Residency Selection Preferences and Orthopaedic Career Perceptions: A Notable Mismatch.

BACKGROUND: Despite near-equal enrollment of males and females in medical schools, orthopaedic surgery continues to have one of the lowest percentage of female orthopaedic residents. This suggests there may be factors that specifically influence females to select other specialties. Some of these possible reasons have been explored in other studies; however, in this study, we sought to identify latent or unobserved variables that may be influencing this difference by conducting an explanatory factor analysis of male and female residency preferences. PURPOSES/QUESTIONS: In this study, by surveying a cohort of medical students at a single institution, we asked, is there a difference between males and females (1) in their perception of orthopaedic surgery and (2) in their preferences for residency and practice? We further asked, if there are differences, (3) is there a correlation between perception and preferences for residency and practice? METHODS: A 46-question survey was sent to all current medical students (n = 628) at a major urban university with near-equal enrollment of males (55%, 345 of 628) and females (45%, 283 of 628) from September 2017 to November 2017. The survey consisted of two main parts: (1) desired attributes of a residency program and (2) perceptions of orthopaedic residency and practice. The design of the survey instruments closely followed The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) checklist and went through several variations and pilot studies before release. In all, 33% (205 of 628) total medical students responded to the email survey, 55% (112 of 205) were male and 45% (93 of 205) were female. The proportion of male and female respondents matched the gender distribution of the total population surveyed, which at the time of the survey was 55% male and 45% female.The data analysis was performed using a Mann-Whitney U test and an explanatory factor analysis. The explanatory factor analysis was used to identify the correlation between survey variables among male and female students. An alpha less than 0.05 was considered significant for the Mann-Whitney U test and a factor greater than 0.5 was considered significant for the factor analysis. RESULTS: Both male and female students ranked "work-life balance" and "variety in specialty" among the top three most important preferences. Females ranked "range of practice options," higher than males (72% females versus 60% males, r = 0.18; p = 0.009), and males ranked "previous exposure to the specialty" higher than females (65% females versus 71% males, r = 0.03; p = 0.70). Both male and female students had similar overall perceptions of orthopaedic surgery. Both males and females indicated that orthopedics is "male dominated," has "competitive entrance requirements," and requires "long residency work hours." They differed in their perception of "requires physical strength" (60% females versus 38% males, r = 0.28; p < 0.0005), and by how much orthopaedics is "male dominated" (95% females versus 77% males, r = 0.26; p < 0.0005). The factor analysis recognized that, although male and female students do have some similar residency preferences, the influence or weighing of those preferences is different for male and female students. In a manner similar to a personality assessment, the factor analysis produced four latent factors that can help explain variation seen in responses and helped identify influential factors that were not directly tested by the survey. The first such latent factor for females consisted of "work-life balance," "residency length," 'residency work hours," and "family-friendly specialty." Although the first latent factor for males consisted of "prestige," "income potential," "grade or step scores," and "competitiveness of residency program." The three subsequent latent factors also displayed variation in the make-up of the latent factors between males and female students. CONCLUSIONS: This study of medical students at an urban medical school found that male and female students shared many preferences for residency specialties and held many of the same perceptions regarding orthopaedic surgery. The explanatory factor analysis indicated that male and female students weight preferences differently when selecting a specialty; this difference may account for the large differences in proportion between males and females in orthopaedic residency. CLINICAL RELEVANCE: Attracting talented residents and attending physicians is important for the success of any medical department. Although orthopaedics attracts some of the most talented students, these students are predominantly male. By identifying the multifactorial areas that may be inadvertently discouraging females from applying, orthopaedic residency programs may be able to better address those issues and attract the best talent of both genders.

Gender Diversity in Sports Medicine: Current Trends.

As the sports medicine field has grown, the need for a more diverse workforce has become more evident. Given the growing athlete diversity that exists at all recreational and competitive levels of organized sports, it is important to better understand the current state of athletic health care diversity. This review assesses the current state of diversity in sports medicine from the perspective of the medical and athletic training professions. Men and women currently display nearly equivalent participation levels; however, the distribution of female team physicians and athletic trainers could better match the teams that they serve. Although progress has been made, much more needs to be done to bring more female athletic trainers and team physicians into athletic health care leadership roles. Early mentoring programs have shown efficacy for increasing the number of female candidates who might become the foundation of future athletic health care and academic program leaders. Level of Evidence: V, expert opinion.

The Use of a Robotic Arm for Fixation of Pelvic Fractures.

OBJECTIVES: The objective of this study was to evaluate unplanned cortical or neuroforaminal violation of iliosacral and transsacral screw placement using fluoroscopy versus screw placement using a robotic arm. DESIGN: This is a prospective cohort study. SETTING: Single surgeon, single North American level 1 trauma center. PATIENTS: Radiographic and clinical data for 21 consecutive adult trauma patients with pelvic ring fractures undergoing surgical treatment were prospectively collected. Treatment consisted of iliosacral and/or transsacral screws with or without anterior fixation. INTERVENTION: Ten patients were treated with the assistance of a robotic arm. Eleven patients were treated with standard fluoroscopic techniques. MAIN OUTCOME MEASUREMENTS: Thirty-two screws were placed and evaluated with postoperative computed tomography or O-arm spins to assess unplanned cortical or neuroforaminal violation. Violations were graded according to the Gertzbein and Robbins system for pedicle screw violation, categorizing screw violation in 2-mm increments. The postoperative images were blindly reviewed by 5 fellowship-trained orthopaedic traumatologists. The treating surgeon was excluded from review. RESULTS: The Mann-Whitney U test on the Gertzbein and Robbins system results demonstrated significantly (P = 0.02) fewer violations with robotic assistance. χ2 analysis of whether there was a cortical violation of any distance demonstrated significantly (P = 0.003) fewer cortical violations with robotic assistance. There were no neurovascular injuries in either group. CONCLUSION: Robotic assistance demonstrated significantly fewer unplanned cortical or neuroforaminal violations. Further research is needed with additional surgeons and sites to evaluate the accuracy of iliosacral and transsacral screw placement with robotic assistance. LEVEL OF EVIDENCE: Therapeutic, level II.

Placement of LC-II and trans-sacral screws using a robotic arm in a simulated bone model in the supine position - a feasibility study.

PURPOSE: The use of a robotic arm has been well-described in the literature for the placement of pedicle screws in spine surgery as well as implants for sacroiliac joint fusion. There are no reports describing the use of a robotic arm to place screws in osseous fixation pathways (OFPs) employed in the treatment of pelvic ring and acetabular fractures outside of a single center in China. Using a Sawbones model, the authors describe a technique for using a robotic arm widely available in Europe and the Americas for placement of 6.5 mm cannulated screws into two OFPs commonly used in the treatment of pelvic and acetabular fractures. METHODS: Using the Mazor X Stealth Edition (MSXE) robot from Medtronic, the authors were able to place a pin into the pelvis onto which the robot was docked. The authors were then able to designate the area of interest using navigated instruments, and in combination with the MSXE "scan and plan" marker, obtain cross-sectional imaging using the O-Arm and successfully register the MSXE robot. We then used the provided software to plan trajectories for the lateral compression type 2 (LC-II) screw pathway as well as a pathway for a trans-ilio-trans-sacral screw. We describe in detail the steps for setup, planning and placement of 6.5 mm cannulated screws using the MSXE robotic arm into these two OFPs. RESULTS: Visual inspection and plain x-rays demonstrated successful placement of the screws into the two planned OFPs. No breach of cortical bone was seen on either visual inspection of the model or demonstrated on post-procedure x-rays. CONCLUSION: It is possible to use the Mazor X Stealth Edition robot to place screws into the LC-II and trans-ilio-transsacral screw pathways in a Sawbones model. This is only a feasibility study, and should in no way be taken to suggest that clinical application of this technique should be attempted.

Immediate outcomes of early versus late definitive fixation of acetabular fractures: A narrative literature review.

The ideal timing of acetabular fractures fixation remains contentious. Early immediate fixation was thought to increase the surgery duration and blood loss while facilitating earlier mobilization and shorter hospital stay; and vice versa for the late fixation after 7 days. The purpose of this review was to compare the impact of early (defined as within 48 hours) versus later definitive fixation of acetabular fractures on postoperative outcomes. It was found that early surgical treatment has certain advantages with regards to blood loss, operative time, and LOS especially in patients with lower ISS. However, further studies are necessary to provide more evidence in terms of long-term outcomes.

Endogenous and iatrogenic sources of variability in response to opioid therapy in Post-Surgical and injured orthopedic patients.

BACKGROUND: Hydrocodone is the most prescribed opioid in the US. The objective was to evaluate associations between genetic, intrinsic, and extrinsic patient factors, plasma hydrocodone and metabolites, common side effects, and pain scores in a cohort of orthopedic surgery patients. METHODS: Data for each patient was collected by review of the electronic hospital record (EHR), and patient interview. Patients were recruited from those with trauma or undergoing scheduled elective surgery for total knee replacement or total hip at the University of Louisville Hospital, Baptist East Hospital, and Jewish Hospital, Louisville, KY. Plasma opiate concentrations and a targeted genotyping panel was performed. RESULTS: There were statistically significant correlations with daily (p < 0.001) and total dose (p = 0.002) of hydrocodone in hospital and duration of opioid therapy. The length of opioid administration was significantly shorter in CYP2D6 EM/UM versus CYP2D6 PM/IM patients (p = 0.018). Subjects with the OPRM1 c.118G variant were also on opioids longer (p = 0.022). The effect of co-administration of a CYP2D6 inhibitor had a significant effect on the length of opioid therapy (P < 0.001). And not surprisingly the effect of the inhibitor adjusted CYP2D6 phenotype was greater in both the hospital stay period and days of opioid use post hospital discharge (p < 0.001). CONCLUSIONS: Based on this study, patients should be evaluated for the use of inhibitors of CYP2D6, during hydrocodone therapy can alter the phenotype of the patient (phenocopy) and increase the probability that the patient will be on opioids for longer periods of time.

Necessity for fibular fixation associated with distal tibia fractures.

INTRODUCTION: Intramedullary (IM) nailing is a well-accepted treatment for distal third tibia fractures in combination with injury to the fibula. However, the indications for operative stabilisation of the fibula remain controversial. METHODS: The authors performed a retrospective review on a consecutive series of patients who underwent intramedullary nailing of a non-comminuted distal third tibia fracture with or without fibular fixation at a Level I urban trauma centre. A review of surgical records identified 120 patients who initially were included in this study, while a total of 98 patients who met the inclusion criteria were included in the final analysis. RESULTS: Our results found no difference in the mean value of coronal and sagittal plane alignment in both the immediate post-operative and follow-up time periods. We also saw no statistically significant difference when comparing malalignment between patients treated with or without fibula fixation. There were no deep infections between the two groups. No significant differences were seen between the fibular fixation group and the non-fixation group. Distal screw removal due to prominence or pain was the most common reason for future surgery in both groups. CONCLUSION: These findings suggest that the addition of fibular fixation does not affect whether or not alignment is maintained in either the immediate post-operative or short-term follow-up period.