Simulation Training in Orthopaedic Surgery.

Simulation training encompasses all methods of learning technical skills that do not require practicing on a live patient. Surgical training typically uses an apprenticeship model, in which responsibility is gradually shifted from attending surgeon to the trainee over years of experiences with live patients. Skill acquisition from simulation modalities can prevent unnecessary harm to patients if trainees have practice and experience from simulation before participation in live surgeries. Surgeons are morally required to prevent unnecessary harm to patients, regardless of whether they are consequentialist or nonconsequentialist in one's metaethics. It is the authors' opinion that simulation training is a moral imperative, as there is early empirical evidence for preventing harm to patients and it should be incorporated to the extent it is feasible in every surgical training program. Further definitive studies need to be performed.

Issues in Ethics in Orthopaedic Surgery Following the COVID-19 Pandemic.

The COVID-19 pandemic has caused changes in health care as well as human suffering, and consideration of the principles of ethics can build a foundation to consider dilemmas that have arisen. Diversity, equity, and inclusion have become key issues. Simulation training and the related ethics of its application have taken on new meaning. Access to health care continues to evolve and will need further evaluation in the years following the COVID-19 pandemic.

Dual Nonlocked Plating as an Alternative to Locked Plating for Comminuted Distal Fibula Fractures: A Biomechanical Comparison Study.

The purpose of this cadaveric study was to compare the biomechanical properties of dual nonlocked plating and single-locked plating using matched pairs of isolated fibula specimens. Fractures were simulated in 10 matched pairs of isolated cadaveric fibulae and plated with a single lateral locking plate for right-sided specimens, or with a one-third tubular plate and a 7-hole 2.4-mm minifragment adaption plate for left-sided specimens. An external rotation torque was applied at a rate of 1°/second, and torque at 10° was measured. Each fibula specimen was evaluated using a micro computed tomography scanner, and bone mineral density was calculated as milligrams of bone per cubic centimeter of volume. Dual nonlocked plating and locked plating specimens demonstrated torque measurements that were not significantly different at 10° of external rotation (1.48 N·m and 1.92 N·m, respectively; p = .093). The stiffness of the dual nonlocked plated and locked plating constructs were not significantly different (p = .228 and p = .543, respectively). The effect of bone mineral density on maximum torque at failure was not a reliable predictor of maximum torque in either the dual nonlocked plating or locked plating specimens (R2 = 0.548 and R2 = 0.096, respectively). We found no differences in torque at 10° of external rotation or stiffness between locking plate and dual nonlocking plate fixation constructs. This study provides evidence that dual nonlocked plating likely constitutes adequate fixation in situations in which a locking plate is being considered for comminuted distal fibula fractures.

BUILDING PHYSICIANS WITH SELF-AWARENESS.

Learn how three training programs used personality assessment - and shared the results with the participants - to assess and facilitate leadership development in orthopedic surgery.

Review of Pediatric Spondylolysis and Spondylolisthesis.

Pediatric spondylolysis and spondylolisthesis present with a wide spectrum of pathology and clinical findings, including back pain, leg pain, crouch gait, or neurological deficit. The treatment of spondylolysis alone is typically conservative with bracing, non-steroidal anti-inflammatory drug, and activity restriction, but refractory pain can be successfully surgically managed with intralaminar compression screw, wires, or pedicle screws with rods and laminar hook constructs. The treatment of dysplastic spondylolisthesis is aggressive to prevent neurological deficit, whereas even high-grade isthmic slips can be treated safely with nonoperative measures if no significant neurological deficits are present. However, patients with higher slip angles tend to progress and require fusion. More long-term data are needed to compare the outcomes of operative versus nonoperative treatment of high-grade slips. Although more evidence will be helpful in guiding surgical treatment, fortunately, the vast majority of these patients are successfully managed nonsurgically.

Activation of Wnt Planar Cell Polarity (PCP) signaling promotes growth plate column formation in vitro.

Disrupting the Wnt Planar Cell Polarity (PCP) signaling pathway in vivo results in loss of columnar growth plate architecture, but it is unknown whether activation of this pathway in vitro is sufficient to promote column formation. We hypothesized that activation of the Wnt PCP pathway in growth plate chondrocyte cell pellets would promote columnar organization in these cells that are normally oriented randomly in culture. Rat growth plate chondrocytes were transfected with plasmids encoding the Fzd7 cell-surface Wnt receptor, a Fzd7 deletion mutant lacking the Wnt-binding domain, or Wnt receptor-associated proteins Ror2 or Vangl2, and then cultured as three-dimensional cell pellets in the presence of recombinant Wnt5a or Wnt5b for 21 days. Cellular morphology was evaluated using histomorphometric measurements. Activation of Wnt PCP signaling components promoted the initiation of columnar morphogenesis in the chondrocyte pellet culture model, as measured by histomorphometric analysis of the column index (ANOVA p = 0.01). Activation of noncanonical Wnt signaling through overexpression of both the cell-surface Wnt receptor Fzd7 and receptor-associated protein Ror2 with addition of recombinant Wnt5a promotes the initiation of columnar architecture of growth plate chondrocytes in vitro, representing an important step toward growth plate regeneration.