A Curricular Model for Simulation Within Orthopaedic Residency Training.

Introduction: American Board of Orthopaedic Surgery/American Council on GraduateMedical Education Residency Review Committee training requirements have necessitated the need for the adoption of simulation education into existing programmatic requirements. Current guidelines focus only on interns at a potentially significant cost to programs; both in total dollar amount and time. Methods: The authors aim to provide a model that can maximize utility for all resident levels, manage cost by maximizing the use of cadaveric material, and allow integration of varied industry support. Results: The Oregon Health & Science University Orthopaedic education program has developed a high-fidelity training curriculum that (1) is applicable to both junior and senior residents (2) has minimized the cost per resident with the reuse of cadaveric specimens and (3) has nurtured partnerships with industry stakeholders to reduce bias in training by collaborating with most major industry representatives. Conclusion: The simulation curriculum outlined in this manuscript may serve as a reference for other programs and institutions to develop their own residency educational curriculum models.

Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management.

BACKGROUND: Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated. METHODS: A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated. RESULTS: Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses. CONCLUSIONS: Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

Traditional Versus Digital Media-Based Hand Therapy After Distal Radius Fracture.

PURPOSE: Distal radius fractures (DRFs) are common injuries with a rising incidence. A substantial portion of the cost of care is attributable to therapy services. Our purpose was to evaluate the effectiveness of a self-directed hand therapy program guided by digital media compared with that of traditional therapy. METHODS: We conducted a randomized controlled trial in patients aged 18 years or older who underwent open reduction and internal fixation of a DRF with volar plating. Subjects were randomized to traditional hand therapy using a 12-week protocol or an identical protocol presented in digital videos and performed at home. Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores were collected as the primary outcome at 2 weeks (baseline), 6 weeks, and 12 weeks or greater. Pain visual analog scale (VAS) scores, Veterans RAND 12-Item Health Survey (VR-12) scores, wrist and forearm range of motion, wrist circumference, and grip strength were recorded as secondary outcomes. RESULTS: Fifty-one patients were enrolled. Forty-nine patients were included in the analysis-21 in the digital media group and 28 in the traditional group. Both groups demonstrated significant improvements in QuickDASH scores between baseline and 12-week or greater time points. The QuickDASH scores in the digital media group were slightly more improved than those in the traditional group at the 6-week and 12-week or greater time points; however, these differences were not statistically significant. Pain VAS and VR-12 scores were comparable between group differences at each time point. CONCLUSIONS: Our digital media program was at least as effective as traditional therapy for patients undergoing volar plating of DRF. These results may help inform the design of future trials investigating the effectiveness of digital media-based hand therapy programs. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Optimizing Graft Extraction From the Femoral Condyle for Fresh Osteochondral Allograft Transplantation in Treating Osteochondritis Dissecans of the Capitellum: Best Fit Based on Radius of Curvature.

BACKGROUND: Osteochondritis dissecans (OCD) of the capitellum is a common cause of pain and dysfunction in adolescents that engage in repetitive elbow loading. For large, unstable lesions fresh osteochondral allograft transplantation (FOCAT) from the femoral condyle has been described as an effective treatment. Current practice involves significant guesswork in obtaining an appropriately sized graft, with anatomic variations resulting in poor graft fit. No studies currently exist that analyze and identify the best distal femur FOCAT graft site to repair OCD lesions of the capitellum based on the radius of curvature (ROC) and simulated matching. METHODS: Computed tomography scans of the elbow were used to estimate the subchondral bone ROC of capitella in adolescents aged 11 to 21 years. The capitellar location used corresponds to the most commonly reported site of OCD lesions in the elbow. Computed tomography scans of the lower extremity were used to estimate the subchondral bone ROC of 4 potential donor femoral condyle grafts. ROC from distinct regions at the posterior section of both the medial and lateral femoral condyles were measured: 2 areas representing 10 mm grafts from the center (MC1 and LC1), and 2 areas estimating 10 mm grafts posterior and adjacent to the physeal scar (MC2 and LC2). Intraobserver and interobserver reliability measurements were preformed to corroborate precision and validate the method. RESULTS: The mean ROC of healthy subchondral bone at the region of the capitellum were OCD lesions most commonly occur was 9.79±1.39 mm. The mean ROC of MC1 was 18.61±2.26 mm. The average ROC of the MC2 was 15.23±1.43 mm. The average ROC of LC1 was 16.47±1.34 mm. The average ROC of LC2 was 18.19±3.09 mm. After 15,000 simulated condyle-to-capitellar site matchings based on these measurements, a good fit graft was achieved at a frequency of 15%. DISCUSSION: No site measured from the femoral condyle demonstrated a subchondral ROC that exactly matched the subchondral ROC of the capitellum at the center location where OCD lesions most commonly occur; of the locations measured, a 10 mm section from MC2 demonstrated the closest match. On the basis of this analysis, extracting a graft from MC2 has the potential to further optimize FOCAT fit to the capitellum. LEVEL OF EVIDENCE: Level III.

Minimally Invasive Surgery: Is There a Role in Distal Radius Fracture Management?

PURPOSE OF REVIEW: This review explores minimally invasive surgical techniques for distal radius fractures and guides their use in conjunction with, or as an alternative to, volar locked plating. RECENT FINDINGS: Fractures of the lunate facet, die-punch fractures, and marginal articular shear injuries present challenges that cannot be easily addressed with volar plating. The use of external fixation, Kirschner wires, and dorsal bridge plating should all be considered. These techniques, in combination and in addition to volar locked plating, continue to play an important role in fracture management. Arthroscopically assisted surgery with minimally invasive fixation allows for detailed inspection of the radiocarpal joint. Closed treatment and casting continue to play an important role in distal radius fracture care. The role of minimally invasive surgery for distal radius fractures is still being defined. While fixation using a volar locking plate is by far the most common treatment method, other techniques should be considered to improve outcomes and decrease complications.

Neer Type-II Distal Clavicle Fractures: A Cost-Effectiveness Analysis of Fixation Techniques.

BACKGROUND: Neer type-II distal clavicle fractures are unstable and are generally appropriately managed with operative fixation. Fixation options include locking plates, hook plates, and suture button devices. No consensus on optimal technique exists. METHODS: A decision tree model was created describing fixation of Neer type-II fractures using hook plates, locking plates, or suture buttons. Outcomes included uneventful healing, symptomatic implant removal, deep infection requiring debridement, and nonunion requiring revision. Weighted averages derived from a systematic review were used for probabilities. Cost-effectiveness was evaluated by calculating incremental cost-effectiveness ratios (ICERs). The ICER is defined as the ratio of the difference in cost and difference in effectiveness of each strategy, and is measured in cost per quality-adjusted life year (QALY). The model was evaluated using thresholds of $50,000/QALY and $100,000/QALY. Sensitivity analysis was performed on all outcome probabilities for each fixation strategy to assess cost-effectiveness across a range of values. RESULTS: Forty-three papers met final inclusion criteria. Using suture buttons as the reference case in the health-care cost model, suture button repair was dominant (both less expensive and clinically superior). Hook plates cost substantially more ($5,360.52) compared with suture buttons and locking plates ($3,713.50 and $4,007.44, respectively). Suture buttons and locking plates yielded similar clinical outcomes (0.92 and 0.91 QALY, respectively). Suture button dominance persisted in the societal perspective model. Sensitivity analysis on outcome probabilities showed that locking plates became the most cost-effective strategy if the revision rate after their use was lowered to 2.2%, from the overall average in the sources of >19%. No other changes in outcome probabilities for any of the 3 techniques allowed suture buttons to be surpassed as the most cost-effective. CONCLUSIONS: The cost-effectiveness of suture buttons is driven by low revision rates and high uneventful healing rates. Similar QALY values for locking plate and suture button fixation were observed, which is consistent with existing literature that has failed to identify either as the clinically superior technique. Cost-effectiveness should fit prominently into the decision-making rubric for these injuries. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A new technique for olecranon osteotomy in the treatment of distal humeral fractures.

BACKGROUND: Olecranon osteotomy is a commonly used method for obtaining adequate exposure of the articular surface in complex distal humeral fractures. We describe a new technique whereby a precontoured olecranon plate is first fixed to the olecranon, and a Gigli saw is used to perform the osteotomy while the plate is in place. METHODS: By use of a standard posterior approach, a precontoured olecranon plate is applied to the olecranon and affixed with screws both proximally and distally to the planned osteotomy site. A Gigli saw is passed anterior to the olecranon and is used to create an osteotomy through the bare area of the sigmoid notch. The plate is removed from the distal fragment. The proximal olecranon fragment, plate, and extensor mechanism are retracted proximally en bloc to expose the articular surface. After fracture repair, the osteotomy fragments are reapproximated, and the plate is reattached to the distal fragment. QuickDASH (short version of the Disabilities of the Arm, Shoulder and Hand questionnaire) and Veterans RAND 12-Item Health Survey (VR-12) scores for patients treated with this technique were compared with those of patients treated with the standard chevron osteotomy method. RESULTS: All patients achieved radiographic and clinical union of the osteotomy site. QuickDASH, VR-12 physical, and VR-12 mental scores were not significantly different from those of patients in the chevron osteotomy group (P = .93, P = .79, and P = .68, respectively; t test). CONCLUSION: The described method provides excellent visualization of the joint, is less technically challenging than the standard chevron osteotomy, and reduces operative time. Osteotomy union was attained in all 5 cases, with functional outcomes comparable with those attained with the chevron technique.

Use of a Large Tenaculum Clamp as a Reduction Technique for Treatment of Distal Radius Fractures.

Distal radius fractures are common upper extremity injuries requiring surgical treatment. In the context of management with a volar locking plate (VLP), a number of described techniques assist with restoration of individual anatomical parameters such as radial length, volar tilt, and articular congruity. We present a surgical technique that utilizes a large tenaculum bone clamp to provide an efficacious reduction in several planes. With anteroposterior compression, the clamp enables volar translation of the distal fracture fragment. This compression also decreases the interval between the distal portion of the VLP and the fracture fragments. With a rotational force, the clamp can restore volar tilt of the articular surface. By positioning the tines of the clamp across the fracture in the coronal plane, a clamping force can correct medial or lateral translation of the distal fracture fragment. Proper reduction substantially minimizes complications such as abrasion or rupture of the flexor tendons along the VLP.

Dorsal Distraction Plating and Lunate Decortication for Stage III Kienböck Disease: A Novel Technique.

Kienböck disease (KD) is a progressive condition and difficult to manage. A number of treatment algorithms exist but there is no clear consensus as to which method produces the best outcome, particularly for Lichtman stage III disease. The majority of the current treatment options for KD emphasize lunate unloading and restoration of biology with bone graft. However, less attention has been given to the protection of the lunate during revascularization process. We report a novel technique of lunate decompression and bone grafting, combined with wrist distraction with or without radial shortening osteotomy via dorsal wrist bridge plating for the treatment of stage II-IIIa/b KD. This technique provides the advantages of distraction of the carpus unloading the lunate after bone grafting and during revascularization without the issues inherent to external fixation. In addition, this technique allows compression through a radial osteotomy site when performed. Our approach to the treatment of KD has incorporated this technique for patients with stage II or IIIa/b disease.

Effects of patellofemoral overstuffing on knee flexion and patellar kinematics following total knee arthroplasty: a cadaveric study.

PURPOSE: The purpose of this study was to test the hypothesis that overstuffing the patellofemoral joint during total knee arthroplasty (TKA) would decrease passive knee flexion and alter patellar kinematics during knee flexion. METHODS: Ten cadaveric knees were implanted with cruciate-retaining TKAs, and the patellofemoral joint was overstuffed in 2-mm increments with custom-augmented patellar prostheses (+2 mm through +8 mm). Changes to knee flexion, patellar shift, tilt and rotation were measured with an imageless optical-tracking computer navigation system. RESULTS: Knee flexion decreased an average 1.2° with each additional 2 mm of patellar thickness. Compared with control TKA (+0 mm), no significant decrease in knee flexion was detected until the patellofemoral joint was overstuffed with the +8-mm patellar prosthesis. Kinematic tracking data showed significantly greater lateral shift of patella with the +6- and +8-mm prostheses and significantly greater lateral tilt with the +8-mm prosthesis. Overstuffing had no appreciable effect on patellar rotation. CONCLUSIONS: Passive knee flexion after TKA is significantly reduced when overstuffing the patellofemoral joint by +8 mm, and patellofemoral kinematics are altered when overstuffing the joint by +6 mm. These results demonstrate the relatively modest effects of patellofemoral overstuffing on knee flexion and patellar tracking kinematics after TKA.

Fibrin glue augmentation for flexor tendon repair increases friction compared with epitendinous suture.

PURPOSE: To compare the gliding resistance, repair gapping, and ultimate strength of a common suture construct with a modified construct with fibrin glue augmentation. METHODS: Twelve human cadaveric flexor digitorum profundus tendons were transected and repaired with a 4-strand core suture. Specimens were divided into 2 groups and augmented with epitendinous suture (n = 6) or fibrin glue (n = 6). We compared gliding resistance, 2-mm gapping, and ultimate strength of the repaired tendon between groups. RESULTS: The linear stiffness, force to produce a 2-mm gap, and ultimate failure were similar in both repair methods. However, the 4-strand suture repair with fibrin glue augmentation displayed significantly higher gliding resistance compared with the 4-strand suture with a running epitendinous suture. CONCLUSIONS: The significantly increased gliding resistance associated with fibrin glue raises questions regarding the use of this material for flexor tendon repair augmentation. CLINICAL RELEVANCE: In a human cadaveric study, fibrin glue augmentation to zone II flexor tendon repairs significantly increased friction in the tendon sheath compared with an epitendinous suture.