four components showed no differences in length change from 0° to 90° when comparing SP to the anatomic MPFC insertion. MPFL length changes from 0° to 90° were greatest at the QT point (13.9 ± 3.0 mm) and smallest at the MP point (2.7 ± 4.4 mm). The FC and SM points had a length change of 6.6 ± 4.2 and 9.0 ± 3.8, respectively. Finally, when examining how the length of the MPFC components changed through flexion, the greatest differences were seen at QT where all comparisons were significant (p < 0.01) except when comparing 0° vs 20° (n.s.). CONCLUSION: The MPFC demonstrates the most significant length changes between 0° and 20° of flexion, while more isometric behavior was seen during 20°-90°. The attachment points along the extensor mechanism demonstrate different length behaviors, where the more proximal components of the MPFC display greater anisometry through the arc of motion. When performing a proximal MPFC reconstruction, surgeons should expect increased length changes compared to reconstructions utilizing distal attachment sites.

A Novel, Automated Text-Messaging System Is Effective in Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Digital patient engagement platforms are designed to improve the efficacy of the perioperative surgical home, but the currently available solutions have shown low patient and provider adoption. The purpose of this study was to evaluate the effectiveness of a text-messaging (Short Message Service [SMS]) bot with respect to patient engagement following joint replacement procedures in a randomized clinical trial. METHODS: One hundred and fifty-nine patients (83 patients in the control group and 76 patients in the intervention group) were enrolled in a randomized controlled trial comparing the effectiveness of an SMS bot (intervention group) with the traditional perioperative education process (control group) in patients undergoing primary total knee or hip arthroplasty. There were no significant differences in the demographic characteristics between the 2 groups. The primary outcome of time participating in home-based exercises and the secondary outcomes of knee range of motion, the use of narcotics, visual analog scale (VAS) mood score, telephone calls to the office, patient satisfaction, and visits to the emergency department were measured and were compared between the 2 groups. Continuous outcomes were analyzed using linear regression, and categorical outcomes were analyzed using the Pearson chi-square test. RESULTS: Patients in the intervention group exercised for 8.6 minutes more per day: a mean time (and standard deviation) of 46.4 ± 17.4 minutes compared with 37.7 ± 16.3 minutes for the control group (p < 0.001). The intervention group had an improved mood (mean VAS, 7.5 ± 1.8 points compared with 6.5 ± 1.7 points for the control group; p < 0.001), stopped their narcotic medications 10 days sooner (mean time, 22.5 ± 13.4 days compared with 32.4 ± 11.8 days for the control group; p < 0.001), placed fewer telephone calls to the surgeon's office (mean calls, 0.6 ± 0.8 compared with 2.6 ± 3.4 for the control group; p < 0.001), and had greater knee range of motion 3 weeks after the surgical procedure (mean flexion, 101.2° ± 11.2° compared with 93.8° ± 14.5° for the control group; p = 0.008), but had an equal range of motion at 6 weeks. There was a trend toward fewer visits to the emergency department in the intervention group, but this comparison lacked statistical power. CONCLUSIONS: An SMS bot can improve clinical outcomes and increase patient engagement in the early postoperative period in patients undergoing hip or knee arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Innovation and Entrepreneurship: Perspectives From Orthopedic Surgery.

Orthopedic surgeons are tasked with treating complex patients while employing critical surgical skills, clinical knowledge, and new technologies. The constant inundation of information, coupled with hours in the hospital setting, provides unique perspectives on various aspects of how health care is delivered, thereby creating a milieu ripe for innovation. The rigors of an orthopedic career make it challenging for physicians to translate an idea into a great product. Through the authors' experiences at a tertiary orthopedic practice, they review the process of taking an idea from concept to fruition. [Orthopedics. 2018; 41(3):135-140.].

Involvement of Residents Does Not Increase Postoperative Complications After Open Reduction Internal Fixation of Ankle Fractures: An Analysis of 3251 Cases.

Ankle fractures are common injuries frequently treated by foot and ankle surgeons. Therefore, it has become a core competency for orthopedic residency training. Surgical educators must balance the task of training residents with optimizing patient outcomes and minimizing morbidity and mortality. The present study aimed to determine the effect of resident involvement on the 30-day postoperative complication rates after open reduction and internal fixation of ankle fractures. A second objective of the present study was to determine the independent risk factors for complications after this procedure. We identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who had undergone open reduction internal fixation for ankle fractures from 2005 to 2012. Propensity score matching was used to help account for a potential selection bias. We performed univariate and multivariate analyses to identify the independent risk factors associated with short-term postoperative complications. A total of 3251 open reduction internal fixation procedures for ankle fractures were identified, of which 959 (29.4%) had resident involvement. Univariate (2.82% versus 4.54%; p = .024) and multivariate (odds ratio 0.71; p = .75) analyses demonstrated that resident involvement did not increase short-term complication rates. The independent risk factors for complications after open reduction internal fixation of ankle fractures included insulin-dependent diabetes, increasing age, higher American Society of Anesthesiologists score, and longer operative times.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain.

BACKGROUND: Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space. PURPOSE: To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores. RESULTS: Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities. CONCLUSION: In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

The impact of obesity on outcomes and complications after top-down retropubic midurethral sling.

AIMS: Obese women (BMI ≥ 30 kg/m2 ) have been considered at higher risk for postoperative complications and failure in efficacy after SUI surgery. We compare the outcomes in this population with non-obese women (BMI < 30 kg/m2 ) undergoing top-down retropubic polypropylene midurethral sling (RPM). METHODS: We retrospectively identified 328 non-obese women and 294 obese women who underwent RPM. Evaluation included SEAPI (stress incontinence, emptying, anatomy, protection, inhibition) assessment and validated QoL questionnaires. Cure was defined as absence of subjective and objective SUI and no additional procedures to correct SUI. Perioperative details were abstracted from the hospital and clinic charts. Groups and outcomes were statistically compared. RESULTS: All women had a minimum follow up of 12 months. Preoperative demographic variables, SEAPI scores, and QoL indices were similar between BMI groups. SUI cure rates were significantly higher for non-obese women (82.9% vs. 74.5%; P < 0.01). When controlling for concomitant pelvic surgery, cure rates were not statistically different (76.9% vs. 73.7%; P = 0.65). Statistically significant improvement in SEAPI scores and QoL indices was achieved in both groups. Overall, obese women had no increase in complications compared with the non-obese. The chance of passing an initial postoperative voiding trial was statistically higher in the obese group. CONCLUSIONS: Obese women have similar success rates and significant improvement in QoL as non-obese women after RPM. Obesity alone does not appear to be a risk factor for additional complications during sling surgery and obese women may have earlier return to normal voiding after surgery.

Influence of Surgeon Volume on Inpatient Complications, Cost, and Length of Stay Following Total Ankle Arthroplasty.

BACKGROUND: Increased surgeon volume may be associated with improved outcomes following operative procedures. However, there is a lack of information on the effect of surgeon volume on inpatient adverse events and resource utilization following total ankle arthroplasty (TAA). METHODS: A retrospective cohort study of TAA patients was performed using the Nationwide Inpatient Sample (NIS) from 2003 to 2009. High-volume surgeons were considered as those with volume ≥90th percentile of surgeons performing TAA. Multivariate regression was used to compare the rates of adverse events, hospital length of stay, and total hospital charges between surgeon volume categories. RESULTS: A total of 4800 TAA patients were identified. The 90th percentile for surgeon volume was 21 cases per year. Mean length of stay was 2.8 ± 2.3 days and mean hospital charges were $45 963 ± $43 983. On multivariate analysis, high-volume surgeons had decreased overall complications (OR 0.5, P = .034) and rate of medial malleolus fracture (OR 0.1, P = .043), decreased length of stay (-0.9 days, P < .001), and decreased hospital charges (-$20 904, P < .001). CONCLUSIONS: Surgeons with volume ≥90th percentile had a decreased rate of complications, decreased length of stay, and reduced hospital charges compared to other surgeons. LEVEL OF EVIDENCE: Level III, comparative study.