Women in Orthopaedics: 10-Year Trends of Fellowship Match Rate and Subspecialty.

BACKGROUND: Orthopaedic surgery has consistently remained one of the least diverse specialties in medicine. There are limited data on the match rate by sex into orthopaedic fellowships. PURPOSE: The goals of this study were to determine (1) how the percentage of women applying to orthopaedic fellowships has changed from 2011 to 2021, (2) whether there was a correlation between sex and the likelihood of a successful fellowship match, and (3) which subspecialties tend to have a greater proportion of female applicants and fellows. METHODS: The San Francisco (SF) Match service was used to obtain US orthopaedic fellowship applicant data from 2010 to 2021. San Francisco Match has run the match for the orthopaedic fellowship match since 2010. International medical graduates' applications, incomplete applications, or withdrawn applications were excluded. The following variables were collected and assessed: sex, subspecialty choice (except for hand because they do not use SF Match services), and match outcome. The number of female applicants and matches was recorded by year and compared with the number of male applicants and matches. Chi-square analysis was used to analyze categorical variables. RESULTS: A total of 6969 applicants to all orthopaedic specialties within SF Match were included during the study period. Overall, 859 were female (12.3%), and 6110 were male (87.7%). The number of female applicants had an increasing trend over the 10-year period from 65 applicants in 2011 to 111 in 2021. The overall proportion of female applicants was between 10.1% and 14.4%. The annual match rate for female applicants was 90.7% to 100% during the study period while the match rate for male applicants was 93.7% to 97.3%. Regarding successful matches, pediatrics had the highest proportion of women (range: 30.2% to 46.2%), followed by foot and ankle (range: 9.8% to 26.4%). Spine (range: 3.2 to 10.9%) and adult reconstruction (range: 3.9% to 9%) had the least number of women among matched applicants. DISCUSSION: This study found that the number of female applicants to orthopaedic fellowships has increased over the past 10 years. The difference in fellowship match rates among male versus female applicants did not statistically differ during this 10-year period; however, the proportion of female fellows is not equally distributed among subspecialties, with a higher proportion of women matching into pediatrics and foot and ankle and lower proportion in reconstruction and spine. These data can provide a benchmark for department chairs and society leadership to ensure they are recruiting, interviewing, and selecting candidates who are representative of the current sex demographics of orthopaedic fellowship graduates.

From seaweed to healing: the potential of fucoidan in wound therapy.

This bibliometric review examines the current state of research on fucoidan, a sulphated polysaccharide found in brown seaweed species, and its potential for wound healing. The review included 58 studies that investigated fucoidan's effects on wound healing, revealing that it possesses anti-inflammatory and antioxidant properties that could aid in the healing process. Fucoidan was also found to promote cell proliferation, migration, and angiogenesis, essential for wound healing. However, the optimal dosage, treatment duration, safety, and efficacy of fucoidan in various wound types and patient populations still require further investigation. Additionally, advanced wound dressings like hydrogels have garnered significant attention for their potential in wound healing. While this review indicates promise for fucoidan as a natural wound healing compound, it underscores the need for additional clinical trials to determine its optimal use as a commercial therapeutic agent in wound healing.

Immediate Weight-bearing Through Walker or Crutches After Surgical Fixation of Clavicle Fractures in Patients With Lower Extremity Fractures: A Retrospective Cohort Study.

OBJECTIVES: To assess the safety of immediate upper extremity weight-bearing as tolerated (WBAT) rehabilitation protocol after clavicle fracture open reduction internal fixation (ORIF). DESIGN: Retrospective cohort study. SETTING: Three Level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients older than 18 years who had ORIF of mid-shaft clavicle fractures and lower extremity fractures who were allowed immediate WBAT on their affected upper extremity through use of a walker or crutches were included. All clavicles were fixed with either precontoured clavicular plates or locking compression plates. Included patients were those who had clinical/radiographic follow-up until fracture union, nonunion, or construct failure. OUTCOME MEASURES AND COMPARISONS: WBAT patients were matched in a one-to-one fashion to a cohort with isolated clavicle fractures who were treated non-weight-bearing (NWB) postoperatively on their affected upper extremity. Matching was done based on age, sex, and temporality of fixation. After matching, treatment and control groups were compared to determine differences in possible confounding variables that could influence the primary outcome, including patient demographics, fracture classification, cortices of fixation, and construct type. All patients were assessed to verify conformity with weight-bearing recommendation. Primary outcome was early hardware failure (HWF) with or without revision surgery. Secondary outcomes included postoperative infections and union of fracture. RESULTS: Thirty-nine patients were included in the WBAT cohort; there were no significant differences with the matched NWB cohort based on patient demographics. Both the WBAT and the NWB cohorts had 2.5% chance of acute HWF that required surgical intervention ( P = 1.0). Additionally, there was no difference in overall HWF ( P = 0.49). All patients despite weight-bearing status including those who required revision ORIF for acute HWF had union of their fracture ( P = 1.0). CONCLUSIONS: Our data would support that immediate weight-bearing after clavicle fracture fixation in patients with concomitant lower extremity trauma does not lead to an increase in HWF or impact ultimate union. This challenges the dogma of prolonged postoperative weight-bearing restrictions and allow for earlier rehabilitation. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Clavicular Fractures in the Adolescent.

➤: Current evidence suggests that the majority of clavicular fractures in adolescents can and should be treated nonoperatively. ➤: Although rare, in certain patients or fracture patterns, nonoperative management may be associated with delayed healing, prolonged disability, and/or poor functional outcome requiring secondary reconstruction. ➤: When warranted, primary open reduction and internal fixation with plate and screw application has consistently good outcomes with a low complication rate, with the most common complication being implant-related symptoms requiring a secondary surgical procedure for implant removal. ➤: Prospective, comparative studies examining operative and nonoperative treatment, including measures of early return to function, injury burden, return to athletic activity, complication and reoperation rates, and shoulder-girdle-specific, long-term outcome measures are warranted to further elucidate which fractures may benefit from primary fixation.

Reliability of Current Classification Systems for Periprosthetic Fractures of the Humerus.

OBJECTIVE: Numerous classification systems exist to evaluate periprosthetic humerus fractures, although most are based on limited patient numbers. The Wright and Cofield system is the most widely used classification system. We sought to evaluate the interobserver and intraobserver reliabilities of this system compared with the Unified Classification System (UCS) using the largest patient sample to date. METHODS: This retrospective study identified patients between December 2011 and January 2021 with a periprosthetic fracture of the humerus around the stem of a shoulder arthroplasty component. Three upper extremity fellowship-trained surgeons evaluated all radiographs for stem stability, evidence of preinjury stem loosening, Wright and Cofield classification, UCS classification, and recommended treatment for each case at 2 timepoints separated by 2 months. The kappa statistic for interobserver and intraobserver reliability was calculated. RESULTS: Seventy-six patients were included. There was moderate interobserver (kappa 0.53) and substantial intraobserver (kappa 0.69) agreement when classifying stem stability after fracture. There was moderate interobserver (kappa 0.48) and intraobserver (kappa 0.60) agreement when evaluating for stem loosening before fracture. There was fair interobserver (kappa 0.29) and moderate intraobserver (kappa 0.51) agreement regarding the UCS class. There was moderate interobserver (kappa 0.41) and intraobserver (kappa 0.57) agreement regarding the proposed treatment. There was slight interobserver (kappa 0.04) and moderate intraobserver (kappa 0.44) agreement regarding the Wright and Cofield classification. CONCLUSION: The Wright and Cofield system is less reliable than the UCS classification. A more reliable and clinically relevant classification system is needed to standardize discussion of periprosthetic proximal humerus fractures.

Operative vs Nonoperative Treatment of Acute Unstable Chest Wall Injuries: A Randomized Clinical Trial.

Importance: Unstable chest wall injuries have high rates of mortality and morbidity. In the last decade, multiple studies have reported improved outcomes with operative compared with nonoperative treatment. However, to date, an adequately powered, randomized clinical trial to support operative treatment has been lacking. Objective: To compare outcomes of surgical treatment of acute unstable chest wall injuries with nonsurgical management. Design, Setting, and Participants: This was a multicenter, prospective, randomized clinical trial conducted from October 10, 2011, to October 2, 2019, across 15 sites in Canada and the US. Inclusion criteria were patients between the ages of 16 to 85 years with displaced rib fractures with a flail chest or non-flail chest injuries with severe chest wall deformity. Exclusion criteria included patients with significant other injuries that would otherwise require prolonged mechanical ventilation, those medically unfit for surgery, or those who were randomly assigned to study groups after 72 hours of injury. Data were analyzed from March 20, 2019, to March 5, 2021. Interventions: Patients were randomized 1:1 to receive operative treatment with plate and screws or nonoperative treatment. Main Outcomes and Measures: The primary outcome was ventilator-free days (VFDs) in the first 28 days after injury. Secondary outcomes included mortality, length of hospital stay, intensive care unit stay, and rates of complications (pneumonia, ventilator-associated pneumonia, sepsis, tracheostomy). Results: A total of 207 patients were included in the analysis (operative group: 108 patients [52.2%]; mean [SD] age, 52.9 [13.5] years; 81 male [75%]; nonoperative group: 99 patients [47.8%]; mean [SD] age, 53.2 [14.3] years; 75 male [76%]). Mean (SD) VFDs were 22.7 (7.5) days for the operative group and 20.6 (9.7) days for the nonoperative group (mean difference, 2.1 days; 95% CI, -0.3 to 4.5 days; P = .09). Mortality was significantly higher in the nonoperative group (6 [6%]) than in the operative group (0%; P = .01). Rates of complications and length of stay were similar between groups. Subgroup analysis of patients who were mechanically ventilated at the time of randomization demonstrated a mean difference of 2.8 (95% CI, 0.1-5.5) VFDs in favor of operative treatment. Conclusions and Relevance: The findings of this randomized clinical trial suggest that operative treatment of patients with unstable chest wall injuries has modest benefit compared with nonoperative treatment. However, the potential advantage was primarily noted in the subgroup of patients who were ventilated at the time of randomization. No benefit to operative treatment was found in patients who were not ventilated. Trial Registration: ClinicalTrials.gov Identifier: NCT01367951.

Using the Greater Tuberosity as a Reference for Placement of Proximal Humerus Plates Leads to a High Rate of Calcar Screw Malposition.

OBJECTIVES: Achieving calcar fixation is critical to minimize the failure of proximal humerus fractures repaired with proximal humeral locking plates (PHLPs). Many operative technique manuals reference the greater tuberosity (GT) for plate placement. The objective of this study was to examine the accuracy of calcar screw placement when PHLPs were placed based on distance from the GT. METHODS: Twenty cadaveric specimens were acquired representing a height distribution across the US population. Thirteen different PHLPs were applied. A drill bit was placed through the designated calcar screw hole and measured on radiographs, with the inferior 25% of the head representing an ideal placement. RESULTS: Three hundred fifty constructs were studied. In 28% of the specimens, the calcar screw was misplaced. In 20% of the specimens, it was too low, whereas in 8%, it was too high. The calcar screw missed low in 30% of patients shorter than 5 feet, 5.5 inches versus 8% of taller patients ( P = 0.007). It missed high in 13% of taller patients versus 2% of shorter patients ( P = 0.056). Calcar screws in variable-angle plates missed 0% of the time, whereas those in fixed-angle plates missed 36% of the time ( P = 0.003). CONCLUSIONS: Placement of PHLPs based on distance from the GT results in unacceptable position of the calcar screw 28% of the time and up to 36% in fixed-angle plates. This could be further compounded if the GT is malreduced. Current technique guide recommendations result in an unacceptably high rate of calcar screw malposition.

Allies in Orthopaedic Trauma Surgery.

From the casting couch to the board room, the media, and beyond, the topic of sexual harassment and bullying can no longer be ignored. Sexual harassment and bullying in medicine has the potential to be the next big headline on these topics. The culture in medicine and especially the hierarchy in surgery often permit this behavior. To improve the culture in orthopaedic surgery regarding sexual harassment and bullying, education must occur. With education, comes acknowledgment and recognition. This permits an ability to act on and improve the culture. This paper will start the dialogue of this difficult topic and provide a call to action for sexual harassment and bullying to become "Never events".

Comparative effectiveness of treatment options for displaced midshaft clavicle fractures : a systematic review and network meta-analysis.

AIMS: The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures. METHODS: Initial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores. RESULTS: In all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47). CONCLUSION: Surgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery. Cite this article: Bone Jt Open 2021;2(8):646-654.

Operative Versus Nonoperative Treatment of Acute Displaced Distal Clavicle Fractures: A Multicenter Randomized Controlled Trial.

OBJECTIVES: To evaluate the differences in patient outcomes after operative or nonoperative treatment of displaced, type II distal clavicle fractures. DESIGN: Multicenter, prospective, randomized controlled trial. SETTING: Level I trauma centers. PATIENTS/PARTICIPANTS: Patients with completely displaced type II distal clavicle fractures were included. Fifty-seven patients were randomized: 27 to the operative group and 30 to the nonoperative group. INTERVENTION: Patients randomized to nonoperative care received a standard shoulder sling, followed by pendulum or gentle range of motion shoulder exercises at any time as directed by the attending surgeon. Patients randomized to the operative group received plate fixation with a precontoured distal clavicular plate or a "hook" plate within 28 days from injury. MAIN OUTCOME MEASURE: Disabilities of the Arm, Shoulder and Hand scores at 1 year. RESULTS: There were no between-group differences in Disabilities of the Arm, Shoulder and Hand or Constant scores at 1 year. More patients in the operative group went on to union (95% vs. 64%, P = 0.02) within 1 year. Twelve patients in the operative group underwent a second operation for implant removal (12/27, 44%). In the nonoperative group, 6 patients (6/30, 20%) subsequently underwent 8 operative procedures. CONCLUSION: Although this study failed to demonstrate a difference in functional outcomes between operative and nonoperative treatment of Neer type II distal clavicle fractures, nonoperative management led to more complications including a moderate rate of nonunion, which often required secondary surgery to correct, a higher rate of early dissatisfaction with shoulder appearance, and a delayed return to activities in the first 6 months. Operative management provided a safe and reliable treatment option with few complications, but often required secondary implant removal, especially with hook plate fixation. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

In Situ Placement Versus Anterior Transposition of the Ulnar Nerve for Distal Humerus Fractures Treated With Plate Fixation: A Multicenter Randomized Controlled Trial.

OBJECTIVES: To compare clinical scores and electrodiagnostic evidence of ulnar neuropathy, between ulnar nerve mobilization and placement back in the cubital tunnel versus anterior transposition, during plate and screw fixation of a bicolumnar fracture of the distal humerus. DESIGN: Multicenter randomized controlled trial. SETTING: Eight tertiary care centres in Canada. PATIENTS: Fifty-eight patients with distal humerus fractures undergoing plate fixation of both columns were recruited and randomized. INTERVENTION: All patients underwent bicolumnar plate fixation for an acute, displaced fracture of the distal humerus with identification, mobilization, and protection of the ulnar nerve as part of the surgical approach. At the conclusion of the procedure, they were randomized to either (1) replacing the nerve in situ in the cubital tunnel or (2) anterior transposition. MAIN OUTCOME MEASUREMENTS: The primary outcome was the Gabel & Amadio rating scale for ulnar neuropathy. Secondary outcomes included a functional outcome score (Mayo Elbow Performance Score), disabilities of the arm, shoulder and hand instrument, 2-point discrimination, nerve conduction testing, complications, and secondary surgeries. RESULTS: Thirty-one patients were randomized to in situ placement and 27 to anterior transposition. The mean age was 53 years, and 60% were women. There was no difference between the 2 groups with regards to age, gender, body mass index, smoking, diabetes, injury characteristics, time to operation, length of operation, or surgical approach. There was no difference in outcome between the 2 groups at any time point with regards to Gabel & Amadio ulnar neuropathy scores, Mayo Elbow Performance Score, disabilities of the arm, shoulder and hand instrument, or 2-point discrimination. The incidence of ulnar nerve dysfunction, as measured by use of the Gabel & Amadio ulnar neuropathy score, was poor in both groups acutely; however, there was significant improvement at 12 months postoperatively (6.0-7.8, P < 0.001). CONCLUSIONS: This study was unable to demonstrate any significant difference in outcomes when comparing ulnar nerve mobilization and in situ placement and anterior subcutaneous transposition after bicolumnar plate fixation of a distal humerus fracture. Either strategy for managing the ulnar nerve is acceptable and can be used at the discretion of the treating surgeon. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Management of Monteggia Injuries in the Adult.

Monteggia fracture-dislocation of the elbow is a fracture of the proximal ulna with associated dislocation of the radial head or radial neck fracture. In adults, this injury is managed with open reduction and internal fixation of the ulna fracture. Care should be taken to ensure anatomic reduction of the proximal ulna. If radial head dislocation or subluxation persists, reduction of the ulna should be reassessed. Rarely, interposed soft tissue may block radial head reduction, and requires removal. Complications include hardware prominence, stiffness, infection, heterotopic ossification, nerve injury, malunion or nonunion of the ulna, radioulnar synostosis, and persistent radial head instability.

Long-term outcomes of total elbow arthroplasty for distal humeral fracture: results from a prior randomized clinical trial.

BACKGROUND: Total elbow arthroplasty (TEA) is a reliable treatment for elderly patients with comminuted intra-articular distal humeral fractures. However, the longevity and long-term complications associated with this procedure are unknown. The objectives of this study were to examine long-term outcomes and implant survival in elderly patients undergoing TEA for fracture. METHODS: Patients from a previously published randomized controlled trial of 42 patients in which TEA was compared with open reduction-internal fixation (ORIF) were followed up long term. Patients were aged 65 years or older with comminuted intra-articular distal humeral fractures. Outcomes included patient-reported grading of function and pain, revision surgical procedures, and implant survival. RESULTS: Data were obtained for 40 patients, 15 treated with ORIF and 25 treated with TEA, with a mean follow-up period of 12.5 years for surviving patients and 7.7 years for deceased patients. The reoperation rate was 3 of 25 in the TEA group and 4 of 15 in the ORIF group (P = .39). Of the 25 patients with TEAs, only 1 required (early) revision arthroplasty; 7 were living with their original arthroplasty, and 15 died with a well-functioning implant in situ. Three were lost to follow-up. CONCLUSIONS: TEA is an effective and reliable procedure for the treatment of comminuted distal humeral fractures in the elderly patient. Our study reveals reliable implant long-term survival, with no patient requiring a late revision. For the majority of these patients, a well-performed TEA will give them a well-functioning elbow for life and will be the last elbow procedure required.

Plate fixation for management of humerus fractures.

Proximal humerus, humeral shaft, and distal humerus fractures are all common adult fractures, and often occur in older patients. While the treatment of proximal humerus fractures remains controversial, certain fractures benefit from plate fixation such as fracture-dislocations and head-split fractures. When plate fixation is chosen, anatomic reduction and restoration of the medial calcar are important for successful results. Further research is required to minimize complications and determine the optimal surgical candidates for plate fixation. Humeral shaft fractures are generally treated non-operatively. However, certain shaft fractures warrant plate fixation, such as open fractures, those with associated forearm fractures, and those in poly-trauma patients. Choice of surgical approach and plate depends on the location and type of the fracture. The majority of intra-articular distal humerus fractures should be treated with plate fixation. Dual plating is generally accepted as the gold standard treatment, while the optimal surgical approach and plate configuration requires more research.

Challenges in plate fixation of chest wall injuries.

Unstable chest wall injuries can result from multiple rib fractures or a flail chest, and are associated with high rates of morbidity and mortality. Traditionally such injuries have been treated non-operatively, with mechanical ventilation when required, and pain management. Surgical treatment of these fractures is technically possible, and studies suggest improved outcomes, such as lower time on mechanical ventilation and length of time in the intensive care unit, compared to non-operative treatment. However, there are many challenges and controversies regarding indications for surgical fixation, patient selection, outcomes, and fixation strategy. Further research in this area is warranted to better answer these questions.