Learning Curve for Surgical Treatment of Acetabular Fractures: A Retrospective Clinical Study of a Practical and Theoretical Training Course

Physician Workforce in Kansas: Where are the Orthopedic Surgeons?

Introduction

Rural patients have greater need but less access to orthopedic surgical care than their urban counterparts. Previous studies have investigated rural surgical care, but this is the first to assess the Kansas orthopedic surgery workforce to identify changes over time and rurality and inform thinking about future workforce composition.

Methods

The authors analyzed 2009 and 2019 AMA MasterFile and Area Health Resource File (AHRF) data. Using frequencies, percentages, and calculations of orthopedic surgeons per capita, we assessed workforce changes by rurality (Rural Urban Continuum Codes).

Results

The dataset included 307 orthopedic surgeons; 197 were in both 2009 and 2019. Of these, 165 were in active practice in 2009 and 244 in 2019, an increase of 79 (47.9%). Kansas had smaller proportions of surgeons in rural (non-metro) versus urban (metro) counties in both years. Orthopedic surgeons per capita grew throughout the state, but the increase was smaller in rural counties. There were 11 women orthopedic surgeons in both years, 3.6% of the total 307. Among the 197 surgeons in both years, four (2.0%) were women. No women orthopedic surgeons were in non-metro counties either year.

Conclusions

Although the Kansas orthopedic surgery workforce grew from 2009 to 2019, rural Kansas remains a surgery desert based on orthopedic surgeons per capita. Further studies could determine whether this trend is similar to that in other rural states and how to attract orthopedic surgeons to rural practice.

Anterior approaches in acetabular fractures: a true learning curve analysis

Today, acetabular surgeons in training have to learn ilioinguinal and anterior intrapelvic approaches (AIP). The aim of this study was to describe the 5-years learning curve of a surgeon. Objective was to assess clinical and radiological results; and to assess factors which could influence this learning curve. Between November 2015 and May 2020, patients with an acetabular fracture operated by the surgeon during the 5-years learning curve with an anterior approach were included in this single-center retrospective study based on a prospective database. Epidemiological, operative, clinical, radiological and complications data's were collected. To assess learning-curve effect the series was divided into two groups: first 2.5-years and last 2-years. Subgroup analysis were performed according to the surgical approach, to the reduction quality and the prognostic factors. In total, 46 patients were included, 23 in period 1 and 23 in period 2. 16 patients (35%) had ilioinguinal approach and 30 patients (65%) had modified Stoppa-Cole approach. At mean follow-up of 24 months, 38 patients (83%) were reviewed. Anatomical reduction (< 1 mm) was achieved in 28 patients (60.9%) with a 9% rate of perioperative complications and 37% rate of post-operative complications. In conclusion, this study gives a realistic overview of the learning curve of anterior approaches in acetabular fractures surgery. Our results should encourage surgeons, while keeping in mind how much this surgery can be challenging, with high rate of complications and difficulty to obtain a systematic anatomical reduction.

Lateral Compression Type 2 Pelvic Fractures-A Clinical Study of Fracture Displacement Measurement and Closed Reduction

Objective

To evaluate the displacement in four lateral compression type 2 (LC2) fracture subtypes (iliac wing and three kinds of crescent fractures) and to investigate the appropriate closed reduction for treatment using a pelvic reduction frame.

Methods

A total of 71 patients with LC2 pelvic fractures from February 2014 to November 2019 were included in this retrospective cohort study. Preoperative X‐ray and computed tomography data were used to assess the direction of the fracture displacement and the sacroiliac joint dislocation. The fractures in all patients were reduced with a pelvic reduction frame and fixed with percutaneous screws as well as an anterior subcutaneous pelvic ring internal fixator. Two different closed reduction strategies were adopted, one was first longitudinal traction and then transverse traction, the other was first transverse traction then longitudinal and LC2 traction. The Matta score system was used to evaluate the postoperative X‐ray and the Majeed score system was used for follow‐up evaluation.

Results

A total of 13 iliac wing fractures (86.7%) and 16 Day type 1 fractures (94.1%) were vertically stable with only internal displacement, the ring width displacements were 5 (3, 8.75) and 8 (4, 12) mm, the posterior superior iliac spine (PSIS) differences were 0 (0, 0) mm and 0 (0, 0) mm. A total of 21 Day type 2 fractures (95.5%) and 16 Day type 3 fractures (94.1%) were characterized by cephalic and dorsal fracture dislocation on the basis of internal displacement, the ring width displacements were 6 (4.25, 12) and 4 (0, 7.5) mm and the PSIS differences were 4 (2, 5) and 0 (0, 3.75) mm. Based on the Matta scores, excellent reduction was achieved in 51 patients, good reduction in 17 patients, and poor reduction in three patients. The average Majeed score was 91.6, with a minimum outpatient follow‐up of 12 months (average 31.6 months).

Conclusion

LC2 fractures involve two different kinds of fracture displacement: internal displacement only and a combination of internal, cephalic, and dorsal dislocation through the sacroiliac joint. Good clinical outcomes can be achieved for LC2 fractures using two different closed reduction strategies.

Treatment of anterior column posterior hemitransverse fracture with supra-ilioinguinal approach

Objective

To report the feasibility and effect of the supra-ilioinguinal approach for treatment of anterior posterior hemitransverse fracture of the acetabulum.

Methods

Nineteen consecutive patients who underwent treatment for an anterior column posterior hemitransverse fracture of the acetabulum from January 2013 to June 2018 were retrospectively analyzed. All patients underwent treatment by the single supra-ilioinguinal approach with at least 1 year of follow-up.

Results

The mean time to surgery, operative time, incision length, and blood loss were 10.2 ± 3.8 days, 157 ± 125 minutes, 10.2 ± 0.6 cm, and 876 ± 234 mL, respectively. According to the Matta scoring system, the reduction quality was excellent in 13 patients, good in 6, and poor in 0. According to the Merle d'Aubigné scoring system, the outcome at the last follow-up was excellent in 12 patients, good in 5, fair in 1, and poor in 1. Postoperative complications occurred in three patients (deep vein thrombosis in one, lateral femoral cutaneous nerve injury in one, and both complications in one).

Conclusions

Use of the supra-ilioinguinal approach for treatment of anterior column posterior hemitransverse fracture of the acetabulum produced excellent clinical results because of the direct visualization of the anterior column and quadrilateral plate.

Participation in Dissection Affects Student Performance on Gross Anatomy Practical and Written Examinations: Results of a Four-Year Comparative Study

The role of human dissection in modern medical curricula has been a topic of intense debate. In part, this is because dissection can be time-consuming and curricular hours are being monitored more carefully. This has led some to question the efficacy and importance of dissection as a teaching method. While this topic has received considerable attention in the literature, the question of how dissection impacts learning has been difficult to evaluate in a real-world, high-stakes setting since participation in dissection is often one of many variables. In this study, this challenge was overcome due to a change in the curriculum of a Special Master Program (SMP) that permitted a comparison between two years of students that learned anatomy using prosection only and two years of students that participated in dissection laboratories. Since each class of SMP students took courses in the medical school, and the medical school anatomy curriculum was constant, medical student performance served as a control throughout the study period. Results demonstrate that SMP students who learned through prosection had lower performance on anatomy practical and written examinations compared to medical students. When the SMP program changed and students started participating in dissection, there were measurable improvements in both practical and written examinations. These findings provide evidence of dissection's role in learning and applying anatomy knowledge both within and outside the gross anatomy laboratory.

An enhanced recovery after surgery program in orthopedic surgery: a systematic review and meta-analysis

Objectives

There is an increased interest in enhanced recovery after surgery (ERAS) minimizing adverse events after orthopedic surgery. Little consensus supports the effectiveness of these interventions. The purpose of present systematic review and meta-analysis is to comprehensively analyze and evaluate the significance of ERAS interventions for postoperative outcomes after orthopedic surgery.

Methods

PubMed, EMBASE, and Cochrane databases were totally searched from the inception dates to May 31, 2018. Two reviewers independently extracted the data from the selected articles using a standardized form and assessed the risk of bias. The analysis was performed using STATA 12.0.

Results

A total of 15 published studies fulfilled the requirements of inclusion criteria. We found that the ERAS group showed a significant association with lower incidence of postoperative complications (OR, 0.70; 95% CI, 0.64 to 0.78). Meanwhile, ERAS was also associated with the decline in 30-day mortality rate and Oswestry Disability Index (ODI). However, no significant differences were identified between the two groups regarding the 30-day readmission rate (P = 0.397).

Conclusions

Our meta-analysis suggested that the ERAS group had more advantages in reducing incidence of postoperative complications, 30-day mortality rate, and ODI after orthopedic surgery, but not of 30-day readmission rate. However, further research with standardized, unbiased methods and larger sample sizes is required for deeper analysis.

Electronic supplementary material

The online version of this article (10.1186/s13018-019-1116-y) contains supplementary material, which is available to authorized users.

Learning curve with a new primary total knee arthroplasty implant: a multicenter perspective with more than 2000 patients

Background

This study provides an example for evaluating learning curve when introducing a new knee system.

Methods

Thirty-five investigators across 22 sites prospectively implanted 843 subjects with currently available products (group A). Seventy-seven investigators across 48 sites prospectively implanted 2330 subjects with the ATTUNE Knee System; in which the first 10 subjects for each surgeon were the learning curve cases (group B, N = 611), and the later subjects were designated as group C (N = 1719). Surgical time, rates of intraoperative and early postoperative complications, and patient-reported outcome measures (PROMs) at a minimum of 1 year were compared.

Results

Mean (standard deviation) surgical time was 72.0 (21.6) minutes for group A, 83.0 (24.2) for group B, and 72.1 (24.1) for group C (P < .001 for group B vs group C; P = .955 for group C vs group A). Intraoperative, early (<90 day) complication rates, and PROMs were similar for all groups.

Conclusions

The new knee system learning curve was characterized by a slightly longer surgical time with no negative impact on complications or PROMs.

Level of Evidence

III.