The Relative Importance of Factors That Applicants Weigh When Ranking Adult Reconstruction Fellowships as Well as Their Perspectives on Robotic-Assisted Arthroplasty.

BACKGROUND: Orthopedic Surgery Fellowship programs offer highly specialized training that varies based on the training environment and surgical experience. Additionally, for Adult Reconstruction programs, robotic-assisted surgery exposure has been a widely discussed topic. The purpose of this study was to determine the relative value of various factors to Adult Hip and Knee Fellowship applicants, and their perceptions of robotic-assisted arthroplasty. METHODS: We surveyed 780 applicants who applied to our fellowship to matriculate in 2020 to 2024. We received 158 responses (20.3% response rate). We assessed factors concerning people and perceptions, logistics, salary and benefits, program reputation and curriculum, and surgical experience. Additionally, we surveyed fellows' attitudes toward using robotic surgery and its impact on patient outcomes. RESULTS: The highest-rated factors were Level of Hands-On Operative Experience (4.83), Revision Hip Volume (4.72), Revision Knee Volume (4.71), Multiple Surgical Exposures to the Hip (4.59), and Clinical Case Variety (4.59). Respondents who were postfellowship matriculation placed significantly more value on Exposure to Multiple Attendings with Surgical Diversity (P = .01), and Anterior Hip Volume (P = .04), and less value on Geographic Location (P = .04) and Patient-Specific Instrumentation (P = .02) than prematriculates. Overall, 65% of applicants plan to or currently use robotics, 7.6% do not, and 27.2% said "Maybe". Those who plan to or currently use robotics most cited procedure fidelity, patient-preference, and marketability as reasons to use robotics. CONCLUSIONS: Hands-on surgical experience and revision volume were the most important factors for fellowship applicants. Applicants placed lower importance on robotics exposure and their perspectives on robotics in their future practice were highly variable. Our results will inform fellowship programs and future applicants what previous applicants have valued in their training to help guide fellowship program structure, resource management, as well as recruitment.

Comparing Orthopaedic Randomized Control Trials Published in High-Impact Medical and Orthopaedic Journals.

INTRODUCTION: Orthopaedic studies published in high-impact medical journals are often believed to have a high prevalence of negative or neutral results and possess methodological characteristics that may bias toward nonsurgical treatments. The purpose of this study was to compare study characteristics, methodologic quality, exposure, and outcome direction among orthopaedic randomized control trials (RCTs) published in high-impact medical and orthopaedic journals and to identify study attributes associated with greater impact. METHODS: RCTs published between January 2010 and December 2020 in the five medical journals and 10 orthopaedic journals with the highest 5-year impact factors were analyzed. Inclusion criteria were RCTs reporting on orthopaedic surgical intervention compared with nonsurgical or less-invasive surgical procedures. Study characteristics, methodologic quality (Jadad scale), outcomes, and altmetric data were collected. Primary outcomes were categorized as positive (favoring surgical/more-extensive surgery), negative (favoring nonsurgical/less-extensive surgery), or neutral. RESULTS: One hundred twenty-eight RCTs were analyzed; 26 from medical and 102 from orthopaedic journals. Studies published in medical journals included more authors ( P < 0.001), larger sample sizes ( P < 0.001), more institutions ( P < 0.001), and more often received funding ( P < 0.001). The average Jadad scale did not significantly differ between journals ( P = 0.14). The direction of the primary study outcome did not differ between journals ( P = 0.22). Average AAS and annual citation rates were higher in RCTs published in medical journals ( P < 0.001). Publication in a medical journal was the only covariate associated with higher annual citation rates ( P < 0.001) and AAS ( P < 0.001) on multivariable analyses. DISCUSSION: High-impact medical journals do not publish orthopaedic RCTs with negative or neutral findings at a rate that significantly differs from orthopaedic journals. However, the higher impact and digital coverage of the studies published in medical journals may disproportionally influence the practices of nonorthopaedic providers. Raising awareness of critical findings published in orthopaedic journals may be particularly important for improving healthcare policies and orthopaedic referral patterns for musculoskeletal problems.

How to place a cephalomedullary screw when visualization is obscured by the jig in peritrochanteric hip fractures using "peek radiographs."

Lag screw positioning can be difficult to discern intraoperatively on lateral fluoroscopic imaging during intramedullary fixation of proximal femur fractures in some nailing systems due to the drill guide handle obstructing the view. We have described a method of obtaining non-obstructed lateral-oblique "peek" views that reliably assist in obtaining adequate tip-apex distance (TAD) measurements when using intramedullary fixation for these fractures. The purpose of this study was (1) to describe an intraoperative radiographic technique to obtain non-obscured views for appropriate center-center placement of the lag screw(s) within the femoral head during jig-aided cephalomedullary nailing of peritrochanteric hip fractures and (2) to present a case series detailing the radiographic results using this technique. This clinical series of sixty-five patients with intertrochanteric or subtrochanteric proximal femur fractures stabilized with a cephalomedullary nail had an average TAD of 15.1 ± 3.3mm (range: 9.4mm-26.2mm). This suggests that our technical trick of obtaining "peek" radiographs intraoperatively may aid in a precise lag-screw placement.

Open lower extremity fractures in the geriatric population.

INTRODUCTION: Open fractures in the elderly are distinct compared to younger populations. The purpose of this study is to follow a series of open fractures of the lower extremity in the geriatric population to better prognosticate outcomes. METHODS: We performed a retrospective chart review of patients over the age of 65 years old who were treated for an open, lower extremity fracture across two level I trauma medical systems. Patients were included if they had documented wound healing problems in the postoperative period, or 6 months of follow-up, or if they had a definitive radiographic outcome. Sixty-four patients were included of an average age of 76.23, of whom 73.4% were female. RESULTS: The fracture types were midshaft femur in 3, distal femur in 9, patella in 2, proximal tibia in 3, proximal fibula in 1, midshaft tibia in 14, distil tibia in 8, ankle in 23, and talar neck/calcaneus in 1. Forty-two fractures were the result of low energy mechanism and 22 fractures were from high energy mechanism. Fourteen fractures were type 1, 32 were type 2, 11 were type 3A, 6 were type 3B, and 1 was type 3C. At final follow-up, 13 wounds were well healed, 39 wounds were healed following a delay of more than 6 weeks to achieve healing, 3 were infected, 3 had been treated with amputation, 2 had chronic ulceration, 2 with active draining, and 2 had draining sinuses. DISCUSSION: Open lower extremity fractures are serious injuries with high rates of morbidity. Such risks are even higher in the geriatric population, particularly with regard to wound healing. This study provides important prognostic information in counseling geriatric patient with an open lower extremity fracture, as well as informs treatment in terms of wound surveillance and care in the postoperative period.

Cardiovascular intensive care unit variables inform need for feeding tube utilization in infants with hypoplastic left heart syndrome.

OBJECTIVE: Feeding strategies in infants with hypoplastic left heart syndrome (HLHS) following stage 1 palliation (S1P) include feeding tube utilization (FTU). Timely identification of infants who will fail oral feeding could mitigate morbidity in this vulnerable population. We aimed to develop a novel clinical risk prediction score for FTU. METHODS: This was a retrospective study of infants with HLHS admitted to the Boston Children's Hospital cardiovascular intensive care unit for S1P from 2009 to 2019. Infants discharged with feeding tubes were compared with those on full oral feeds. Variables from early (birth to surgery), mid (postsurgery to cardiovascular intensive care unit transfer), and late (inpatient transfer to discharge) hospitalization were analyzed in univariate and multivariable models. RESULTS: Of 180 infants, 66 (36.7%) discharged with a feeding tube. In univariate analyses, presence of a genetic disorder (early variable, odds ratio, 3.25; P = .014) and nearly all mid and late variables were associated with FTU. In the mid multivariable model, abnormal head imaging, ventilation duration, and vocal cord dysfunction were independent predictors of FTU (c-statistic 0.87). Addition of late variables minimally improved the model (c-statistic 0.91). A risk score (the HV2 score) for FTU was developed based on the mid multivariable model with high specificity (93%). CONCLUSIONS: Abnormal head imaging, duration of ventilation, and presence of vocal cord dysfunction were associated with FTU in infants with HLHS following S1P. The predictive HV2 risk score supports routine perioperative head imaging and vocal cord evaluation. Future application of the HV2 score may improve nutritional morbidity and hospital length of stay in this population.

Technical Performance Score: A Predictor of Outcomes After the Norwood Procedure.

BACKGROUND: The Technical Performance Score (TPS) can predict outcomes after congenital cardiac surgery. We sought to validate TPS as a predictor of both short- and long-term outcomes of the Norwood procedure. METHODS: We conducted a retrospective review of patients who underwent the Norwood procedure from 1997 to 2017. We assigned TPS (class 1, no residua; class 2, minor residua; class 3, major residua or reintervention for major residua before discharge) based on subcomponent scores from discharge echocardiograms or unplanned reinterventions, or both. Multivariable Cox or competing risk analysis, adjusted for preoperative patient- and procedure-related covariates, examined the association of TPS with postoperative hospital length of stay, transplant-free survival, and postdischarge reinterventions. RESULTS: Among 500 patients, 319 (64%) were male, 54 (11%) were premature, 56 (11%) had noncardiac anomalies/syndromes, 146 (29%) had preoperative risk factors, and 480 (96%) were assigned TPS. On multivariable analysis, class 3 had greater hazard for reinterventions in transplant-free survivors (class 3: subdistribution hazard ratio [HR], 2.06; 95% confidence interval [CI] 1.34-3.16; P = .001) and was associated with increased hospital length of stay vs class 1 (HR, 0.25; 95% CI, 0.18-0.34; P < .001). Transplant-free survival after Norwood surgery was shorter for both class 2 (HR, 2.48; 95% CI, 1.68-3.66; P < .001) and class 3 (HR, 3.29; 95% CI, 2.18-4.95; P < .001). CONCLUSIONS: TPS predicts early and late outcomes after Norwood. Absence of residual lesions results in improved long-term prognosis for single-ventricle patients. TPS may improve outcomes after Norwood by identifying patients warranting closer follow-up and potentially earlier reintervention.