Postoperative Opioid Prescribing Practices and Patient Opioid Utilization in Pediatric Orthopaedic Surgery Patients.

INTRODUCTION: Amid a national opioid epidemic, it is essential to review the necessity of opioid prescriptions. Research in adults has demonstrated patients often do not use their entire postoperative opioid prescription. Limited data suggest that the trend is similar in children. This study investigated the prescription volume and postoperative utilization rate of opioids among pediatric orthopaedic surgery patients at our institution. METHODS: We identified pediatric patients (ages below 18 y old) who presented to our institution for operating room intervention from May 24, 2021, to December 13, 2021. Patient demographics and opioid prescription volume were recorded. Parents and guardians were surveyed by paper "opioid diary" or phone interview between postoperative days 10 to 15, assessing pain level, opioid use, and plans for remaining opioid doses. Wilcoxon rank-sum test, Independent t test, and Pearson correlation were used for the analysis of continuous variables. Multivariable logistic regression was used to control for patient demographic variables while analyzing opioid usage relationships. RESULTS: Prescription volume information was collected for 280 patients during the study period. We were able to collect utilization information for 102 patients (Group 1), whereas the remaining 178 patients contributed only prescription volume data (Group 2). Patients with upper extremity fractures received significantly fewer opioid doses at discharge compared with other procedure types ( P =0.036). Higher BMI was positively correlated with more prescribed opioid doses ( R2 =0.647, P <0.001). The mean opioid utilization rate was 22.37%. A total of 50.6% of patients prescribed opioids at discharge used zero doses. A total of 96.2% of patients used opioids for 5 days or less. Most families had not disposed of excess medication by postoperative day 10. CONCLUSIONS: We found significant differences in opioid prescribing practices based on patient and procedure-specific variables. In addition, although our pediatric orthopaedic surgery patients had low overall rates of postoperative opioid utilization, there was significant variation in opioid use among procedure types. These results provide insights that can guide opioid prescribing practices for pediatric orthopaedic patients and promote patient education to ensure safe opioid disposal.

Management Principles and Current Debates Surrounding Common Pediatric Elbow Fractures.

Elbow fractures are among the most common fractures sustained in pediatric patients. A specific set of pediatric elbow fractures (olecranon, radial neck, and lateral condyle fractures) comprises the ones that occur most often. It is important to review commonly accepted principles in the evaluation and treatment of these injuries as well as highlight some debates that exist within the literature regarding the optimal management of these injuries. Although management of pediatric olecranon, radial neck, and lateral condyle fractures has been well described, controversy persists among orthopaedic surgeons regarding the surgical indications and preferred fixation techniques for these injuries.

Bilateral Tibial Tubercle Avulsion Fractures With an Associated Patellar Tendon Avulsion in an Adolescent Patient.

Tibial tubercle fractures in pediatric patients are increasing in frequency as more children participate in sports. These injuries are often seen in boys engaging in jumping activities before closure of their proximal tibial physis. Bilateral tibial tubercle fractures have been reported in the literature, but less frequent are associated patellar tendon ruptures with fracture of the tubercle. In this case report, we present an 11-year-old girl who sustained bilateral tibial tubercle fractures, including an associated patellar tendon rupture from the tubercle on the right lower extremity. We describe our technique for the management of both injuries, which included a primary patellar tendon repair for the right leg and Kirschner wire fixation of the displaced tubercle for the left leg. The patient ultimately had a successful outcome at the final follow-up with healed fractures and full range of motion of both knees. In this case report, we also present similar cases from the literature and the differing treatment strategies.

Longitudinal Assessment of Modern Spine Surgery Training: 10-Year Follow-up of a Nationwide Survey of Residency and Spine Fellowship Program Directors.

Spine surgeons complete training through residency in orthopaedic surgery (ORTH) or neurosurgery (NSGY). A survey was conducted in 2013 to evaluate spine surgery training. Over the past decade, advances in surgical techniques and the changing dynamics in fellowship training may have affected training and program director (PD) perceptions may have shifted. Methods: This study is a cross-sectional survey distributed to all PDs of ORTH and NSGY residencies and spine fellowships in the United States. Participants were queried regarding characteristics of their program, ideal characteristics of residency training, and opinions regarding the current training environment. χ2 tests were used to compare answers over the years. Results: In total, 241 PDs completed the survey. From 2013 to 2023, NSGY increased the proportion of residents with >300 spine cases (86%-100%) while ORTH remained with >90% of residents with < 225 cases (p < 0.05). A greater number of NSGY PDs encouraged spine fellowship even for community spine surgery practice (0% in 2013 vs. 14% in 2023, p < 0.05), which continued to be significantly different from ORTH PDs (∼88% agreed, p > 0.05). 100% of NSGY PDs remained confident in their residents performing spine surgery, whereas ORTH confidence significantly decreased from 43% in 2013 to 25% in 2023 (p < 0.05). For spinal deformity, orthopaedic PDs (92%), NSGY PDs (96%), and fellowship directors (95%), all agreed that a spine fellowship should be pursued (p = 0.99). In both 2013 and 2023, approximately 44% were satisfied with the spine training model in the United States. In 2013, 24% of all PDs believed we should have a dedicated spine residency, which increased to 39% in 2023 (fellowship: 57%, ORTH: 38%, NSGY: 21%) (p < 0.05). Conclusion: Spine surgery training continues to evolve, yet ORTH and neurological surgery training remains significantly different in case volumes and educational strengths. In both 2013 and 2023, less than 50% of PDs were satisfied with the current spine surgery training model, and a growing minority believe that spine surgery should have its own residency training pathway. Level of Evidence: IV.

A Comparison of Match Rates to Orthopaedic Surgery Residency Programs Between First-Time Versus Repeat Applicants: An Analysis of the National Resident Matching Program Data from 2018 to 2022.

Orthopaedic surgery has become one of the most competitive specialties to match into among medical students applying to residency. The purpose of this study was to compare match rates to orthopaedic surgery residency programs among first-time vs. repeat applicants. Methods: Data were obtained from the National Resident Matching Program from 2018 to 2022. For each year, the total number of applicants to orthopaedic surgery residency programs was obtained, as well as the number of applicants who successfully matched into orthopaedics. The match rate was compared between first-time vs repeat applicants. A subanalysis was performed on allopathic graduates (MDs) and osteopathic graduates (DOs)/international medical graduates (IMGs). In addition, the match rate for first-time applicants and reapplicants was compared between MD and DO/IMG applicants. Results: Overall, there was a significantly higher match rate among first-time applicants (89.8%) vs. repeat applicants (22.5%, p < 0.0001). When substratified by MD and DO/IMG applicants, first-time applicants still matched at a significantly higher rate than reapplicants within each group (p < 0.0001 for each). Among first-time applicants, MDs (93.1%) matched at a significantly higher rate than DOs/IMGs (68.6%, p < 0.0001). Among reapplicants, DOs/IMGs (25.3%) matched at a significantly higher rate than MDs (20.1%, p < 0.01). Conclusion: First-time applicants to orthopaedic surgery residency programs have a significantly higher rate of matching compared with reapplicants, irrespective of degree. In recent years, first-time MD applicants have matched at a significantly higher rate than first-time DO/IMG applicants.

The Transition to Practice from Residency and Fellowship: The Need to Better Prepare Residents and Fellows for What Lies Ahead.

¼: There is currently no standard method or time requirement devoted to the teaching of practice management in orthopaedic residency, but there is widespread agreement that it is a necessary part of orthopaedic education. ¼: Overall, there are 3 major components to an effective transition-to-practice model: mock independent practice, appropriate feedback and oversight, and consistent exposure. ¼: An overarching theme is the importance of debriefing by senior faculty, coupled with mock practice scenarios.

Variability in evaluation and treatment of tibial tubercle fractures among pediatric orthopedic surgeons.

The purpose of this study was to determine the variability in clinical management of tibial tubercle fractures among a group of pediatric orthopedic surgeons. Nine fellowship-trained academic pediatric orthopedic surgeons reviewed 51 anteroposterior and lateral knee radiographs with associated case age. Respondents were asked to describe each fracture using the Ogden classification (type 1-5 with A/B modifiers), desired radiographic workup, operative vs. nonoperative treatment strategy and plans for post-treatment follow-up. Fair agreement was reached when classifying the fracture type using the Ogden classification (k = 0.39; P < 0.001). Overall, surgeons had a moderate agreement on whether to treat the fractures operatively vs. nonoperatively (k = 0.51; P < 0.001). Nonoperative management was selected for 80.4% (45/56) of type 1A fractures. Respondents selected operative treatment for 75% (30/40) of type 1B, 58.3% (14/24) of type 2A, 97.4% (74/76) of type 2B, 90.7% (39/43) of type 3A, 96.3% (79/82) of type 3B, 71.9% (87/121) of type 4 and 94.1% (16/17) of type 5 fractures. Regarding operative treatment, fair/slight agreement was reached when selecting the specifics of operative treatment including surgical fixation technique (k = 0.25; P < 0.001), screw type (k = 0.26; P < 0.001), screw size (k = 0.08; P < 0.001), use of washers (k = 0.21; P < 0.001) and performing a prophylactic anterior compartment fasciotomy (k = 0.20; P < 0.001). Furthermore, surgeons had fair/moderate agreement regarding the specifics of nonoperative treatment including degree of knee extension during immobilization (k = 0.46; P < 0.001), length of immobilization (k = 0.34; P < 0.001), post-treatment weight bearing status (k = 0.30; P < 0.001) and post-treatment rehabilitation (k = 0.34; P < 0.001). Significant variability exists between surgeons when evaluating and treating pediatric tibial tubercle fractures.

The Impact of a Resident's Sense of Control on Burnout in Orthopaedic Surgery Residency.

¼: Physician burnout is a barrier to the patient-centered approach to health care. ¼: One of the driving factors of resident burnout is the decreased level of control that residents have over their everyday lives. ¼: Providing residents with a sense of control over their lives and their jobs increases job satisfaction and leads to a decrease in reports of negative effects on health, rest, participation in extracurricular activities, and time with family.

Variability of the Orthopaedic Away Rotation: A Survey of Orthopaedic Program Directors.

INTRODUCTION: With the increasing interest and pursuit of away rotations by orthopaedic surgery applicants, program directors (PDs) must use information from the 4-week performance to determine who is good fit for their program. For students, despite the increasing cost and time, they are faced with a variable experience from program to program. The purpose of this study was to survey PDs from Accreditation Council of Graduate Medical Education-accredited orthopaedic residency programs to better understand how programs approach the away rotation process. METHODS: An anonymous online survey was distributed to PDs of all 164 accredited allopathic orthopaedic surgery residency programs in the United States. The survey included questions regarding PD demographics, away rotations structure, and the process of interviewing rotating students. The data were aggregated, and an analysis was done. RESULTS: A total of 61 of 164 (37%) surveys were completed. There was variability regarding the number of away students that a program accepted over the course of a year, and the number of students that a program will accept at one time. Fifty-two of 55 (94%) programs evaluated medical students immediately after their rotation. Visiting students were most commonly evaluated by the program's residents, followed by attendings they rotated with, and only 46% of PDs. Furthermore, PDs placed the most emphasis on work ethic and social interaction when evaluating students compared with surgical skills and orthopaedic knowledge. Only 38.5% of programs reported that visiting students were guaranteed an interview. If granted an interview, 80% of programs require that the students return for interview day. CONCLUSIONS: The visiting rotation has become increasingly more valuable for students; however, there is notable variability in the process between programs. Creating a more standardized away rotation could decrease the variability and facilitate a more beneficial experience to the student and program.

Parenthood Among Orthopedic Surgery Residents: Assessment of Resident and Program Director Perceptions on Training.

Orthopedic residency training overlaps with common childbearing ages. The purpose of this study was to describe factors affecting male and female residents' family-planning decisions and attitudes of program directors (PDs) toward parenthood during residency. In 2018, using an anonymous survey model, residents and PDs in Accreditation Council for Graduate Medical Education-accredited orthopedic surgery programs were asked about their perceptions of parenthood on training, the availability of family-oriented services at their programs, and the effect of residency culture and policies on their decision to have children. This survey occurred in 2018. Three hundred forty-nine (76.2%) of 458 resident respondents were male and 109 (23.8%) were female. Two hundred four (49.9%) of 409 residents were unsure of their program's parental leave policy. Male residents reported taking an average of 0.8 weeks (95% CI, 0.0-4.0 weeks) of parental leave and females an average of 4.6 weeks (95% CI, 2.0-6.5 weeks) (P<.001). Female residents were more likely to report delaying having children during residency (56.73% vs 38.71%, P=.001) and were more likely to cite reputational concerns (57.63% vs 0.76%, P<.001) and effects on career opportunities (42.37% vs 7.57%, P<.001) as reasons for delaying parenthood. The most commonly cited negative effect of parenthood on residency training by PDs was reduction in off-duty educational time (15 of 29, 51.72%). Twenty-four (80%) of 30 PDs believe that training may need to be extended based on amount of maternity/paternity leave time taken off. Although parenthood during orthopedic training is common, both male and female residents reported delaying parenthood because of residency-related factors. Improved clarification of leave policies and establishment of clear guidelines for parenthood in residency may improve resident wellness. [Orthopedics. 2021;44(2):98-104.].

Suture Stabilization of Open Physeal Fractures of the Great Toe Distal Phalanx (Seymour Fracture).

BACKGROUND: Open physeal fractures of the distal phalanx of the hallux are analogous to Seymour fractures of the hand. When missed, these injuries can result in long-term sequelae including infection, pain, nail deformity, and physeal arrest. Nevertheless, there is a paucity in the literature regarding optimal surgical treatment for these challenging injuries. We present a novel technique and case series for suture-only stabilization of Seymour fractures of the great toe. METHODS: Billing records were used to identify all children aged 18 years or younger who underwent operative treatment open distal phalanx fracture of the hallux with an associated nail bed injury. Electronic medical records and plain imaging were reviewed to identify mechanism of injury, surgical technique, results, complications, and follow-up. RESULTS: Five boys with a mean age of 10.3 years (range, 5 to 13 y) met inclusion criteria. Forty percent (2/5) of injuries were missed by the initial treating providers. Only 2 patients presented to our institution primarily; 60% (3/5) patients were transferred from other facilities. The mechanism of injury was variable but generally involved "stubbing" the toe. The mean time from injury to surgical treatment was 2.6 days (range, 0 to 6 d). Median follow-up was 2 months (range, 1 to 96 mo). No patient complications (including infection) or reoperations were reported. On follow-up imaging, no physeal bars were evident on patients treated with suture-only technique. CONCLUSIONS: Seymour fracture of the hallux are uncommon, and there is frequently a delay in both presentation and diagnosis. Providers should have increased suspicion for these injuries when a physeal fracture of the great toe is associated with bleeding or nail bed injury. Currently, no consensus exists for treatment of these injuries. Suture-only stabilization represents a simple, reliable alternative to pin fixation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Investigation of the Injury Rate of Female Fitness Competitors.

BACKGROUND: Female fitness competitions are increasing in popularity. Athletes are participating in weight-cutting protocols to help reduce body fat percentage to improve muscle definition and physique. METHODS: The goal of the study was to investigate weight-cutting practices and determine if these practices were associated with increased injury rates. A survey was distributed at a New England fitness competition. RESULTS: Thirty-five female fitness competitors participated in the survey at a single competition. The calculated injury rate for female fitness competitors is 0.18 injuries per 1000 hours of training. Age over 35 (p=0.014) and a history of or current eating disorder (p=0.005) were significant risk factors for sustaining an injury. Menstrual cycle abnormalities were present in 11 of 35 individuals (31.4%). CONCLUSIONS: Female fitness competitor injury rates are low; however, injuries were more common in athletes over age 35 and those with either a history of or a current eating disorder.

Management of Post-Amputation Pain.

INTRODUCTION: The prevalence of amputation and post-amputation pain (PAP) is rising. There are two main types of PAP: residual limb pain (RLP) and phantom limb pain (PLP), with an estimated 95% of people with amputations experiencing one or both. Medical Management: The majority of chronic PAP is due to phantom limb pain, which is neurogenic in nature. Common medications used include tricyclic antidepressants, gabapentin, and opioids. Newer studies are evaluating alternative drugs such as ketamine and local anesthetics. Rehabilitation Management: Mirror visual feedback and cognitive behavioral therapy are often effective adjunct therapies and have minimal adverse effects. Surgical Management: Neuromodulatory treatment and surgery for neuromas have been found to help select patients with PAP. CONCLUSION: PAP is a complex condition with mechanisms that can be located at the residual limb, spinal cord, and brain - or a combination. This complex pain can be difficult to treat. The mainstays of treatment are largely medical, but several surgical options are also being studied.

Analysis of growth and biofilm formation of bacterial pathogens on frequently used spinal implant materials.

STUDY DESIGN: A microscopy-based investigation of the permissive factors leading towards bacterial adherence on commonly utilized spinal implants. OBJECTIVE: The adherence and subsequent colonization and biofilm formation of bacteria on orthopaedic implants represents one of the most serious problems facing orthopaedic surgeons. Once a biofilm is formed, surgeons may have to resort to implant removal, a strategy that may cause substantial patient morbidity and lead to additional cost to the healthcare system. This problem has been further compounded by the rise of antibiotic-resistant strains of bacterial pathogens. In this study, two commonly encountered bacterial pathogens in surgical site infections (SSI) were characterized for adherence pattern, density, and propagation on five commonly used spinal implant materials via scanning electron microscopy (SEM) and confocal laser scanning microscopy (CLSM). The results show that bacterial adherence is largely dependent on the microtopographical features observed on the surface of the materials tested. METHODS: Five commonly utilized spinal implant materials were inoculated with two of the most common nosocomial pathogens and visualized via scanning electron microscopy and confocal laser scanning microscopy. RESULTS: Analysis of 90 spinal implant pieces showed that even though no material showed the ability to prevent adherence of both pathogens tested, the presence of surface imperfections and rougher microtopography was found to harbor the most bacterial presence. CONCLUSION: Our data suggests that implants materials with uniform surface and minimal imperfections may reduce the ability of bacterial to adhere to implants. LEVEL OF EVIDENCE: Level I evidence: "Investigation of a diagnostic test".

Fluoroscopy as Definitive Postreduction Imaging of Pediatric Wrist and Forearm Fractures Is Safe and Saves Time.

BACKGROUND: Recent studies indicate that formal postreduction radiographs may be unnecessary for closed, isolated pediatric wrist, and forearm when mini C-arm fluoroscopy is used for reduction. Our institution changed the Emergency Department (ED) management protocol to reflect this by allowing orthopaedic providers to determine if fluoroscopy was acceptable to assess fracture reduction. We hypothesized that using fluoroscopy as definitive postreduction imaging would decrease total encounter time, without an increase in the rate of rereduction or surgery. METHODS: Patients with closed, isolated distal radius/distal ulna (DR/DU) or both bone forearm (BBFA) fractures that required sedation and reduction under mini C-arm fluoroscopy at our Level 1 pediatric ED were reviewed for 6 months both before and after this policy change. Before, all patients had formal postreduction radiographs; after, the decision was left to the orthopaedic physician. Timestamp data were collected, as was the need for rereduction or surgery. In addition to descriptive statistics, between-group differences were analyzed with the Student t test, χ test, and multivariable regression as appropriate. RESULTS: A total of 243 patients (119 before, 124 after) had 165 DR/DU and 78 BBFA fractures. Demographic data were similar before and after. After protocol implementation, univariable analysis (Student t test) showed that sedation times were longer, while total ED time and the time from sedation beginning to discharge were similar. The proportion of patients requiring rereduction or surgery were similar.After multivariable regression, "fluoroscopy as definitive imaging" was the only independent determinant of the time intervals compared with using conventional radiography. Sedation was an average of 13.8 minutes longer (P<0.001), while the interval from sedation beginning to discharge was 15.8 minutes shorter (P=0.007), and total ED time was 33.0 minutes shorter (P=0.018). Fluoroscopy as definitive imaging was not a predictor of surgery (odds ratio=0.63, P=0.520), although having a BBFA increased the likelihood (odds ratio=4.50, P=0.008). CONCLUSIONS: Implementing a protocol in which the provider could use mini C-arm fluoroscopy for definitive postreduction imaging did not result in increased rates remanipulation or need for surgery. Regression analysis further demonstrated time savings associated with foregoing conventional radiographs. LEVEL OF EVIDENCE: Level III-therapeutic.

Characterization and Fate of Unpublished Research Articles Reported by Orthopedic Surgery Residency Applicants.

OBJECTIVE: As the competitiveness of matching to an orthopedic residency continues to increase, applicants attempt to bolster their application by participating in research activities. However, due to the brief duration of medical school, applicants' articles may not be published at the time of applying. The purpose of this study was to identify projects that were listed under "publications-other than published" within Electronic Residency Application System (ERAS) applications of prospective orthopedic surgery residents to determine the rate and time of these projects to future publication in a peer-reviewed journal. Program directors can use this information to help interpret the importance of such articles on the applications of future residency candidates. DESIGN: Retrospective study of prospective residents' applications to a single orthopedic residency program during the 2014 to 2015 application cycle were reviewed to identify articles designated as "other than published." Articles which advanced to official publication were confirmed using the Embase, PubMed, and Google Scholar databases. Applicant and article characteristics were recorded to identify variables associated with an increased proportion of articles that were able to be confirmed. PARTICIPANTS: Prospective residents to a single orthopedic residency program during the 2014 to 2015 application cycle. RESULTS: A total of 1957 article titles were listed amongst 563 applicants, with 48% of applicants (n = 271) having at least one peer-reviewed article listed as "other than published." Overall, 34.2% (709) of the articles were designated as being unpublished including 208 listed as accepted/in-press and 501 listed as submitted/under review. Of the accepted/in-press articles, 90.7% (n = 189) were able to be confirmed as successfully published papers, compared to 63.4% (n = 318) of articles designated as submitted/under review (p < 0.001). Factors predictive of articles which advanced to official publication were being accepted/in-press at the time of applying, a lower United States Medical Licensing Exam (USMLE) Step 1 score, and articles on orthopedic topics. CONCLUSIONS: Nearly one-half of orthopedic residency applicants report unpublished research articles on their ERAS application. While 90.7% of the articles listed as being accepted/ in press were eventually published, less than two-thirds of the articles designated as being in submission/under-review progressed to official publication.

The Cost and Utility of Postreduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures.

BACKGROUND: Formal radiographs are frequently obtained after reduction of closed pediatric wrist and forearm fracture performed under mini C-arm fluoroscopy. However, their utility has not been clearly demonstrated to justify the increased time, cost, and radiation exposure. We hypothesized that formal postreduction radiographs do not affect the rereduction rate of pediatric wrist and forearm fractures. We further sought to determine the time, monetary, and opportunity costs associated with obtaining these radiographs. METHODS: A total of 119 patients presented to our urban, level I pediatric trauma center from April 2015 to September 2015 with isolated, closed wrist and forearm fractures who underwent sedation and reduction using mini C-arm fluoroscopy. Demographic and injury variables were collected, along with incidence of rereduction and need for future surgery. Time intervals for sedation, awaiting x-ray, and total encounter periods were noted, and total direct and variable indirect costs for each encounter were obtained from our institution's cost accounting and billing databases. Marginal time and monetary costs were noted and further calculated as a percentage of the total encounter. Opportunity costs were calculated for the time spent obtaining the postreduction radiographs. RESULTS: Of 119 patients with isolated, closed wrist or forearm fractures, none required rereduction after initial reduction using sedation and mini C-arm fluoroscopy. Postreduction radiographs required an average of 26.2 minutes beyond the end of sedation, or 7.3% of the encounter time and cost. The direct cost of the x-ray was 2.6% of the encounter cost. With our institution's annual volume, this time could have been used to see an additional 656 patients per year. CONCLUSIONS: Postreduction formal radiographs did not result in changes in management. There are significant direct and opportunity costs for each patient who undergoes additional formal radiographs. Pediatric patients with isolated, closed wrist or forearm fractures do not routinely need formal radiographs after reduction under mini C-arm fluoroscopy. LEVEL OF EVIDENCE: Level IV-Therapeutic.

Pediatric Polytrauma: What Is the Role of Damage Control Orthopaedics in the Pediatric Population?

Severe pediatric trauma can be complicated for clinicians to manage because it is unusual and behaves somewhat differently from severe trauma in adults. Damage control orthopaedics is a philosophy that has gained traction in the past 30 years and has become standard in unstable adult trauma patients. Studies have failed to demonstrate clear utility for this approach in pediatric patients. Clinicians should understand the concepts of early total care and damage control orthopaedics for the patient with polytrauma, the physiologic factors associated with trauma in both children and adults who sustain severe trauma, and the role of early total care versus damage control orthopaedics in the treatment of the pediatric patient with polytrauma.