Real-Time High-Sensitivity Reaction Monitoring of Important Nitrogen-Cycle Synthons by 15N Hyperpolarized Nuclear Magnetic Resonance.

Here, we show how signal amplification by reversible exchange hyperpolarization of a range of 15N-containing synthons can be used to enable studies of their reactivity by 15N nuclear magnetic resonance (NO2- (28% polarization), ND3 (3%), PhCH2NH2 (5%), NaN3 (3%), and NO3- (0.1%)). A range of iridium-based spin-polarization transfer catalysts are used, which for NO2- work optimally as an amino-derived carbene-containing complex with a DMAP-d2 coligand. We harness long 15N spin-order lifetimes to probe in situ reactivity out to 3 × T1. In the case of NO2- (T1 17.7 s at 9.4 T), we monitor PhNH2 diazotization in acidic solution. The resulting diazonium salt (15N-T1 38 s) forms within 30 s, and its subsequent reaction with NaN3 leads to the detection of hyperpolarized PhN3 (T1 192 s) in a second step via the formation of an identified cyclic pentazole intermediate. The role of PhN3 and NaN3 in copper-free click chemistry is exemplified for hyperpolarized triazole (T1 < 10 s) formation when they react with a strained alkyne. We also demonstrate simple routes to hyperpolarized N2 in addition to showing how utilization of 15N-polarized PhCH2NH2 enables the probing of amidation, sulfonamidation, and imine formation. Hyperpolarized ND3 is used to probe imine and ND4+ (T1 33.6 s) formation. Furthermore, for NO2-, we also demonstrate how the 15N-magnetic resonance imaging monitoring of biphasic catalysis confirms the successful preparation of an aqueous bolus of hyperpolarized 15NO2- in seconds with 8% polarization. Hence, we create a versatile tool to probe organic transformations that has significant relevance for the synthesis of future hyperpolarized pharmaceuticals.

Resident Wellness During the COVID-19 Pandemic: A Nationwide Survey of Orthopaedic Residents.

INTRODUCTION: The COVID-19 pandemic has influenced the resident workforce to a particularly powerful and unexpected extent. Given the drastic changes to resident roles, expectations, and responsibilities, many valuable lessons regarding resident concerns and wellness can be garnered from this unique experience. METHODS: A voluntary survey was sent to 179 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency program directors to distribute to their residents. Questions focused on issues that may have occurred, program's responses, and expectations of programs during the pandemic. RESULTS: In total, 507 residents completed the survey, and 10% reported being deployed to do nonorthopaedic-related care, with junior classes being more likely to receive this assignment (P < 0.001). The greatest concern for respondents was the possibility of getting family members sick (mean = 3.89, on scale of 1-5), followed by personally contracting the illness (mean = 3.38). DISCUSSION: The COVID-19 pandemic has resulted in numerous changes and novel sources of adversity for the orthopaedic surgery resident. Contrary to popular opinion, most residents are comfortable with the proposition of providing nonorthopaedic care. The possibility of bringing a pathogen to the home environment and infecting family members seems to be an overarching concern, and efforts to ensure resident and family safety are key.

Patient Opioid Requirements Are Often Far Less Than Their Discharge Prescription After Orthopaedic Surgery: the Results of a Prospective Multicenter Survey.

INTRODUCTION: Evidence-based, procedure-specific guidelines for opioid prescribing after orthopaedic surgery are urgently needed to standardize care and minimize excess opioids. METHODS: We developed a prospective, multicenter survey study conducted from March 2017 to January 2018 including 7 common elective orthopaedic surgical procedures (total knee arthroplasty, total hip arthroplasty, lumbar fusion, lumbar laminectomy, rotator cuff repair, arthroscopic meniscectomy, and carpal tunnel release). Phone surveys were conducted between 21 and 35 days postoperatively. We aimed to document both the amount and length of time patients consumed opioid medications to inform further improvements in opioid management and prescribing. RESULTS: Among the 919 orthopaedic patients who completed the survey, 94.3% received opioids at discharge with a median of 388 oral morphine equivalents (OMEs) (interquartile range [IQR] 225 to 675). A median of 128 (IQR 23 to 360) OME were consumed with 77% of patients having leftover opioids. Sixty percent of prescribed opioids were unused; 18.2% of patients used no opioids, and 34.7% required <50 OME. In comparison to departmental guidelines, 50.2% of patients consumed <50% of the recommended prescription maximum per procedure. DISCUSSION: Most patients used far fewer opioids after orthopaedic surgery than prescribed. These data have informed further improvement of our opioid prescription guidelines to more precisely align with anticipated procedure- and patient-specific requirements.

Implementation of Procedure-Specific Opioid Guidelines: A Readily Employable Strategy to Improve Consistency and Decrease Excessive Prescribing Following Orthopaedic Surgery.

BACKGROUND: Evidence-based, procedure-specific guidelines for prescribing opioids are urgently needed to optimize pain relief while minimizing excessive opioid prescribing and potential opioid diversion in our communities. A multidisciplinary panel at our institution recently developed procedure-specific guidelines for discharge opioid prescriptions for common orthopaedic surgical procedures. The purpose of this study was to evaluate postoperative opioid prescription quantities, variability, and 30-day refill rates before and after implementation of the guidelines. METHODS: This retrospective cohort study was conducted at a single academic institution from December 2016 to March 2018. Guidelines were implemented on August 1, 2017, with a recommended maximum opioid prescription quantity for 14 common orthopaedic procedures. Patients who underwent these 14 procedures during the period of December 2016 to May 2017 made up the pre-guideline cohort (n = 2,223), and patients who underwent these procedures from October 2017 to March 2018 made up the post-guideline cohort (n = 2,300). Opioid prescription quantities were reported as oral morphine equivalents (OME), with medians and interquartile ranges (IQRs). Four levels were established for recommended prescription maximums, ranging from 100 to 400 OME. RESULTS: In the pre-guideline cohort, the median amount of prescribed opioids across all procedures was 600 OME (IQR, 390 to 863 OME), which decreased by 38% in the post-guideline period, to a median of 375 OME (IQR, 239 to 400 OME) in the post-guideline cohort (p < 0.001). The 30-day refill rate did not change significantly, from a rate of 24% in the pre-guideline cohort to 25% in the post-guideline cohort (p = 0.43). Multivariable analysis demonstrated that guideline implementation was the factor most strongly associated with prescriptions exceeding guideline maximums (odds ratio [OR] = 9.9; p < 0.001). Age groups of <80 years (OR = 2.0 to 2.4; p < 0.001) and males (OR = 1.2; p = 0.025) were also shown to have higher odds of exceeding guideline maximums. CONCLUSIONS: Procedure-specific guidelines are capable of substantially decreasing opioid prescription amounts and variability. Furthermore, the absence of change in refill rates suggests that pain control remains similar to pre-guideline prescribing practices. Evidence-based guidelines are a readily employable solution that can drive rapid change in practice and enhance the ability of orthopaedic surgeons to provide responsible pain management.

Operative Approach to Adult Hallux Valgus Deformity: Principles and Techniques.

Hallux valgus deformity is a progressive forefoot deformity consisting of a prominence derived from a medially deviated first metatarsal and laterally displaced great toe, with or without pronation. Although there is agreement that the deformity is likely caused by multifactorial intrinsic and extrinsic factors, the best method of operative management is debated despite the creation of basic algorithms. Our understanding of the deformity and the development of newer techniques is continuously evolving. Here, we review the general orthopaedic principles of operative decision-making and management of hallux valgus deformity.

Use of Asynchronous Video Interviews for Selecting Obstetrics and Gynecology Residents.

OBJECTIVE: To assess the effect of using of asynchronous video interviewing as a screening tool for obstetrics and gynecology residency selection. METHODS: This project was part of a quality-improvement effort to enhance the resident application process. Applications to a single obstetrics and gynecology residency program were scored using standardized criteria. In the 2018 Match, top-scored applicants were invited to in-person interviews, and second-tier applicants were asked to complete a three-question asynchronous video interview. Video interviews were scored and used to invite the remaining applicants for in-person interviews. In the 2019 Match, video interviewing was expanded to all applicants with top application scores, and the video score was used to determine in-person interview invitations. Applicants for 2019 were surveyed on their views regarding video interviewing. RESULTS: Half of the candidates interviewed in person in the 2018 season were screened by the video interview process compared with 82% in the 2019 season. The mean in-person interview score increased from 59.0 in 2017, before screening with asynchronous video interviews, to 62.2 in 2018 (effect size 0.50; 95% CI 0.09-0.90) In 2018, a nonsignificant correlation was seen between the video interview score and rank list percentile (r=0.22, P=.15, n=27) and in-person interview score (r=0.18, P=.12, n=46). United States Medical Licensing Examination step 1 and 2 scores were not correlated with video interview scores in either season. Most (58%) candidates indicated that the asynchronous video interview was an effective way to tell their story; however, only 42% were comfortable with the interview process. CONCLUSION: Video interviewing may have promise as a tool for program directors to use to select candidates from a competitive applicant pool by measuring important noncognitive skills. Acceptance by obstetrics and gynecology applicants was mixed.

Generational Differences in Grit, Self-Control, and Conscientiousness Among Orthopaedic Surgeons: From Millennials to Baby Boomers.

BACKGROUND: The training process and practice of orthopaedic surgery is demanding and arduous. Accordingly, grit, self-control, and conscientiousness are desirable qualities in orthopaedic surgeons. Some established orthopaedists have expressed concern that the future generation of surgeons may not possess the same level of grit as their predecessors. The purpose of this study was to evaluate levels of grit among attending orthopaedic surgeons, identify predictors of grit in orthopaedic surgeons, and compare grit scores between attending surgeons and orthopaedic residency applicants. We hypothesized that applicants would demonstrate lower grit and self-control scores but greater conscientiousness scores than attending surgeons. METHODS: A total of 2,342 attending orthopaedic surgeons and 895 orthopaedic residency applicants from the 2016-2017 National Resident Matching Program (NRMP) were given surveys that quantified their grit, self-control, and conscientiousness. Demographic and career information also was collected. RESULTS: Assessments were completed by 655 (28%) of 2,342 practicing orthopaedic surgeons and 455 (50.8%) of 895 orthopaedic residency applicants. The residency applicants demonstrated higher mean grit scores (4.12 of 5.0) than the attending orthopaedic surgeons (4.03) (p < 0.01). These average scores placed applicants and attending surgeons at the 70th and 65th percentile, respectively, when compared with the general population. There were no differences in self-control (p = 0.68) or conscientiousness (p = 0.93) between the 2 groups. Attending surgeons with more publications had increased grit (p < 0.01), self-control (p = 0.04), and conscientiousness (p = 0.01) scores. Attending surgeons who had been inducted into the Alpha Omega Alpha honor society as medical students demonstrated greater conscientiousness scores than those who were not members (p = 0.04). CONCLUSIONS: Orthopaedic residency applicants were at least as gritty, consistent in their interest, persevering in their efforts, and ambitious as currently practicing orthopaedic surgeons. Although these results may be encouraging and diverge from some preconceived perceptions of "millennials," it is unclear if they will be predictive of career success in the next generation of orthopaedists.

Evaluation of Medical School Grading Variability in the United States: Are All Honors the Same?

PURPOSE: The medical student performance evaluation (MSPE) summarizes a residency applicant's academic performance. Despite attempts to improve standardized clerkship grading, concerns regarding grade inflation and variability at United States medical schools persist. This study's aim was to describe current patterns of clerkship grading and applicant performance data provided in the MSPE. METHOD: The authors evaluated Electronic Residency Application Service data submitted to a single institution for the 2016-2017 Match cycle. Clerkship grading characteristics regarding grading tiers, school rank, location, and size were obtained. Data regarding methods for summative comparisons such as key word utilization were also extracted. Descriptive statistics were generated, and generalized linear modeling was performed. RESULTS: Data were available for 137/140 (98%) MD-granting U.S. medical schools. Pass/fail grading was most commonly used during the preclinical years (47.4%). A 4-tier system was most common for clerkship grading (31%); however, 19 different grading schemes were identified. A median of 34% of students received the highest clerkship grade (range, 5%-97%). Students attending a top 20 medical school were more likely to receive the highest grade compared with those attending lower-rated schools (40% vs 32%, P < .001). Seventy-three percent of schools ranked students, most commonly using descriptive adjectives. Thirty-two different adjectives were used. CONCLUSIONS: There is significant institutional variation in clinical grading practices and MSPE data. For core clerkships where most students received the highest grade, the ability to distinguish between applicants diminishes. A standardized approach to reporting clinical performance may allow for better comparison of residency applicants.

Is Grit the New Fit?-Assessing Non-Cognitive Variables in Orthopedic Surgery Trainees.

OBJECTIVE: The purpose of this study was to determine overall levels of grit, self-control, and conscientiousness among orthopedic surgery residents, to compare levels of grit across orthopedic resident training levels, and to identify common applicant variables which may correlate with these valuable noncognitive attributes. DESIGN: A cross-sectional study composed of a confidential electronic survey consisting of a 17-item Grit scale, 10-item Self-control scale, and 9-item Conscientiousness scale was completed by Orthopedic residents and fellows. SETTING: Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; a tertiary medical center. PARTICIPANTS: Grit, ambition, consistency of interest, perseverance of effort, self-control, and conscientiousness were assessed in orthopedic surgery residents and fellows. The survey was distributed to program coordinators of ACGME accredited Orthopedic Surgery residency programs and fellowship. 431 (431 out of 621, 69.4%) respondents completed the assessment. RESULTS: Orthopedic residents demonstrated high baseline levels of grit (4.0 of 5.0), self-control (3.8 of 5.0), and conscientiousness (4.4 of 5.0). The grit score of 4.0 places them in the 65th percentile of the general adult population. There were no significant differences in scores between training levels of orthopedic residents and fellows. Significantly higher self-control scores were seen in female trainees (p = 0.042), inductees of Alpha Omega Alpha honor society (p = 0.008), and those with higher numbers of publications (p = 0.037). Orthopedic trainees with more publications scored higher in the ambition sub-score (0 publications: 4.0 ± 0.7; 1-3 publications: 4.2 ± 0.5, 3 or more publications: 4.3 ± 0.5; p < 0.001). CONCLUSIONS: Orthopedic surgery residents demonstrated high levels of grit compared to the general population. Key objective variables utilized in the residency application process including Alpha Omega Alpha status and volume of research publications were predictive of these qualities.

Cystic Adventitial Disease of the Tibial Vein Arising From the Subtalar Joint: A Case Report.

Soft tissue ganglion cysts are a well-known cause of tibial nerve compression in the tarsal tunnel. We describe a patient who presented with tibial nerve symptoms and was found to have an adventitial cyst of the tibial vein arising from the subtalar joint, with the joint connection confirmed both on imaging and at surgery. Surgical decompression of the cyst with transection of the vascular pedicle arising from the subtalar joint improved her symptoms at 6 months, and postoperative magnetic resonance imaging showed resolution of the cyst. Cystic adventitial disease is a rare, poorly understood condition in which a cyst is identified in the adventitia of a vessel, usually an artery. Only 3 cases of adventitial cysts have been reported in the foot and ankle region, 2 in the lesser and 1 in the greater saphenous vein. None of the previous cases have been recognized to be joint connected. This case provides additional evidence for an articular origin for adventitial cysts and helps guide management strategies for these joint-connected cysts.

Objective Predictors of Grit, Self-Control, and Conscientiousness in Orthopaedic Surgery Residency Applicants.

INTRODUCTION: The purpose of this study was to identify objective predictors of grit, self-control, and conscientiousness in orthopaedic surgery residency applicants. METHODS: The following attributes were assessed in 455 applicants: grit, self-control, conscientiousness, consistency of interest, perseverance of effort, and ambition. These measures were correlated with standard, objective demographics obtained during the application process. RESULTS: Alpha Omega Alpha status, additional degrees, and number of publications did not predict any of the studied attributes. Grit increased with age (P < 0.001) but decreased with increasing board scores (P = 0.004). Former collegiate athletes demonstrated greater grit (P < 0.001), consistency of interest (P = 0.007), perseverance (P = 0.006), and self-control (P = 0.019). Female applicants demonstrated more grit (P = 0.044), consistency of interest (P = 0.003), and conscientiousness (P = 0.029) than males. Applicants with military experience had increased ambition (P = 0.033) and conscientiousness (P = 0.001). CONCLUSION: Overall, orthopaedics applicants possess increased grit compared with the general public, and a number of objective variables reliably predicted the studied attributes. LEVEL OF EVIDENCE: Level III, Cross-sectional study.

Outcomes Following Treatment of the Infected Achilles Tendon.

BACKGROUND: Infection following Achilles tendon surgery is a devastating complication and can be difficult to treat and often leads to poor outcomes. A number of treatments have been described, but there is little information concerning outcomes of these treatments. Our purpose was to evaluate the clinical and functional outcomes of patients who have undergone treatment for an infected Achilles tendon after acute and chronic midsubstance repair. METHODS: We retrospectively reviewed the medical records of 20 patients who had undergone surgical treatment for an infected Achilles tendon between 2000 and 2016. The mean follow-up time was 21 months (range, 2-68 months). All patients underwent extensive debridement of the tendon with removal of all infected tissue and foreign material. Soft tissue wound coverage was utilized for large wounds that were not amenable to primary or secondary closure. All patients received culture-specific intravenous (IV) antibiotics for 3 to 6 weeks. Postoperatively, the extremity was immobilized in a splint followed by a cast until the wound was healed. The cast was then replaced with a walking boot and the patients were provided a physical therapy program. Functional outcomes were measured using the Foot and Ankle Ability Measure (FAAM) Activity of Daily Living (ADL) scale. RESULTS: All wounds had healed at the time of last follow-up. Three patients (15%) required an unplanned return to the operating room for repeat debridement. All patients were able to walk without the use of a gait aid. Five patients (25%) required continued use of a boot or brace during ambulation. Fourteen patients participated in the FAAM ADL survey. There were 6 patients lost to follow-up. The average FAAM score was 87 (range, 71.4-100). At last follow-up, most patients reported their overall function as "normal" or "nearly normal." Eradication of infection and satisfactory functional results can be attained after radical debridement, wound closure, and administration of culture-specific IV antibiotics. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Unlocking a Diazirine Long-Lived Nuclear Singlet State via Photochemistry: NMR Detection and Lifetime of an Unstabilized Diazo-Compound.

Diazirines are important for photoaffinity labeling, and their photoisomerization is relatively well-known. This work shows how hyperpolarized NMR spectroscopy can be used to characterize an unstable diazo-compound formed via photoisomerization of a 15N2-labeled silyl-ether-substituted diazirine. This diazirine is prepared in a nuclear spin singlet state via catalytic transfer of spin order from para-hydrogen. The active hyperpolarization catalyst is characterized to provide insight into the mechanism. The photochemical isomerization of the diazirine into the diazo-analogue allows the NMR invisible nuclear singlet state of the parent compound to be probed. The identity of the diazo-species is confirmed by trapping with N-phenyl maleimide via a cycloaddition reaction to afford bicyclic pyrazolines that also show singlet state character. The presence of singlet states in the diazirine and the diazo-compound is validated by comparison of experimental nutation behavior with theoretical simulation. The magnetic state lifetime of the diazo-compound is determined as 12 ± 1 s in CD3OD solution at room temperature, whereas its chemical lifetime is measured as 100 ± 5 s by related hyperpolarized NMR studies. Indirect evidence for the generation of the photoproduct para-N2 is presented.

An Analysis of Research Quality and Productivity at Six Academic Orthopaedic Residencies.

OBJECTIVE: It remains largely unknown what factors impact the research productivity of residency programs. We hypothesized that dedicated resident research time would not affect the quantity and quality of a program's peer-reviewed publication within orthopedic residencies. These findings may help programs improve structure their residency programs to maximize core competencies. DESIGN: Three hundred fifty-nine residents and 240 staff from six different US orthopedic residency programs were analyzed. All publications published by residents and faculty at each program from January 2007 to December 2015 were recorded. SCImago Journal Rankings (SJR) were found for each journal. RESULTS: There were no significant differences in publications by residents at each program (p > 0.05). Faculty with 10+ years of on staff, had significantly more publications than those with less than 10 years (p < 0.01). Programs with increased resident research time did not consistently produce publications with higher SJR than those without dedicated research time. CONCLUSIONS: Increased dedicated resident research time did not increase resident publication rates or lead to publications with higher SJR.

Intraosseous "Lipoma" of the Calcaneus Developing in an Intraosseous Ganglion Cyst.

Intraosseous lipomas are rare primary bone tumors, most common to the calcaneus. There are several proposed theories of the natural etiology of intraosseous lipomas; however, all lack definitive support. In this report, an 18-year-old man presented with radiologic evidence of a simple bone cyst of the calcaneus. Over a 4-year period, the patient was followed with interval magnetic resonance imaging. The cyst demonstrated progressive development of peripheral intralesional fat with final magnetic resonance imaging features characteristic of an intraosseous lipoma. To our knowledge, this is the first longitudinal study that shows gradual peripheral fat deposition within an intraosseous ganglion cyst, illustrating a potential cause of intraosseous lipomas of the calcaneus.

Residents and Program Director Perspectives Often Differ on Optimal Preparation Strategies and the Value of the Orthopedic In-Training Examination.

OBJECTIVES: The purpose of this work was to compare resident and program director (PD) perspectives on the value of the Orthopaedic In-Training Examination (OITE), resident study habits, and best resources for optimal performance. DESIGN: A national survey of orthopedic surgery residents and PDs. SETTING: Mayo Clinic, Rochester, MN PARTICIPANTS: The survey was completed by 445 (41.5%) eligible orthopedic surgery residents and 37 (77.1%) PDs. RESULTS: Although residents and PDs agreed on when (p = 0.896) and how much (p = 0.171) residents currently study, residents felt that the OITE was not as valuable of an assessment of their knowledge, and also felt their individual scores were less likely to remain confidential compared to PDs (p < 0.001). The mean OITE score below which residents were concerned about their ability to pass American Board of Orthopaedic Surgeons Part 1 was 9.7 percentile points higher than PDs threshold (42.3% vs. 32.6%, respectively, p = 0.003). Both groups agreed that it is important to dedicate focused study time to the OITE (p = 0.680) and to perform well (p = 0.099). Regarding the best resources and preparation strategies, both residents and PDs tended to agree on the value of most (6 of 10) study methods. Residents ranked practice question websites (mean ranking of 2.6 vs. 3.8 of 10, respectively; p < 0.001) and formal rotations in a subspecialty (6.0 vs. 7.7 respectively, p < 0.001) higher than PDs. In contrast, PDs tended to value their program's formal OITE prep program (4.1. vs. 5.3, respectively, p = 0.012) and reading primary literature (5.6 vs. 6.6, respectively, p = 0.012) more than residents. CONCLUSION: Residents and PDs agreed on many critical components of this process; however, a number of key differences in perspectives exist.

Orthopedic In-Training Examination: A Performance Review Based on Program- and Resident-Specific Characteristics.

OBJECTIVES: The orthopedic in-training examination (OITE) is the most common and objective method used to assess resident knowledge in the United States. As such, residents and programs use a number of strategies to maximize OITE performance. The purpose of this work was to better understand what strategies were being implemented and to determine which program-specific and resident-specific characteristics best correlate with improved scores. DESIGN: A national survey of orthopedic residents and program directors (PDs) was performed to better understand OITE performance and correlate scores with various test preparation strategies. SETTING: Mayo Clinic, Rochester, MN. PARTICIPANTS: The survey was completed by 33 of 48 (68.8%) PDs and 341 of 878 (38.8%) eligible residents. RESULTS: The most commonly used program-wide strategies were as follows: negative consequences for poor performance (72.7%), formal OITE prep program (54.5%), and purchase of OITE test prep material for residents (51.5%). The program-specific characteristics that had the strongest correlation with increased scores were negative consequences for poor performance (p < 0.001), high value placed on the OITE by PD and residents (p < 0.001), excusing residents from clinical duties the evening prior (p < 0.001), having residents take the examination on different days (p = 0.012), and allowing residents to lead a review course (p = 0.047). The resident-specific characteristics that correlated most with score were increased study time leading up to the test (p = 0.031) and attendance at their program's OITE prep program (p = 0.062). CONCLUSIONS: Although programs and residents looking to improve knowledge acquisition and OITE scores use a number of techniques, a few distinct strategies correlate with the greatest increases in OITE performance. These may be appropriate methods to consider for those looking to improve their performance in coming years.

What Factors Are Predictive of Outcome in the Treatment of Soft Tissue Sarcomas of the Foot and Ankle?

Soft tissue sarcomas of the foot and ankle are common. Currently, there exist limited data on prognostic variables. The aim of this study was to review our institution's experience with soft tissue sarcomas of the foot and ankle to identify factors affecting outcomes and survivorship. We reviewed the records of 62 foot and ankle soft tissue sarcomas treated with definitive surgery at our institution between 1992 and 2013. The cohort consisted of 35 males and 27 females with a mean age at diagnosis of 45 years and a mean follow-up of 7 years. The most common tumor subtype was synovial sarcoma (n = 16). The overall limb salvage rate was 53%. Local recurrence was observed in 9 patients and distant metastases in 15 patients. Tumor size ≥3 cm in maximal dimension was the greatest risk factor in mortality. Posttreatment complications occurred in 15 patients. Local recurrence and development of distant disease was relatively common following wide excision of a soft tissue sarcoma of the foot and ankle. Tumors that were ≥3 cm in maximal dimension were associated with a worse overall survival and patients with neoadjuvant radiation were at increased risk of complications. LEVELS OF EVIDENCE: Level IV: Retrospective Case Series.

Learning by (video) example: a randomized study of communication skills training for end-of-life and error disclosure family care conferences.

BACKGROUND: Teaching residents to lead end of life (EOL) and error disclosure (ED) conferences is important. METHODS: We developed and tested an intervention using videotapes of EOL and error disclosure encounters from previous Objective Structured Clinical Exams. Residents (n = 72) from general and orthopedic surgery programs at 2 sites were enrolled. Using a prospective, pre-post, block group design with stratified randomization, we hypothesized the treatment group would outperform the control on EOL and ED cases. We also hypothesized that online course usage would correlate positively with post-test scores. RESULTS: All residents improved (pre-post). At the group level, treatment effects were insignificant, and post-test performance was unrelated to course usage. At the subgroup level for EOL, low performers assigned to treatment scored higher than controls at post-test; and within the treatment group, post graduate year 3 residents outperformed post graduate year ​1 residents. CONCLUSIONS: To be effective, online curricula illustrating communication behaviors need face-to-face interaction, individual role play with feedback and discussion.

The Cost of Getting Into Orthopedic Residency: Analysis of Applicant Demographics, Expenditures, and the Value of Away Rotations.

OBJECTIVES: Little is known about the demographics and expenditures of applicants attempting to match into the competitive field of orthopedic surgery. In attempt to better inform potential applicants, the purposes of this work are to (1) better understand the demographics of successfully matched applicants, (2) determine the monetary cost of applying, and (3) assess the value of away rotations for improving chances of a successful match. DESIGN: Prospective comparative survey. SETTING: Mayo Clinic Department of Orthopedic Surgery, Rochester, MN. PARTICIPANTS: A week following the 2015 Orthopedic Surgery Residency Match, a survey was sent to 1,091. The survey focused on applicant demographics, number of programs applied to, cost of applying, and the value of away rotations. RESULTS: A total of 408 applicants completed the survey (response rate = 37%). Of these, 312 (76%) matched and 96 (24%) did not match into a US Orthopedic Surgery Residency. Of the matched applicants, 300 (96%) were from US allopathic medical schools, 9 (3%) US Osteopathic Schools, and 3 (1%) were international graduates. Males comprised 84% of these applicants whereas 16% were female. The mean number of programs applied to was 71 (range: 20-140). On average, applicants were offered 16 interviews (range: 1-53) and they attended 11 (range: 0-12). Completing a rotation at a program increased an applicant׳s chances of matching into that program by a factor of 1.5 (60% vs 40%). Of the applicants who matched, most applicants matched to an orthopedic residency in the same region where the applicant attended medical school (58%). The average cost of the application was $1,664 (range: $100-$5,000) whereas the cost of interviews (travel, food, etc.) was $3,656 (range: $15-$20,000). Total expenditures ranged from $450 to $25,000 (mean = $5,415). Over 8% of matched applicants spent >$10,000. CONCLUSIONS: Gaining acceptance into orthopedic surgery residency remains a very competitive process. Away rotations appear to correlate strongly with match status; however, the process remains quite expensive for applicants.