Ascertaining the Readiness of Military Orthopedic Surgeons: A Revision to the Knowledge, Skills, and Abilities Methodology.

INTRODUCTION: Decay of military surgeons' critical wartime skills is a persistent and growing concern among leaders in the military health system (MHS). The Knowledge, Skills and Abilities (KSA) Clinical Readiness Program was developed to quantify the readiness of clinicians in the MHS; however, the utility of the data is questionable due to a lack of focus on the operative expeditionary skillset in the original methodology. A revised methodology emphasizing the most relevant to expeditionary orthopedic surgery procedures is described. MATERIALS AND METHODS: All Current Procedural Terminology (CPT) codes included in the original KSA methodology were reviewed and, if appropriate, removed, or reassigned to more suitable categories. Category scores were weighted to better align with the most performed procedures in the deployed environment. All surgical cases and procedures performed from 2017-2019 in military treatment facilities by orthopedic surgeons were recorded in total and by MHS market. Cases were recorded for all military orthopedic surgeons who performed at least one KSA credit procedure during the study period. The 10 MHS markets with the greatest number of procedures were included in the analysis. The change in creditable KSA procedure codes and procedures performed from the original to revised methodology was determined for each KSA category and MHS market. RESULTS: Overall, 403 CPT codes were recategorized and 79 were deleted from the original KSA methodology. The deletions represented less than 4% of the original creditable CPT codes, with most being supply or injection codes. Three of the five most common expeditionary KSA categories increased in the number of creditable procedure codes. The impact of the revision on the MHS markets was mixed, but the overall volume of credited procedures decreased. The weighted scoring did not disproportionately affect the analyzed markets. CONCLUSIONS: The revised methodology is better aligned with the most common procedures in the most recent large-scale military engagements. The improved applicability of the KSA scoring to necessary CWS will allow military medical leaders to better determine the readiness opportunities available in the MHS.

Impact of Civilian Patient Care on Major Amputation Case Volume in the Military Health System.

BACKGROUND: Sustaining critical wartime skills (CWS) during interwar periods is a recurrent and ongoing challenge for military surgeons. Amputation surgery for major extremity trauma is exceptionally common in wartime, so maintenance of surgical skills is necessary. This study was designed to examine the volume and distribution of amputation surgery performed in the military health system (MHS). STUDY DESIGN: All major amputations performed in military treatment facilities (MTF) for calendar years 2017-2019 were identified by current procedural terminology (CPT) codes. The date of surgery, operating surgeon National Provider Identifier, CPT code(s), amputation etiology (traumatic versus nontraumatic), and beneficiary status (military or civilian) were recorded for each surgical case. RESULTS: One thousand one hundred and eighty-four major amputations at 16 of the 49 military's inpatient facilities were identified, with two MTFs accounting for 46% (548/1,184) of the total. Six MTFs performed 120 major amputations for the treatment of acute traumatic injuries. Seventy-three percent (87/120) of traumatic amputations were performed at MTF1, with the majority of patients (86%; 75/87) being civilians emergently transported there after injury. Orthopedic and vascular surgeons performed 78% of major amputations, but only 9.7% (152/1,570) of all military surgeons performed any major amputation, with only 3% (52) involved in amputations for trauma. Nearly all (87%; 26/30) of the orthopedic surgeons at MTF1 performed major amputations, including those for trauma. CONCLUSION: This study highlights the importance of civilian patient care to increase major amputation surgical case volume and complexity to sustain critical wartime skills. The preservation and strategic expansion of effective military-civilian partnerships is essential for sustaining the knowledge and skills for optimal combat casualty care.

Establishing an Orthopedic Program-Specific, Comprehensive Competency-Based Education Program.

BACKGROUND: Competency-based education (CBE) seeks to determine resident proficiency in the knowledge, skills, and behaviors required for independent patient care. Multiple assessment instruments evaluate technical skills or direct patient care in the clinic setting, but there are few reports incorporating both within an orthopedic specialty rotation. This study reports a residency program's comprehensive CBE initiative using formative assessments in the clinic and operating room during a sports medicine rotation. MATERIALS AND METHODS: The sports medicine rotation used validated formative assessments to evaluate resident performance during clinic encounters and program-defined surgical entrustable professional activities (EPAs). Junior resident (postgraduate year [PGY] 1-2) EPAs included basic knee/shoulder arthroscopic procedures. Senior resident (PYG 5) EPAs comprised anterior cruciate ligament reconstruction, biceps tenodesis, shoulder stabilization, and rotator cuff repair. Assessment scores were compared between individuals and PGY groups. RESULTS: Sixty-six clinical skills (CS) and 106 surgical skills assessments were conducted for 22 residents in one academic year. Surgical skills assessments demonstrated significant differences between each PGY group (P < 0.01). All PGY2 and PGY5 residents achieved independence on the evaluated EPAs. PGY5s earned higher scores in CS assessments than the other classes (P < 0.01). PGY2 residents scored higher than PGY1s in 7 of 9 CS domains. CS independence was achieved by 21 of 22 residents by the end of the rotation. CONCLUSIONS: The CBE program effectively quantified expected differences in resident performance by PGY for clinic and surgical assessments on a sports medicine rotation. Assessments built an environment where feedback was more structured and standardized, creating a culture to improve resident education.

Diagnosis and Management of Acute Compartment Syndrome.

The Major Extremity Trauma and Rehabilitation Consortium and the American Academy of Orthopaedic Surgeons have developed the Appropriate Use Criteria (AUC) for the Diagnosis and Management of Acute Compartment Syndrome (ACS). Evidence-based information, in conjunction with the clinical expertise of physicians, was used to develop the criteria to improve patient care, aid decision-making, and obtain the best possible outcomes while considering the subtleties and distinctions necessary in making clinical decisions. The AUC for the Diagnosis and Management of ACS were derived by identifying clinical indications typical of patients suspected of an ACS in clinical practice. These indications were most often parameters observable by the clinician, including symptoms or results of diagnostic tests. The 135 patient scenarios and five treatments were developed by the writing panel, a group of clinicians who are specialists in this AUC topic. Next, a separate, multidisciplinary, voting panel (made up of specialists and nonspecialists) rated the appropriateness of treatment of each patient scenario using a nine-point scale to designate a treatment as "appropriate" (median rating, seven to nine), "may be appropriate" (median rating, four to six), or "rarely appropriate" (median rating, one to three).

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.

The Role of CT Angiography in Evaluating Lower Extremity Trauma: 157 Patient Case Series at a Military Treatment Facility.

INTRODUCTION: Physical exam and angiography have important roles in the diagnosis of traumatic lower extremity vascular injury with similar reported high rates of sensitivity and specificity. It has been previously shown that CTA is not universally indicated in the setting of acute lower extremity trauma when a reliable physical examination is obtained. As such, the purpose of this study was to determine if obtaining a CTA following physical examination altered the clinical care of patients following high-energy lower extremity trauma and the generalizability to the military population. MATERIALS AND METHODS: Retrospective review of all patients who underwent lower extremity CTA during the initial trauma evaluation at a Level 1 Trauma Center from 2007 to 2014. RESULTS: One hundred and fifty-seven patients met inclusion criteria. One hundred and seventeen patient's initial physical exam excluded limb ischemia with 67 vascular injuries on CTA (9 underwent angiogram in the OR) with no reperfusions required. 40 patients had hard signs of ischemia or ABI's <0.90, 29 had injuries on CTA, and fifteen underwent a vascular reperfusion procedure for acute vascular injury. Ten of 15 reperfusions required no further angiography after CTA. The sensitivity and negative predictive value of physical exam for needed reperfusion were both 100%. There were no instances of missed vascular injury or readmission and 53 patients were discharged directly from the emergency room after a negative CTA. CONCLUSIONS: This study suggests that physical exam alone achieves a high sensitivity for vascular injury in lower extremity trauma. Physical exam excluded all lower extremity ischemia without the need for advanced imaging. While CTA was useful to confirm and localize the source of acute vascular injury, the majority of vascular injuries identified on CTA did not affect immediate clinical care and lead to additional unnecessary procedures. However, in patients with suspected vascular injury, a negative CTA was also used as rationale for immediate discharge from the emergency department without further clinical observation. When applied to the deployed military setting the results of this study support the use of physical exam to accurately diagnose limb threatening ischemia at the time of injury or Role 1 facilities with CTA reserved for diagnosing the level of the vascular injury and for potential patient clearance prior to prolonged evacuation.

Early vs Delayed Weightbearing After Microfracture of Osteochondral Lesions of the Talus: A Prospective Randomized Trial.

BACKGROUND: Osteochondral lesions of the talus (OLTs) are common injuries in young, active patients. Microfracture is an effective treatment for lesions less than 150 mm2 in size. Most commonly employed postoperative protocols involve delaying weightbearing for 6 to 8 weeks (DWB), though one study suggests that early weightbearing (EWB) may not be detrimental to patient outcomes. The goal of this research is to compare outcomes following EWB and DWB protocols after microfracture for OLTs. METHODS: We performed a prospective, randomized, multicenter clinical trial of subjects with unilateral, primary, unifocal OLTs treated with microfracture. Thirty-eight subjects were randomized into EWB (18 subjects) and DWB (20 subjects) at their first postsurgical visit. The EWB group began unrestricted WB at that time, whereas the DWB group were instructed to remain strictly nonweightbearing for an additional 4 weeks. Primary outcome measures were the American Academy of Orthopaedic Surgery (AAOS) Foot and Ankle score and numeric rating scale (NRS) pain score. RESULTS: The EWB group demonstrated significant improvement in AAOS Foot and Ankle Questionnaire scores at the 6-week follow-up appointment as compared to the DWB group (83.1 ± 13.5 vs 68.7 ± 15.8, P = .017). Following this point, there were no significant differences in AAOS scores between groups. At no point were NRS pain scores significantly different between the groups. CONCLUSIONS: EWB after microfracture for OLTs was associated with improved AAOS scores in the short term. Thereafter and through 2 years' follow-up, no statistically significant differences were seen between EWB and DWB groups. LEVEL OF EVIDENCE: Level II, prospective randomized trial.

Progressive Autonomy in the Era of Increased Supervision: AOA Critical Issues.

The observation of decreased resident autonomy, ultimately influencing the readiness of a new graduate to practice, has been supported with a number of recent surveys. This perceived lack of autonomy is felt to be due, in part, to many reasons, including duty-hour regulations, increased supervision requirements, patient safety measures, concern for complication rates, and other performance measures. Pressure on faculty members to have increased clinical productivity may not allow for more resident autonomy.Increased clinical exposure to improve resident independence may come from several suggested areas. First, restructuring the residency program to allow for more clinical time may be one way to improve education. Second, increased use of surgical simulation will allow for more experience to develop technical skills within a controlled environment. Surgical simulators can be used to acquire new skills and also as a means of assessing competence. Third, competency-based education (CBE) has been offered as a way to improve resident education. At its core, CBE offers criterion-based assessments for residents and faculty that allow for more frequent feedback.

A Systems Biology Approach for Studying Heterotopic Ossification: Proteomic Analysis of Clinical Serum and Tissue Samples.

Heterotopic ossification (HO) refers to the abnormal formation of bone in soft tissue. Although some of the underlying processes of HO have been described, there are currently no clinical tests using validated biomarkers for predicting HO formation. As such, the diagnosis is made radiographically after HO has formed. To identify potential and novel biomarkers for HO, we used isobaric tags for relative and absolute quantitation (iTRAQ) and high-throughput antibody arrays to produce a semi-quantitative proteomics survey of serum and tissue from subjects with (HO+) and without (HO-) heterotopic ossification. The resulting data were then analyzed using a systems biology approach. We found that serum samples from subjects experiencing traumatic injuries with resulting HO have a different proteomic expression profile compared to those from the matched controls. Subsequent quantitative ELISA identified five blood serum proteins that were differentially regulated between the HO+ and HO- groups. Compared to HO- samples, the amount of insulin-like growth factor I (IGF1) was up-regulated in HO+ samples, whereas a lower amount of osteopontin (OPN), myeloperoxidase (MPO), runt-related transcription factor 2 (RUNX2), and growth differentiation factor 2 or bone morphogenetic protein 9 (BMP-9) was found in HO+ samples (Welch two sample t-test; P < 0.05). These proteins, in combination with potential serum biomarkers previously reported, are key candidates for a serum diagnostic panel that may enable early detection of HO prior to radiographic and clinical manifestations.

An Analysis of Research Quality and Productivity at Six Academic Orthopaedic Residencies.

OBJECTIVE: It remains largely unknown what factors impact the research productivity of residency programs. We hypothesized that dedicated resident research time would not affect the quantity and quality of a program's peer-reviewed publication within orthopedic residencies. These findings may help programs improve structure their residency programs to maximize core competencies. DESIGN: Three hundred fifty-nine residents and 240 staff from six different US orthopedic residency programs were analyzed. All publications published by residents and faculty at each program from January 2007 to December 2015 were recorded. SCImago Journal Rankings (SJR) were found for each journal. RESULTS: There were no significant differences in publications by residents at each program (p > 0.05). Faculty with 10+ years of on staff, had significantly more publications than those with less than 10 years (p < 0.01). Programs with increased resident research time did not consistently produce publications with higher SJR than those without dedicated research time. CONCLUSIONS: Increased dedicated resident research time did not increase resident publication rates or lead to publications with higher SJR.

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.

Use of ankle magnetic resonance imaging in the active duty military population: the results of a process improvement project.

BACKGROUND: Preventing overuse of magnetic resonance imaging (MRI) for diagnosing ankle pathology was the goal of a process improvement project at a military treatment facility. METHODS: Ordering patterns for MRI of nonorthopaedic providers and orthopaedic surgeons were evaluated over 2 separate periods. An educational initiative on appropriate use of MRI in evaluating ankle complaints was conducted between the 2 periods. RESULTS: Between October 2009 and March 2010, 230 ankle MRIs were performed at our institution, compared to 347 ankle MRIs performed between December 2012 and August 2013. A lower number of patients underwent operative procedures after the education process than before (17% versus 25%). Fellowship-trained foot and ankle surgeons produced the highest number of operative patients with their MRI ordering practices (P=.003 and P=.0001 for Phases 1 and 2 respectively). There was no change in the number of ankle MRI studies ordered each month following the educational initiative (38.3 and 38.5 for Phases 1 and 2 respectively). CONCLUSIONS: The majority of patients undergoing ankle MRI did not undergo operative intervention. Foot and ankle surgeons produce the highest number of operative patients with their MRI ordering practices. Education alone was ineffective in altering ankle MRI ordering patterns.

A survey of proteomic biomarkers for heterotopic ossification in blood serum.

BACKGROUND: Heterotopic ossification (HO) is a significant problem for wounded warriors surviving high-energy blast injuries; however, currently, there is no biomarker panel capable of globally characterizing, diagnosing, and monitoring HO progression. The aim of this study was to identify biomarkers for HO using proteomic techniques and blood serum. METHODS: Isobaric tags for relative and absolute quantitation (iTRAQ) was used to generate a semi-quantitative global proteomics survey of serum from patients with and without heterotopic ossification. Leveraging the iTRAQ data, a targeted selection reaction monitoring mass spectrometry (SRM-MS) assay was developed for 10 protein candidates: alkaline phosphatase, osteocalcin, alpha-2 type I collagen, collagen alpha-1(V) chain isoform 2 preprotein, bone sialoprotein 2, phosphatidate phosphatase LPIN2, osteomodulin, protein phosphatase 1J, and RRP12-like protein. RESULTS: The proteomic survey of serum from both healthy and disease patients includes 1220 proteins and was enriched for proteins involved in the response to elevated platelet Ca+2, wound healing, and extracellular matrix organization. Proteolytic peptides from three of the ten SRM-MS proteins, osteocalcin preprotein, osteomodulin precursor, and collagen alpha-1(v) chain isoform 2 preprotein from serum, are potential clinical biomarkers for HO. CONCLUSIONS: This study is the first reported SRM-MS analysis of serum from individuals with and without heterotopic ossification, and differences in the serum proteomic profile between healthy and diseased subjects were identified. Furthermore, our results indicate that normal wound healing signals can impact the ability to identify biomarkers, and a multi-protein panel assay, including osteocalcin preproprotein, osteomodulin precursor, and collagen alpha-1(v) chain isoform 2 preprotein, may provide a solution for HO detection and monitoring.

Partial foot amputations in the combat wounded.

Throughout the current conflicts in Afghanistan and Iraq, there have been more than 1100 combat-related major limb amputations, with approximately 80% involving the lower extremity. There is, however, a paucity of data regarding the number of amputations below the level of the ankle. Although not as common, partial foot amputations, in the appropriate setting, offer a way to improve function and decrease energy consumption when compared to proximal amputations. Sound surgical tenets are prerequisite for successful outcomes when performing a distal amputation. Maintaining a robust soft tissue envelope allowing for tension-free wound closure is paramount in determining the feasibility of a partial foot amputation. Careful consideration of tendon balancing is also of utmost importance in avoiding common complications of contracture and deformity. Partial foot amputations present a viable surgical option for successful outcomes and maximization of patient function in the combat injured when certain criteria are met.

Direct retroperitoneal pelvic packing versus pelvic angiography: A comparison of two management protocols for haemodynamically unstable pelvic fractures.

OBJECTIVE: To evaluate the outcomes of haemodynamically unstable cases of pelvic ring injury treated with a protocol focused on either direct retroperitoneal pelvic packing or early pelvic angiography and embolisation. METHODS: A retrospective review of a prospectively collected database in an academic level I trauma centre, treating matched haemodynamically unstable cases of pelvic fracture with either pelvic packing (PACK group, n=20) or early pelvic angiography (ANGIO group, n=20). Physiological markers of haemorrhage, time to intervention, transfusion requirements, complications and early mortality were recorded. RESULTS: The PACK group underwent operative packing at a median of 45min from admission; the median time to angiography in the ANGIO group was 130min. The PACK group, but not the ANGIO group, demonstrated a significant decrease in blood transfusions over the next 24h post intervention. In the ANGIO group, ten people required embolisation and six died, two from acute haemorrhage; in the PACK group, three people required embolisation; four died, none due to uncontrolled haemorrhage. CONCLUSIONS: Pelvic packing is as effective as pelvic angiography for stabilising haemodynamically unstable casualties with pelvic fractures, decreases need for pelvic embolisation and post-procedure blood transfusions, and may reduce early mortality due to exsanguination from pelvic haemorrhage.

Preperitonal pelvic packing for hemodynamically unstable pelvic fractures: a paradigm shift.

BACKGROUND: The current management of pelvic fracture patients who are hemodynamically unstable in the United States consists of aggressive resuscitation, mechanical stabilization, and angioembolization. Despite this multidisciplinary approach, our recent analysis confirms an alarming 40% mortality in these high-risk patients. Therefore, we pursued alternate therapies to improve patient outcomes. European trauma groups have suggested the technique of pelvic packing via laparotomy to directly address the venous bleeding that comprises 85% of pelvic fracture hemorrhage. We hypothesized that a modified technique of direct preperitoneal pelvic packing (PPP) would reduce the need for angiography, decrease blood transfusion requirements, and lower mortality. METHODS: Since September 2004, all patients at our ACS-verified level I trauma center with hemodynamic instability and pelvic fractures underwent PPP/external fixation, according to our protocol. Statistics are reported as mean +/- SEM and analyzed using Student's t test. RESULTS: During the study period, 28 consecutive patients underwent PPP. There was one protocol deviation of prePPP angiography to evaluate an extremity vascular injury. The majority were men (68%) with a mean age of 40 +/- 3.9 years and a mean injury severity score of 55 +/- 3.0. The mean emergency department (ED) systolic blood pressure was 77 +/- 3.0 mm Hg, heart rate was 120 +/- 4.3 bpm, and base deficit 13 +/- 0.8 mmol/L. Pelvic fracture classifications included lateral compression (LC) II (9), anteroposterior compression (APC) III (8), LC I (3), vertical shear (3), LC III (3), and APC II (2). Patients required 4 +/- 1.2 units of packed red blood cells (PRBCs) during 82 +/- 13 minutes in the ED. Blood transfusion requirements before postoperative surgical intensive care unit (SICU) admission compared with the subsequent 24 postoperative hours were significantly different (12 +/- 2.0 versus 6 +/- 1.1; p = 0.006). The first 4 patients underwent routine angiography postPPP, with 1 undergoing therapeutic embolization; 4 of the subsequent 24 patients underwent angioembolization with clinical concern of ongoing pelvic hemorrhage. Seven (25%) patients died from multiple organ failure (2), postinjury myocardial infarction/pulseless electrical activity (PEA) arrest (2), invasive mucormycosis (1), withdrawal of care (1), and closed head injury (1); there were no deaths as a result of acute blood loss. CONCLUSIONS: PPP is a rapid method for controlling pelvic fracture-related hemorrhage that can supplant the need for emergent angiography. There is a significant reduction in blood product transfusion after PPP, and this approach appears to reduce mortality in this select high-risk group of patients.