A Suprapatellar Approach, When Compared With an Infrapatellar Approach, Yields Less Anterior Knee Pain and Better Patellofemoral Joint Function, for Intramedullary Nailing of Diaphyseal Tibial Fractures: Results of a Randomized Controlled Trial.

OBJECTIVES: To assess if a suprapatellar (SP) approach, when compared with an infrapatellar (IP) approach, yielded less patient-reported anterior knee pain and higher patellofemoral joint function at 6 weeks and 12 months postoperatively, when treating tibial fractures with intramedullary nailing. DESIGN: Prospective, parallel-group randomized control trial. SETTING: Tertiary level 1 trauma care center, Brisbane, Australia. PATIENTS SELECTION CRITERIA: Skeletally mature patients with an acute diaphyseal tibial fracture (AO/OTA 41A2/3, 42 A1-43A3) amenable to an intramedullary nailing were included. Exclusion criteria were periprosthetic fractures, nonunions, and presence of a contralateral injury that would restrict weight-bearing. OUTCOME MEASURES AND COMPARISONS: Anterior knee pain through the visual analog scale (VAS) and patellofemoral function using the Kujala scale at 6 weeks and 12 months were compared between those treated with a SP and IP approach. RESULTS: Ninety-five tibia fractures were included in the randomized trial, with complete follow-up data for 44 and 46 tibia fractures in the SP and IP groups, respectively. The SP cohort exhibited better patellofemoral knee function at both 6 weeks (Kajula 53.0 for SP vs. 43.2 for IP, P < 0.01) and 12 months (Kujala 92.0 for SP vs. 81.3 for IP, P < 0.01) postoperatively and a reduction in anterior knee pain at 12 months postoperatively (VAS 0.7 SP vs. 2.9 IP, P < 0.01). CONCLUSIONS: This randomized trial demonstrated clinically meaningful differences in patellofemoral function, for a SP versus IP approach, with a greater than 10 point discrepancy in Kujala score at both 6 weeks and 12 months. In addition, there was a clinically important difference in VAS knee pain scores for patients at 12 months, but not at 6 weeks, postoperatively. These results contribute to the growing body of evidence demonstrating the functional and clinical benefits of the SP approach. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes.

INTRODUCTION: Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS. METHODS: To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs. RESULTS: Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma. DISCUSSION: There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

What Does It Take to Become an Academic Plastic Surgeon in Canada: Hiring Trends Over the Last 50 Years.

Objective: Academic plastic surgery positions have become highly competitive secondary to delayed retirement, stagnant hospital funding, and an increasing number of plastic surgery graduates. Little information is available to help residents navigate this challenging landscape. Our objectives were to evaluate the training backgrounds of all Canadian academic plastic surgeons and to develop recommendations for residents interested in an academic career. Methods: All Canadian academic plastic surgeons were included. Training histories were obtained from institutions' websites. Surgeons were subsequently emailed to confirm this information and complete missing details. Multivariate regressions were designed to analyze the effect of gender and FRCSC year on graduate and fellowship training and time to first academic position. Results: Training information was available for 196 surgeons (22% female), with a 56% email response rate; 91% of surgeons completed residency in Canada; 94% completed fellowship training, while 43% held graduate degrees; 74% were employed where they previously trained. Female gender significantly lengthened the time from graduation to first academic job, despite equal qualification. Younger surgeons were more likely to hold graduate degrees (P < .01). Conclusions: We identified objective data that correlate with being hired at an academic centre, including training at the same institution, obtaining a graduate degree during residency, and pursuing fellowship training. In addition, we demonstrated that women take significantly longer to acquire academic positions (P < .01), despite equal qualification. Trainees should consider these patterns when planning their careers. Future research should explore gender-based discrepancies in hiring practices.

Objectif: Les postes universitaires en chirurgie plastique sont hautement convoités en raison des retraites reportées, du gel du financement des hôpitaux et d'un nombre grandissant de diplômés en chirurgie plastique. Il y a peu d'information visant à aider les résidents à s'y retrouver dans ce contexte difficile. Nos objectifs consistaient à évaluer la formation de tous les chirurgiens plasticiens universitaires au Canada et de mettre au point des recommandations à l'intention des résidents souhaitant mener une carrière universitaire. Méthodologie: Tous les chirurgiens plasticiens universitaires du Canada ont été inclus. L'historique de formation a été obtenue auprès des sites Web des établissements. On a ensuite fait parvenir aux chirurgiens un courriel visant à confirmer ces renseignements et à compléter l'information manquante. Des régressions multifactorielles ont été conçues pour analyser l'effet du sexe et de l'année d'obtention du titre FRCSC sur l'accès à la formation aux cycles supérieurs et l'octroi des bourses de formation, ainsi que sur le délai précédant le moment où les chirurgiens plasticiens décrochent leur premier poste universitaire. Résultats: Les renseignements sur la formation étaient disponibles pour 196 chirurgiens (dont 22 % de sexe féminin), et le taux de réponse par courriel a été de 56 %. Quatre-vingt-onze pour cent des chirurgiens ont terminé leur résidence au Canada. Quatre-vingt-quatorze pour cent des chirurgiens avaient reçu une bourse de formation, tandis que quarante-trois pour cent détenaient des diplômes d'études supérieures. Soixante-quatorze pour cent des chirurgiens sont devenus des employés de l'établissement où ils avaient déjà suivi une formation. À compétences égales, les chirurgiens de sexe féminin tardaient beaucoup plus à décrocher un premier emploi universitaire après l'obtention de leur diplôme que ceux de sexe masculin. Plus les chirurgiens étaient jeunes, plus ils étaient susceptibles de détenir un diplôme d'études supérieures (p < 0,01). Conclusions: Nous avons obtenu des données objectives présentant une corrélation avec l'embauche dans un centre universitaire, y compris une formation au même établissement, l'obtention d'un diplôme d'études supérieures durant la résidence et le maintien d'une bourse de formation. En outre, nous avons montré que même à compétences égales, les femmes prennent beaucoup plus de temps à décrocher des postes universitaires (p < 0,01). Les étudiants doivent tenir compte de ces profils dans leur planification de carrière. Des recherches futures devront explorer les écarts entre les sexes pour ce qui est des pratiques d'embauche.

Job Satisfaction Among Plastic Surgery Residents in Canada.

Objective: Resident wellness is a focus of medical training and is prioritized in both Canadian and American accreditation processes. Job satisfaction is an important component of wellness that is not examined in the literature. The purpose of this study was to analyze job satisfaction in a national sample of plastic surgery residents, and identify factors that influence satisfaction. Methods: We designed a cross-sectional survey adapted from existing instruments, with attention to thorough item generation and reduction as well as pilot and clinical sensibility testing. All plastic surgery residents at Canadian institutions were surveyed regarding overall job satisfaction as well as personal- and program-specific factors that may affect satisfaction. Predictors of satisfaction were identified using multivariable regression models. Results: The response rate was 40%. Median overall job satisfaction was 4.0 on a 5-point Likert scale. Operative experience was considered both the most important element of a training program, and the area in most need of improvement. Senior training year (P < .01), shorter commute time (P = .04), fewer duty hours (P = .02), fewer residents (P < .01), and more fellows (P < .01) were associated with significantly greater job satisfaction. Conclusions: This is the first study to gather cross-sectional data on job satisfaction from a national sample of plastic surgery residents. The results from this study can inform programs in making tangible changes tailored to their trainees' needs. Moreover, our findings may be used to inform a prospectively studied targeted intervention to increase job satisfaction and resident wellness to address North American accreditation standards.

Objectif: Le bien-être des résidents est un point central de la formation en médecine et représente une priorité dans le processus d'agrément canadien et américain. La satisfaction au travail constitue un volet important du bien-être qui n'est pas évalué dans les publications. La présente étude visait à analyser la satisfaction au travail dans un échantillon national de résidents en plasturgie et à déterminer les facteurs qui influent sur la satisfaction. Méthodologie: Les chercheurs ont conçu un sondage transversal adapté d'outils existants, en s'attardant à la production et à la réduction de points approfondis et à un test de sensibilité clinique. Tous les résidents en plasturgie des établissements canadiens ont reçu un sondage sur leur satisfaction au travail et sur les facteurs personnels et propres à leur programme, susceptibles d'influer sur leur satisfaction. Les chercheurs ont déterminé les prédicteurs de satisfaction au moyen de modèles de régression multivariables. Résultats: Le taux de réponse s'élevait à 40%. La satisfaction au travail médiane globale obtenait un résultat de 4,0 sur l'échelle de Likert de cinq points. L'expérience opératoire était considérée à la fois comme l'élément le plus important d'un programme de formation et comme le secteur qui a le plus besoin d'être amélioré. L'année de formation senior (P < .01), une durée de déplacement plus courte (P = .04), un moins grand nombre d'heures de garde (P = .02) et de résidents (P < .01) et un plus grand nombre de boursiers postdoctoraux (P < .01) ont été associés à une satisfaction au travail considérablement plus marquée. Conclusions: C'est la première étude pour colliger des données transversales sur la satisfaction au travail auprès d'un échantillon national de résidents en plasturgie. Les résultats de cette étude peuvent éclairer les programmes pour apporter des changements tangibles adaptés aux besoins de leurs stagiaires. De plus, nos observations pourraient éclairer une intervention prospective ciblée pour accroître la satisfaction au travail et le bien-être des résidents afin de satisfaire aux normes d'agréments nord-américaines.

Safety and early results of Subchondroplasty® for the treatment of bone marrow lesions in osteoarthritis: a systematic review.

PURPOSE: Subchondroplasty® is a novel minimally invasive procedure for painful subchondral bone marrow lesions (BMLs). The aim of this systematic review was to characterize the clinical outcomes of the Subchondroplasty® procedure, a novel minimally invasive procedure for the treatment of BMLs. The hypothesis tested was that patients experience improvements in pain and functional outcomes following the Subchondroplasty® procedure. METHODS: MEDLINE, Embase, Web of Science, and Clinicaltrials.gov were searched from database inception to search date (June 10, 2020) for all clinical studies which discussed Subchondroplasty®. Two reviewers independently screened 45 unique results and 17 studies were included in the final analysis. Data were collected regarding patient demographics, indications, pain, functional scores, conversion to TKA, and complications of the procedure. RESULTS: All but one study were level IV evidence; the mean MINORS score was 9 ± 2. There were 756 patients included, 45.1% were female, and the mean age was 54 years (range 20-85). Thirteen studies investigated the effect Subchondroplasty® to the knee, while four studied the impact on the foot and ankle. Median length of follow-up was 12 months. The most common indication for Subchondroplasty® was joint pain with corresponding BML. Major contraindications to Subchondroplasty® included severe OA, joint instability, and malalignment. Mean pain score on visual analogue scale (VAS) prior to Subchondroplasty® was 7.8 ± 0.6, but decreased to 3.4 ± 0.7 postoperatively. All studies investigating functional scores reported improvement following Subchondroplasty® (IKDC 31.7 ± 1.9-54.0 ± 4.2 and KOOS 38.1 ± 0.6-70.0 ± 4.1). There were consistently high levels of patient satisfaction; 87 ± 8% of patients would be willing to undergo the procedure again. Seven cases of complications were reported, most seriously osteomyelitis and avascular necrosis. Conversion to knee arthroplasty ranged from 12.5 to 30% with length of follow-up ranging from 10 months to 7 years. CONCLUSIONS: Existing low-quality studies show Subchondroplasty® to benefit patients with BMLs through reduction in pain and improvement in function, along with a high degree of satisfaction following the procedure. The low short-to-medium term conversion rate to arthroplasty suggests that Subchondroplasty® may play a role in delaying more invasive and expensive procedures in patients with BMLs. Subchondroplasty® is a novel procedure that has promising initial findings, but requires further high-quality, comparative studies with long-term follow-up to better understand the outcomes of the procedure and impact clinical practice recommendations. LEVEL OF EVIDENCE: Systematic Review of Level III and IV Studies, Level IV.

Early Discharge After Total Hip and Knee Arthroplasty-An Observational Cohort Study Evaluating Safety in 330,000 Patients.

BACKGROUND: There has been considerable interest in recent years for early discharge after arthroplasty. We endeavored to evaluate the safety of same-day discharge given the rapid uptake of this practice approach. METHODS: This is a retrospective observational cohort study of the American College of Surgeons National Surgical Quality Improvement Program registry database. We included patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) between 2015 and 2018. We categorized length of stay (LOS) as same-day discharge (LOS = 0 days), accelerated discharge (LOS = 1 day), and routine discharge (LOS = 2-3 days). For each LOS cohort, we determined the incidence of major complications within 30 days (surgical site infection [SSI], reoperation, readmission, deep vein thrombosis [DVT], and PE) and evaluated risk using multivariate logistic regression analysis if incidence was >1%. Patients undergoing THA and TKA were evaluated independently. RESULTS: The final study cohort consisted of 333,212 patients, including 124,150 who underwent THA (37%) and 209,062 who had TKA (63%). In the THA same-day discharge cohort, the incidence of superficial SSI (0.2%), deep/organ space SSI (0.3%), DVT (0.2%), and PE (0.2%) was low. The risk of reoperation was comparable to routine discharge (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.09; P = .17) and readmission rate was significantly lower (OR, 0.60; 95% CI, 0.48-0.76; P < .001). The risk of reoperation and readmission was also lower in the accelerated discharge cohort compared to routine discharge. In the TKA same-day discharge cohort, the risk of superficial SSI (0.3%), deep/organ space SSI (0.3%), reoperation (0.8%), DVT (0.4%), and PE (0.5%) was low. The risk of readmission after same-day discharge was comparable to routine discharge (OR, 0.85; 95% CI, 0.71-1.01; P = .07). In the accelerated discharge cohort, there was a small reduction in readmission risk (OR, 0.87; 95% CI, 0.81-0.93; P < .001). CONCLUSION: This large, observational, real-world study suggests that same-day and accelerated discharge management is safe clinical practice for patients undergoing total joint arthroplasty, yielding a similar risk of major acute 30-day complications. Further clinical trials evaluating long-term major outcomes, including patient-reported outcomes and experiences, would offer further and definitive insight into this practice approach.

Total Hip Arthroplasty Versus Hemiarthroplasty for Displaced Femoral Neck Fracture: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Hip fractures are a leading cause of disability worldwide, with displaced femoral neck fractures being of particular concern. A recent meta-analysis reported that total hip arthroplasty (THA) was superior to hemiarthroplasty (HA) in terms of reoperations, but inferior in terms of dislocations. However, publication of 4 additional randomized controlled trials that enrolled nearly 1,780 additional patients merits an updated meta-analysis. METHODS: We conducted a literature search of 4 databases to identify randomized controlled trials comparing THA and HA in patients with displaced femoral neck fractures. For patient-reported outcomes, the minimally important difference informed calculation of risk differences. We performed a subgroup analysis to address the possible impact of risk of bias and performed meta-regression to assess the possible impact of duration of follow-up. RESULTS: Sixteen studies that enrolled 3,084 patients randomized to undergo THA (n = 1,521) or HA (n = 1,563) proved eligible. There were no significant differences between the 2 groups in terms of the revision rate at up to 5 years of follow-up or functional outcome at up to 3 years. Health-related quality of life was superior in the THA group (mean difference [MD] = 0.05, 95% confidence interval [CI] = 0.02 to 0.07, minimally important difference, 0.145). There was no significant difference between the groups in terms of dislocation or periprosthetic fracture incidence. Operative time was significantly shorter in the HA group (MD = 22 minutes, 95% CI = 9 to 35 minutes). Analyses addressing risk of bias and length of follow-up did not reveal subgroup differences. Certainty of evidence for all outcomes was rated as moderate. CONCLUSIONS: The best evidence showed, with moderate certainty, that HA and THA likely result in similar revision rate, function, mortality, periprosthetic fracture, and dislocation at up to 5 years, with a small, possibly unimportant benefit in health-related quality of life with THA. More specifically, the improvements are well below established cutoffs for clinical importance. Almost half of all patients were from a single large randomized controlled trial, although the results were consistent across the studies. In addition, HA likely results in a clinically unimportant reduction in operative time. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

What Is the Best Evidence for Management of Displaced Midshaft Clavicle Fractures? A Systematic Review and Network Meta-analysis of 22 Randomized Controlled Trials.

BACKGROUND: Displaced mid-third clavicle fractures are common, and their management remains unclear. Although several meta-analyses have compared specific operative techniques with nonoperative management, it is not possible to compare different operative constructs with one another using a standard meta-analysis. Conversely, a network meta-analysis allows comparisons among more than two treatment arms, using both direct and indirect comparisons between interventions across many trials. To our knowledge, no network meta-analysis has been performed to compare the multiple treatment options for displaced clavicle fractures. QUESTIONS/PURPOSES: We performed a network meta-analysis of randomized, controlled trials (RCTs) to determine from among the approaches used to treat displaced midshaft clavicle fractures: (1) the intervention with the highest chance of union at 1 year, (2) the intervention with the lowest risk of revision surgery, and (3) the intervention with the highest functional outcome scores. Secondarily, we also (4) compared the surgical subtypes in the available RCTs on the same above endpoints. METHODS: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were reviewed for relevant randomized controlled trials published up to July 25, 2018. Two hundred and eighty four papers were reviewed, with 22 meeting inclusion criteria of RCTs with appropriate randomization techniques, adult population, minimum of 1 year follow-up and including at least one operative treatment arm. In total, 1002 patients were treated with a plate construct, 378 with an intramedullary device, and 585 patients were managed nonoperatively. Treatment subtypes included locked intramedullary devices (56), unlocked intramedullary devices (322), anterior plating (89), anterosuperior plating (150), superior plating (449) or plating not otherwise specified (314). We performed a network meta-analysis to compare and rank the treatments for displaced clavicle fractures. We considered the following outcomes: union achievement, revision surgery risk and functional outcomes (DASH and Constant Scores). The minimal clinically important difference (MCID) was considered for both Constant and DASH scores to be at 8 points, representing the average of MCID scores reported for both DASH and Constant in the evidence, respectively. RESULTS: Union achievement was lower in patients treated nonoperatively (88.9%), and higher in patients treated operatively (96.7%, relative risk [RR] 1.128 [95% CI 1.1 to 1.17]; p < 0.001), Number needed to treat (NNT) = 10). Union achievement increased with any plate construct (97.8%, RR 1.13 [95% CI 1.1 to 1.7]; p < 0.0001, NNT = 9) and with anterior or anterosuperior plates (99.3%, RR 1.14 [95% CI 1.1 to 1.8]; p < 0.0001, NNT = 8). Risk of reoperation, when considering planned removal of hardware, was similar across all treatment arms. Lastly, operative treatment outperformed nonoperative treatment with minor improvements in DASH and Constant scores, though not approaching the MCID. At the subtype level, anterosuperior plating ranked highest in DASH and Constant functional scores with mean differences reaching 10-point improvement for Constant scores (95% CI 4.4 to 2.5) and 7.6 point improvement for DASH (95% CI 5.2 to 20). CONCLUSIONS: We found that surgical treatment led to a greater likelihood of union at 1 year of follow-up among adult patients with displaced mid-third clavicle fractures. In aggregate, surgical treatment did not increase functional scores by amounts that patients were likely to consider clinically important. Use of specific subtypes of plating (anterior, anterosuperior) resulted in improvements in the Constant score that were slightly above the MCID but did not reach the MCID for the DASH score, suggesting that any outcomes-score benefits favoring surgery were likely to be imperceptible or small. In light of these findings, we believe patients can be informed that surgery for this injury can increase the likelihood of union incrementally (about 10 patients would need to undergo surgery to avoid one nonunion), but they should not expect better function than they would achieve without surgery; most patients can avoid surgery altogether with little absolute risk of nonunion. Patients who opt for surgery must be told that the decision should be weighed against complications and the possibility of undergoing a second procedure for hardware removal. Patients opting not to have surgery for acute midshaft clavicle fractures can be told that nonunion occurs in slightly more than 10% of patients, and that these can be more difficult to manage than acute fractures. LEVEL OF EVIDENCE: Level I, therapeutic study.