A Novel Prescription Method Reduces Postoperative Opioid Distribution and Consumption: A Randomized Clinical Trial.

BACKGROUND: Prescription opioid abuse in the United States has risen substantially over the past 2 decades. Narcotic prescription refill restrictions may paradoxically be contributing to this epidemic. We investigated a novel, refill-based opioid prescription method to determine whether it would alter postoperative narcotic distribution or consumption. METHODS: In this randomized controlled trial, patients undergoing internal fixation of distal radius fractures or thumb carpometacarpal joint arthroplasty received either a single prescription for all postoperative narcotics (control arm) or the same amount of pain medication divided into 3 equal prescriptions to be filled as needed (experimental arm). Outcomes included total narcotics dispensed, measured in morphine milligram equivalents (MME) through a prescription monitoring program, patient-reported opioid consumption versus opioid not consumed, and a satisfaction survey. RESULTS: Forty-eight participants were enrolled; 25 were randomized to the control arm and 23 to the experimental arm. At 8 weeks post-op, fewer opioids had been dispensed to the experimental arm (177 ± 94 vs 287 ± 123 MME, P = .0025). At 6-week follow-up, the experimental arm reported lower narcotic consumption (124 ± 105 vs 214 ± 110 MME, P = .0131). Subanalysis of the independent surgeries yielded similar results. Some patients reported insurance issues when filling subsequent prescriptions. Consequently, although 100% of control arm patients reported good pain control, only 82.6% of experimental arm patients said likewise (P = .0455). CONCLUSIONS: This randomized clinical trial demonstrated that patients obtained and consumed fewer narcotics when postoperative opioids were given in a refill-based prescription method. More research is needed to determine whether this opioid distribution method is reproducible, translatable, and feasible.

Research priorities for neuroimmunology: identifying the key research questions to be addressed by 2030.

Neuroimmunology in the broadest sense is the study of interactions between the nervous and the immune systems. These interactions play important roles in health from supporting neural development, homeostasis and plasticity to modifying behaviour. Neuroimmunology is increasingly recognised as a field with the potential to deliver a significant positive impact on human health and treatment for neurological and psychiatric disorders. Yet, translation to the clinic is hindered by fundamental knowledge gaps on the underlying mechanisms of action or the optimal timing of an intervention, and a lack of appropriate tools to visualise and modulate both systems. Here we propose ten key disease-agnostic research questions that, if addressed, could lead to significant progress within neuroimmunology in the short to medium term. We also discuss four cross-cutting themes to be considered when addressing each question: i) bi-directionality of neuroimmune interactions; ii) the biological context in which the questions are addressed (e.g. health vs disease vs across the lifespan); iii) tools and technologies required to fully answer the questions; and iv) translation into the clinic. We acknowledge that these ten questions cannot represent the full breadth of gaps in our understanding; rather they focus on areas which, if addressed, may have the most broad and immediate impacts. By defining these neuroimmunology priorities, we hope to unite existing and future research teams, who can make meaningful progress through a collaborative and cross-disciplinary effort.

Orthopedic Surgery Residency Application Process in 2020 - Has Diversity been Affected?

Background: Orthopedic surgery is currently the least diverse field in medicine. COVID-19 necessitated a virtual rotation and interview process for orthopedic residency applications in 2020. Given the pressing need to address disparities within the field, any change in the application process should be examined with regard to the potential effects it could have on the diversity of trainees in orthopedic surgery. The purpose of this study was to evaluate the effect of virtual rotations and interviews on the demographic distribution of applicants to orthopedic surgery residency. Methods: A retrospective review of orthopedic surgery residency applicants was performed comparing the 2018 and 2020 application cycle. Self-reported ethnicity on Electronic Residency Application Service (ERAS) forms was recorded for all applicants who met prescreening criteria, were invited to interview and who completed interviews. The proportion of underrepresented minority (URM) applicants was compared between these two cohorts. Results: There were no significant differences between the 2018 and 2020 application cohorts in terms of number or proportion of URM applicants that met initial screening criteria (p=0.7598), female applicants that met initial screening criteria (p=0.3106), URM applicants who were invited to interview (p=0.6647), or female applicants who were invited to interview (p=0.63). Overall, applicants in the 2018 cycle were 2.38 times more likely to be invited to interview (OR 2.38, 95% CI 1.6886-3.3623, p<0.0001) and applicants who were invited to interview were 20.96 times more likely to interview in the 2020 cycle than in the 2018 cycle (OR 20.96, 95% CI 4.89-90.09, p<0.0001). Conclusion: The proportion of URMs applying to orthopedic surgery residency was not significantly different after transitioning to a virtual rotation and interview platform at the single institution studied. Applicants were 2.38 times more likely to be invited to interview in 2018 and were 20.96 times more likely to attend the interview in 2020.Level of Evidence: III.

Identifying Barriers: Current Breastfeeding Policy in Orthopedic Surgery Residency.

BACKGROUND: Family planning is a challenge for physicians at all stages of their careers but can be particularly difficult during residency. As the field of orthopedic surgery strives to increase diversity and recruit exceptional female candidates, barriers to entry should be identified. For many women, successful family planning including pregnancy, breast-feeding, and childcare, presents a daunting endeavor during residency training and a difficult topic to broach with superiors when planning future careers. Prospective residents often look to websites to obtain information regarding potential residency programs. We sought to identify current breast-feeding policies available at orthopedic residency programs via a thorough review of individual programs websites. METHODS: Residency program websites from 178 ACGME-accredited orthopedic surgery residencies were reviewed to determine currently available departmental lactation policies and facilities. Region and number of female staff and residents were recorded and organized into a central database. Descriptive analyses to determine programs with available resources was performed. Logistic regression to determine association between region and number of programs written policy available was also performed. RESULTS: 178 ACGME-accredited orthopedic surgery programs were reviewed. Five (2.8%) programs were found to have written breastfeeding policies available on the orthopedic surgery residency website. Thirty-six (20%) programs provided links to institutional GME websites which gave written lactation policies. Dedicated lactation facilities were mentioned for 3 (1.7%) programs. The average number of female attendings per program was two (range 0-19), and the average number of female residents per program was three (range 0-14). The odds of a program having a written breastfeeding policy increased along with an increasing number of female attendings, OR 1.1 (CI 1.03-1.24, p=0.01). Programs in the Southwest region of the U.S. were found to have a higher association with presence of a written breastfeeding policy, OR 3.7 (CI 1.01-13.4, p=0.04). CONCLUSION: Scarce information is available to prospective orthopedic surgery residents regarding breast-feeding policies and available lactation facilities. Only 2.8% of current programs have website information discussing breastfeeding support. Ensuring available breastfeeding support for female orthopedic surgeon trainees and the transparency of these policies by orthopedic departments could contribute to an improved perception of childbearing during residency.Level of Evidence: IV.

Safety and Efficacy of Forearm Tourniquet Compared to Upper Arm Tourniquet for Local Intravenous Regional Anesthesia in Hand Surgery: A Randomized Clinical Trial.

BACKGROUND: Forearm tourniquets may offer decreased doses of anesthetic, shorter procedure times, and less pain compared to upper arm tourniquets. There is limited data comparing the clinical efficacy of forearm Bier blocks to conventional upper arm Bier blocks. The purpose of this study was to assess the effectiveness, complications, duration, cost, and patient satisfaction between forearm and upper arm Bier blocks during surgery. METHODS: Sixty-six carpal tunnel release, ganglion excision, or trigger finger procedures were performed. Patients were randomized to 3 groups: upper arm tourniquet for 25 minutes, forearm tourniquet for 25 minutes, or forearm tourniquet with immediate deflation following the procedure (<25 minutes). The efficacy of surgical anesthesia, tourniquet discomfort, and supplementary local anesthetic administration were recorded. Pain was assessed intraoperatively and postoperatively. Patient satisfaction was assessed on the first postoperative day. RESULTS: No difference was observed between groups with respect to pain, satisfaction, or administration of supplemental medication. The tourniquet time for the group with immediate deflation following procedure was shorter by an average of 9.3 minutes. Total hospital charges were 9.95% cheaper with immediate tourniquet deflation compared to procedures where the tourniquet remained inflated for at least 25 minutes. CONCLUSION: The forearm Bier block is a safe, efficient, cost-effective technique for intravenous regional anesthesia during hand surgery, and tourniquet deflation immediately following the procedure (<25 minutes) does not increase incidence of complications. The forearm tourniquet reduces the dose of local anesthetic and therefore risk for systemic toxicity, with similar effectiveness as compared to the upper arm technique.Level of Evidence: II.

Does Removing the Photograph and Name Change the Reviewer's Perception of Orthopaedic Residency Applicants?

INTRODUCTION: Orthopaedic surgery remains the least diverse field in medicine regarding female and minority representation. Scarce literature exists evaluating the role of implicit bias in the residency application process. We hypothesized that applicants perceived as underrepresented minorities in orthopaedic surgery (URMs) based on their photograph or name would have a decreased likelihood of being invited to interview. METHODS: Data from the 2018 to 2019 orthopaedic residency application cycle were collected from a single institution. Applications were classified URM or non-URM. After the application cycle was completed, the URM applications were propensity matched with non-URM applicants. Photographs and names were removed, and the applications were rereviewed by the Residency Applicant Review committee. Rank-in-group and the likelihood of being invited for an interview were compared. RESULTS: Four hundred eleven applications were included with 27.5% URM and 72.5% non-URM. During the regular application cycle, 34.7% of those invited to interview were URM and 50% of those who were ranked-to-match range were URM. After propensity matching, 90 matched pairs were rereviewed with their photograph and name removed. In the regular application cycle, the URM applicant was 3.8 times more likely to get an interview than the matched non-URM applicant (odds ratio, 3.8, 95% confidence interval, 1.7 to 8.8, P = 0.0014). In the "blinded" condition, the URM candidate was 2.5 times more likely to get an interview than the non-URM candidate (odds ratio, 2.5, 95% confidence interval, 1.1 to 6.2 P = 0.034). In the unblinded condition, the URM candidate had a higher ranking within their group than the corresponding non-URM applicant (P = 0.0005). DISCUSSION: Contrary to our initial hypothesis, URM applicants were invited to interview at a higher rate than non-URM applicants, both in the regular application cycle and in the propensity-matched "blinded" condition. This suggests that implicit bias based on the picture or name is not negatively affecting URM students during the application review process at our institution. LEVEL OF EVIDENCE: 3.

Maximising the potential of neuroimmunology.

Technological developments in recent years have led to a surge in advances in neuroimmunology, making real progress towards improving human health. With the scale of the challenges ahead, realising this potential requires a collaborative effort. The neuroscience, immunology and wider scientific community, both academia and industry, must come together to pool together ideas, experiences and resources.

Postoperative care via smartphone following carpal tunnel release.

INTRODUCTION: This study explores a novel smartphone application for postoperative care following carpal tunnel release (CTR). We hypothesized that a software-based 'virtual visit' for CTR could be safe, effective and convenient for the patient. METHODS: Our group developed the software application utilized in this study. Interactive steps with video instructions enabled patients to complete dressing and suture removal, capture a wound photo, answer a question about median nerve symptoms and capture a video of finger range of motion. Adult patients undergoing endoscopic or open CTR were enrolled. Prior to their scheduled postoperative visit, patients received and completed the module using their smartphone. Agreement between findings of the virtual visit and the corresponding in-person clinical visit was assessed using kappa values. RESULTS: Twenty-two patients were contacted regarding study enrolment and 17 patients were enrolled (ages 23-63, mean 48.2, 6M, 11F). Of 16 patients who participated, all completed dressing removal. Ten of 16 patients removed their sutures successfully. Fourteen patients captured a clinically adequate wound photo and 15 patients answered a question about median nerve symptoms. Fourteen patients captured a range of motion video. Software assessments of surgical wounds, nerve symptoms and physical exams agreed strongly with clinical assessments. DISCUSSION: Most patients were able to respond to a question about their symptoms, provide clinical assessment of their wound via a photo and record a video of their range of motion. Suture removal was the most difficult task. More investigation is needed to determine which patients can reliably remove their sutures.

Breaking Barriers: A Brief Overview of Diversity in Orthopedic Surgery.

Diversity within the field of orthopedic surgery has been slow to progress, even well into the 21st century. Despite the barriers broken in 1932 by Ruth Jackson - the first female member of the American Academy of Orthopedic Surgeons (AAOS) - gender, racial and ethnic diversity continues to be lacking. Research has shown there are clear advantages of a diverse physician population, not only in medicine and patient care but in commercial industry as well. Although the representation of females and underrepresented minorities (URM) in orthopedics is increasing, it is doing so at a slower rate as compared to other surgical subspecialties. Targeted efforts have been made to investigate and promote gender and cultural diversity in orthopedic surgery. New programs and initiatives have been developed to promote diversity in orthopedics through mentorship and enhancing visibility of females and URM in the field.

Intraoperative Point of View Video Capture and Surgical Segmentation in Carpal Tunnel Release: A Feasibility Analysis.

OBJECTIVE: The purpose of this study was to (1) examine the feasibility of intraoperative point of view video while performing open and endoscopic carpal tunnel release (CTR), (2) define surgical segments of CTR, and (3) describe the duration of various surgical steps of open versus endoscopic CTR in a teaching setting. DESIGN: Fellowship trained hand surgeons reached consensus on surgical segments for CTR. Adult patients 18 and older previously indicated for CTR in clinic were eligible. Head-mounted point-of-view cameras were worn during endoscopic and open CTR by resident surgeons. Video was reviewed to determine segment duration. Independent sample t tests were used for comparison of duration by technique with statistical significance set as p < 0.05. SETTING: University of Iowa Hospitals and Clinics; 200 Hawkins Dr, Iowa City, IA 52242; Tertiary Academic Medical Center. PARTICIPANTS: Orthopedic Surgery Residents and Orthopedic Surgery Faculty. RESULTS: Surgical segments were defined as incision, dissection of superficial soft tissue structures, transection of the carpal ligament, and surgical incision closure. Twelve of 14 video capture events yielded data. In the teaching setting, the average duration of endoscopic CTR was 609.5 seconds (±111.07) versus 547.75 seconds (±82.06) for open with p value = 0.406. No surgical segments were significantly different. Transition time from dissection to ligament transection differed significantly (p = 0.004) between endoscopic (46.88 seconds ± 19.19) and open (9.0 seconds ± 7.90) CTR. Transition time between ligament transection and closure was significantly different (p = 0.029) among endoscopic (50.5 seconds ± 15.0) and open (26.25 seconds ± 2.99) CTR. CONCLUSIONS: Point-of-view video capture is feasible for the capture of video during a common hand surgery procedure. A method for managing device battery power is necessary for future applications. CTR can be defined as, and described in, individual procedure segments potentially useful for surgical education as well as efficiency improvements. Identification of surgical segments may aid the development of better objective tools for the assessment of surgeon skill and competency for common orthopedic procedures.

Regeneration of Dopaminergic Neurons in Adult Zebrafish Depends on Immune System Activation and Differs for Distinct Populations.

Adult zebrafish, in contrast to mammals, regenerate neurons in their brain, but the extent and variability of this capacity is unclear. Here we ask whether the loss of various dopaminergic neuron populations is sufficient to trigger their functional regeneration. Both sexes of zebrafish were analyzed. Genetic lineage tracing shows that specific diencephalic ependymo-radial glial (ERG) progenitor cells give rise to new dopaminergic [tyrosine hydroxylase-positive (TH+)] neurons. Ablation elicits an immune response, increased proliferation of ERG progenitor cells, and increased addition of new TH+ neurons in populations that constitutively add new neurons (e.g., diencephalic population 5/6). Inhibiting the immune response attenuates neurogenesis to control levels. Boosting the immune response enhances ERG proliferation, but not addition of TH+ neurons. In contrast, in populations in which constitutive neurogenesis is undetectable (e.g., the posterior tuberculum and locus ceruleus), cell replacement and tissue integration are incomplete and transient. This is associated with a loss of spinal TH+ axons, as well as permanent deficits in shoaling and reproductive behavior. Hence, dopaminergic neuron populations in the adult zebrafish brain show vast differences in regenerative capacity that correlate with constitutive addition of neurons and depend on immune system activation.SIGNIFICANCE STATEMENT Despite the fact that zebrafish show a high propensity to regenerate neurons in the brain, this study reveals that not all types of dopaminergic neurons are functionally regenerated after specific ablation. Hence, in the same adult vertebrate brain, mechanisms of successful and incomplete regeneration can be studied. We identify progenitor cells for dopaminergic neurons and show that activating the immune system promotes the proliferation of these cells. However, in some areas of the brain this only leads to insufficient replacement of functionally important dopaminergic neurons that later disappear. Understanding the mechanisms of regeneration in zebrafish may inform interventions targeting the regeneration of functionally important neurons, such as dopaminergic neurons, from endogenous progenitor cells in nonregenerating mammals.

Systematic Review of Tendon Transfer Versus Nerve Transfer for the Restoration of Wrist Extension in Isolated Traumatic Radial Nerve Palsy.

PURPOSE: To compare the outcomes of tendon transfer and nerve transfer for radial nerve palsy. METHODS: We performed a systematic review of the literature in EMBASE, PubMed, and Cochrane Database to include studies that address persistent traumatic radial nerve palsy treated with tendon transfer or nerve transfer surgery. RESULTS: We identified 2,044 citations; 1,512 texts were excluded because of content, and 96 texts were screened for eligibility. Texts were excluded if they did not report the motor score (M0 to M5 as determined by the British Medical Research Council) or measurements of range of motion of the wrist. Sixteen texts were eligible for qualitative synthesis. Outcomes of these studies show heterogeneity with regard to the technique and functional restoration. CONCLUSIONS: On the basis of the results of this systematic review, there does not seem to be a clearly superior technique; rather, there are advantages and disadvantages to each. Patient selection and surgeon experience are important when considering surgical interventions in this challenging clinical scenario. Nerve transfer surgery is an emerging technique that may offer patients meaningful functional gains with reduced donor site morbidity. LEVEL OF EVIDENCE: Level III.

Single Forearm Vessel Injury in a Perfused Hand: Repair or Ligate? A Systematic Review.

Background: The purpose of this study was to systematically review available literature reporting vessel patency and how this correlates with cold symptoms following the treatment of a single forearm artery injury when the hand remains perfused. The outcomes of those treated by ligation were compared to those treated with vessel repair. Methods: Electronic databases including PubMed, Embase (Elsevier) and Cochrane Central Register of Controlled Trials (Willey) were searched for studies that reported the outcomes of patients who underwent either ligation or repair of single vessel injuries to hands that remained perfused at time of presentation. Level of evidence was determined by two independent reviewers. Studies were then sorted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and application of inclusion and exclusion criteria. A total of 19 studies were included for statistical analysis. The patency of repaired vessels was calculated (with comparison between those with radial versus ulnar repair) as was the prevalence of cold symptoms in both ligation (or repairs that went on to occlusion) and repair groups. Results: The average patency of radial and ulnar artery repairs was 68.39% and 65.56% respectively. There was no significant difference between the success rates of these repair groups (pooled estimates for odd ratios was 1.02, p=0.867). The average incidence of cold symptoms in those who underwent ligation (or repair that when on to occlusion) and those that had patent repairs were 19.82% and 17.27% respectively. There was no significant difference between the incidence of cold symptoms between these groups (pooled estimate for proportion of patients with cold symptoms was 0.223, p=0.573). Conclusions: This review showed there to be no significant difference in patency of isolated radial or ulnar artery repairs. There was also no significant difference in the prevalence of cold sensitivity in patients who underwent vessel ligation compared to those who underwent repair (and subsequently remained patent). These results support the conclusion of there being no clear benefit to attempting repair of a single vessel, although further studies are needed given the often incomplete reporting of clinical outcomes in this patient population. Additionally, though a cost-benefit analysis was not included in this review, exploring this aspect of the decision making process could be valuable.Level of Evidence: IV.

Detection of Retained Foreign Objects in Upper Extremity Surgical Procedures With Incisions of Two Centimeters or Smaller.

BACKGROUND: While the true incidence of retained foreign bodies after surgery is unknown, it has been approximated at 1:5,500 operations overall, with substantially less frequency in hand and upper extremity procedures. Despite the rarity of foreign body retention in hand and upper extremity surgery, universal radiofrequency scanning for electronically-tagged sponges and automatic radiographic evaluation for incorrect sponge counts are employed for all surgical procedures at our institution. We demonstrate the infeasibility of retaining an operative sponge of a standard size in commonly performed hand and upper extremity procedures with incision sizes of two centimeters or less, and establish that visual detection of sponges in these cases is adequate. METHODS: Eighteen trigger finger releases, five carpal tunnel releases, three trigger thumb releases, and three de Quervain's tenosynovitis releases were successfully performed upon five cadaveric specimens by residents under supervision of fellowship-trained hand surgeons for a total of 29 two-centimeter or smaller incisions. Randomized surgical sponge placement was evaluated by a blinded observer at two distances and incision sizes were quantified. Kappa values were calculated to determine the acuity of visual detection versus the actual presence of a sponge. RESULTS: The maximum length of the standard surgical sponge that could be contained within an incision was three centimeters. When compared with the gold standard (whether the sponge had been placed or not by the operating resident), the placement of a standard surgical sponge could be detected correctly in 100% of cases at both "across the room" and "at the table" distances, for kappa values of 1.0 and 1.0 respectively. This did not vary with incision size or surgical procedure. CONCLUSIONS: The added cost and time from radiofrequency detection of retained sponges and radiographic evaluation in the event of incorrect sponge counts can be safely eliminated if sponges can be reliably visually detected. CLINICAL RELEVANCE: This cadaveric study informs patient safety practices by demonstrating that visual detection of surgical sponges is adequate for certain upper extremity procedures.

Detection of Femoral Neck Fractures in Pediatric Patients With Femoral Shaft Fractures.

BACKGROUND: Ipsilateral femoral neck fractures occur in 1% to 9% of adult trauma patients with femoral shaft fractures making dedicated imaging important. This is not as clear in children. Our purpose is to establish the incidence of ipsilateral femoral neck fractures in children with femoral shaft fractures and to provide recommendations regarding diagnostic imaging protocols. METHODS: A retrospective analysis of medical records was performed for pediatric patients (below 18 y) with femoral shaft fractures seen at our trauma center over a 10-year period. Mechanism of injury, associated injuries, procedures, and follow-up data were collected, and all radiographs reviewed. Exclusion criteria included peri-implant fractures or evidence of pathologic fracture. A similar retrospective analysis was performed in a cohort of adult patients. RESULTS: Of 267 pediatric patients with femoral shaft fractures, 2 patients (0.7%) had ipsilateral femoral neck fractures. One femoral neck fracture was detected on initial plain radiographs and the other on a pelvic computed tomography (CT) scan. Both of these fractures resulted from high-energy trauma, which accounted for 92 (42%) of pediatric femoral shaft fractures. The cohort of 100 adults aged 18 to 89 years with femoral shaft fractures revealed 6 adult patients (6%) with ipsilateral femoral neck fractures, all from high-energy trauma. High-energy trauma accounted for 85% of the adult femoral shaft fractures, and was more common than in the pediatric population (P<0.005). The difference in incidence of ipsilateral femoral neck fracture between the pediatric (0.7%) and the adult group (6%) was significant (P=0.007). No missed or delayed diagnoses were identified. CONCLUSIONS: The incidence of associated ipsilateral femoral neck fracture in pediatric patients with femoral shaft fracture is very low (0.7%). Most (58%) pediatric femur fractures are caused by low-energy trauma. We were unable to demonstrate a need for routine CT scanning of the femoral neck in children with femoral shaft fractures. Given the increased risks of radiation exposure with younger and smaller patients, it does not appear that routine CT scanning low-energy pediatric femoral shaft fractures to evaluate for femoral neck fractures is justified unless there is a high level of clinical suspicion. LEVEL OF EVIDENCE: Level II.

A Novel Arthroscopic Inside-Out Repair Technique for PASTA Lesions.

There is no current consensus in the literature on the optimal technique for surgical treatment of partial articular-sided supraspinatus tendon avulsion (PASTA) lesions, although most techniques described to date require takedown of the partially torn tendon or passage of an anchor through the already damaged tendon. We describe a novel inside-out repair technique for partial articular surface supraspinatus tears that does not require further disruption of the partially torn tendon by passage of an anchor.