Atypical femur fractures: a survey of current practices in orthopedic surgery

The results of a self-administered online survey demonstrate that orthopedic surgeons' management practices for AFF are variable. These data will inform the development of clinical practice guidelines.

INTRODUCTION

We aimed to determine current AFF treatment practices of orthopedic surgeons to inform clinical practice guideline development.

METHODS

A self-administered online survey was developed and sequentially posted on the Orthopaedic Trauma Association (OTA) website from July to August 2015 and the Canadian Orthopaedic Association (COA) website from December 2015 to January 2016. Level of confidence in diagnosis and treatment as well as treatment preferences between respondents who self-identified as trauma surgeons vs. non-trauma surgeons were compared.

RESULTS

A total of 172 completed surveys were obtained (OTA, N = 100, 58%; COA, N = 72, 8%). Seventy-eight percent of respondents had treated ≥1 AFF in the previous 6 months. Seventy-six percent reported feeling extremely or very confident in diagnosing AFF (trauma 84% vs. non-trauma surgeons 70%, p = 0.04), and 63% reported feeling extremely or very confident in treating AFF (trauma 82%, non-trauma surgeons 50%, p < 0.01). Preferred management for complete and symptomatic incomplete AFFs was surgical fixation with a cephalomedullary nail (CMN) by 88 and 79%, respectively, while close follow-up was preferred for asymptomatic incomplete AFFs in 72% of respondents. Trauma surgeons used the CMN more frequently than non-trauma surgeons (90 vs. 76% p = 0.03). In patients with bilateral AFFs, with one side surgically treated, 56% were extremely likely to surgically treat the contralateral side, if symptomatic. Most felt guidelines (81%) and educational resources (73%) would be valuable.

CONCLUSIONS

Current orthopedic treatment practices for AFFs are variable. The results of this survey will inform the development of practice guidelines and educational resources.

The association between the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and real-world clinical outcomes in lumbar spine surgery

BACKGROUND CONTEXT

The patient experience of care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to determine hospital reimbursement. The current literature inconsistently demonstrates an association between patient satisfaction and surgical outcomes.

PURPOSE

To determine whether patient satisfaction with hospital experience is associated with better clinical outcomes in lumbar spine surgery.

STUDY DESIGN

A retrospective cohort study conducted at a single institution.

PATIENT SAMPLE

A total of 249 patients who underwent lumbar spine surgery between 2013 and 2015 and completed the HCAHPS survey.

OUTCOME MEASURES

Self-reported health status measures, including the EuroQol 5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and visual analog score for back pain (VAS-BP).

METHODS

All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy, scoliosis, or had less than 1 year of follow-up. Patients who selected a 9 or 10 overall hospital rating (OHR) on HCAHPS were placed in the satisfied group, and the remaining patients comprised the unsatisfied group. The primary outcomes of this study include patient-reported health status measures such as EQ-5D, PDQ, and VAS-BP. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.

RESULTS

Our study population consisted of 249 patients undergoing lumbar spine surgery. Of these, 197 (79%) patients selected an OHR of 9 or 10 on the HCAHPS survey and were included in the satisfied group. The only preoperative characteristics that differed significantly between the twogroups were gender, a diagnosis of degenerative disc disease (DDD), heavy preoperative narcotic use, and a diagnosis of chronic renal failure. At 1 year follow-up, no statistically significant differences in EQ-5D, PDQ, or VAS-BP were observed. After using multivariable linear regression models to assess the association between patient satisfaction and pre- to 1-year postoperative changes in health status measures, selecting a top-box OHR was not found to be significantly associated with change in either EQ-5D (beta=0.055 [95% confidence interval {CI}: -0.035 to 0.145]), PDQ (beta=-9.013 [95% CI: -23.782 to 5.755]), or VAS-BP (beta=-0.849 [95% CI: -2.125 to 0.426]). These results suggest high satisfaction with the hospital experience may not necessarily correlate with favorable clinical outcomes.

CONCLUSIONS

Top-box OHR was not associated with pre- to 1-year postoperative improvement in EQ-5D, PDQ, and VAS-BP. Although the associations between high satisfaction and improvement in health status did not reach statistical significance, the best estimates from our multivariable models reflect greater clinical improvement with top-box satisfaction. Future studies should seek to investigate whether HCAHPS are a reliable indicator of quality care in lumbar spine surgery.

Does a dedicated orthopaedic day surgery list improve delivery of trauma services?

Our aim was to implement a 23-hour pathway for uncomplicated trauma to overcome delays and improve efficiency. A retrospective review of a single surgeon series of 105 consecutive patients operated on between July 2010 and July 2011 was performed. With recently revised trauma tariffs, we believe an efficient day surgery trauma list improves theatre utilisation, reduces inpatient bed demands, prioritises major and sub-specialist trauma and delivers patient satisfaction.

A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature

BACKGROUND

Platelet-rich plasma (PRP) is a blood-derived preparation whose use has grown exponentially in orthopaedic practice. However, there remains an unclear understanding of the biological properties and effects of PRP on musculoskeletal healing. Heterogeneous processing methods, unstandardized nomenclature, and ambiguous classifications make comparison among studies challenging. A comprehensive assessment of orthopaedic clinical PRP trials is key to unraveling the biological complexity of PRP, while improving standardized communication. Toward this goal, we performed a systematic review of the PRP preparation protocols and PRP composition utilized in clinical trials for the treatment of musculoskeletal diseases.

METHODS

A systematic review of the literature was performed from 2006 to 2016. Inclusion criteria were human clinical trials, English-language literature, and manuscripts that reported on the use of PRP in musculoskeletal/orthopaedic conditions. Basic-science articles, editorials, surveys, special topics, letters to the editor, personal correspondence, and nonorthopaedic applications (including cosmetic use or dental application studies) were excluded.

RESULTS

A total of 105 studies (in 104 articles) met the inclusion criteria for analysis. Of these studies, only 11 (10%) provided comprehensive reporting that included a clear description of the preparation protocol that could be used by subsequent investigators to repeat the method. Only 17 studies (16%) provided quantitative metrics on the composition of the final PRP product.

CONCLUSIONS

Reporting of PRP preparation protocols in clinical studies is highly inconsistent, and the majority of studies did not provide sufficient information to allow the protocol to be reproduced. Furthermore, the current reporting of PRP preparation and composition does not enable comparison of the PRP products being delivered to patients. A detailed, precise, and stepwise description of the PRP preparation protocol is required to allow comparison among studies and provide reproducibility.

An Assessment of the Safety of an Orthopedic Specialty Hospital: A 5-Year Experience

One of the goals of orthopedic specialty hospitals is to provide safe and efficient care to medically optimized patients. The authors' orthopedic specialty hospital is a physician-owned, 24-bed facility that accommodates a multispecialty orthopedic practice in the areas of spine, hip and knee arthroplasty, shoulder and elbow, sports, foot and ankle, and hand surgery. The purpose of this study was to examine the first 5 years of an institutional experience with an orthopedic specialty hospital and to determine if any procedures were at increased risk of postoperative transfer. When higher-level emergency treatment was required, patients were appropriately and expeditiously transferred and treated at an acute care facility. Length of stay compared favorably with that in traditional acute care hospitals. The specialty hospital may be an appropriate model for delivery of care to medically screened patients in the United States. [Orthopedics. 2017; 40(4):223-229.].

Continuing Anti-thrombotic Medication During Low-to-Intermediate Risk Spinal Procedures: A Retrospective Evaluation

BACKGROUND

The current American Society of Regional Anesthesia (ASRA) guidelines recommend discontinuing anti-thrombotic therapy prior to any interventional spine procedures to decrease the incidence of bleeding complications. However, discontinuing anti-thrombotics may pose considerable danger in terms of cerebrovascular and cardiovascular events. Recent evidence suggests that some spinal interventions may still be performed safely with anti-thrombotics on board and some practitioners thus elect to continue certain anti-thrombotics for these procedures.

OBJECTIVE

To assess the rate of adverse events in patients undergoing spine procedures that are currently classified by the ASRA guidelines as "low-to-intermediate bleeding risk," while being on continued anti-thrombotic therapy.

STUDY DESIGN

Retrospective cohort study.

SETTING

Interventional pain management practice.

METHODS

A retrospective chart review was performed on patients who underwent low-to-intermediate risk spine procedures with variable anti-thrombotic medications continued throughout the course of treatment.

RESULTS

Between October 2015 and May 2016, out of 2,204 patients who underwent low-to-intermediate risk spine procedures, we identified 490 patients on anti-thrombotic medications. These included aspirin (N = 275), P2Y12 inhibitors (N = 129), warfarin (N = 62), heparin (N = 10), factor Xa inhibitors (N = 55), and dipyridamole (N = 1). Forty-two patients were on multiple anti-thrombotics. Anti-thrombotics were continued throughout the procedure for 467 of 490 patients (88%). One bleeding complication (injection site bleeding) occurred in a patient that continued clopidogrel and aspirin during a lumbar radiofrequency ablation. We encountered no bleeding complications attributable to anti-thrombotics in the other 466 procedures in which anti-thrombotics were continued during lumbar (N = 260), thoracic (N = 18), and cervical (N = 40) medial branch injections, sacroiliac injections (N = 47), and during lumbar (N = 87) thoracic (N = 2), and cervical (N = 12) medial branch radiofrequency ablations.

LIMITATIONS

The retrospective nature of the study and its reliance on electronic medical records are potential limitations.

CONCLUSIONS

Continuing anti-thrombotic medication during medial branch and sacroiliac injections may be possible.

KEY WORDS

Interventional pain management, thrombotic complications, hemostasis, anti-coagulation, bleeding complications.

Concordance of Patient and Physician Perceptions of Care in an Orthopedic Clinic

It is essential to study whether physicians' perceptions align with their patients' views, as understanding patient perception leads to superior satisfaction and health outcomes. Previous studies have established differences in physician-patient perceptions, but no studies have been conducted in orthopedic clinics. The authors' primary goal was to evaluate differences in physician and patient perceptions of an orthopedic clinic visit. Their secondary objective was to determine the influence of visit length, demographics, and depression risk-level on patient satisfaction. The authors surveyed 143 new patients being seen by orthopedic surgeons at a level I trauma center. After their appointment, these patients completed surveys on satisfaction and likelihood of depression. The authors recorded wait times and visit lengths. Simultaneously, the physicians completed a self-evaluative satisfaction survey. Patients' and physicians' answers were compared using a Wilcoxon signed-rank test. Mann-Whitney and Spearman correlation analyses were used to assess factors that impact satisfaction. Physicians and patients showed no significant differences on most questions of the satisfaction survey, except that physicians reported feeling less satisfied with their own explanations (P<.001). Length of visit was positively correlated with patient satisfaction (R=0.276, P=.001), while waiting times had no effect. Patients at risk for depression were less satisfied with physicians' effort to include them in decision-making (P=.044). Age was a predictor of greater satisfaction with explanations (P=.032) and instructions (P=.009) from the physician. Thus, orthopedic clinics may not exhibit the same physician-patient perception patterns as primary care clinics, potentially because of differences in patient populations, conditions, or expectations. [Orthopedics. 2017; 40(4):242-246.].

The Scholarly Influence of Orthopaedic Research According to Conventional and Alternative Metrics: A Systematic Review

BACKGROUND

Researchers are experiencing an innovative shift toward online distribution of their work, and metrics related to online scholarly influence are gaining importance. Our objectives were to determine which types of online activity are most prevalent in orthopaedics, to identify associated factors, and to explore a complementary approach to measuring overall scholarly influence using online activity and conventional citations.

METHODS

We performed a systematic review of randomized controlled trials of surgical or nonsurgical interventions in participants with, or at specific risk for, injuries and diseases of the musculoskeletal system. We collected data on online activity in social media, mainstream media, blogs, forums, and other sources from a commercial provider of alternative metric data for medical journals. We tested associations with use of negative binomial regression.

RESULTS

We identified 1,697 trials, published between 2011 and 2014, that had a total of 12,995 conventional citations and 15,068 online mentions. The median number of online mentions of each trial was 2 (interquartile range, 0 to 5). Twitter (82%) and Facebook (13%) mentions were the most prevalent types of online activity. Counts of online mentions correlated with conventional citations (r = 0.11, p < 0.01) but accumulated more rapidly. Higher total counts of online mentions were consistently associated with longer time since publication, higher journal impact factor, higher author h-index values, and less risk of bias (p < 0.01 for each). We found the best model fit for a complementary approach by weighting citations and online mentions equally.

CONCLUSIONS

Online activity in orthopaedics is dominated by activity on Twitter and Facebook and is associated with increasing time since publication, journal impact factor, and author h-index values, and less risk of bias. Institutions, publishers, funding agencies, and clinicians may consider a complementary approach to measuring scholarly influence that weights online mentions and conventional citations equally.

The Correlation Between a Numerical Rating Scale of Patient Satisfaction With Current Management of an Upper Extremity Disorder and a General Measure of Satisfaction With the Medical Visit

Background: Patient satisfaction is used as an indicator of quality of care, but the measures currently available are lengthy and cumbersome and may not be feasible in orthopedic surgical practices. We set out to assess the relationship between the Medical Interview Satisfaction Scale (MISS-21) and a numerical rating scale (NRS) of patient satisfaction with current management of an orthopedic upper extremity condition. Methods: In this cross-sectional study, 86 patients from the practices of 2 hand surgeons were included during an initial or follow-up visit. Questionnaires assessing demographics, upper extremity specific disability, pain during rest and activity, satisfaction with the medical visits (MISS-21), and satisfaction with current management of an orthopedic upper extremity condition (NRS satisfaction) were completed. Results: Eighty-six patients completed all questionnaires. A small correlation of .21 (P = .050) was found between the MISS-21 and the NRS satisfaction. In bivariate analysis, NRS pain at rest and during activity had small correlations with the MISS-21 (-.29, P = .05 and -.23, P = .034) and with NRS satisfaction (-.27, P = .011 and -0.27, P = 0.012). Quick Disability of Arm, Shoulder and Hand (QuickDASH) had a small correlation with NRS satisfaction (-0.023, P ≤ 0.001), but did not correlate with MISS-21. Conclusions: Although there is small overlap about the 2 satisfaction measures, a complex patient satisfaction questionnaire consisting of multiple facets of patient satisfaction like MISS-21 is not replaceable by 1 simple NRS patient satisfaction question.

Evaluation and Referral for Developmental Dysplasia of the Hip in Infants

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force "inconclusive" determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

Design of an orthopaedic-specific discharge summary

BACKGROUND

Patients undergoing orthopaedic procedures experience major changes in function and daily routines upon their return home. Discharge summaries are an important communication tool that may play a role in optimizing a safe transition from hospital. Current care gaps and key elements of an ideal discharge summary specific for orthopaedic population are unknown. We sought to identify the challenges of current orthopaedic discharge summaries and to determine key elements of an ideal document.

METHODS

Qualitative study survey using semi-structured interviews with a sample of 17 patients and clinicians representing diverse professions, backgrounds, and practice settings. We used the constant comparative method of qualitative analysis to define the experiences and perceptions of quality gaps and strategies to improve orthopaedic-specific discharge summaries.

RESULTS

We identified 3 major themes describing factors perceived to be limiting the quality of current discharge summaries: 1) physician-centric documentation and the absence of a comprehensive, inter-professional perspective; 2) access to resources and health informatics; and 3) process variations in document creation and dissemination.

CONCLUSIONS

Clinicians and patients identified several factors limiting the quality of discharge summaries among orthopaedic inpatients. Incorporating these elements could improve hospital transitions.

Perioperative coagulation assessment of patients undergoing major elective orthopedic surgery

Traditional coagulative parameters are of limited use in identifying perioperative coagulopathy occurring in patients undergoing major elective orthopedic surgery (MEOS). The aim of our study was to evaluate the coagulation changes in patients undergoing MEOS and to facilitate an early detection of perioperative coagulopathy in patients experiencing major intraoperative bleeding. We enrolled 40 consecutive patients (M/F 10/30, age range 34-90 years) who underwent MEOS at the Orthopedic Unit of the Padua University Hospital, Italy, between January 2014 and January 2015. Blood samples were obtained at the following time points: T0-pre: 30 min before surgery; T0-post: 30 min after the end of the procedure; T1: morning of the first postoperative day; T2: 7 ± 2 days after surgery. Patients who experienced an intraoperative blood loss ≥250 mL/h were considered as cases. Routine coagulative parameters, thromboelastometry and thrombin generation (TG) profiles were evaluated. At baseline, a significantly lower platelet count and FIBTEM MCF/AUC were observed in patents with excessive bleeding (p < 0.05 and 0.02/0.01, respectively). At T0-post and T1 intervals, cases showed hypocoagulation characterized by a significantly low platelet count (p = 0.001), prolonged CFT INTEM/EXTEM, reduction of alpha-angle and MaxV INTEM/EXTEM, MCF and AUC INTEM/EXTEM/FIBTEM (p < 0.05 in all comparisons). The only TG parameter standing out between study groups was time to peak at T0-pre. A low platelet count and fibrinogen activity were associated with significant intraoperative bleeding in patients undergoing MEOS. Thromboelastometry performed by ROTEM(®) identifies patients with coagulopathy.

Negative Pressure Wound Therapy With Instillation and Dwell Time Used to Treat Infected Orthopedic Implants: A 4-patient Case Series

Infection following orthopedic implants for bone fixation or joint replacement is always serious and may require removal of the osteosynthetic material. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) is an emerging therapy for the treatment of complex wounds, including infected wounds with osteosynthetic material. The purpose of this case study was to evaluate the outcomes of 4 patients (1 man, 3 women; age range 49 to 71 years) with a postoperative wound infection (POWI) following fracture repair and internal fixation. All patients were at high risk for surgical complications, including infections. Standard infection treatments (antibiotics) had been unsuccessful. Based on the available literature, a NPWTi-d protocol was developed. Following surgical debridement, wounds were instilled with polyhexanide biguanide with a set dwell time of 15 minutes, followed by continuous NPWTi-d of -125 mm Hg for 4 hours. The system was changed every 3 to 4 days until sufficient granulation tissue was evident and negative pressure without instillation could be used. Systemic antibiotics were continued in all patients. Granulation tissue was found to be sufficient in 12 to 35 days in the 4 cases, no recurrence of infection was noted, and the osteosynthesis material remained in place. No adverse events were observed. Research is needed to compare the safety and effectiveness of this adjunct treatment in the management of challenging wounds to other patient and wound management approaches.

The use of damage control orthopaedics to minimize negative sequelae of surgery delay in elderly comorbid patients with hip fracture

Hip surgeries count to the most frequent orthopaedic operations in older patients. Nonelective surgeries for hip fractures cause substantial economic burden because of high costs of medical treatment and high associated mortality. Surgery for hip fracture in the elderly comorbid patient still presents a challenge to orthopaedic surgeons. It is recommended that this surgery is performed within 48 hours after sustaining the hip fracture to decrease mortality. Yet the recommended early surgery (i.e. 48 hours after the incident) is not always feasible due to the frequent overall frailty of the patients or conditions of concomitant disease. The care of patients unfit for early surgery has been not adequately addressed in the literature. We have previously introduced an algorithm based on ASA-PS and P-POSSUM scores to stratify elderly comorbid patients for early vs delayed hip surgery, and used principles of Damage Control Orthopaedics to minimized negative sequelae of surgery delay (Dong C et al., PLoS One 2016). In this paper, we elaborate on Damage Control Orthopaedics and the proposed approach in the context of frequent comorbidities in the elderly orthopaedic patients. Further studies on this subject are urgently needed to establish international consensus on hip fracture surgery delayed due to overall patient frailty or extensive comorbidities.

Skill Acquisition and Retention Following Simulation-Based Training in Pavlik Harness Application

BACKGROUND

Simulation-based learning is increasingly prevalent in many surgical training programs, as medical education moves toward competency-based curricula. In orthopaedic surgery, developmental dysplasia of the hip is a commonly treated condition, where the standard of care for patients less than six months of age is an orthotic device such as the Pavlik harness. However, despite widespread use of the Pavlik harness and the potential complications that may arise from inappropriate application, we know of no previously described formal training curriculum for Pavlik harness application.

METHODS

We developed a video and model-based simulation learning module for Pavlik harness application. Two novice groups (residents and allied health professionals) were exposed to the module and, at pre-intervention, post-intervention, and retention testing, were evaluated on their ability to apply a Pavlik harness to the model. Evaluations were completed using a previously validated Objective Structured Assessment of Technical Skills (OSATS) and a global rating scale (GRS) specific to Pavlik harness application. A control group that did not undergo the module was also evaluated at two time points to determine if exposure to the Pavlik harness alone would affect skill acquisition. All groups were compared with a group of clinical experts, whose scores were used as a competency benchmark. Statistical analysis of skill acquisition and retention was conducted using t tests and analysis of variance (ANOVA).

RESULTS

Exposure to the learning module improved resident and allied health professionals' competency in applying a Pavlik harness (p < 0.05) to the level of the expert clinicians, and this level of competency was retained one month after exposure to the module. Control subjects who were not exposed to the module did not improve, nor did they achieve competency.

CONCLUSIONS

The simulation-based learning module was shown to be an effective tool for teaching the application of a Pavlik harness, and learners demonstrated retainable skills post-intervention. This learning module can form the cornerstone of formal teaching of Pavlik harness application for developmental dysplasia of the hip.

Reflections in a time of transition: orthopaedic faculty and resident understanding of accreditation schemes and opinions on surgical skills feedback

INTRODUCTION

Orthopaedic surgery is one of the first seven specialties that began collecting Milestone data as part of the Accreditation Council for Graduate Medical Education's Next Accreditation System (NAS) rollout. This transition from process-based advancement to outcome-based education is an opportunity to assess resident and faculty understanding of changing paradigms, and opinions about technical skill evaluation.

METHODS

In a large academic orthopaedic surgery residency program, residents and faculty were anonymously surveyed. A total of 31/32 (97%) residents and 29/53 (55%) faculty responded to Likert scale assessments and provided open-ended responses. An internal end-of-rotation audit was conducted to assess timeliness of evaluations. A mixed-method analysis was utilized, with nonparametric statistical testing and a constant-comparative qualitative method.

RESULTS

There was greater familiarity with the six core competencies than with Milestones or the NAS (p<0.05). A majority of faculty and residents felt that end-of-rotation evaluations were not adequate for surgical skills feedback. Fifty-eight per cent of residents reported that end-of-rotation evaluations were rarely or never filled out in a timely fashion. An internal audit demonstrated that more than 30% of evaluations were completed over a month after rotation end. Qualitative analysis included themes of resident desire for more face-to-face feedback on technical skills after operative cases, and several barriers to more frequent feedback.

DISCUSSION

The NAS and outcome-based education have arrived. Residents and faculty need to be educated on this changing paradigm. This transition period is also a window of opportunity to address methods of evaluation and feedback. In our orthopaedic residency, trainees were significantly less satisfied than faculty with the amount of technical and surgical skills feedback being provided to trainees. The quantitative and qualitative analyses converge on one theme: a desire for frequent, explicit, timely feedback after operative cases. To overcome the time-limited clinical environment, feedback tools need to be easily integrated and efficient. Creative solutions may be needed to truly achieve outcome-based graduate medical education.

Treatment of degenerative cervical spondylosis with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery

INTRODUCTION

Degenerative cervical spondylosis (DCS) with radiculopathy is the most common indication for cervical spine surgery despite favorable natural history. Advances in spinal surgery in conjunction with difficulties in measuring the outcomes caused the paucity of uniform guidelines for the surgical management of DCS.

AIMS

The aim of this paper is to develop guidelines for surgical treatment of DCS. For this purpose the available up-to-date literature relevant on the topic was critically reviewed.

METHODS AND RESULTS

Six questions regarding most important clinical questions encountered in the daily practice were formulated. They were answered based upon the systematic literature review, thus creating a set of guidelines. The guidelines were categorized into four tiers based on the level of evidence (I-III and X). They were designed to assist in the selection of optimal and effective treatment leading to the most successful outcome.

CONCLUSIONS

The evidence based medicine (EBM) is increasingly popular among spinal surgeons. It allows making unbiased, optimal clinical decisions, eliminating the detrimental effect of numerous conflicts of interest. The key role of opinion leaders as well as professional societies is to provide guidelines for practice based on available clinical evidence. The present work contains a set of guidelines for surgical treatment of DCS officially endorsed by the Polish Spine Surgery Society.

Unfolding the Remarkable Orthopedic Surgeon. How to unleash the quest for excellence and the sense of caring

Orthopedic surgery is a challenging profession, both at the diagnostic and therapeutic level. Successful treatment of patients requires teamwork with different stakeholders, with various personalities and motives. Coping with the stress of the quest for the ultimate surgical result might not be easy for everyone. While some surgeons see their activities as a job or at best as a career, others who face similar difficulties seem to respond to a higher calling. They are the ones striving for continuous improvement and excellence, and are committed to serving their patients with a deep sense of caring. In this article, we introduce a surgeon typology based on these two variables. We also introduce global coaching as a novel approach to help surgeons on this potentially transformational journey. We focus on the qualities that global coaching can help to develop as well as briefly mention some of the models and tools that can be called upon. Evidence from the Harvard Grant longitudinal study confirms that humans continue to develop during their adulthood and suggests that the following hypothesis is likely to be accurate: remarkable surgeons committed to technical excellence and caring deeply for their patients are likely to be most successful both in their careers and in their lives. If necessary, surgeons have a chance, a choice and a responsibility to change course, to reconnect with their profession and to establish more intimate relationships with their patients, colleagues as well as in their personal lives. By growing into becoming remarkable surgeons, they will serve others as well as themselves.