Medical Student Mentorship in Orthopaedic Surgery.

Mentorship is a key aspect of medical education, but the availability and quality of mentorship varies considerably between institutions. The lack of standardization results in information asymmetry and creates notable inequities. This disparity is particularly important for students interested in pursuing competitive specialties, such as orthopaedic surgery. The purpose of this study was to (1) demonstrate the importance of mentorship in orthopaedics, (2) provide a framework for orthopaedic surgeon mentors, and (3) guide medical students interested in activating and expanding their networks.

The Impact of COVID-19 on the Orthopaedic Surgery Residency Application Process.

Over recent months, coronavirus disease 2019 (COVID-19) has swept the world as a global pandemic, largely changing the practice of medicine as it was previously known. Physician trainees have not been immune to these changes-uncertainty during this time is undeniable for medical students at all levels of training. Of particular importance is the potential impact of COVID-19 on the upcoming residency application process for rising fourth-year students; a further source of added complexity in light of the newly integrated allopathic and osteopathic match in the 2020 to 2021 cycle. Owing to the impact COVID-19 could have on the residency match, insight regarding inevitable alterations to the application process and how medical students can adapt is in high demand. Furthermore, it is very possible that programs will inquire about how applicants spent their time while not in the hospital because of COVID-19, and applicants should be prepared to provide a meaningful answer. Although competitive at a basal level, the complexity of COVID-19 now presents an unforeseen, superimposed development in the quest to match. In this article, we aim to discuss and provide potential strategies for navigating the impact of COVID-19 on the residency application process for orthopaedic surgery.

Unifying the Orthopaedic Surgery Residency Application Process Under a Single Accreditation System: A Primer.

In 2020, the Accreditation Council for Graduate Medical Education and the American Osteopathic Association will merge creating a single accreditation system for graduate medical education in the United States under the National Residency Match Program. The goal of this merger is to ensure nationwide consistency in purpose and practice of medical care in the United States, specifically in the context of residency education and training for the next generation of physicians. The proposed impact is still speculative since we do not know what lasting effects, if any, this merger will have on subspecialties such as orthopaedic surgery. There are many considerations that medical school advisors need to take into account when guiding their students applying to residency after the match merge. The newly unified accreditation system will pose additional competition, considering that there will be more applicants than spots available in competitive specialties, including orthopaedic surgery. These are important caveats to keep in mind as the residency application process is evolving actively. It is the authors' hope that concepts discussed in this article stimulate further discussion, catalyze research, and optimize the ability for students to succeed in the match process.

Fascial Nomenclature: An Update.

Throughout the development of anatomy as a scientific study, authors have been challenged to give a singular comprehensive definition of what should be considered as a fascial tissue. Instead, the multiplicity of synthesis and analysis is the true richness of scientific research: individual points of view and background look at the fascia from their own perspective, sometimes influenced by their own cultural assumptions. No person or organization in science ever have the absolute truth, because scientific truth is always evolving, driven by new observations and analysis of data. Only by observing the fascia from multiple perspectives (doctor, surgeon, osteopath, physiotherapist, bioengineer and more) can we define more fully what fascial tissue is. It becomes the synergistic result of several scientific disciplines (anatomy, cardiology, angiology, orthopaedics, osteopathy, cytology, and more). The fascia is not the exclusive domain of a few people or individual private associations, but of all researchers who journey through the study of knowledge and arrive at an understanding, improving the clinical aspects for the good of the patient, without profit. This article reviews the embryological evolution of muscle and connective tissue to affirm how the fascial system should be ideally conceptualized: an absolute anatomic functional continuum.

Metatarsalgia in Metatarsus Adductus Patients: A Rational Approach.

Metatarsus adductus (MA) is a congenital condition resulting in adduction of the forefoot at the tarsometatarsal joint, medial metatarsal deviation, supination of the hindfoot through the subtalar joint, and plantarflexed first ray. The exact underlying pathophysiology remains elusive. There is increasing evidence highlighting the importance of recognizing MA as an associated deformity that complicates management of hallux valgus (HV). Unfortunately, metatarsalgia and lesser toe pathology is also common in this population. We present a review regarding the epidemiology, pathomechanics, and a comprehensive surgical treatment algorithm to optimize the management of patients with MA, HV, lesser toe deformity, and metatarsalgia.

Keeping Up With the Orthopaedic In-Training Examination: National Survey on Orthopaedic Residency Training in Practice Management.

The evolving health care environment warrants its physicians to be competent in basic practice management (PM) areas. A manifestation of this importance was reflected in the inaugural inclusion of a PM subsection on the 2017 Orthopaedic In-Training Examination. The purpose of this orthopaedic resident national survey study was to gain insight on the current state of formal residency education in PM. This study surveyed 500 orthopaedic residents nationwide in 2016. Resident participation was online, anonymous, and voluntary. Only complete survey responses were included, yielding a 49.2% (246/500) response rate. The majority of orthopaedic residents (72.4%, 178/246) reported no formal education in PM topics, and 86.2% (212/246) responded that they do not receive direct feedback on individual accuracy of Current Procedural Terminology (CPT) code case logging. Of the residents without formal education in PM, 87.1% (155/178) desire its implementation. The evolving health care system is becoming increasingly reliant on physicians to provide cost-effective, value-based health care to its patients. Consideration should be given to formally incorporating basic teaching elements on important PM topics at the residency training level. (Journal of Surgical Orthopaedic Advances 28(2):81-88, 2019).

Biotensegrity or Fascintegrity?

The biotensegrity view of the living is a theoretical model and there is no mathematical study in vitro or in vivo that demonstrates its validity, taking into account the presence of liquids (blood, lymph, water), the tension produced by nerves and blood vessels, just as the displacement of the viscera and their resistances and contractions are not taken into consideration. The concept of cellular transduction is reviewed as it is the key to understanding if the passage of different mechanical information occurs only through solid structures, such as the cytoskeleton, or even liquid and viscous. The article focuses on reviewing the weaknesses of the biotensegrity model in the light of new scientific information, trying to coin another term that better reflects the dynamics of living: fascintegrity.

Diagnosing posterior tibial tendon tear with dynamic ultrasound following tibial intramedullary nailing.

Complications following tibial intramedullary nailing include anterior knee pain, malunion, nonunion, and symptomatic/prominent interlocking screws. We report a case of a posterior tibial tendon tear caused by placement of a distal interlocking screw which was detected via dynamic ultrasound. This is a rare and possibly underreported complication which could be the cause of persistent medial sided ankle pain following locked tibial nail placement.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

OBJECTIVES: To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN: Retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS: Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION: None. MAIN OUTCOME MEASURES: Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS: Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS: Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

Joint perception and patient perceived satisfaction after total hip and knee arthroplasty in the American population.

BACKGROUND: Total hip (THA) and knee arthroplasty (TKA) are two of the most successful procedures in orthopedics. Current evaluation trends focus on patient-reported outcomes. We sought to compare the changing WOMAC scores from various time points from pre-operative to 1-year follow-up between separate THA and TKA cohorts. In addition, we compared THA and TKA patients' joint perception, satisfaction, and function via a questionnaire. METHODS: One hundred elective THA (n = 50) and TKA (n = 50) patients at one institution were randomly selected and contacted between 2 and 4 years after the index surgery. A questionnaire assessed joint perception, satisfaction and function of their total joint. Clinical function scores utilizing the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from the pre-operative, 3-month and 1-year post-arthroplasty visits were compared between groups. RESULTS: 78% of the THA group perceived their replaced joint as "native" vs 32% of TKA patients. 54% of THA patients (vs 16% of TKA patients) reported uninhibited function of their total joint. 24% of TKA patients noted to be least satisfied with their total joint compared to 2% in the THA group. Both groups demonstrated significant improvement in WOMAC scores after surgery, but the mean 3-month (12.4 (THA) vs 19.3 (TKA)) and 1-year (6.5 (THA) vs 14.1 (TKA)) follow-up WOMAC scores were significantly better in the THA group. CONCLUSION: Evaluation of a patient's joint perception is a valuable tool that should be used to assess function in conjunction with validated clinical functional scores. Our data suggest further improvements in total knee implant design and implantation strategies are necessary.

Improving Orthopedic Resident Knowledge of Documentation, Coding, and Medicare Fraud.

BACKGROUND: Most residency programs still lack formal education and training on the basic clinical documentation and coding principles. Today's physicians are continuously being held to increasing standards for correct coding and documentation, yet little has changed in the residency training curricula to keep pace with these increasing standards. Although there are many barriers to implementing these topics formally, the main concern has been the lack of time and resources. Thus, simple models may have the best chance for success at widespread implementation. PURPOSE: The first goal of the study was to assess a group of orthopedic residents' fund of knowledge regarding basic clinical documentation guidelines, coding principles, and their ability to appropriately identify cases of Medicare fraud. The second goal was to analyze a single, high-yield educational session's effect on overall resident knowledge acquisition and awareness of these concepts. SUBJECT SELECTION AND STUDY PROTOCOL: Orthopedic residents belonging to 1 of 2 separate residency programs voluntarily and anonymously participated. All were asked to complete a baseline assessment examination, followed by attending a 45-minute lecture given by the same orthopedic faculty member who remained blinded to the test questions. Each resident then completed a postsession examination. Each resident was also asked to self-rate his or her documentation and coding level of comfort on a Likert scale (1-5). Statistical significance was set at p < 0.05. MAIN FINDINGS: A total of 32 orthopedic residents were participated. Increasing postgraduate year-level of training correlated with higher Likert-scale ratings for self-perceived comfort levels with documentation and coding. However, the baseline examination scores were no different between senior and junior residents (p > 0.20). The high-yield teaching session significantly improved the average total examination scores at both sites (p < 0.01), with overall improvement being similar between the 2 groups (p > 0.10). PRINCIPAL CONCLUSIONS: The current healthcare environment necessitates better physician awareness regarding clinical documentation guidelines and coding principles. Very few adjustments to incorporate these teachings have been made to most residency training curricula, and the lack of time and resources remains the concern of many surgical programs. We have demonstrated that orthopedic resident knowledge in these important areas drastically improves after a single, high-yield 45-minute teaching session.

Ten-Year Trends and Independent Risk Factors for Unplanned Readmission Following Elective Total Joint Arthroplasty at a Large Urban Academic Hospital.

BACKGROUND: Total joint arthroplasty procedures continue to provide consistent, long-term success and high patient satisfaction scores. However, early unplanned readmission to the hospital imparts significant financial risks to individual institutions as we shift away from the traditional fee-for-service payment model. METHODS: Using a combination of our hospital's administrative database and retrospective chart reviews, we report the 30-day and 90-day readmission rates and all causes of readmission following all unilateral, primary elective total hip and knee arthroplasty procedures at a large, urban, academic hospital from 2004 to 2013. RESULTS: In total, 1165 primary total hip (511) and knee (654) arthroplasty procedures were identified, and the 30-day and 90-day unplanned readmission rates were 4.6% and 7.3%, respectively. A multivariate regression model controlled for a variety of potential clinical and surgical confounders. Increasing body mass index levels, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each independently correlated with risk of both 30-day and 90-day unplanned readmission to our institution. Additionally, use of general anesthesia during the procedure independently correlated with risk of readmission at 30 days only, while congestive heart failure independently correlated with risk of 90-day unplanned readmission. Readmissions related directly to the surgical site accounted for 47% of the cases, and collectively totaled more than any single medical or clinical complication leading to unplanned readmission within the 90-day period. CONCLUSION: Increasing body mass index values, general anesthesia, an American Society of Anesthesiologists score of ≥3, and discharge to an inpatient rehab facility each were independent risk factors for early unplanned readmission.

Osteoporosis and its complications.

This article provides an overview of the current burden of osteoporosis and its complications in today's health care system. The impact of osteoporosis on patients' quality of life and direct financial consequences to the entire health care system are emphasized to highlight the need for increased knowledge and awareness of its complications if left untreated or treated incorrectly. Special attention is given to hip fracture and vertebral compression fracture, stressing the importance of diagnosing osteoporosis before fragility fractures occur. Models for improved care of fragility fractures during follow-up in the outpatient setting and the use of pharmacologic agents are discussed.

Patients' response toward an automated orthopedic osteoporosis intervention program.

Osteoporosis is overshadowed in an era of chronic illnesses, and a care gap exists between physicians and patients. The aim of this study was to determine the effectiveness of implementing an automated system for identifying and sending a letter to patients at high risk for osteoporosis. Patients 50 years of age and older were tagged with an International Classification of Diseases, Ninth Revision, diagnostic code upon initial visit to the emergency department (ED), identifying potential fragility fractures. Automatically generated letters were sent via our osteoporosis database system to each patient 3 months after the initial visit to the ED. The letter indicated that he or she was at risk for osteoporosis and suggested that the patient schedule a follow-up appointment with a physician. Patients were subsequently telephoned 3 months after receiving the letter and asked about their current plan for follow-up. The control group did not receive a letter after departure from the ED. In the control group, 84 (85.71%) individuals of the total 98 did not have any follow-up but the remaining 14 (14.29%) sought a follow-up. In the intervention group, 62 (60.19%) individuals of 103 did schedule a follow-up, while the remaining 41 (39.81%) did not seek a follow-up. Thus, the patient follow-up response rate after fracture treatment improved with intervention (P < .0001). Current literature has demonstrated the low rate of follow-up care addressing osteoporosis in patients experiencing fragility fractures (1%-25% without intervention). Research has shown the effectiveness of various types of intervention programs for improving the continuum of care for these high-risk patients. Nonautomated intervention programs can have a multitude of human-related system failures in identifying these patients. Our study successfully implements an automated system that is able to be applied to most hospitals with minimal cost and resources.