The Prevalence of Hip Dysplasia on Radiographs for Adolescent Idiopathic Scoliosis.

BACKGROUND: During radiographic assessment of adolescent idiopathic scoliosis (AIS), upright images frequently capture the hip. The purpose of this study was to assess the prevalence of radiographic hip dysplasia on postero-anterior (PA) scoliosis radiographs, as defined as a lateral center edge angle (LCEA) ≤25 degrees. METHODS: All patients with upright PA scoliosis radiographs over a one-year study period at a single tertiary academic medical center (2020 to 2021) were included in the study. Radiographs containing the hip joints were annotated by 3 reviewers for left and right LCEA, and triradiate cartilage (TRC) status. Inter-rater reliability was determined among the 3 reviewers. RESULTS: Two hundred fifty patients {500 hips, 75.6% female, median age 14 [interquartile range (IQR)=3]} had PA scoliosis radiographs that captured the hip, which qualified for analysis. Seventy-four hips (14.8%) demonstrated evidence of dysplasia (LCEA ≤25 deg) in 55/250 patients (22%). The median LCEA was significantly lower in the dysplastic hip cohort (23.9 deg, IQR=4.8 deg), compared with those without dysplasia (33 deg IQR=7.3 deg; P=0.001). A higher percentage of dysplastic hip patients were female than male (72.7% vs. 27.3%). Patients with bilateral dysplasia had a similar LCEA ( 22.9 deg) [to those with unilateral dysplasia (22.9 deg left, 23.9 deg right, P=0.689)]. CONCLUSIONS: In a cohort of 250 AIS patients, 22% demonstrated evidence of hip dysplasia, as defined as an LCEA ≤2 degrees. The dysplastic patients were more likely to be female. Screening for hip symptomatology in AIS patients may be of benefit, considering the frequency of radiographic hip dysplasia in this population. LEVEL OF EVIDENCE: III. Type of Evidence: diagnostic.

Intraoperative Radiation Exposure in Adolescent Idiopathic and Neuromuscular Scoliosis.

BACKGROUND: Intraoperative imaging is often used to aid pedicle screw placement during scoliosis operations. Higher rates of cancer and death have been observed in orthopaedic surgeons and radiation technologists, including a fourfold higher rate of breast cancer in female orthopaedic surgeons. The purpose of this study was to evaluate variability in intraoperative radiation during spinal fusions for both adolescent idiopathic scoliosis (AIS) and neuromuscular scoliosis (NMS). METHODS: A retrospective review of posterior spinal fusion and segmental spinal instrumentation for scoliosis performed by pediatric orthopaedic surgeons from 2017 to 2019 at a single institution was performed. Inclusion criteria included: a diagnosis of AIS or NMS and patients between 8 and 18 years of age. Exclusion criteria included: revision surgery, use of intraoperative navigation, and patients younger than 10 at the time of scoliosis onset within the AIS cohort. Data collected included: preoperative curve, body mass index (BMI), number of levels fused, number of Ponte osteotomies, and fluoroscopy time. One-way analysis of variance tests, Bonferroni post hoc tests, independent t tests, and Pearson correlations were utilized with significance determined at the 95% confidence level ( a = 0.05). RESULTS: A total of 148 patients were included in the study. The average fluoroscopy time was 143 ± 67 seconds. Patients with NMS had higher average fluoroscopy times (193 ± 75 s) compared with patients with AIS (129 ± 58 s, P < 0.001). In patients with AIS, fluoroscopy time correlated to the patient's preoperative curve ( r = 0.182, P = 0.050). Patients with AIS with fewer than 12 levels fused had significantly less radiation exposure than those with 12 or more levels fused ( P = 0.01). When controlling for the number of levels fused, patients with AIS with higher BMIs had significantly greater fluoroscopy times ( P = 0.001). In patients with NMS, fluoroscopy time negatively correlated with BMI ( r = -0.459, P = 0.009) and positively correlated with a preoperative curve ( r = 0.475, P = 0.007). CONCLUSION: Fluoroscopy times vary greatly during adolescent spinal fusions for scoliosis. Longer fluoroscopy times are correlated with: NMS diagnosis, larger preoperative curve, BMI, and number of levels fused. Surgeons' knowledge of factors affecting fluoroscopy time will increase awareness and may be the first step in decreasing intraoperative radiation risks. LEVEL OF EVIDENCE: Level III; Therapeutic-a retrospective study.

Increased Prevalence of Breast and All-cause Cancer in Female Orthopaedic Surgeons.

INTRODUCTION: Cancer is the second leading cause of death among women in the United States. Previous studies demonstrate a higher prevalence of cancer among female orthopaedic surgeons. This study aimed to provide an updated prevalence of breast and all-cause cancer among female orthopaedic surgeons using a larger and more current study population. METHODS: We distributed surveys to female orthopaedic surgeons in national orthopaedic specialty societies. Six hundred seventy-two survey responses were collected. We calculated standardized prevalence ratios (SPRs) and 95% confidence intervals (CIs) based on gender-specific, race-specific, and age-specific cancer prevalence statistics in the US population. We compared the distribution of breast cancer risk factors with that of women in the 2018 and 2009 California Health Interview Survey. RESULTS: Fifty-one of the 672 surveyed surgeons reported a diagnosis of invasive cancer. Twenty reported breast cancer with a prevalence higher among female orthopaedic surgeons compared with the US female population (SPR: 2.89, 95% CI: 2.16 to 3.81, P < 0.001). The breast cancer prevalence was also higher among orthopaedic surgeons compared with the US female population (SPR: 3.97, 95% CI: 2.43 to 6.14, P = 0.003). DISCUSSION: The increased prevalence of breast and all-cause cancer among a larger and more diverse cohort of female orthopaedic surgeons confirms previous studies and provides an update regarding a concerning public health issue within this specialty.

Methods for Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons.

BACKGROUND: Standard lead aprons and vests do not adequately shield the most common breast cancer site, the upper outer quadrant (UOQ), from intraoperative radiation. The purpose of the present study was to determine if lead sleeves, wings, and/or axillary supplements decreased intraoperative radiation exposure of the UOQ of the breast. METHODS: An anthropomorphic torso phantom (simulating the female surgeon) was placed adjacent to a standard operating room table. Dosimeters were placed bilaterally over the UOQ of the breast. Scatter radiation dose equivalent rates (mrem/hr) were measured during continuous fluoroscopy of a pelvic phantom (simulating the patient). Five protection configurations (no lead; lead vest; and vest with sleeves, wings, and axillary supplements), 2 surgeon positions (facing the table and perpendicular to the table), and 2 C-arm positions (anteroposterior and cross-table lateral projection) were tested. The t test was utilized with a Bonferroni correction for multiple t tests. RESULTS: Lead sleeves and axillary supplements decreased intraoperative radiation exposure to the UOQ of the breast when compared with a well-fitted standard lead vest alone (p < 0.01) across all surgeon and C-arm positions. The addition of wings decreased radiation exposure to a lesser extent than sleeves or axillary supplements, and the difference when compared with the lead vest alone did not reach significance (p = 0.29). Breast radiation exposure in the C-arm cross-table lateral projection was highest across all testing. CONCLUSIONS: The UOQ of the breast is not adequately protected by standard lead vests alone or vests with the addition of wings. Axillary supplements and sleeves improved protection of the breast. CLINICAL RELEVANCE: Modifications of lead protective vests may improve intraoperative breast radiation protection.

Evaluation and Management of Common Accessory Ossicles of the Foot and Ankle in Children and Adolescents.

Accessory ossicles are a common radiographic finding about the foot and ankle in children and adolescents. They are often noted incidentally during evaluation of foot and ankle injuries, and most can be managed nonsurgically. Although over 20 accessory ossicles have been described around the foot and ankle, five specific structures generate the most concern in pediatric patients. An accessory navicular presents commonly with medial midfoot pain and may require surgical intervention after failure of nonsurgical treatment. Although an accessory navicular can be treated surgically with simple excision, there is some recent evidence that supports concomitant reconstruction of associated flatfoot deformities. Os trigonum, an ossicle posterior to the talus, is also commonly asymptomatic. However, os trigonum may be associated with persistent posterior ankle pain, and open and endoscopic resection techniques are successful. Os subfibulare is an uncommon ossicle that may be associated with recurrent ankle sprains. Recent literature reports successful return to activities after ossicle excision and ligament reconstruction. Os subtibiale may be confused with a medial malleolar fracture in skeletally immature patients. Os peroneum may contribute to lateral midfoot pain.

What Proportion of Orthopaedic Surgery Residency Programs Have Accessible Parental Leave Policies, and How Generous are They?

BACKGROUND: Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed? METHODS: All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected. RESULTS: Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave. CONCLUSIONS: Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training. CLINICAL RELEVANCE: Parental leave policies are increasingly relevant to today's trainees []. Applicants to orthopaedic surgery today value work/life balance including protected parental leave [].

Titanium integration with bone, welding, and screw head destruction complicating hardware removal of the distal radius: report of 2 cases.

Increasingly, surgeons treat distal radius fractures with locking plate systems. Recent case reports have focused on technical insertion errors resulting in removal difficulties: poor drilling orientation or cross-threading, destruction of the screw head, and filling of the screw recess with tissue. We report 2 complications of titanium locked plate removal secondary to in vivo reactions including titanium integration with bone and mechanical binding between the titanium screw and plate. We clarify and discuss terminology relevant to implant removal, including cold-welding, galling, fretting, and anodization. Even with optimal technique, in situ reactions can complicate titanium implant removal.

Methodologies for establishing validity in surgical simulation studies.

BACKGROUND: Validating assessment tools in surgical simulation training is critical to objectively measuring skills. Most reviews do not elicit methodologies for conducting rigorous validation studies. Our study reports current methodological approaches and proposes benchmark criteria for establishing validity in surgical simulation studies. METHODS: We conducted a systematic review of studies establishing validity. A PubMed search was performed with the following keywords: "validity/validation," "simulation," "surgery," and "technical skills." Descriptors were tabulated for 29 methodological variables by 2 reviewers. RESULTS: A total of 83 studies were included in the review. Of these studies, 60% targeted construct, 24% targeted concurrent, and 5% looked at predictive validity. Less than half (45%) of all the studies reported reliability data. Most studies (82%) were conducted in a single institution with a mean of 37 subjects recruited. Only half of the studies provided rationale for task selection. Data sources included simulator-generated measures (34%), performance assessment by human evaluators (33%), motion tracking (6%), and combined modes (28%). In studies using human evaluators, videotaping was a common (48%) blinding technique; however, 34% of the studies did not blind evaluators. Commonly reported outcomes included task time (86%), economy of motion (51%), technical errors (48%), and number of movements (25%). CONCLUSION: The typical validation study comes from a single institution with a small sample size, lacks clear justification for task selection, omits reliability reporting, and poses potential bias in study design. The lack of standardized validation methodologies creates challenges for training centers that survey the literature to determine the appropriate method for their local settings.