Healthcare educational debt in the united states: unequal economic impact within interprofessional team members.

BACKGROUND: Advancing healthcare access and quality for underserved populations requires a diverse, culturally competent interprofessional workforce. However, high educational debt may influence career choice of healthcare professionals. In the United States, health professions lack insight into the maximum educational debt that can be supported by current entry-level salaries. The purpose of this interprofessional economic analysis was to examine whether average educational debt for US healthcare graduates is supportable by entry-level salaries. Additionally, the study explored whether trainees from minoritized backgrounds graduate with more educational debt than their peers in physical therapy. METHODS: The study modeled maximum educational debt service ratios for 12 healthcare professions and 6 physician specialties, incorporating profession-specific estimates of entry-level salary, salary growth, national average debt, and 4 loan repayment scenarios offered by the US Department of Education Office of Student Financial Aid. Net present value (NPV) provided an estimate for lifetime "economic power" for the modeled careers. The study used a unique data source available from a single profession (physical therapy, N = 4,954) to examine whether educational debt thresholds based on the repayment model varied between minoritized groups and non-minoritized peers. RESULTS: High salary physician specialties (e.g. obstetrics/gynecology, surgery) and professions without graduate debt (e.g. registered nurse) met debt ratio targets under any repayment plan. Professions with strong salary growth and moderate debt (e.g. physician assistant) required extended repayment plans but had high career NPV. Careers with low salary growth and high debt relative to salary (e.g. physical therapy) had career NPV at the lowest range of modeled professions. 29% of physical therapy students graduated with more debt than could be supported by entry-level salaries. Physical therapy students from minoritized groups graduated with 10-30% more debt than their non-minoritized peers. CONCLUSIONS: Graduates from most healthcare professions required extended repayment plans (higher interest) to meet debt ratio benchmarks. For several healthcare professions, low debt relative to salary protected career NPV. Students from minoritized groups incurred higher debt than their peers in physical therapy.

Glucocorticoid-Induced Bone Loss: Dietary Supplementation Recommendations to Reduce the Risk for Osteoporosis and Osteoporotic Fractures.

Glucocorticoids (GCs) are among the most widely prescribed medications in dermatologic practice. Although considered generally safe and efficacious, prolonged use and high dosing regimens may precipitate GC-induced osteoporosis, which contributes to an increased risk for fragility fractures. Dermatologists using and prescribing GCs must be aware of the risk for GC-induced osteoporosis. This review details the risks for osteoporosis and osteoporotic (OP) fractures in the setting of topical, intralesional, intramuscular, and systemic GC treatment, as well as nutritional supplementation recommendations that may reduce the risk of these adverse effects.

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.

Factors Impacting Initial Arthroscopy Performance and Skill Progression in Novice Trainees.

Background: Arthroscopy is one of the cornerstone skills learned during orthopaedic residency training. Previous studies have attempted to identify characteristics of arthroscopy naive individuals leading to superior initial arthroscopic performance with conflicting findings. Furthermore, other virtual reality simulator studies consisting of beginner trainees, have noted that certain individuals fail to progress at the rate of their peers despite rigorous training. Therefore the purpose of this study was to 1) identify trainee characteristics that may have an impact on initial arthroscopy skill and performance and 2) identify trainee characteristics affecting their ability to improve through training on an arthroscopy simulator. Methods: Forty-three medical students with no prior arthroscopy experience performed a diagnostic knee arthroscopy using an anatomic virtual reality simulator. Prior to the procedure, information was collected about each participant regarding various demographics, sports involvement, hand dominance, specialty interest, 3-D video game use and experience assisting in the operating room. Their baseline performance was measured using the following outcomes: time (seconds), camera path length (CPL) (centimeters), and an overall composite score. A subgroup consisting of 22 students underwent training with a non-anatomic virtual arthroscopy simulator consisting of a series of 5 self-guided modules after their initial knee scope. This group was retested using the same diagnostic knee scope one to two weeks later. Participant background characteristics were correlated with initial performance on the knee scope and the change from the first to second knee scope in the sub-group that completed the training. Results: At the time of the initial diagnostic knee arthroscopy, performance was most strongly correlated with how often an applicant currently plays video games and how often they have played video games in the past. However, this was only a weak correlation (r= 0.29 and 0.24, respectively). Interestingly, students pursuing a non-surgical residency outperformed those interested in a surgical specialty in all outcome measurements at baseline, although this did not reach a level of significance. Year of training in medical school, age, hand dominance, current or past participation in sports requiring hand-eye coordination, and number of surgical cases they have assisted in for did not influence initial performance. Participants that have operated another type of scope (e.g. bronchoscopy, laparoscopy) in the past showed a trend towards higher performance in composite score (21.6 vs 14.9, p = 0.07), although this did not reach a level of significance. Regarding the change in performance of those that completed the non-anatomic training prior to the second knee scope, change in time to complete the procedure was significantly different between participants in different years of medical school. Fourth year medical students improved by an average of 421 seconds compared to 98 seconds, 127, and 140 seconds for the other classes, p = 0.02. Those who have regularly participated in sports requiring hand eye coordination in the past improved their time (182 vs 78 seconds, p = 0.0245) and camera path length (96 vs 31 cm, p = 0.0372) significantly more than those were not involved in sports. Discussion and Conclusions: Our study demonstrates that baseline arthroscopy performance correlates most highly with 3D video game experience. The ability of trainees to learn arthroscopy using a virtual reality simulator appears to be influenced more by those who have regularly participated in sports requiring hand eye coordination rather than video game use.Level of Evidence: III.

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.

Efficacy and Validation of a Simulation-Based Compartment Syndrome Instructional Course.

Background: This study reports the validity and effectiveness of a simulation-based compartment syndrome instructional course. Methods: Six post-graduation year one (PGY1) orthopaedic residents and six PGY5 residents participated in the study. All PGY1 residents participated in a four-hour compartment syndrome training simulation. An anatomic compartment model was used to test needle placement accuracy in four leg muscle compartments. Pre-training, immediate post-training, and one-month post-training performance data were collected from all PGY1 residents, as well as data from a onetime assessment of all PGY5 residents. These assessments included a paper test for lower leg anatomy (anatomy module), a procedural test of needle placement accuracy using an anatomic compartment syndrome simulation module (needle placement module), and an assessment of ability to measure compartment pressure via low cost simulation (pressure measurement module). Face validity of the needle placement module and pressure measurement module were assessed using a structured questionnaire given to all 12 study participants and three orthopaedic faculty. Results: The PGY1 residents demonstrated significant improvement at immediate post-training in all three assessments compared to their pre-training performances (anatomy p=0.019, needle placement p=0.026, pressure measurement p=0.033 and Objective Structured Assessment of Technical Skill (OSATS) score for pressure measurement p <0.0001). This performance was maintained at the one-month post-training assessment. Immediate post-training and one-month post-training PGY1 resident performances were comparable with PGY5 resident performance in all tests.Fifteen participants rated the face validity of the needle placement and pressure measurement modules. For the needle placement module, 73.3% of participants highly rated (4 out of 5 or greater) for realism, 86.7% highly rated for being an effective tool for teaching, and 80% highly rated for needing the model to be available throughout their training. The pressure measurement module did not receive high face validity ratings. Conclusions: With minimal, inexpensive training, the performance of junior residents in a compartment syndrome simulation was improved to a level comparable with senior residents. In addition, this performance was maintained at one-month post-training. The compartment syndrome anatomic module had highly-rated face validity. Clinical Relevance: Training junior residents to accurately diagnose compartment syndrome using a realistic simulation may allow for greater diagnostic accuracy in the clinical setting.

Acute Periacetabular Osteotomy for Recurrent Posttraumatic Dislocation of the Hip: A Case Report.

CASE: A 23-year-old woman with injury-induced acetabular dysplasia developed subacute recurrent dislocation of the right hip following closed reduction of a traumatic dislocation. The initial dislocation had been associated with small posterior wall and femoral head fractures. The recurrent dislocation was addressed with an acute periacetabular osteotomy (PAO) for hip stabilization and femoral head fragment excision. CONCLUSION: An acute PAO is an unusual yet viable treatment strategy for addressing recurrent dislocation following traumatic fracture-dislocation in patients with posterior wall deficiency and injury-induced hip dysplasia. In the patient described herein, the procedure resulted in early stability, but she developed posttraumatic osteoarthritis at 1 year and 4 months after the injury.

Fundamentals of Arthroscopic Surgery Training Program Improves Knee Arthroscopy Simulator Performance in Arthroscopic Trainees.

PURPOSE: To determine the effectiveness of a nonanatomic simulator in developing basic arthroscopy motor skills transferable to an anatomic model. METHODS: Forty-three arthroscopy novice individuals currently enrolled in medical school were recruited to perform a diagnostic knee arthroscopy using a high-fidelity virtual reality arthroscopic simulator providing haptic feedback after viewing a video of an expert performing an identical procedure. Students were then randomized into an experimental or control group. The experimental group then completed a series of self-guided training modules using the fundamentals of arthroscopy simulator training nonanatomic modules including camera centering, tracking, periscoping, palpation, and collecting stars in a three-dimensional space. Both groups completed another diagnostic knee arthroscopy between 1 and 2 weeks later. Camera path length, time, tibia and femur cartilage damage, as well as a composite score were recorded by the simulator on each attempt. RESULTS: The experimental group (n = 22) showed superior performance in composite score (30.09 vs 24, P = .046) and camera path length (71.51 cm vs 109.07 cm, P = .0274) at the time of the second diagnostic knee arthroscope compared with the control group (n = 21). The experimental group also showed significantly greater improvement in composite score between the first and second arthroscopes compared with the control group (14.27 vs 4.95, P < .01). Femoral and tibial cartilage damage were not significantly improved between arthroscopy attempts (-0.86% vs -1.45%, P = .40) and (-1.10 vs -1.27%, P = .83), respectively. CONCLUSIONS: The virtual reality-based fundamentals of arthroscopy simulator training nonanatomic simulator is beneficial in developing basic motor skills in arthroscopy novice individuals resulting in significantly greater composite performance in an anatomic knee model. Based on the results of this study, it appears that there may be benefit from nonanatomic simulators in general as part of an arthroscopy training program. LEVEL OF EVIDENCE: Level II, randomized trial.

Popliteal (Baker's) Cysts in the Setting of Primary Knee Arthroplasty.

BACKGROUND: Popliteal (Baker's) Cysts are rare complications of knee arthroplasty. Enlargement, irritation, or rupture of the cyst can lead to significant pain, tightness, and tenderness. The literature regarding popliteal cysts occurring following knee arthroplasty is limited and does not report prevalence, natural history, and treatment of popliteal cyst in the setting of knee arthroplasty. METHODS: Following Institutional Review Board approval, 2,025 primary total and partial knee arthroplasties by four surgeons at one institution from 2011-2016 were reviewed for occurrence of popliteal cysts. Twelve cases occurring after arthroplasty were identified, including four unicompartmental knee arthroplasties and eight total knee arthroplasties. Demographic data were evaluated and symptoms, time of onset following arthroplasty, attempted treatment strategies, and success or failure of attempted treatments or interventions were recorded. RESULTS: The mean age of patients that presented with a popliteal cyst was 63.6 years old (range = 45 - 78 years). There were 5 males and 7 females. The mean BMI was 26.32 (range = 19.0 - 35.0). In 2,205 primary knee arthroplasties performed from 2011-2016 (including 175 partial and 1850 total), the prevalence of popliteal cysts following surgery was 0.6% (n=12). All popliteal cysts were discovered between six weeks and two years following surgery, with the majority occurring during the first year. Twenty-five percent (3/12) of patients presented with minimal symptoms. These were managed expectantly. Seventy-five percent (9/12) were symptomatic. One patient had only a diagnostic ultrasound, two patients underwent ultrasound-guided aspiration and steroid injection, three underwent simple aspiration. Two underwent surgical excision. One cyst ruptured. All cases went on to symptomatic resolution. There was no association with diabetes, smoking, or body mass index. A disproportionately high number (25% or 4/12) occurred in partial knee arthroplasty. CONCLUSION: While popliteal cysts following primary total knee arthroplasty are rare, they can become a persistent and even disabling problem for arthroplasty patients. Given the lack of formalized recommendations in the existing literature, we propose a treatment algorithm that has been successful in our clinic, including observation initially, ultrasound-guided injection/aspiration if symptomatic, and surgical excision as a last resort. LEVEL OF EVIDENCE: Level 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.

Use of 2-Octyl Cyanoacrylate Adhesive and Polyester Mesh for Wound Closure in Primary Knee Arthroplasty.

Wound closure in primary knee arthroplasty is important both for surgical success, by minimizing the risk of wound complications and infection, and for patient satisfaction with wound care and cosmesis. This article reports the use of a topical self-adhering, pressure-sensitive polyester mesh combined with 2-octyl cyanoacrylate adhesive for final skin closure of primary knee arthroplasty without external staples or sutures. During a 2.5-year period, 360 consecutive primary knee arthroplasty procedures (321 total knee arthroplasty procedures and 39 partial knee arthroplasty procedures) performed by 1 surgeon at 1 institution were reviewed. For all primary arthroplasty procedures, closure was performed with a standardized method. Final skin closure was performed with 2-octyl cyanoacrylate adhesive and polyester mesh. Patients returned at 6 weeks and 1 year postoperatively. The study found a 0.8% rate of superficial wound complications, no cases of dehiscence, no wound complications requiring operative irrigation and debridement, and no prosthetic joint infections. One patient had a reaction consistent with previously reported localized contact dermatitis that was believed to be related to the 2-octyl cyanoacrylate adhesive. In 2 cases, treatment with cephalexin was required, in 1 case for 2 small suture abscesses and in the other case for periincisional cellulitis. All wound complications resolved by 6 weeks. The results showed that 2-octyl cyanoacrylate adhesive and polyester mesh can be used successfully in the setting of primary knee arthroplasty for closure of high-tension knee arthroplasty wounds. This series found a 0.8% rate of superficial wound complications, no cases of dehiscence, and no infections. [Orthopedics. 2017; 40(5):e784-e787.].

Knee, Shoulder, and Fundamentals of Arthroscopic Surgery Training: Validation of a Virtual Arthroscopy Simulator.

PURPOSE: To validate the knee, shoulder, and virtual Fundamentals of Arthroscopic Training (FAST) modules on a virtual arthroscopy simulator via correlations with arthroscopy case experience and postgraduate year. METHODS: Orthopaedic residents and faculty from one institution performed a standardized sequence of knee, shoulder, and FAST modules to evaluate baseline arthroscopy skills. Total operation time, camera path length, and composite total score (metric derived from multiple simulator measurements) were compared with case experience and postgraduate level. Values reported are Pearson r; alpha = 0.05. RESULTS: 35 orthopaedic residents (6 per postgraduate year), 2 fellows, and 3 faculty members (2 sports, 1 foot and ankle), including 30 male and 5 female residents, were voluntarily enrolled March to June 2015. Knee: training year correlated significantly with year-averaged knee composite score, r = 0.92, P = .004, 95% confidence interval (CI) = 0.84, 0.96; operation time, r = -0.92, P = .004, 95% CI = -0.96, -0.84; and camera path length, r = -0.97, P = .0004, 95% CI = -0.98, -0.93. Knee arthroscopy case experience correlated significantly with composite score, r = 0.58, P = .0008, 95% CI = 0.27, 0.77; operation time, r = -0.54, P = .002, 95% CI = -0.75, -0.22; and camera path length, r = -0.62, P = .0003, 95% CI = -0.8, -0.33. Shoulder: training year correlated strongly with average shoulder composite score, r = 0.90, P = .006, 95% CI = 0.81, 0.95; operation time, r = -0.94, P = .001, 95% CI = -0.97, -0.89; and camera path length, r = -0.89, P = .007, 95% CI = -0.95, -0.80. Shoulder arthroscopy case experience correlated significantly with average composite score, r = 0.52, P = .003, 95% CI = 0.2, 0.74; strongly with operation time, r = -0.62, P = .0002, 95% CI = -0.8, -0.33; and camera path length, r = -0.37, P = .044, 95% CI = -0.64, -0.01, by training year. FAST: training year correlated significantly with 3 combined FAST activity average composite scores, r = 0.81, P = .0279, 95% CI = 0.65, 0.90; operation times, r = -0.86, P = .012, 95% CI = -0.93, -0.74; and camera path lengths, r = -0.85, P = .015, 95% CI = -0.92, -0.72. Total arthroscopy cases performed did not correlate significantly with overall FAST performance. CONCLUSIONS: We found significant correlations between both training year and knee and shoulder arthroscopy experience when compared with performance as measured by composite score, camera path length, and operation time during a simulated diagnostic knee and shoulder arthroscopy, respectively. Three FAST activities demonstrated significant correlations with training year but not arthroscopy case experience as measured by composite score, camera path length, and operation time. CLINICAL RELEVANCE: We attempt to validate an arthroscopy simulator that could be used to supplement arthroscopy skills training for orthopaedic residents.

Imaging Pediatric Spondylolysis: A Systematic Review.

STUDY DESIGN: A systematic review. OBJECTIVE: The aim of this study was to provide an evidence-based recommendation for when and how to employ imaging studies when diagnosing back pain thought to be caused by spondylolysis in pediatric patients. SUMMARY OF BACKGROUND DATA: Spondylolysis is a common structural cause of back pain in pediatric patients. The radiologic methods and algorithms used to diagnose spondylolysis are inconsistent among practitioners. METHODS: A literature review was performed in PubMed and Cochrane databases using the search terms "spondylolysis," "pediatric," "adolescent," "juvenile," "young," "lumbar," "MRI," "bone scan," "CT," and "SPECT." After inclusion criteria were applied, 13 articles pertaining to diagnostic imaging of pediatric spondylolysis were analyzed. RESULTS: Ten papers included sensitivity calculations for comparing imaging performance. The average sensitivity of magnetic resonance imaging (MRI) with computed tomography (CT) as the standard of reference was 81.4%. When compared with single-photon emission CT (SPECT), the average sensitivity of CT was 85% and the sensitivity of MRI was 80%. Thirteen studies made a recommendation as to how best to perform diagnostic imaging of patients with clinically suspected spondylolysis. When compared with two-view plain films, bone scans had seven to nine times the effective radiation dose, while four-view plain films and CT were approximately double. Of the diagnostic methods examined, MRI was the most expensive followed by CT, bone scan, four-view plain films, and two-view plain films. CONCLUSION: Due to their efficacy, low cost, and low radiation exposure, we find two-view plain films to be the best initial study. With unusual presentations or refractory courses, practitioners should pursue advanced imaging. MRI should be used in early diagnosis and CT in more persistent courses. However, the lack of rigorous studies makes it difficult to formulate concrete recommendations. LEVEL OF EVIDENCE: 3.

Superficial zone cellularity is deficient in mice lacking lubricin: a stereoscopic analysis.

BACKGROUND: Lubricin, a mucinous glycoprotein secreted by synoviocytes and chondrocytes plays an important role in reducing the coefficient of friction in mammalian joints. Elevated cartilage surface friction is thought to cause chondrocyte loss; however, its quantification and methodological approaches have not been reported. We adapted a stereological method and incorporated vital cell staining to assess cellular loss in superficial and upper intermediate zones in lubricin deficient mouse cartilage. METHODS: The femoral condyle cartilage of the intact knees from lubricin wild type (Prg4 (+/+)), heterozygote (Prg4 (+/-)), and knockout (Prg4 (-/-)) mice was imaged using fluorescein diacetate (FDA), propidium iodide (PI), and Hoechst staining, and confocal microscopy. Three dimensional reconstructions of confocal images to a depth of 14 µm were analyzed using Matlab to determine the volume fraction occupied by chondrocytes in cartilage of both medial and lateral femoral condyles. Living chondrocyte volume fraction was defined as FDA stained chondrocyte volume/total volume of superficial + upper intermediate zone. Living and dead (total) chondrocyte volume fraction was defined as FDA + PI stained chondrocyte volume/total volume of superficial + upper intermediate zone. MicroCT provided an orthogonal measure of cartilage thickness. Immunohistology for activated caspase-3 and TUNEL staining were performed to evaluate the presence of apoptotic chondrocytes in Prg4 mutant mice. RESULTS: Living chondrocyte volume fraction of the medial femoral condyle was significantly lower in Prg4 (-/-) mice compared to Prg4 (+/+) (p = 0.002) and Prg4 (+/-) (p = 0.002) littermates. There was no significant difference in medial condyle chondrocyte volume fraction between Prg4 (+/+) and Prg4 (+/-) mice (p = 0.82). No significant differences were observed for the chondrocyte volume fraction for the lateral condyle (p > 0.26). Cartilage thickness increased in the medial condyle for Prg4 (-/-) mice compared to Prg4 (+/+) (p = 0.02) and Prg4 (+/-) (p = 0.03) littermates, and the lateral condyle for Prg4 (-/-) mice compared to Prg4 (+/+) (p < 0.0001) and Prg4 (+/-) (p < 0.0001) littermates, indicating that a multi-dimensional increase in cartilage volume did not artifactually lower the chondrocyte volume fraction in the medial condyle. Significantly higher number of caspase-3 positive cells were observed in the superficial and upper intermediate zone cartilage of the medial femoral condyle of Prg4 (-/-) mice compared to Prg4 (+/+) (p = 0.01) and Prg4 (+/-) (p = 0.04) littermates, and the lateral femoral condyle of Prg4 (-/-) mice compared to Prg4 (+/+) (p = 0.02) and Prg4 (+/-) (p = 0.02) littermates. There were no significant differences in TUNEL staining among different Prg4 genotypes in both condyles (p > 0.05 for all comparisons). CONCLUSIONS: Increased Caspase-3 activation is observed in Prg4 deficient mice compared to Prg4 sufficient littermates. Absence of Prg4 induces loss of chondrocytes in the superficial and upper intermediate zone of mouse cartilage that is quantifiable by a novel image processing technique.

Orthopedic Surgery Resident Debt Load and Its Effect on Career Choice.

Student loan debt has become a topic of discussion and debate among physicians and legislators. This study seeks to assess the level of debt of orthopedic surgery residents and to determine whether debt burden affects the career choice of orthopedic trainees. A 26-question, anonymous survey was distributed via email to resident trainees enrolled in different medical and surgical specialty training programs across the United States. Orthopedic trainees were compared with trainees in other specialties using comparative statistics. Of the approximately 13,503 residents who were sent the survey, a total of 3076 responded, including 167 of an estimated 580 orthopedic residents, for approximate response rates of 22.8% and 28.8%, respectively. On average, orthopedic surgery residents were at a later post-graduate year than overall respondents (P<.025). When asked if student loan debt would influence the next step in their career, nonorthopedic residents were statistically more likely to respond "yes" compared with orthopedic surgery residents (57.21% vs 49.08%, respectively; P=.041). More than 50% of all respondents agreed that student loan debt would affect their type or location of practice. The majority of orthopedic residents take student loan debt into consideration when determining their final location and type of practice, although less so for orthopedic trainees compared with other specialties. As medical education continues to become more expensive and the threat of dropping physician reimbursement looms on the horizon, student debt may become a primary driving factor for young American physicians' career plans. [Orthopedics. 2016; 39(3):e438-e443.].

What is the role and limit of calcaneal osteotomy in the cavovarus foot?

Calcaneal osteotomy is a commonly used tool in cavovarus foot reconstructions. Understanding the indications and limitations of such an osteotomy is critical to success in reconstruction. We present a comprehensive review of surgical calcaneal osteotomy techniques and the currently available state of literature for their indications and limitations.