Hold the Antibiotics: Are Preoperative Antibiotics Unnecessary in the Treatment of Pediatric Supracondylar Humerus Fractures?

BACKGROUND: Supracondylar humerus (SCH) fracture is the most common elbow injury in children and often treated with closed reduction and percutaneous pinning (CRPP). There is little published evidence supporting or refuting the use of perioperative prophylactic antibiotics for SCH CRPP in the pediatric population. The purpose of this study is to evaluate the rate of surgical site infection for patients with and without preoperative antibiotics. METHODS: A retrospective chart review was conducted of patients less than or equal to 16 years from 2012 to 2018 who underwent primary CRPP. Open fractures, multilimbed polytraumas, and immunodeficient patients were excluded. Infection rates were compared using a noninferiority test assuming a 3% infection rate and a predefined noninferiority margin of 4%. A total of 255 patients were needed to adequately power the study. RESULTS: Of the 1253 cases identified, 845 met eligibility criteria. A total of 337 received antibiotics, and 508 did not. Preoperative nerve injury (P=0.0244) and sterilization technique (P<0.0001) were associated with antibiotic use: 4 patients developed an infection; there were successfully treated superficial infections, and 1 was a deep infection requiring a formal debridement. There were 8 patients that had a recorded mal-union, and 6 patients required additional procedures; 1 patient had a postoperative compartment syndrome on postoperation day 1. The infection rates among patients treated with and without antibiotics were 0.60% and 0.40%, respectively. The absence of antibiotics was not clinically inferior to using antibiotics (P=0.003). CONCLUSIONS: Infection remains a rare complication following CRPP of SCH fractures. According to our current data, not giving perioperative antibiotics was not inferior to using perioperative antibiotics for preventing superficial or deep infection in patients undergoing CRPP of SCH fractures. With the increase in attention to antibiotic stewardship, it is important to eliminate unnecessary antibiotic use while continuing to maintain a low rate of surgical site infection. LEVEL OF EVIDENCE: Level IV-case series. This is a therapeutic study that investigates the results from a case series.

Resident Education and Wellness: A Strategy for Future Pandemics.

The Coronavirus Disease 2019 (COVID-19) pandemic presented a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation dramatically affected resident training. The objective of this article is to develop new strategies to maintain a healthy, competent residency program while combating the unique challenges to resident education and wellness. In 2020, our institution implemented a revolving 3-Team system. While the "Inpatient-Team" delivered direct care, the "Back-up Team" and "Quarantine-Team" managed the telemedicine virtual clinic and education-wellness strategy, respectively. Our 3-Team system allowed delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. The efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represent an opportunity for lasting improvement. (Journal of Surgical Orthopaedic Advances 31(3):150-154, 2022).

Appropriate Use Criteria for Treatment of Pediatric Supracondylar Humerus Fractures With Vascular Injury: Do Our Hospital Practice Patterns Agree With Current Recommendations?

BACKGROUND: Managing the pulseless pediatric supracondylar humerus fracture (PSHF) remains a significant clinical decision-making challenge for the treating surgeon. The purpose of the study is to determine frequency of the treatments according to the American Academy of Orthopaedic Surgeons (AAOS) Appropriate Use Criteria (AUC) for the PSHF with vascular injury and evaluate the appropriateness of these interventions. METHODS: We identified all PSHF with concern for vascular injury at one high volume, level 1 trauma center managed by 6 fellowship-trained pediatric orthopaedic surgeons over 4.5 years. Demographic information and other injury and treatment variables were obtained. Each patient was classified as 1 of the 6 patient scenarios specified by the AAOS AUC. Each of the 18 interventions identified in the AUC were documented, including the level of "appropriateness" as specified by AAOS AUC. RESULTS: A total of 638 PSHF were managed identified; of these, 52 were pink, pulseless, or dysvascular (8.2%). Only 7 of the 18 treatment options suggested by the AUC were used in this cohort. Across all 7 interventions used in this cohort, 20.2% (17/84) of interventions were "appropriate," 52.4% (44/84) were "maybe appropriate," 22.6% (19/84) were "rarely appropriate," and 4.8% (4/84) were not listed in treatment options. CONCLUSIONS: Supracondylar fractures are the most common injury to the elbow seen in children and are variable in presentation and management. The pink, pulseless fracture continues to be a major topic for research and discussion due to the morbidity if not treated "appropriately." The AUC were created to help guide practitioners when strong evidence is lacking. In this study at a single, pediatric hospital, there was variation and disagreement with "appropriateness" of treatments that were performed but this discrepancy did not result in any poor outcomes. Although the AUC do offer valuable guidance, our findings highlight a need for continued research in this area to help validate the AUC and help strengthen the recommendations moving forward. LEVEL OF EVIDENCE: Level III-retrospective.

Development and Implementation of a Pediatric Trauma Survivors Network Program.

: The Trauma Survivors Network (TSN) was developed as a program of the American Trauma Society (ATS) to support recovery for adult trauma patients. However, the children of adult trauma patients, families of pediatric trauma patients, and pediatric trauma patients previously had scarce resources. Our institution, in collaboration with the ATS, sought to expand the TSN to support pediatric trauma patients, caregivers, and family members. We aimed to determine whether the TSN could be transferred to the pediatric population. Focus groups identified psychosocial needs of younger survivors, children of adult survivors, and caregivers. A Pediatric TSN Coordinator was hired, Pediatric TSN Peer Visitors were recruited and trained, and Pediatric TSN Activity Hour was implemented for pediatric patients and families. Since implementation 1 year ago, 26 peer visitors have been trained and have conducted approximately 200 visitations. In total, 93 patients and family members have attended Pediatric TSN Activity Hour. TSN services can be adapted to address psychosocial needs of pediatric trauma survivors, families, and children of trauma survivors. When possible, sharing resources between an existing adult TSN program and a pediatric program is valuable to facilitate expansion. TSN complements and strengthens the care offered at our institution by providing patient-centered and family-centered care services for the entire family at various stages of development. The implementation of this program might be different at sites without an existing adult TSN with established resources and support. This article describes the development and implementation of the program; we did not assess outcomes.

Design and application of a fluorogenic assay for monitoring inflammatory caspase activity.

Various fluorogenic assays exist for monitoring the activity of inflammatory caspases. However, there are no continuous assays that provide C-terminal substrate sequence specificity for inflammatory caspases. As a first step towards this, we have developed a continuous in vitro assay that relies on monitoring emission from tryptophan after cleavage of a quenching coumarin chromophore. The coumarin can be attached as an amino acid side chain or capping the C-terminus of the peptide. When the coumarin is a side chain, it allows for C-terminal and N-terminal sequence specificities to be explored. Using this assay, we obtained Michaelis-Menten kinetic data for four proof-of-principle peptides: WEHD-AMC (KM = 15 ± 2 µM), WEHD-MCA (KM = 93 ± 19 µM), WEHDG-MCA (KM = 21 ± 6 µM) and WEHDA-MCA (KM = 151 ± 37 µM), where AMC is 7-amino-4-methylcoumarin and MCA is ß-(7-methoxy-coumarin-4-yl)-Ala. The results indicate the viability of this new assay approach in the design of effective fluorogenic substrates for inflammatory caspases.

Opioid Prescribing in the Pediatric Orthopaedic Trauma Population.

The purpose of this article is to describe opioid prescribing patterns for children with orthopaedic injuries. A retrospective chart review was conducted on pediatric orthopaedic trauma patients (n = 124) who were discharged from the hospital or emergency department or had a clinic visit during a 1-month period. Patient demographics, prescription specifics, injury details, and fracture fixation information were collected. Results show that most children received opioids after injury (82.3%). While children undergoing operative fixation typically received opioids, only 39.5% with closed reduction did. Hydrocodone- acetaminophen accounted for 93% of prescriptions, but adolescents were more likely to receive other drugs. There was a significant trend of increasing daily dosage with increased age; 36.73% of adolescents received > 50 morphine milligram equivalents per day. Children with orthopaedic injuries are typically prescribed opioids; older children more commonly receive higher dosages. Further study is needed to define prescribing trends across facility and specialty types to aid in development of standardized prescribing guidelines. (Journal of Surgical Orthopaedic Advances 27(4):269-273, 2018).

Surgical Correction of Scoliosis in Patients With Duchenne Muscular Dystrophy: 30-Year Experience.

BACKGROUND: The natural history of scoliosis in Duchenne muscular dystrophy (DMD) is progressive and debilitating if neglected. The purpose of this study was to evaluate outcomes related to spinal deformity surgery in patients with DMD over a 30-year period. METHODS: This was a single center retrospective study of all operatively treated scoliosis in DMD patients over 30 years. Minimum follow-up was 2 years. Owing to changes in instrumentation over time, patients were divided into 2 groups: Luque or pedicle screws (PS) constructs. Radiographic, perioperative variables, pulmonary function test (preoperatively and postoperatively), and complication data were evaluated. RESULTS: There were 60 subjects (Luque: 47, PS: 13). The Luque group was on average 13 years old, 53 kg, and had 7 years of follow-up. Coronal Cobb was 31±12 degrees preoperatively, 16±11 degrees at first postoperatively, and 21±15 degrees at final follow-up (P≤0.001). Pelvic obliquity was 7±6 degrees preoperatively, 5±5 degrees at first postoperatively (P=0.43), and 5±4 degrees at final follow-up (P=0.77). The majority of this group was fused to L5 (45%) or the sacrum (49%). The PS group was on average 14 years old, 65 kg, and had 4 years of follow-up. Coronal Cobb was 43±19 degrees preoperatively, 12±9 degrees at first postoperatively (P≤0.001), and 12±8 degrees at final follow-up. Pelvic obliquity was 6±5 degrees preoperatively, 3±3 degrees at first postoperatively (P=0.06), and 2±2 degrees at final follow-up (P=0.053). The majority were fused to the pelvis (92%). Both groups' pulmonary function declined with time. Both groups had high complication rates (Luque 68%; PS group 54%). The Luque group had more implant-related complications (26%); the PS group had a higher rate of early postoperative infections (23%). CONCLUSIONS: Over a 30-year period of operative treatment of scoliosis in DMD, both PS constructs and Luque instrumentation improved coronal Cobb. The PS group had improved and maintained pelvic obliquity. Both groups had high complication rates. LEVEL OF EVIDENCE: Level IV-therapeutic.

Adolescent Distal Humerus Fractures: ORIF Versus CRPP.

BACKGROUND: Although supracondylar humerus fractures are common in young children, the incidence in adolescents is much lower. As a result, there is a paucity of literature to guide treatment. The purpose of this study was to review the treatment and outcomes for a consecutive series of distal humerus fractures in adolescents and to compare outcomes between patients treated with percutaneous skeletal fixation and those treated with open reduction and fixation. METHODS: A retrospective review of patients 10 to 17 years of age who underwent surgical treatment for a distal humerus fracture from 2005 to 2014 was performed. Patients with medial epicondyle fractures and those with insufficient follow-up to document union or return of motion were excluded. Medical records were reviewed to collect demographic data as well as operative approach and method of fixation. Clinical outcomes included range of motion, time to maximum motion, and complications [nerve dysfunction, heterotopic ossification (HO), need for secondary surgery]. Radiographs were reviewed to determine time to union as well as coronal and sagittal alignment. RESULTS: One hundred eighteen adolescents with displaced distal humerus fractures were identified. Eighty-one met inclusion criteria. Forty-four of these were classified as extra-articular [Orthopaedic Trauma Association (OTA) 13-A], and 37 were intra-articular fractures (10 OTA 13-B and 27 OTA 13-C).Although not statistically significant, closed treatment with percutaneous fixation of extra-articular fractures resulted in greater flexion-extension arc of motion at final follow-up (128 vs. 119 degrees, P=0.17) and demonstrated more rapid return of motion (2.8 vs. 3.9 mo, P=0.05) when compared with open treatment despite a longer duration of immobilization and less formal physical therapy. Complications such as HO (P=0.05), nerve dysfunction (P=0.02), and secondary surgery (P=0.001) were more common in the open treatment group.Closed treatment with percutaneous fixation of intra-articular fractures was performed in younger patients of similar size (12.8 vs. 14.4 y, P<0.01; 154 vs. 142 lbs, P=0.5). There were no significant differences between groups in regard to outcomes or complications. There were trends toward increased frequency of HO, nerve dysfunction, and secondary surgery in the open treatment group.Patients with intra-articular fractures were older (14.2 vs. 11.5 y, P<0.001) and heavier (144 vs. 94 lbs, P<0.001) than patients with extra-articular fractures and were more likely to be treated open (74% vs. 11%, P<0.001). Extra-articular fractures demonstrated a greater total arc of motion (126 vs. 118 degrees, P=0.04) at final follow-up despite longer duration of immobilization (23 vs. 15 d, P=0.002), and less physical therapy (27% vs. 73%, P<0.001). Radiographic carrying angle (16.6 vs. 22.3 degrees, P=0.08) and anterior humeral line (95% vs. 81%, P=0.07) trended toward more anatomic alignment in the extra-articular group. Secondary surgery was more common after intra-articular fracture (24% vs. 7%, P=0.03). CONCLUSIONS: Closed reduction and pinning of extra-articular distal humerus fractures in adolescents resulted in predictable clinical and radiographic outcomes and allowed for earlier return of motion and fewer complications when compared with open treatment. Intra-articular distal humerus fractures occur more frequently in older adolescents and are more likely to require open reduction and internal fixation to obtain joint congruity. Patients with intra-articular injuries should be cautioned that regaining full elbow motion may be more difficult, and there is an increased risk for complications and need for additional surgery. Closed reduction and percutaneous fixation of intra-articular injuries appears to be a reasonable option in select patients. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Biomechanical Testing of Unstable Slipped Capital Femoral Epiphysis Screw Fixation: Worth the Risk of a Second Screw?

BACKGROUND: In a prior biomechanical study, 2-screw fixation of anatomically reduced slipped capital femoral epiphysis (SCFE) demonstrated marginally greater stability than single-screw fixation. However, the authors judged the benefits of a second screw to be minimal compared with the additional complication risk. A similar evaluation of fixation stability in unstable moderately displaced SCFE is performed. METHODS: SCFE model: Transverse periosteal incision and epiphyseal separation from the metaphysis by leveraging in 25-month-old porcine femurs. Four groups were evaluated: pinned (3.5 mm cortex screws; Synthes, Monument, CO) with no displacement (1 screw=group N1; 2 screws=group N2) or with moderate posterior-inferior displacement of 50% of the epiphyseal diameter (1 screw=group D1; 2 screws=group D2). Biomechanical testing: Cyclical shear forces (40 to 200 N, 1 Hz) were applied along the physeal plane. Maximum load increased by 100 N every 500 cycles until failure (epiphyseal translation greater than one third the epiphyseal diameter). Force cycles (the sum of the maximum cycle loads) and number of cycles to failure were reported. RESULTS: A sample from each D1 and D2 had fixation problems (D1, D2: n=4; N1, N2: n=5). One D1 failed through the femoral neck; all others failed through the epiphysis. The data showed nonsignificant trends of greater force cycles for nondisplaced over displaced (P=0.13) and for 2 screws over 1 (P=0.19). Number of cycles to failure showed similar trends, with no significant differences between nondisplaced and displaced (P=0.10) and screw number (P=0.13). Force cycles were significantly greater in the N2 group than in the D1 group. CONCLUSIONS: A trend toward higher force cycles to failure in nondisplaced and 2-screw groups was observed. Higher force cycles correspond to greater physeal stability and thus decreased risk for subsequent displacement. Within displacement groups, adding a second screw did not significantly increase stability. Reduction of displaced SCFE also did not significantly increase stability. Only the D1 and N2 groups were significantly different. CLINICAL RELEVANCE: Nondisplaced SCFE does not require 2 screws. In situ fixation of displaced SCFE might be optimized with 2 screws.

The deepwater oxygen deficit in stratified shallow seas is mediated by diapycnal mixing.

Seasonally stratified shelf seas are amongst the most biologically productive on the planet. A consequence is that the deeper waters can become oxygen deficient in late summer. Predictions suggest global warming will accelerate this deficiency. Here we integrate turbulence timeseries with vertical profiles of water column properties from a seasonal stratified shelf sea to estimate oxygen and biogeochemical fluxes. The profiles reveal a significant subsurface chlorophyll maximum and associated mid-water oxygen maximum. We show that the oxygen maximum supports both upward and downwards O2 fluxes. The upward flux is into the surface mixed layer, whilst the downward flux into the deep water will partially off-set the seasonal O2 deficit. The results indicate the fluxes are sensitive to both the water column structure and mixing rates implying the development of the seasonal O2 deficit is mediated by diapcynal mixing. Analysis of current shear indicate that the downward flux is supported by tidal mixing, whilst the upwards flux is dominated by wind driven near-inertial shear. Summer storminess therefore plays an important role in the development of the seasonal deep water O2 deficit.

Health Literacy Awareness Among Orthopaedic Surgery Residents: A COERG Survey.

Musculoskeletal health literacy (HL) is an emerging concept in orthopaedic patient care. Estimated rates of low musculoskeletal HL in patients surpass those of general HL. Studies in other specialties suggest that medical trainees are ill equipped to interact with low HL patients, often with detrimental patient outcomes. The purpose of this study was to (1) establish the current state of HL awareness among orthopaedic surgery trainees, (2) characterize the current state of HL training in orthopaedic surgery programs, and (3) evaluate the desire for formalized HL training among orthopaedic surgery trainees. Methods: This study was endorsed by the Collaborative Orthopaedic Education Research Group board. A 17-item questionnaire was administered anonymously to orthopaedic residents through a secure online platform in the 2020 to 2021 academic year. All participation was voluntary. Results: One hundred ninety-two residents (42%) from 19 orthopaedic programs completed the survey. Most residents felt "somewhat comfortable" with issues related to HL. Most residents reported no specific training in HL issues during residency (77.5%). Of the 43 residents (22.3%) who did receive formal training, most of these individuals felt that the training is effective (N = 42, 97.7%). Role playing/standardized patient encounters were reported as the most effective form of HL training. Residents felt it was somewhat important to receive formal HL training in residency (median = 4.0, interquartile range = 3.0-5.0), and there was a modest desire for formalized training (39%). Discussion: This study is the first to characterize orthopaedic resident perceptions of HL issues in practice and training. Residents were somewhat confident in their understanding of HL concepts, and those who received formal training felt it was effective. However, there remains a low rate of formal orthopaedic resident training in HL issues, which may be an area for improvement in orthopaedic training paradigms.

OrthoACCESS: Implementing a Sub-Internship Curriculum for MS4s Applying to Orthopaedic Surgery.

OBJECTIVE: Medical students pursuing orthopedic surgery residency build foundational knowledge during clinical rotations. Most clinical rotations, home and away, were paused during the COVID-19 pandemic. Given the lack of structured fourth-year medical student (MS4) education for basic orthopedics, educators developed the Ortho Acting-Intern Coordinated Clinical Education and Surgical Skills (OrthoACCESS) curriculum in 2019. This study demonstrates the accessibility and usability of a MS4 virtual orthopedic curriculum and examines the curriculum's role in increasing learner familiarity with basic orthopedic topics in 2020. DESIGN: OrthoACCESS faculty presented weekly lectures from July to October 2020 using Zoom Webinar. Website content included recorded webinars, external resources, and skills videos. Registrants were anonymously surveyed after each webinar characterizing the knowledge and utility of individual lectures. After the webinar series, registrants were emailed an anonymous post-curriculum survey characterizing their experience using the OrthoACCESS curriculum. RESULTS: OrthoACCESS had 1062 registrants, with 59% (624/1,062) MS4s. 4528 users accessed the OrthoACCESS website from 66 countries. The 15 lectures were viewed 3743 times, 1553 live views and 2190 asynchronous views. 444 postwebinar surveys were completed. Weekly response rates ranged from 18% to 45%. Respondents felt more knowledgeable and more able to apply their knowledge after viewing each lecture (p < 0.001), and found the webinars to be well-organized, well-paced, enthusiastically taught, and level-appropriate. 122/976 (13%) students and 45/291 (15%) faculty completed the postcurriculum survey. Faculty reported that OrthoACCESS was "quite useful" (4 [3-5]) for providing knowledge for an incoming orthopaedic intern. Faculty and students would recommend OrthoACCESS to future learners (5 [4-5]). CONCLUSIONS: OrthoACCESS delivered foundational musculoskeletal instruction during a period of increased need. In its initial iteration, this virtual curriculum demonstrated high utilization in the United States and internationally and improved participants' self-reported topical knowledge and ability to apply it clinically.

Benefits of an Orthopedic Education Research Collaborative: An Innovative Approach.

Background Graduate Medical Education (GME) research in orthopedic surgery is an important but underrepresented subject in the medical literature. It was unknown if orthopedic residency leaders were interested in a surgical education research collaborative (orthopedic collaborative). The objectives of this study were to assess the potential benefit of an orthopedic collaborative from orthopedic residency leaders and investigate the factors associated with the support of a research collaborative within a surgical subspecialty. Methodology An anonymous 19-question survey-based study was distributed through REDCap (Nashville, TN, USA) to orthopedic residency leaders in the United States, from July to October 2020. The main outcome was perceived benefit. Additional aspects included program characteristics, challenges in performing resident education research, and organizational issues such as authorship, frequency of study requests, and governance. Results Almost all orthopedic faculty leadership (99%, 73/74) stated that resident education and faculty development research projects would benefit from an orthopedic education research collaborative. In comparison to unsupportive respondents, younger age (P = 0.006), 15 or fewer years in practice (P = 0.04), and having 0 to 100 peer-reviewed publications (P = 0.047) were associated with support for an orthopedic collaborative. Conclusions Challenges related to survey-based study quality and generalizability at single institutions can benefit from multi-institutional collaboration to develop high-quality studies that capture a representative sample to support orthopedic surgery program development.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center.

OBJECTIVES: Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic. DESIGN: Retrospective chart review. SETTING: Outpatient visits (in-person, telephone, virtual-Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic. INTERVENTION: Virtual visits utilizing the Doxy.me platform. MAIN OUTCOME MEASURES: Accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). METHODS: All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit ("Virtual") or having telephone or in-person visits only ("No virtual"). RESULTS: Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028). CONCLUSION: A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

Skeletal traction versus external fixation in the initial temporization of femoral shaft fractures in severely injured patients.

BACKGROUND: : Damage control with external fixation (DC-EF) of femoral shaft fractures in polytrauma patients is becoming standard treatment in many trauma centers. However, skeletal traction (ST) has long been used in the temporization of fractures. The purpose of this study was to compare the major physiologic clinical outcomes of provisional ST with DC-EF of femoral shaft fractures in severely injured patients. METHODS: : We retrospectively reviewed 205 patients sustaining blunt trauma, a femoral shaft fracture, and an Injury Severity Score > or =17 from 2001 to 2007 at a level I trauma center. Patients underwent definitive fixation in the first 24 hours with intramedullary nailing (IMN) (N = 126), initial DC-EF with delayed definitive treatment (N = 19), or initial ST with delayed definitive treatment (N = 60). Incidences of adult respiratory distress syndrome, multiple organ failure, sepsis, pneumonia, pulmonary embolism, and deep vein thrombosis were evaluated. Length of stay (LOS), intensive care unit LOS, days of mechanical ventilation, and mortality were also compared. RESULTS: : There were no significant differences between ST and DC-EF groups in age, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score on arrival, mean time to definitive fixation (4.1 days versus 5.0 days, respectively), or Abbreviated Injury Scale for chest. However, the ST group had a higher Abbreviated Injury Scale-head (2.5 versus 1.0, p = 0.0026). There were no significant differences in subsequent rates of adult respiratory distress syndrome, multiple organ failure, pulmonary embolism, deep vein thrombosis, pneumonia, mechanical ventilation days, intensive care unit LOS, and death. However, the ST group had a lower rate of sepsis (8.3% versus 31.6%, p = 0.0194) and a shorter LOS (26.5 days versus 36.2 days, p = 0.0237) than the EF group. CONCLUSION: : DC-EF of femur fractures in severely injured patients offers no significant advantage in clinical outcomes compared with ST. Unless initially subjected to general anesthesia for life saving procedures, the use of ST as a temporization method remains a practical option.

Pediatric Open Both-Bone Forearm Fracture Stabilized with Titanium and Stainless Steel Stacked Extension Internal Plating: A Case Report.

CASE: A 12-year-old male patient sustained a multisegmental both-bone forearm fracture. Definitive stabilization was ulna intramedullary pinning, with stainless steel plating of the radius followed by a titanium plate stacked atop and extending internal fixation. Currently, 36 months after surgery, he experiences no limitations or complications. All hardware remains in situ. CONCLUSION: We believe this is the first description of different material plates in direct contact, of stacked plates, and of 1 plate extending another's fixation. No adverse effects developed.

Matching in Orthopaedic Surgery.

In 2016, 1,137 fourth year medical students submitted applications for orthopedic surgery residency positions. Students applied to an average of 79 programs, resulting in in a total of 89,846 applications being submitted for 727 first year residency positions. This ratio of 124 applications per position is two SDs above the mean relative to other medical specialties. The average applicant for orthopaedic surgery residency attends 2.4 away rotations, as attending 2 away rotations increases an applicant's odds of matching, and submits 83 applications. This excessive number of applications overburdens programs, subjects applicants to considerable costs, and diminishes the quality of fit between interviewees and programs. Eighty-three percent of program directors use step 1 United States Medical Licensing Examination scores as a screening tool to decrease the number of applications necessary for review. The average matched applicant attended 11.5 interviews, and Step 1 scores, research productivity, and Alpha Omega Alpha (AOA) status can be used to predict the number of applications necessary to obtain 12 interviews. AOA membership has the strongest influence on interview yield. Applicants report spending an average of approximately $7,000 on the interview process, and 72% borrow money to cover these costs. Post-interview contact, although forbidden by the National Resident Matching Program , has been reported by 60% to 64% of applicants.

Characteristics of Pyogenic Musculoskeletal Infections in Older Children and Adolescents.

The characteristics and clinical consequences of pyogenic bone and joint infections in older children and adolescents have received little attention. This study evaluated the presentation and complications of musculoskeletal infections involving the pelvis and extremities in children older than 10 years. Thirty patients 10 to 17 years old (mean, 12.7 years old) were treated for musculoskeletal infections. Mean time to diagnosis was 9.2 days. Prior to correct diagnosis, 83% were assessed by at least 1 outpatient provider. At the time of admission, 55% were weight bearing and 93% were afebrile. Twenty-eight percent had a multifocal infection. More than one-third had serious medical complications or orthopedic sequelae; compared with patients without complications, this group had a significantly higher admission C-reactive protein and longer hospital stay. Symptoms of musculoskeletal infection common among young children may be absent in adolescents. Axial imaging is recommended to identify adjacent or multifocal disease. The Kocher criteria are less sensitive for septic hip arthritis in the adolescent population. Prompt recognition and treatment are critical to avoid medical and musculoskeletal complications. [Orthopedics. 2020;43(4):e291-e298.].

Obstacles Affecting the Implementation of the O-SCORE for Assessment of Orthopedic Surgical Skills Competency.

OBJECTIVES: There is a need for meaningful and reliable measures of surgical competency in residency education. The goal of the current study is to incorporate the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) into the process of resident evaluation at our institution and to assess the feasibility and effectiveness of its use through a web-based platform. DESIGN: This is a feasibility study that prospectively assesses the implementation of a web-based O-SCORE at our institution. Over a 16-week period, 19 orthopedic surgery residents (PGY2-PGY5) participated in a quality improvement study, which involved collecting 2 feedback forms per week. Each form consisted of a resident form and a linked attending form. At the conclusion of the 16-week trial period, residents and faculty members were asked to complete a survey about their perceptions of the O-SCORE program. SETTING: An academic medical center. PARTICIPANTS: The study included only residents in postgraduate training years (PGY) 2 through 5 (n = 20) and attendings (n = 37). RESULTS: During the 16-week study period, 608 resident surveys were requested for the 19 participating residents, of which 404 surveys (66.5%) were completed. Faculty completed 207 of 326 surveys for an overall compliance rate of 63.5%. The O-SCORE was able to significantly differentiate between all training years (p < 0.0001) with the exception of PGY3 residents when compared to PGY4 residents. Overall, residents and faculty found the program valuable and feasible. Resident and faculty perception of the value of the O-SCORE correlated with compliance rate of the O-SCORE surveys. CONCLUSIONS: This study demonstrates that implementation of an immediate feedback program utilizing an electronic platform is achievable and offers reproducible construct validity. However, issues affecting compliance among both residents and faculty physicians must temper optimism for the program and should be systematically addressed to allow for successful implementation.

Teaching Cortical-Screw Tightening: A Simple, Affordable, Torque-Directed Training Protocol Improves Resident Performance.

BACKGROUND: Cortical-screw insertion is a fundamental skill in orthopaedic surgery, yet, to our knowledge, no standardized method of teaching this skill exists. The purpose of this study was to evaluate a training protocol that was designed to teach residents how to tighten a cortical screw without causing any stripping. METHODS: Twenty-five residents and 8 attending surgeons from an orthopaedic residency program tightened cortical screws in a synthetic bone model with a digital torque screwdriver using 3 different techniques: percutaneous; open, dominant hand; and open, nondominant hand. The residents then participated in a training protocol during which each tightened additional screws while receiving real-time torque feedback. During training, the residents targeted 50% to 70% of the stripping torque for each screw. They were assessed at baseline, immediately after training, and at 12 to 15 weeks after training. During each assessment, the percentage of screws that were tightened in the target range and the percentage of stripped screws were recorded. The costs of the training protocol were assessed. RESULTS: After training, all of the residents tightened screws with lower insertional torque compared with their baseline, but only the senior residents tightened more screws in the target range and stripped fewer screws. The attending surgeons, when compared with the residents at baseline, tightened more screws in the target range and tended to strip fewer screws, but these differences were absent at final testing. Costs included $1,927 for durable equipment and an estimated $74 per resident per training session for consumable goods. CONCLUSIONS: The senior residents inserted more screws in the target range and stripped fewer screws after participating in this training protocol, but the junior residents did not show significant improvement. Implementation of this training protocol for all residents may improve clinical performance but, because our sample size was limited, additional study is required to assess skill transfer to clinical practice. CLINICAL RELEVANCE: Cortical-screw tightening is a fundamental skill in orthopaedics, and completion of this torque-directed training protocol may accelerate residents' skill acquisition.