What Factors Are Associated With Early Career Attrition Among Orthopaedic Surgeons in the United States?

BACKGROUND: The attrition of medical personnel in the United States healthcare system has been an ongoing concern among physicians and policymakers alike. Prior studies have shown that reasons for leaving clinical practice vary widely and may range from professional dissatisfaction or disability to the pursuit of alternative career opportunities. Whereas attrition among older personnel has often been understood as a natural phenomenon, attrition among early-career surgeons may pose a host of additional challenges from an individual and societal perspective. QUESTIONS/PURPOSES: (1) What percentage of orthopaedic surgeons experience early-career attrition, defined as leaving active clinical practice within the first 10 years after completion of training? (2) What are the surgeon and practice characteristics associated with early-career attrition? METHODS: In this retrospective analysis drawn from a large database, we used the 2014 Physician Compare National Downloadable File (PC-NDF), a registry of all healthcare professionals in the United States participating in Medicare. A total of 18,107 orthopaedic surgeons were identified, 4853 of whom were within the first 10 years of training completion. The PC-NDF registry was chosen because it has a high degree of granularity, national representativeness, independent validation through the Medicare claims adjudication and enrollment process, and the ability to longitudinally monitor the entry and exit of surgeons from active clinical practice. The primary outcome of early-career attrition was defined by three conditions, all of which had to be simultaneously satisfied ("condition one" AND "condition two" AND "condition three"). The first condition was presence in the Q1 2014 PC-NDF dataset and absence from the same dataset the following year (Q1 2015 PC-NDF). The second condition was consistent absence from the PC-NDF dataset for the following 6 years (Q1 2016, Q1 2017, Q1 2018, Q1 2019, Q1 2020, and Q1 2021), and the third condition was absence from the Centers for Medicare and Medicaid Services Opt-Out registry, which tracks clinicians who have formally discontinued enrollment in the Medicare program. Of the 18,107 orthopaedic surgeons identified in the dataset, 5% (938) were women, 33% (6045) were subspecialty-trained, 77% (13,949) practiced in groups of 10 or more, 24% (4405) practiced in the Midwest, 87% (15,816) practiced in urban areas, and 22% (3887) practiced at academic centers. Surgeons not enrolled in the Medicare program are not represented in this study cohort. A multivariable logistic regression model with adjusted odds ratios and 95% confidence intervals was constructed to investigate characteristics associated with early-career attrition. RESULTS: Among the 4853 early-career orthopaedic surgeons identified in the dataset, 2% (78) were determined to experience attrition between the first quarter 2014 and the same point in 2015. After controlling for potential confounding variables such as years since training completion, practice size, and geographic region, we found that women were more likely than men to experience early-career attrition (adjusted OR 2.8 [95% CI 1.5 to 5.0]; p = 0.006]), as were academic orthopaedic surgeons compared with private practitioners (adjusted OR 1.7 [95% CI 1.02 to 3.0]; p = 0.04), while general orthopaedic surgeons were less likely to experience attrition than subspecialists (adjusted OR 0.5 [95% CI 0.3 to 0.8]; p = 0.01). CONCLUSION: A small but important proportion of orthopaedic surgeons leave the specialty during the first 10 years of practice. Factors most-strongly associated with this attrition were academic affiliation, being a woman, and clinical subspecialization. CLINICAL RELEVANCE: Based on these findings, academic orthopaedic practices might consider expanding the role of routine exit interviews to identify instances in which early-career surgeons face illness, disability, burnout, or any other forms of severe personal hardships. If attrition occurs because of such factors, these individuals could benefit from connection to well-vetted coaching or counseling services. Professional societies might be well positioned to conduct detailed surveys to assess the precise reasons for early attrition and characterize any inequities in workforce retention across a diverse range of demographic subgroups. Future studies should also determine whether orthopaedics is an outlier, or whether 2% attrition is similar to the proportion in the overall medical profession.

Endoscopic Versus Open Carpal Tunnel Release: A Detailed Analysis Using Time-Driven Activity-Based Costing at an Academic Medical Center.

PURPOSE: In order to effectively improve value in health care delivery, providers must thoroughly understand cost drivers. Time-driven activity-based costing (TDABC) is a novel accounting technique that may allow for precise characterization of procedural costs. The purpose of the present study was to use TDABC to characterize costs in a high-volume, low-complexity ambulatory procedure (endoscopic vs open carpal tunnel release [CTR]), identify cost drivers, and inform opportunities for clinical improvement. METHODS: The costs of endoscopic and open CTR were calculated in a matched cohort investigation using TDABC. Detailed process maps including time stamps were created accounting for all clinical and administrative activities for both the endoscopic and the open treatment pathways on the day of ambulatory surgery. Personnel cost rates were calculated accounting for capacity, salary, and fringe benefits. Costs for direct consumable supplies were based on purchase price. Total costs were calculated by aggregating individual resource utilization and time data and were compared between the 2 surgical techniques. RESULTS: Total procedural cost for the endoscopic CTR was 43.9% greater than the open technique ($2,759.70 vs $1,918.06). This cost difference was primarily driven by the disposable endoscopic blade assembly ($217), direct operating room costs related to procedural duration (44.8 vs 40.5 minutes), and physician labor. CONCLUSIONS: Endoscopic CTR is 44% more expensive than open CTR compared with a TDABC methodology at an academic medical center employing resident trainees. Granular cost data may be particularly valuable when comparing these 2 procedures, given the clinical equipoise of the surgical techniques. The identification of specific cost drivers with TDABC allows for targeted interventions to optimize value delivery. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic Analysis II.

Nonunion Rates Among Ulnar-Shortening Osteotomy for Ulnar Impaction Syndrome: A Systematic Review.

PURPOSE: The purpose of this study was to systematically review all available literature reporting nonunion rates of ulnar-shortening osteotomies (USO) used for the treatment of ulnar impaction syndrome (UIS) and to compare those rates among transverse versus oblique cuts for the osteotomy. METHODS: Electronic databases including PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies that evaluated outcomes of both transverse and oblique USO for UIS. Level of evidence was determined by 2 independent reviewers. Studies were screened based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and inclusion and exclusion criteria were applied. A total of 37 studies (1,423 patients) were included in final analysis. The average rate of nonunion and delayed union for each group (transverse and oblique osteotomy) was calculated. RESULTS: The average rate of nonunion among all osteotomies was 4.0%. The average rate of nonunion was 4.16% and 3.86% in transverse osteotomies and oblique osteotomies, respectively. This difference was not statistically significant. The average rate of delayed union, in those studies that reported delayed union, was 5.7%. The average rate of delayed union was 7.41% and 4.1% in transverse osteotomies and oblique osteotomies, respectively. CONCLUSIONS: Based on our review of the literature, there is no difference in the rate of nonunion between transverse and oblique osteotomies. Therefore, the decision of which of the 2 surgical techniques should not be based on rate of nonunion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Use of an Automated Mobile Phone Messaging Robot in Postoperative Patient Monitoring.

BACKGROUND: Mobile phone messaging software robots allow clinicians and healthcare systems to communicate with patients without the need for human intervention. The purpose of this study was to (1) describe a method for communicating with patients postoperatively outside of the traditional healthcare setting by utilizing an automated software and mobile phone messaging platform and to (2) evaluate the first week of postoperative pain and opioid use after common ambulatory hand surgery procedures. MATERIALS AND METHODS: The investigation was a prospective, multicenter investigation of patient-reported pain and opioid usage after ambulatory hand surgery. Inclusion criteria included any adult with a mobile phone capable of text messaging, who was undergoing a common ambulatory hand surgical procedure at one of three tertiary care institutions. Participants received daily, automated text messages inquiring about their pain level and how many tablets of prescription pain medication they had taken in the past 24 h. Initial 1-week response rate was assessed and compared between different patient demographics. Patient-reported pain and opioid use were also quantified for the first postoperative week. Statistical significance was set as p < 0.05. RESULTS: Forty-seven (n = 47) patients were enrolled in this investigation. Total response rate of both pain and opioid medication questions through 7 days was 88.3%. Pain trended down on a daily basis for the first postoperative week, with the highest levels of pain being reported in the first 48 h after surgery. Patients reported an average use of 15.9 ± 14.8 tablets of prescription opioid pain medication. CONCLUSIONS: We find that a mobile phone messaging software robot allows for effective data collection of postoperative pain and pain medication use. Patients undergoing common ambulatory hand procedures utilized an average of 16 tablets of opioid medication in the first postoperative week.

A Surgical Skills Rotation for Mid-Level Residents.

Introduction: The University of Iowa orthopaedic residency previously designed a month-long surgical skill rotation for postgraduate year (PGY)-1 residents. This successful initiative has become a model of interest for other teaching institutions. In addition to the intern year, an important phase in residency occurs during the transition from PGY2 to PGY3, when residents assume greater responsibility and autonomy in leading surgical procedures. Methods: To directly address this transition and assess residents' readiness, our residency program established a week-long PGY2 surgical skills rotation. This rotation serves as a training checkpoint and focuses on both training and evaluation of level-appropriate skills in joint arthroplasty, trauma, arthroscopy, and wire navigation. The primary objective of the PGY2 surgical skills rotation is to enhance orthopaedic residents' operative skills and experience by providing increased exposure and practice of requisite technical skills. Similar to the Orthopedic In-Training Examinations that assess residents' knowledge, this week-long program, aimed at assessing residents' proficiency in fundamental orthopaedic technical skills, occurs before their PGY3 year. Results: Faculty-led training and assessment sessions in each area offer residents many opportunities for dedicated practice and improvement. Transferring these acquired skills from the laboratory to the operating room is essential for a training program. To confirm improvement, the final day of the surgical skills rotation was exclusively dedicated to structured performance evaluations, with a specific emphasis on establishing proficiency benchmarks. Conclusion: We herein describe the University of Iowa's PGY2 surgical skills rotation, providing insights into its development, implementation, and outcomes. By sharing our experience, we offer a framework for other academic departments seeking to optimize surgical skills education and ensure the successful transition of mid-level residents.

Patient Initiated Discrimination and Harassment-A Descriptive Survey of Experiences Within a Single Academic Department.

Background: Diversity in orthopedics is lacking despite ongoing efforts to create a more inclusive workforce. Increasing diversity necessitates recruitment and retainment of underrepresented providers, which involves representation among leadership, mentorship initiatives, and development of a safe work environment. Discrimination and harassment behaviors are prevalent within orthopedics. Current initiatives aim to address these behaviors among peers and supervising physicians, but patients are an additional underrecognized source of these negative workplace behaviors. This report aims to establish the prevalence of patient-initiated discrimination and harassment within a single academic orthopedic department and establish methods to reduce these behaviors in the workplace. Methods: An internet-based survey was designed using the Qualtrics platform. The survey was distributed to all employees of a single academic orthopedic department including nursing staff, clerks, advanced practice providers, research staff, residents/fellows, and staff physicians. Survey was distributed on two occasions between May and June of 2021. The survey collected information on respondent demographics, experience with patient-initiated discrimination/harassment, and opinions regarding possible intervention methods. Fisher exact test was used for statistical analysis. Results: Over one half of survey respondents report observing or personally experiencing patient-initiated discrimination within our orthopedics department (57%, n=110). Nearly half of respondents report observing or personally experiencing patient-initiated harassment within our department (46%, n=80). Encounters with these behaviors were more commonly reported from resident and staff female physicians. The most frequently reported negative patient-initiated behaviors include gender discrimination and sexual harassment. Discordance exists regarding optimal methods to address these behaviors, but one third of respondents indicate potential benefit from visual aids throughout the department. Conclusion: Discrimination and harassment behaviors is common within orthopedics, and patients are a significant source of this negative workplace behavior. Identification of this subset of negative behaviors will allow us to provide patient education and provider response tools for the protection of orthopedic staff members. Ideally, minimizing discrimination/harassment behaviors within our field will help create a more inclusive workplace environment and allow continued recruitment of diverse candidates into our field. Level of Evidence: V.

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.

Pregnancy During Orthopaedic Surgery Residency: The Iowa Experience.

Family planning is a challenge for physicians at all stages of their careers, but particularly difficult during residency. Residency commonly occurs during prime childbearing years and is associated with long work hours and inflexible schedules. A commonly cited deterrent for women entering orthopaedic surgery is the inability to achieve a healthy and fulfilling work-life balance.1 Further, those women who pursue starting a family during residency have been shown to have higher rates of pregnancy-related complications including infertility with complications rates as high as 30%.2,3 In a recent AAOS article, a call to action for modified policies to prioritize the health of pregnant orthopaedic surgeons and their unborn children was made to decrease the overall risk to women who wish to have children during residency and early practice.4 The University of Iowa has a history of attracting women into the orthopedic training program. We asked past graduates of the University of Iowa Orthopedic Residency program who had children during residency to share their personal experiences and opinions. We asked past graduates to answer five questions surrounding their pregnancy during residency. We have included the good, the bad, and the ugly with real-life testimonies in hopes that despite the statistics, women in our field considering pregnancy will find comfort in those that have been through it. Four prior residents were kind enough to share their experiences. Dr. Sarah Schippers (SS) completed residency in 2021 and is currently finishing a hand and upper extremity fellowship and will soon be starting private practice in Kansas. She shares on her experience regarding two pregnancies during residency. Dr. Tina Hajewski (TH) completed residency in 2021 and is also currently finishing a spine fellowship and will soon be starting private practice in Washington, sharing on her experience having two children during residency. Dr. Elizabeth Weldin (EW) completed residency in 2018 and is a current hand and upper extremity attending in Oklahoma and shares her experience having a child during residency and the contrast to having children during practice. Finally, Dr. Heather Campion (HW) completed residency in 2012 and is a current hand and upper extremity attending in Oregon and shares her experience as being the first Iowa orthopaedic resident to have a child during residency. Level of Evidence: V.

Glass Ceiling in Hand Surgery: Publication Trends by Gender.

Background: Women are frequently underrepresented across surgical subspecialties and may face barriers to academic advancement. Abstracts presented at American Society for Surgery of the Hand annual meeting (ASSH-AM) highlight some of the top research in hand surgery. We sought to explore differences in abstract characteristics and publication rates based on senior author gender.Though there have been increasing efforts at inclusivity in orthopedic and plastic surgery, women face several barriers to entering the field, publish less frequently, and are underrepresented in leadership positions. Understanding the stages at which discrepancies in research productivity exist may help to address these challenges. Methods: Abstracts from the 2010-2017 ASSH-AMs were reviewed to determine basic characteristics. Author gender was determined through both a search of institutional websites for gender-specific pronouns and inference of gender based on first name. Subsequent full manuscript publications corresponding to the abstracts were identified through a systematic search of PubMed and Google Scholar. Results: A total of 560/620 (90.3%) abstracts from 2010-2017 had an identifiable senior author gender (14.5% female). No differences were noted between male- and female-authored abstracts regarding study design including sample size or level of evidence. Female senior authors were more likely than males to author abstracts focused on pediatrics (19.8% vs 9.4%, p=0.01) and were more likely to collaborate with female first authors (41.3% vs 20.0%, p<0.01). Abstract publication rates were lower for female senior authors versus male senior authors (61.7% vs 74.5%, p=0.02). Conclusion: The number of abstracts with female senior authors had similar representation to the membership proportion of women in the ASSH. There were few differences in abstract characteristics based on senior author gender, though senior authors tend to collaborate with investigators of the same gender. Abstracts authored by females were published 13% less frequently overall, meriting further exploration. Level of Evidence: III.

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.

Vascular Changes of the Hand of a Collegiate Softball Catcher: A Case Report.

CASE: A Division I collegiate softball catcher presented with discoloration, coolness, and swelling of her left index finger that worsened with sport participation. Upper extremity arteriogram revealed absent flow to the radial aspect of the finger and compromise of the ulnar digital artery distal to the proximal interphalangeal joint. After failing nonoperative management, she underwent periarterial sympathectomy with relief of symptoms. CONCLUSION: Repetitive trauma to a catcher's hand can result in vascular compromise. When nonoperative measures fail, surgical intervention may be successful. We describe successful treatment using sympathectomy. Surgeons should be able to diagnose this condition and understand treatment options.

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.

Prosthetic Finger Joint Infection Due to Aspergillus terreus.

Fungal periprosthetic joint infections (PJIs) are rare but associated with significant mortality. We report a case of a finger PJI secondary to Aspergillus terreus in an immunocompetent patient with soil exposure, successfully treated with surgical debridement and voriconazole. Identification of A terreus is important because of intrinsic amphotericin B resistance.

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.

Masks for the Reduction of Methyl Methacrylate Vapor Inhalation.

Background: Exposure to methyl methacrylate vapor (MMA) presents an occupational risk to orthopedic surgeons and ancillary personnel in the operating room. The purpose of this study was to identify a disposable face mask to reduce MMA organic vapor inhalation in the operative suite. Methods: First, the effectiveness of MMA vapor filtration was determined in the laboratory. A section of activated carbon impregnated filter face mask (Model 8514, 3M Inc.) was exposed to 150 ppm MMA vapor and MMA ppm of filtered air was monitored until MMA vapor was detectable. The face mask was then worn as directed in the operating room during routine cement mixing during total knee arthroplasty to determine the exposure to MMA vapors during the procedure both with and without the activated carbon impregnated filter face mask. Results: The activated carbon impregnated face mask was effective in reducing MMA vapor inhalation to non-detectable levels for up to 40 minutes in the laboratory at steady-state exposure of 150 ppm MMA vapor as well as throughout cement mixing and curing in the operative suite during routine total knee arthroplasty. Conclusions: An activated carbon impregnated face mask offers a solution for the orthopedic surgeon and supporting personnel who wish to limit their exposure to MMA vapors due to health concerns.Level of Evidence: III.

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.

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.

Chronic instability of the distal radioulnar joint.

The ligament reconstruction technique described closely reconstructs the anatomic origin and insertion of the palmar and dorsal radioulnar ligaments. In a series of 14 patients, stability was completely restored in 12. Patients were able to return to their previous work, athletic activities, and avocations without limitations. Recovery of strength and motion was at least 85%. One patient with initial bidirectional instability and good early surgical correction developed recurrent volar instability. Another patient had persistent preoperative ulnocarpal instability and an insufficient volar rim of the sigmoid notch from a previous fracture, but the DRUJ was stabilized. Ligament reconstruction is effective for DRUJ instability but requires a competent sigmoid notch; however, it may not fully correct ulnocarpal instability.

Delivery of Patient-Reported Outcome Instruments by Automated Mobile Phone Text Messaging.

BACKGROUND: Patient-reported outcome (PRO) instruments allow patients to interpret their health and are integral in evaluating orthopedic treatments and outcomes. The purpose of this study was to define: (1) correlation between PROs collected by automated delivery of text messages on mobile phones compared with paper delivery; and (2) patient use characteristics of a technology platform utilizing automated delivery of text messages on mobile phones. METHODS: Paper versions of the 12-Item Short Form Health Survey (SF-12) and the short form of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) were completed by patients in orthopedic hand and upper extremity clinics. Over the next 48 hours, the same patients also completed the mobile phone portion of the study outside of the clinic which included text message delivery of the SF-12 and QuickDASH, assigned in a random order. Correlations between paper and text message delivery of the 2 PROs were assessed. RESULTS: Among 72 patients, the intraclass correlation coefficient (ICC) between the written and mobile phone delivery of QuickDASH was 0.91 (95% confidence interval [CI], 0.85-0.95). The ICC between the paper and mobile phone delivery of the SF-12 physical health composite score was 0.88 (95% CI, 0.79-0.93) and 0.86 (95% CI, 0.75-0.92) for the SF-12 mental health composite score. CONCLUSIONS: We find that text message delivery using mobile phones permits valid assessment of SF-12 and QuickDASH scores. The findings suggest that software-driven automated delivery of text communication to patients via mobile phones may be a valid method to obtain other PRO scores in orthopedic patients.