Perceptions of USMLE Step 1 Pass/Fail Score Reporting Among Orthopedic Surgery Residency Program Directors.

The United States Medical Licensing Examination (USMLE) Step 1 examination will transition from graded to pass/fail scoring starting no earlier than January 2022. Orthopedic surgery residency programs will need to adapt to these changes. The goal of this study was to investigate the perceptions of orthopedic surgery residency program directors on the change of Step 1 from a graded to a pass/fail examination. We also investigated how the change would affect the other factors that are typically considered in the selection of orthopedic surgery residents. A survey was distributed to 161 directors of allopathic orthopedic surgery programs. Contact information was obtained from a national database. Of those contacted, 75 (46.6%) program directors responded. Most (85.3%) did not support the pass/fail change. Most believe that greater importance will be placed on the Step 2 Clinical Knowledge examination (96.0%), audition elective with their department (84.0%), personal knowledge of the applicant (78.7%), grades (74.7%), letters of recommendation from recognizable orthopedic surgeons (74.7%), and Alpha Omega Alpha status (69.3%). Most also believe that this change will advantage allopathic students who attend highly regarded schools (58.7%). Most of the program directors support a graded preclinical curriculum (69.3%) and caps on the number of orthopedic surgery residency applications (70.7%). Although most orthopedic surgery program directors disagree with the change to a pass/fail Step 1 examination, residency programs will need to reevaluate how they screen applicants for an interview once the scored Step 1 is no longer available. With this change, other factors, such as Step 2 score, audition rotations, and grades in clerkships, will be emphasized more heavily. [Orthopedics. 2022;45(1):e30-e34.].

Descriptive Analysis of Orthopaedic Surgery Residency Program Directors.

The purpose of this study was to analyze the demographics and backgrounds of U.S. orthopaedic surgery residency program directors (PDs). We collected publicly available information on 189 orthopaedic surgery residency PDs. Of those PDs, 90% were male MDs with an average age of 52. The average age at PD appointment was 45. The average duration of appointment was 7 years. About 81% of programs were university-affiliated, and 61% were in an urban environment. PDs attended 100 medical schools, 129 residencies, and 96 fellowships. of PDs, 87% completed fellowships, commonly in trauma and sports medicine. There was no significant difference between male and female PDs when comparing age, academic appointment, or urban/rural environment. Most female PDs (89%) were at university-based hospitals. Of PDs at osteopathic-focused programs, 28% had an MD/PD. No program with an allopathic focus had a DO/PD. Lastly, 38% of PDs worked at the center where they completed residency. (Journal of Surgical Orthopaedic Advances 31(4):252-255, 2022).

A comparison of orthopaedic surgery and internal medicine perceptions of USMLE Step 1 pass/fail scoring.

BACKGROUND: United States Medical Licensing Examination Step 1 will transition from numeric grading to pass/fail, sometime after January 2022. The aim of this study was to compare how program directors in orthopaedics and internal medicine perceive a pass/fail Step 1 will impact the residency application process. METHODS: A 27-item survey was distributed through REDCap to 161 U.S. orthopaedic residency program directors and 548 U.S. internal medicine residency program directors. Program director emails were obtained from the American Medical Association's Fellowship and Residency Electronic Interactive Database. RESULTS: We received 58 (36.0%) orthopaedic and 125 (22.8%) internal medicine program director responses. The majority of both groups disagree with the change to pass/fail, and felt that the decision was not transparent. Both groups believe that the Step 2 Clinical Knowledge exam and clerkship grades will take on more importance. Compared to internal medicine PDs, orthopaedic PDs were significantly more likely to emphasize research, letters of recommendation from known faculty, Alpha Omega Alpha membership, leadership/extracurricular activities, audition elective rotations, and personal knowledge of the applicant. Both groups believe that allopathic students from less prestigious medical schools, osteopathic students, and international medical graduates will be disadvantaged. Orthopaedic and internal medicine program directors agree that medical schools should adopt a graded pre-clinical curriculum, and that there should be a cap on the number of residency applications a student can submit. CONCLUSION: Orthopaedic and internal medicine program directors disagree with the change of Step 1 to pass/fail. They also believe that this transition will make the match process more difficult, and disadvantage students from less highly-regarded medical schools. Both groups will rely more heavily on the Step 2 clinical knowledge exam score, but orthopaedics will place more importance on research, letters of recommendation, Alpha Omega Alpha membership, leadership/extracurricular activities, personal knowledge of the applicant, and audition electives.

Achilles tendon moment arm changes with total ankle arthroplasty.

Prior research on total ankle arthroplasty (TAA) has focused on improvements in pain and function following the surgical treatment of ankle arthritis, but its effect on ankle joint mechanics has received relatively little attention. The plantarflexion moment arm of the Achilles tendon is a critical determinant of ankle function with the potential to be altered by TAA. Here we investigate the effect of TAA on Achilles tendon moment arm assessed using two methods. Standing sagittal-plane radiographs were obtained for ten patients presurgery and postsurgery, from which anterior-posterior distance between the posterior calcaneus and the center of the talar dome was measured. Ultrasound imaging and three-dimensional (3D) motion capture were used to obtain moment arm pre- and post-TAA. The absolute changes in moment arm pre- to post-TAA were significantly different from zero for both methods (9.6 mm from ultrasound and 4.6% of the calcaneus length from radiographs). Only 46% of the variance in postoperative 3D Achilles tendon moment arm was explained by the preoperative value (r2 = 0.460; p = .031), while pre- and post-TAA values from radiographs were not correlated (r2 = 0.192, p = .206). While we did not find significant mean differences in Achilles tendon moment arm between pre- and post-TAA, we did find absolute changes in 3D moment arm that were significantly different from zero and these changes were partially explained by a change in location of the talar dome as indicated by measurements from radiographs (r2 = 0.497, p = .023).

Cost Comparison of Synthetic Hydrogel Implant and First Metatarsophalangeal Joint Arthrodesis.

Background. First metatarsophalangeal (MTP) arthrodesis is the "gold standard" treatment for hallux rigidus. Recently, there has been increased interest in new synthetic cartilage implants to preserve joint motion while eradicating pain. With current health care economics, the cost of a treatment is gaining particular importance. This study set out to perform a cost comparison between MTP arthrodesis and synthetic hydrogel implant to determine which treatment modality is more cost-effective based on direct aggregate costs. Study design. Economic and decision analysis. Methods. Studies in the available literature were analyzed to estimate hardware removal rates for MTP fusion and failure rates for a synthetic hydrogel implant and MTP fusion. Costs were determined by examining direct costs at a single institution for implants and data reported in the literature for operating room time. Sensitivity analysis and Monte Carlo simulation were performed to examine cost and measurement uncertainty. Results. Assuming a 4.76% MTP arthrodesis revision rate and 7.06% hardware removal rate, the total direct cost of MTP joint arthrodesis was $3632. Using a 9.2% failure rate with subsequent conversion to MTP arthrodesis, the total cost of synthetic hydrogel implant was $4565. Sensitivity analysis revealed that MTP fusion was more cost-effective even if the failure rate increased to 15% and synthetic hydrogel implant failure rate was 0%. The synthetic cartilage implant cost would have to be reduced 28% or approximately 200% the cost of MTP fusion implants to be comparable to MTP arthrodesis. Conclusion. Hallux rigidus treatment with a synthetic hydrogel implant resulted in a higher direct aggregate cost than MTP arthrodesis.Level of Evidence: Level II: Cost analysis.

Distal fibula osteotomies improve tibiotalar joint compression: A biomechanical study in a cadaveric model.

BACKGROUND: Successful tibiotalar joint fusion relies on adequate compression. Compression following joint preparation may be affected by the extent to which the fibula holds the joint out to anatomical length. The purpose of this study was to evaluate the effect of various distal fibula osteotomies on tibiotalar joint compression. METHODS: Eight adult cadaveric lower extremity specimens with an intact ankle joint and syndesmotic complex were evaluated. The ankle joint cartilage was denuded to subchondral bone. The fibula was surgically modified with three progressing procedures including an oblique fibula osteotomy, 1 cm resection, and distal fibula resection. A transducer was utilized to measure tibiotalar joint force, contact area, and peak pressure values while compressive forces of 30 N, 50 N, and 100 N were applied to the proximal tibia/fibula. FINDINGS: Distal fibula resection significantly increased tibiotalar joint force, contact area, and peak pressure the most of all fibula conditions tested compared to intact fibula control (p < .05). Tibiotalar joint force and peak pressures were significantly increased with a distal fibula oblique osteotomy, 1 cm resection, and complete resection under both 30 and 50 N applied compressive force (p < .05). INTERPRETATION: Complete distal fibular resection results in higher tibiotalar joint force, contact area, and peak pressure which may improve clinical rates of successful ankle fusion.

Short- to Mid-Term Outcomes Following the Use of an Arthroereisis Implant as an Adjunct for Correction of Flexible, Acquired Flatfoot Deformity in Adults.

BACKGROUND: The use of an arthroereisis implant for the treatment of adolescent flatfoot deformity has been described. However, data that address the outcomes of patients treated with an arthroereisis implant in adults are limited. The purpose of this study was to investigate the radiographic and clinical outcomes and complications following the use of a subtalar arthroereisis implant as an adjunct for correction acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. METHODS: A retrospective case-control study was performed querying all patients undergoing surgical flatfoot correction between January 1, 2010 and January 1, 2015. The experimental group included patients undergoing arthroereisis augmentation at the time of flatfoot correction. Patients undergoing the same flatfoot correction without the use of an arthroereisis implant were used as controls. Radiographic measurements were evaluated preoperatively and at final radiographic follow-up and included talonavicular (TN) coverage angle, and lateral talar-first metatarsal angle (T1MA). Patient-reported outcomes were assessed using preoperative visual analog scale (VAS) pain scores and postoperative Short Form-36, VAS, and satisfaction at final orthopedic follow-up. RESULTS: A total of 15 patients underwent flatfoot correction and were augmented with an arthroereisis implant and were matched with 30 controls. Postoperative, mid-term T1MA and regional analysis was found to be improved in the experimental group versus control. Patients undergoing adjunct subtalar arthroereisis demonstrated an increased likelihood of achieving radiographically normal talonavicular coverage <7° compared with our control group at follow-up. CONCLUSIONS: The adjunct use of an arthroereisis implant resulted in improved and maintained radiographic and clinical measurements in patients undergoing stage II flatfoot. CLINICAL SIGNIFICANCE: These results suggest utility of a subtalar arthroereisis implant as an adjunct to flatfoot correction with little additional risk of harm to the patient. LEVELS OF EVIDENCE: Level III: Case-control study.

Diagnostic Criteria and Treatment of Acute and Chronic Periprosthetic Joint Infection of Total Ankle Arthroplasty.

BACKGROUND: Prosthetic joint infection (PJI) after total ankle arthroplasty (TAA) is a serious complication that results in significant consequences to the patient and threatens the survival of the ankle replacement. PJI in TAA may require debridement, placement of antibiotic spacer, revision arthroplasty, conversion to arthrodesis, or potentially below the knee amputation. While the practice of TAA has gained popularity in recent years, there is some minimal data regarding wound complications in acute or chronic PJI of TAA. However, of the limited studies that describe complications of PJI of TAA, even fewer studies describe the criteria used in diagnosing PJI. This review will cover the current available literature regarding total ankle arthroplasty infection and will propose a model for treatment options for acute and chronic PJI in TAA. METHODS: A review of the current literature was conducted to identify clinical investigations in which prosthetic joint infections occurred in total ankle arthroplasty with associated clinical findings, radiographic imaging, and functional outcomes. The electronic databases for all peer-reviewed published works available through January 31, 2018, of the Cochrane Library, PubMed MEDLINE, and Google Scholar were explored using the following search terms and Boolean operators: "total ankle replacement" OR "total ankle arthroplasty" AND "periprosthetic joint infection" AND "diagnosis" OR "diagnostic criteria." An article was considered eligible for inclusion if it concerned diagnostic criteria of acute or chronic periprosthetic joint infection of total ankle arthroplasty regardless of the number of patients treated, type of TAA utilized, conclusion, or level of evidence of study. RESULTS: No studies were found in the review of the literature describing criteria for diagnosing PJI specific to TAA. CONCLUSIONS: Literature describing the diagnosis and treatment of PJI in TAA is entirely reliant on the literature surrounding knee and hip arthroplasty. Because of the limited volume of total ankle arthroplasty in comparison to knee and hip arthroplasty, no studies to our knowledge exist describing diagnostic criteria specific to total ankle arthroplasty with associated reliability. Large multicenter trials may be required to obtain the volume necessary to accurately describe diagnostic criteria of PJI specific to TAA. LEVEL OF EVIDENCE: Level III, systematic review.

The Role of 3D Reconstruction True-Volume Analysis in Osteochondral Lesions of the Talus: A Case Series.

BACKGROUND: Evaluation and management of osteochondral lesions of the talus (OLTs) often warrant advanced imaging studies, especially in revision or cases with cystic defects. It is possible that orthopedic surgeons may overestimate the size and misinterpret the morphology of OLT from conventional computed tomography (CT), thereby influencing treatment strategies. The purpose of this study was to determine the utility of a novel means to estimate the true-volume of OLTs using 3D reconstructed images and volume analysis. METHODS: With Institutional Review Board approval, an institutional radiology database was queried for patients with cystic OLTs that failed previous microfracture, having compatible CT scans and magnetic resonance imaging (MRI) between 2011 and 2016. Fourteen patients met inclusion criteria. Of these, 5 cases were randomly selected for 3D CT reconstruction modeling. Ten orthopedic surgeons independently estimated the volume of these 5 OLTs via standard CT. Then 3D reconstructions were made and morphometric true-volume (MTV) analysis measurements of each OLT were generated. The percent change in volumes from CT were compared to MTVs determined from 3D reconstructive analysis. RESULTS: On average, the volume calculated by conventional CT scanner grossly overestimated the actual size of the OLTs. The volume calculated on conventional CT scanner overestimated the size of OLTs compared to the 3D MTV reconstructed analysis by 285% to 864%. CONCLUSIONS: Our results showed that conventional measurements of OLTS with CT grossly overestimated the size of the lesion. The 3D MTV analysis of cystic osteochondral lesions may help clinicians with preoperative planning for graft selection and appropriate volume while avoiding unnecessary costs incurred with overestimation. LEVEL OF EVIDENCE: Level IV, case series.

Talar neck fractures treated with closed reduction and percutaneous screw fixation:a case series.

Talus fractures are relatively rare injuries, accounting for approximately 3% of all foot fractures. Fractures of the talar neck account for almost 50% of all talus fractures. Diagnosis and treatment of these fractures play an important role in patients' outcomes. Treatment of talar neck fractures has slowly evolved from closed treatment to open reduction and internal fixation. Treatment of type I and type II talar neck fractures is debated in the orthopedic community. Choosing which treatment to perform depends on injury severity, associated injuries, and surgeon experience and preference. In this article, we report on our retrospective review of all talar neck fractures treated with closed reduction and percutaneous fixation between 1996 and 2001 at the Pennsylvania State University Milton S. Hershey Medical Center.

Functional outcome after percutaneous tendo-Achilles lengthening.

BACKGROUND: Percutaneous tendo-Achilles lengthening (PTAL) is a common procedure performed as an adjunct to other procedures that are used to treat a variety of foot and ankle disorders. Despite the widespread use of PTAL, the only literature to substantiate its efficacy comes from the treatment of forefoot ulceration in diabetics. The complications of the procedure include pain along the Achilles tendon, difficulty using stairs, weakness with toe-off, inadvertent complete tenotomy, and cosmetic appearance. We sought to investigate the functional outcomes specific to PTAL when performed in tandem with triple arthrodesis and subtalar fusion. MATERIALS AND METHODS: A retrospective review of 107 patients who underwent 117 procedures was performed. Outcomes were assessed by telephone interview using a standard questionnaire. The most common procedure in the study population was triple arthrodesis (91%). RESULTS: Fifty-eight percent of the patients reported moderate improvement in motion postoperatively, but 80% reported some degree of persistent stiffness. Despite 38% of patients reporting postoperative weakness, 66% and 61% stated that ascending and descending stairs, respectively, was easier. CONCLUSION: Overall, 81% of the study population had a positive opinion regarding their surgery. In this heterogeneous population, we showed modest improvement in Achilles tendon-related outcomes when PTAL was performed in tandem with other surgeries.

Wound complications in thyroxine-supplemented patients following foot and ankle surgery.

BACKGROUND: Our hypothesis was that thyroxine supplementation in patients undergoing foot and ankle surgery would be associated with increased postoperative wound complications and wound dehiscence compared to patients without thyroxine supplementation. MATERIALS AND METHODS: A retrospective review of 48 patients supplemented with thyroxine that underwent foot and ankle surgery was conducted and analyzed for wound complications. All patients were non-diabetic. A total of 94 historical controls were used to compare the incidence of wound complications to the thyroxine sample. Patient demographics, medical comorbidities, principal diagnosis and procedure performed were recorded. The presence or absence of wound dehiscence, infection or other wound complications was recorded for all patients based on the followup clinical notes in the electronic record. RESULTS: In the thyroxine group, the most common diagnosis was degenerative arthritis (31%, n=15), which also occurred in 28.7% of control patients (n=27). Wound dehiscence was reported in 36.2% (n=17) of thyroxine-supplemented patients compared to 10.8% of control patients (n=10). After adjusting for age, gender, hypertension diagnosis, and vascular disease diagnosis, the odds for wound dehiscence remained significantly greater for the thyroxine group compared to control patients (adjusted OR=3.7; 95% CI: (1.3, 11.4); p=0.01). CONCLUSION: Overall, our results suggest increased wound dehiscence complications in the postoperative period for thyroxine-supplemented patients compared to control patients. This finding remained even after adjusting for the associated cardiovascular comorbidities seen in thyroxine-supplemented patients.

Estrogen receptor expression in posterior tibial tendon dysfunction: a pilot study.

BACKGROUND: The pathophysiology of posterior tibial tendon dysfunction (PTTD) is poorly understood. It has been theorized that changes in hormone physiology may be a factor influencing tendon health. Estrogen's influence on the fibroblast has been studied in other musculoskeletal tissues. Gender differences in anterior cruciate ligament (ACL) injuries have been studied and it has been discovered that the Estrogen receptor (ER) as well as Progesterone receptor (PR) are expressed in the ACL. MATERIAL AND METHODS: Eight patients with PTTD requiring surgery were enrolled in our pilot study. The mean patient age was 52.4 (range, 18 to 73) years. There were five female and three male patients. Tendon samples were harvested from diseased PTT. Tendon samples harvested from healthy PTT and healthy flexor digitorum longus (FDL) tendon were used as controls. Tendon samples were processed using specific protocols for total RNA isolation from hypocellular, dense connective tissues. ERα and ERß transcripts were quantified using real time RT-PCR. Quantitative values were obtained from the threshold cycle (Ct) number at which the increase in fluorescent signal associated with an exponential increase of PCR products can be detected. RESULTS: Transcripts of both ERα and ERß were reproducibly detected in RNA samples isolated from our tendon samples. There was no difference in receptor expression between diseased and control tendon samples. There was no difference in receptor expression between male and female patients. CONCLUSION: We found that the tenocyte of the PTT and FDL tendons express ERα and ERß. Normal and diseased tendons of both male and female patients expressed both estrogen receptors. CLINICAL RELEVANCE: Identifying ERα and ERß gene expression in the fibroblast was an initial step in discovering whether tenocytes are targets for estrogen function. Estrogen receptors were identified indirectly by measuring receptor gene expression but we were unable to show a significant difference between diseased and control tendons.

Effectiveness of composite bone graft substitute plugs in the treatment of chondral and osteochondral lesions of the talus.

A review of outcomes in 13 patients with talar dome osteochondral or chondral lesions treated with a bone graft substitute plug was undertaken in an effort to evaluate its effectiveness in comparison with other reported surgical techniques. Mean patient age was 36.4 (range 16 to 57) years. Mean follow-up was 30.1 (range 7 to 43) months. Medial malleolar osteotomy was performed in 9 (69.23%) cases. Average defect diameter was 9.8 (range 5 to 20) mm. Pain decreased significantly from 6.2 (range 3 to 9) to 4.0 (range 0 to 9) (P = .009). Postoperative American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scores averaged 67.3 (range 26 to 100). Younger age, smaller defect size, and avoidance of medial malleolar osteotomy resulted in better outcomes. Mean Short Form-36 scores for the study group fell below US norms in all categories, and 12 (92.31%) ankles demonstrated persistent lesions radiographically. Postoperative magnetic resonance imaging in 2 (15.39%) patients demonstrated enlarged lesions, and 4 (30.77%) patients underwent revision surgery that revealed abnormal cartilage around the implant site. Complications included 1 (7.69%) deep venous thrombosis, 1 (7.69%) arthrofibrosis, and 1 (7.69%) superficial neuritis. Despite some improvement in pain, comparison of functional outcome showed bone graft substitute plug implantation to be less effective overall than other operative interventions. Future investigations with more specific selection criteria are warranted to gain further insight into the efficacy of these bone graft substitute plugs.

Shock wave therapy compared with intramedullary screw fixation for nonunion of proximal fifth metatarsal metaphyseal-diaphyseal fractures.

BACKGROUND: The current "gold standard" for treatment of chronic fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal is intramedullary screw fixation. Complications with this procedure, however, are not uncommon. Shock wave therapy can be an effective treatment for fracture nonunions. The purpose of this study was to evaluate the safety and efficacy of shock wave therapy as a treatment of these nonunions. METHODS: Twenty-three patients with a fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal received high-energy shock wave therapy (2000 to 4000 shocks; energy flux density per pulse, 0.35 mJ/mm(2)), and twenty other patients with the same type of fracture nonunion were treated with intramedullary screw fixation. The numbers of fractures that were healed at three and six months after treatment in each group were determined, and treatment complications were recorded. RESULTS: Twenty of the twenty-three nonunions in the shock wave group and eighteen of the twenty nonunions in the screw fixation group were healed at three months after treatment. One of the three nonunions that had not healed by three months in the shock wave group was healed by six months. There was one complication in the shock wave group (post-treatment petechiae) and eleven complications in the screw-fixation group (one refracture, one case of cellulitis, and nine cases of symptomatic hardware). CONCLUSIONS: Both intramedullary screw fixation and shock wave therapy are effective treatments for fracture nonunion in the metaphyseal-diaphyseal region of the fifth metatarsal. Screw fixation is more often associated with complications that frequently result in additional surgery.

Combined subtalar and ankle arthritis.

Combined ankle and subtalar arthritis is a difficult problem for which there are varied solutions. Each solution has its advantages and disadvantages. Treatment must be specifically tailored to the patient's needs, comorbidities, and expectations. Because of the complicated nature of this condition and its treatment, complications are common and should be anticipated.

Talar neck fractures.

Talus fractures are rare injuries that account for approximately 3% of all foot fractures; talar neck fractures account for almost 50% of all talus fractures. The appropriate diagnosis and treatment of these fractures play an important role in the patient's outcome. Treatment has evolved slowly throughout the years, from closed treatment to open reduction and internal fixation (ORIF). The treatment of type I and type II talar neck fractures is not uniform in the orthopedic community. The option of closed reduction versus ORIF is dependent upon the degree of injury, surgeon experience, and preference.