A Linguistic Analysis of United States Navy Orthopaedic Surgery Applicant Personal Statements.

INTRODUCTION: Despite the importance of linguistic analysis, no systematic research has been explored in the form of linguistic analysis on personal statements for military orthopedic surgery residency programs. This study was conducted to analyze U.S. Navy (USN) orthopedic surgery applicants' personal statements using an automated textual analysis program to assess personal statements for linguistic styles. METHODS: A retrospective analysis of USN orthopedic applicant personal statements from application years 2016 to 2019 was performed utilizing the Linguistic Inquiry and Word Count (LIWC) software. LIWC analyzed the text for summary variables: analytical thinking, clout, authenticity, and emotional tone. We compared this analysis with Step 1 and Step 2 scores and determined whether an applicant matched. RESULTS: A total of 94 personal statements (60,230 words) were analyzed using LIWC. The average word count was 640.7, with an average of 23 words per sentence. The average-matched applicant USMLE Step 1 and Step 2 scores were 240 and 250, respectively. When examining summary traits utilizing multiple logistic regression analysis, only analytical thinking demonstrated a statistically significant difference in matched versus unmatched applicants with a P = .011 (OR = 1.10). CONCLUSION: As the USMLE Step 1 exam transitions from a scoring system to Pass/Fail grading, programs will look at other characteristics to determine who would likely succeed in residency. From a linguistic analysis standpoint, matched applicants' personal statements demonstrated higher analytical thinking, clout, affiliation, power, and risk focus than unmatched applicants. Unmatched applicants demonstrated higher authenticity than matched applicants.

Are methods to quantify osseous exposure in orthopedic surgery reliable?

BACKGROUND: Our study examined if there were any limitations when using various measurement techniques in the literature to quantify osseous exposure. Additionally, we also examined if surface contour had any influence on obtained measurements, which no previous study has attempted. MATERIALS AND METHODS: Three methods used to quantify osseous exposure area were identified, one in which involves manually applying mesh over exposure area. The other two use digital image capture software (ImageJ, Bethesda, MD). We simulated flat, convex, and mixed surface types using synthetic bone analogs. We assessed the degree of variability between mean values using an ANOVA or Kruskal-Wallis equality of populations rank test. Cronbach's alpha test of internal reliability was used to assess the internal reliability of measurement technique. RESULTS: ANOVA test for difference in measurement techniques on all three surface types was statistically significant (p < 0.05). Cronbach's alpha test of internal reliability for each technique on the convex surface did not obtain adequate significance (alpha >0.70). Only the mesh method obtained adequate alpha value for significance when applied to the flat and mixed surface types. DISCUSSION: Each of the three measurement techniques tested demonstrated poor internal reliability. We suggest taking care when comparing studies that use different quantification techniques when calculating osseous exposure for different surgical approaches. Future studies should explore alternative methods of osseous exposure quantification.

Matching into Orthopedic Surgery in the U.S. Navy: A Review of Applicant Selection Criteria.

INTRODUCTION: The U.S. Navy offers an attractive opportunity for residency training in orthopedic surgery. The factors that Navy orthopedic residency program leadership finds important in applicant selection for training have not been reported. Additionally, data regarding the academic competitiveness of recently matched applicants have not been previously published. This study presents the results of two surveys administered to all navy orthopedic program directors and department chairmen, as well as data for United States Medical Licensing Examination (USMLE) Steps 1 and 2, medical school class percentile, leadership responsibilities, research endeavors, and letters of recommendation of both matched and unmatched applicants. MATERIALS AND METHODS: Two anonymous surveys were administered to all program directors and department chairmen at Navy orthopedic residency training programs with questions designed to gauge perceived importance of various application factors when selecting for the match. The results were compiled, and mean levels of importance were reported. Deidentified data were collected on all applicants to Navy orthopedic residency programs from 2015 to 2019. Data points specific to USMLE Step 1 and 2 board scores, medical school class percentile, research, leadership, and letters of recommendation were analyzed using single and multiple logistic regression analyses, and odds ratios for each variable were calculated. RESULTS: Navy leadership unanimously expressed that clerkship performance at the individual program director's institution was most important, followed by Steps 1 and 2 licensing examination scores. Single logistic regression analyses showed that Step 1 score and clinical, leadership, and recommendation scores were statistically significant. When controlled for Step 1 score, only academic performance and leadership scores maintained statistical significance. CONCLUSIONS: Applicants to Navy orthopedic surgery residency programs should strive to be competitive in all aspects of their application, with specific emphasis placed on outstanding performance during orthopedic clerkships, demonstration of leadership characteristics, and academic excellence. With transition to a pass/fail grading system for Step 1, there will be more emphasis on other measures of academic success, such as Step 2 scores and clinical clerkship grades.

Incorporation of Whipstitch Suture in Tibial Interference Fixation Improves Pullout in Anterior Cruciate Ligament Soft Tissue Grafts.

INTRODUCTION: Interference screw fixation of soft tissue grafts is commonly used in anterior cruciate ligament (ACL) reconstruction. The purpose of this study was to determine whether including suture material at the graft-screw interface affects ultimate fixation strength of soft tissue grafts using a tibialis anterior tendon allograft model. MATERIALS AND METHODS: Forty fresh-frozen human tibialis anterior tendon allografts were fixed to rigid polyurethane foam simulating the tibial tunnel. Twenty grafts underwent fixation with interference screws and 20 with interference bolts. Within each group, 10 grafts had suture in contact with either the screw or bolt. A load-to-failure test was then performed at a rate of 200 mm/min. RESULTS: The group of allografts with sutures in the tibial tunnel had significantly higher load to failure than the group without sutures. Using interference screw fixation, failure load of the grafts without sutures in the tunnel (535.2 ± 73.40 N) was significantly lower (P = .001) than with sutures in the tunnel (696.3 ± 110.0 N). Using interference bolt fixation, failure load of the grafts without sutures in the tunnel (613.0 ± 83.46 N) was significantly lower (P <.0001) than with sutures in the tunnel (845.8 ± 87.23 N). CONCLUSIONS: In a biomechanical model, suture within the tibial tunnel enhances fixation strength with both interference screw and bolt fixation for soft tissue tibialis anterior allografts. Additionally, there was no difference in load to failure when comparing failure of a screw with suture in the tunnel with an interference bolt without suture. Due to improved biomechanical properties, incorporation of suture in the bone-graft interface should be considered when performing soft tissue ACL allograft reconstructions. Failure at the tibial bone-graft interface is a known complication of ACL reconstruction, and incorporation of suture within the interface should be considered for improved biomechanical properties.

Aspirin for Deep-Venous Thrombosis Prophylaxis After Anterior Cruciate Ligament Reconstruction.

AIM: To evaluate whether a daily full-dose aspirin regimen after anterior cruciate ligament (ACL) reconstruction reduces the risk of postoperative symptomatic deep-venous thrombosis (DVT). MATERIALS AND METHODS: Single-center retrospective cohort study of patients who underwent ACL reconstruction from 2007 to 2016. One thousand two hundred thirty-three patients met inclusion criteria: 821 patients received no chemoprophylaxis and 412 patients received daily full-dose aspirin. RESULTS: A total of 10 patients, seven receiving no chemoprophylaxis and three using aspirin, sustained a postoperative symptomatic DVT. Calculated adjusted odds ratio for symptomatic postoperative DVT for aspirin versus no chemoprophylaxis was 0.928 (95% CI 0.237-3.629, P value = 0.91). Odds ratio for symptomatic postoperative DVT occurrence among tobacco users versus non-tobacco users was 3.76 (95% CI 1.077-13.124, P = 0.04). CONCLUSIONS: No statistically significant difference was observed in postoperative symptomatic DVT after ACL reconstruction in those who received full-dose aspirin chemoprophylaxis versus those with no chemoprophylaxis. Additionally, there was a significantly increased risk of postoperative symptomatic DVT with tobacco use.

What Is the Critical Tibial Resection Depth During Unicompartmental Knee Arthroplasty? A Biomechanical Study of Fracture Risk.

BACKGROUND: Fracture after medial unicompartmental knee arthroplasty (UKA) is a rare complication. Biomechanical studies evaluating association between depth of resection and maximum load to failure are lacking. The purpose of this study is to establish the relationship between depth of resection of the medial tibial plateau and mean maximum load to failure. METHODS: Medial tibial resections were performed from 2 to 10 mm in 25 standardized fourth-generation Sawbones composite tibias (Sawbones, Vashon Island, Washington). A metal-backed tibial component with a 9-mm polyethylene bearing was used (Stryker PKR). Tibias were mounted on a biomechanical testing apparatus (MTESTQuattro) and axially loaded cyclically 10 times per cycle and incrementally increased until failure occurred. RESULTS: Load to failure was recorded in 25 proximal tibia model samples after medial UKA using sequential resections from 2 to 10 mm. Analysis of variance testing identified significant differences in mean maximum load to failure between groups (P = .0003). Analysis of regression models revealed a statistically significant fit of a quadratic model (R2 = 0.59, P = .0001). The inflection point of this quadratic curve was identified at 5.82 mm, indicating that the maximum load to failure across experimental models in this study began to decline beyond a resection depth of 5.82 mm. CONCLUSION: In this biomechanical model, medial tibial resections beyond 5.82 mm produced a significantly lower mean load to failure using a quadratic curve model. Resections from 2 to 6 mm showed no significant differences in mean load to failure. Identification of the tibial resection depth at which the mean load to failure significantly decreases is clinically relevant as this depth may increase the risk of periprosthetic fracture after a medial UKA.

Outcomes of Medializing Tibial Tubercle Osteotomy With Medial Reefing and Vastus Medialis Obliquus Advancement Coupled With Lateral Retinacular Z-Lengthening for Recurrent Patellar Instability.

PURPOSE: Patella-femoral dislocations, although rare, can result in functionally limiting symptoms and limited return to prior activity levels. The purpose of this study is to report outcomes of a three-in-one patellar realignment surgery for treatment of recurrent patellar instability in a young, active duty military population. METHODS: We conducted a retrospective chart review of all patients who underwent our senior author's three-in-one patellar realignment surgery for recurrent patellar instability in the setting of underlying anatomic malalignment. Our primary outcome measure was the rate of recurrent instability. Secondary outcome measures included rate of return to full unrestricted active duty military service and the functional outcome scores. RESULTS: A total of 13 patients with an average follow-up of 16 months were included in this study. During the follow-up period, there were no reported instability events (either dislocation or subluxation). Three (23%) patients were separated secondary to issues with their operative knee and two additional patients were no longer on active duty at time of final follow-up. Six patients had paired (pre- and postoperative) Single Assessment Numerical Evaluation scores which showed a statistically significant improvement (p < 0.05) between the median pre- and postoperative Single Assessment Numerical Evaluation scores of 45 and 85, respectively. CONCLUSION: Our study demonstrates that the described patellar realignment procedure is effective at substantially reducing and possibly eliminating the symptoms of recurrent instability and allows a modest return to unrestricted active duty.

Injury Characteristics of Low-Energy Lisfranc Injuries Compared With High-Energy Injuries.

BACKGROUND: Lisfranc injuries result from high- and low-energy mechanisms though the literature has been more focused on high-energy mechanisms. A comparison of high-energy (HE) and low-energy (LE) injury patterns is lacking. The objective of this study was to report injury patterns in LE Lisfranc joint injuries and compare them to HE injury patterns. METHODS: Operative Lisfranc injuries were identified over a 5-year period. Patient demographics, mechanism of injury, injury pattern, associated injuries, missed diagnoses, clinical course, and imaging studies were reviewed and compared. HE mechanism was defined as motor vehicle crash, motorcycle crash, direct crush, and fall from greater than 4 feet and LE mechanism as athletic activity, ground level twisting, or fall from less than 4 feet. Thirty-two HE and 48 LE cases were identified with 19.3 months of average follow-up. RESULTS: There were no differences in demographics or missed diagnosis frequency (21% HE vs 18% LE). Time to seek care was not significantly different. HE injuries were more likely to have concomitant nonfoot fractures (37% vs 6%), concomitant foot fractures (78% vs 4%), cuboid fractures (31% vs 6%), metatarsal base fractures (84% vs 29%), displaced intra-articular fractures (59% vs 4%), and involvement of all 5 rays (23% vs 6%). LE injuries were more commonly ligamentous (68% vs 16%), with fewer rays involved (2.7 vs 4.1). CONCLUSIONS: LE mechanisms were a more common cause of Lisfranc joint injury in this cohort. These mechanisms generally resulted in an isolated, primarily ligamentous injury sparing the lateral column. Both types had high rates of missed injury that could result in delayed treatment. Differences in injury patterns could help direct future research to optimize treatment algorithms. LEVEL OF EVIDENCE: Level III, comparative series.

Primary Arthrodesis versus Open Reduction and Internal Fixation for Low-Energy Lisfranc Injuries in a Young Athletic Population.

BACKGROUND: There are 2 Level I studies comparing open reduction and internal fixation (ORIF) and primary arthrodesis (PA) in high-energy Lisfranc injuries. There are no studies comparing ORIF and PA in young athletic patients with low-energy injuries. METHODS: All operatively managed low-energy Lisfranc injuries sustained by active duty military personnel at a single institution were identified from 2010 to 2015. The injury pattern, method of treatment, and complications were reviewed. Implant removal rates, fitness test scores, return to military duty rates, and Foot and Ankle Ability Measure (FAAM) scores were compared. Thirty-two patients were identified with the average age of 28 years. PA was performed in 14 patients with ORIF in 18. RESULTS: The PA group returned to full duty at an average of 4.5 months whereas the ORIF group returned at an average of 6.7 months ( P = .0066). The PA group ran their fitness test an average of 9 seconds per mile slower than their preoperative average whereas the ORIF group ran it an average of 39 seconds slower per mile ( P = .032). There were no differences between the 2 groups in the FAAM scores at an average of 35 months. Implant removal was performed in 15 (83%) in the ORIF group and 2 (14%) in the PA group ( P = .005). CONCLUSIONS: Low-energy Lisfranc injuries treated with primary arthrodesis had a lower implant removal rate, an earlier return to full military activity, and better fitness test scores after 1 year, but there was no difference in FAAM scores after 3 years. LEVEL OF EVIDENCE: Level III, comparative cohort study.

Preparing adolescents with chronic disease for transition to adult care: a technology program.

BACKGROUND: Adolescents with chronic disease (ACD) must develop independent disease self-management and learn to communicate effectively with their health care team to transition from pediatric to adult-oriented health care systems. Disease-specific interventions have been implemented to aid specific ACD groups through transition. A generic approach might be effective and cost-saving. METHODS: Eighty-one ACD, aged 12 to 20 years, were recruited for a randomized clinical trial evaluating an 8-month transition intervention (MD2Me). MD2Me recipients received a 2-month intensive Web-based and text-delivered disease management and skill-based intervention followed by a 6-month review period. MD2Me recipients also had access to a texting algorithm for disease assessment and health care team contact. The intervention was applicable to adolescents with diverse chronic illnesses. Controls received mailed materials on general health topics. Disease management, health-related self-efficacy, and health assessments were performed at baseline and at 2 and 8 months. Frequency of patient-initiated communications was recorded over the study period. Outcomes were analyzed according to assigned treatment group over time. RESULTS: MD2Me recipients demonstrated significant improvements in performance of disease management tasks, health-related self-efficacy, and patient-initiated communications compared with controls. CONCLUSIONS: Outcomes in ACD improved significantly among recipients of a generic, technology-based intervention. Technology can deliver transition interventions to adolescents with diverse chronic illnesses, and a generic approach offers a cost-effective means of positively influencing transition outcomes. Further research is needed to determine whether improved short-term outcomes translate into an improved transition for ACD.

Appropriateness of radiology procedures performed in children with gastrointestinal symptoms and conditions.

BACKGROUND & AIMS: Exposure to ionizing radiation from diagnostic imaging procedures (DIPs) has been associated with an increased risk of cancer in children. In particular, gastrointestinal imaging has been identified as a significant factor that contributes to exposure of children to radiation during diagnostic procedures. We performed a longitudinal assessment of gastrointestinal-associated DIPs to identify practices that might be targeted to reduce exposure of pediatric patients to radiation. METHODS: DIP insurance claims from 2001 through 2009 were obtained from an Independent Physicians Association in a large US metropolitan area. We retrieved and analyzed Current Procedural Terminology codes, associated International Classification of Diseases, 9th Revision, codes specific for gastrointestinal symptoms and conditions, and patient demographics associated with DIPs from insurance claims data. RESULTS: Overall, 11,473 DIPs were performed on 6550 children with gastrointestinal symptoms; 1 in 30 patients received a DIP for a gastrointestinal complaint. Over the study period, the proportion of higher-radiation DIPs (computed tomography, fluoroscopy, and angiography) increased. Higher-radiation DIPs for gastrointestinal symptoms were performed more frequently in older children and in boys in the emergency department and in inpatient settings for diagnoses of abdominal pain, appendicitis, and noninfectious gastroenteritis. CONCLUSIONS: Higher-radiation diagnostic imaging accounts for an increasing proportion of imaging procedures among children with gastrointestinal symptoms, even though these often are not recommended for evaluation of gastrointestinal disorders. Clinicians should be aware of these findings when ordering DIPs for gastrointestinal complaints, and clinical practice guidelines should be created to reduce diagnostic imaging-related radiation exposure in children.

Diagnostic imaging studies performed in children over a nine-year period.

BACKGROUND AND OBJECTIVE: Diagnostic imaging procedures (DIPs) producing radiation exposure in children have been associated with increased cancer risk. To develop effective clinical practice interventions that reduce pediatric radiation exposure, a longitudinal assessment of DIP ordering practices in the current clinical climate was performed. Our objective was to determine the prevalence and characteristics of DIPs ordered by physicians in an independent physicians association treating a general pediatric population. METHODS: DIP insurance claims from 2001 to 2009 were obtained from an independent physicians association in a large metropolitan area. Current Procedural Terminology codes, associated International Classification of Diseases, Ninth Revision codes, and patient demographics associated with DIPs were retrieved from insurance claim data and analyzed. RESULTS: Overall, 214,538 DIPs were performed on 63,116 children from 2001 to 2009 at a rate of 1 DIP associated with ionizing radiation per 21 patient-months. Over the study period, performance of computed tomography, MRI, ultrasound, and radiography all significantly increased (P < .001 for all). Higher radiation DIPs were most frequently performed in the inpatient and emergency settings on older boy patients for gastrointestinal and congenital disorders. The 3 most common International Classification of Diseases, Ninth Revision codes associated with higher radiation DIPs were abdominal pain, headache, and head injury. CONCLUSIONS: DIPs are frequently performed in children and higher radiation DIPs account for an increasing proportion of DIPs performed, especially among children evaluated in the inpatient and emergency department settings and those with gastrointestinal and neurologic symptoms, and congenital anomalies. Our findings may help guide development of clinical practice interventions to reduce DIP-related radiation exposure in youth.

Clinicians poorly assess health literacy-related readiness for transition to adult care in adolescents with inflammatory bowel disease.

BACKGROUND & AIMS: To prepare for the transition from pediatric to adult-oriented health care systems, adolescents must develop the ability to obtain, process, and understand basic health information; make appropriate health decisions; and interact effectively with health care professionals. However, physicians use subjective methods to determine patients' readiness for this transition. We investigated health care literacy-related readiness for transition of children and adolescents with inflammatory bowel disease (IBD) to identify determinants and compare actual levels with clinicians' opinions. METHODS: The study included 74 pediatric patients with IBD ≥10 years old who were recruited from a pediatric hospital-based clinic. We evaluated their functional and interactive health literacy and recorded clinicians' perceptions of literacy and readiness for transition among pediatric patients. Relationships between health literacy measures, demographic variables, and clinician perceptions were determined. RESULTS: Health literacy-related readiness for transition was observed in 11% of the patients analyzed. However, clinicians found 47% of the cohort ready for the transition, on the basis of literacy standards. Health literacy-related readiness for transition was associated with older age (P < .01), white race (P = .03), and low income (P < .02). Agreement was poor between measures-defined and clinician-defined levels of health literacy-related readiness for transition (P = .18). CONCLUSIONS: Clinicians inadequately judge the health literacy-related readiness for transition to adult care of pediatric IBD patients. Improved awareness of health literacy issues among adolescents with IBD is needed among health care providers and health care systems.