Training and Evaluation of Residents to Ensure Competent Physician Metrics to Recognize Struggling Residents

Assessing competency across domains of knowledge, skills, and behavior is critical to ensure that graduating orthopaedic residents possess the requisite skills and attributes to enter independent orthopaedic practice. Of the domains, knowledge is most easily assessed. In addition to the AAOS Orthopaedic In-Training Examination®, which provides a yearly gauge of residents' orthopaedic knowledge relative to their peers, there are several online platforms such as Orthobullets, the American Academy of Orthopaedic Surgeons ResStudy program, and the Journal of Bone and Joint Surgery Clinical Classroom that offer online learning resources and question banks. Clinical skills are best assessed through a combination of observation tools, including live or video assessments, 360° evaluations, and objective structured clinical examinations. Surgical skills can be evaluated in two domains: live surgical cases or simulations. The American Board of Orthopaedic Surgery is attempting to standardize live surgical evaluations through the use of the O-P tool. Although most available models feature only arthroscopic procedures, surgical simulators provide for opportunity to objectively evaluate resident performance. Behavior and professionalism has traditionally been the most challenging domain to assess. The American Board of Orthopaedic Surgery's Behavior Assessment Tool has demonstrated success in pilot testing and is being introduced as the standard for measuring behavior and professionalism in orthopaedic training. Although no single assessment tool can accurately gauge a resident's overall performance, a combination of readily available tools should be used to assess competence across domains.

Substantial Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture

BACKGROUND

Femoral fragility fractures in older adults can result in devastating loss of physical function and independence. Skeletal muscle atrophy likely contributes to disability. The purpose of this study was to characterize the change in skeletal muscle mass, investigate the relationship with malnutrition and physical function, and identify risk factors for skeletal muscle loss.

METHODS

Adults ≥65 years of age who were treated with operative fixation of an isolated femoral fragility fracture were enrolled in this multicenter, prospective observational study. Skeletal muscle mass was assessed within 72 hours of admission using multifrequency bioelectrical impedance analysis, which was repeated at 6 weeks, 3 months, and 6 months. Sarcopenia was defined by sex-specific cutoffs for the appendicular skeletal muscle mass index. The Mini Nutritional Assessment was used to measure nutritional status at the time of injury. Physical function was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function domain. Linear mixed models were used to evaluate changes in skeletal muscle mass and PROMIS Physical Function scores over time and to evaluate factors associated with skeletal muscle mass changes.

RESULTS

Ninety participants (74% female) with a mean age of 77.6 ± 9.0 years were enrolled. At the time of injury, 30 (33%) were sarcopenic and 44 (49%) were at risk for malnutrition or had malnutrition. Older age was associated with lower skeletal muscle mass (age of ≥75 versus <75 years: least squares mean [and standard error], -3.3 ± 1.6 kg; p = 0.042). From the time of injury to 6 weeks, participants lost an average of 2.4 kg (9%) of skeletal muscle mass (95% confidence interval [CI] = ‒3.0 to ‒1.8 kg; p < 0.001). This early loss did not recover by 6 months (1.8 kg persistent loss compared with baseline [95% CI = ‒2.5 to ‒1.1 kg]; p < 0.001). Participants with normal nutritional status lost more skeletal muscle mass from baseline to 6 weeks after injury compared with those with malnutrition (1.3 kg more loss [standard error, 0.6 kg]; p = 0.036). A 1-kg decrease in skeletal muscle mass was associated with an 8-point decrease in the PROMIS Physical Function (model parameter estimate, 0.12 [standard error, 0.04]; p = 0.002).

CONCLUSIONS

We found that older adults with femoral fragility fractures lost substantial skeletal muscle mass and physical function. Participants with adequate baseline nutrition actually lost more muscle mass than those who were malnourished, indicating that future investigations of interventions to prevent muscle loss should focus on older adults regardless of nutritional status.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Comparisons of Procedures Performed in Training vs in Early Practice by Orthopaedic Trauma Surgeons

INTRODUCTION

The Orthopaedic Trauma Association (OTA) has maintained an accreditation process of orthopaedic trauma fellowships with various requirements including an annually reviewed list of qualifying trauma cases in the form of American Medical Association Current Procedural Terminology (CPT) codes. The correlation between these established and monitored CPTs and the actual practices of orthopaedic trauma surgeons has not been studied.

METHODS

American Board of Orthopaedic Surgery part II case logs (trauma subspecialty) (2012 to 2018) were compared with OTA fellowship case logs (2015 to 2019). Case logs from 447 surgeons and 166 trauma fellowship programs were compared. Four CPT code categories were defined: complex trauma (OTA required CPT codes, excluding Accreditation Council for Graduate Medical Education [ACGME] orthopaedic residency requirements), general trauma (ACGME residency required trauma codes), general orthopaedics (nontrauma ACGME residency requirements), and others (codes not included in residency or trauma fellowship requirements).

RESULTS

OTA fellows performed a higher median percentage of complex trauma compared with American Board of Orthopaedic Surgery candidates (34% vs. 21%, P < 0.001): Both cohorts performed a similar percentage of general trauma (23%). OTA fellows performed more general orthopaedics (40% vs. 1%, P < 0.001). Several OTA required codes were performed infrequently (0 to 3 during board collection) by most surgeons, and several procedures are being performed that are not included in current CPT code requirements.

DISCUSSION

Early-career traumatologists are performing orthopaedic trauma procedures they were trained on during residency and fellowship, with varying complexity. Trauma fellows perform a higher percentage of complex trauma compared with early-career trauma surgeons. Continued surveillance is necessary such that educational improvements can be made to maximize the quality of trauma fellowship education.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Posttraumatic osteoarthritis: from basic science to clinical implications

Posttraumatic osteoarthritis (PTOA) is a subset of osteoarthritis that occurs after joint injury and is associated with degradation of articular cartilage and subchondral bone. As compared with primary osteoarthritis, PTOA occurs in a time window initiated by a traumatic event resulting in damage to layers of joint structure and alterations in joint shape. As techniques in open reduction and internal fixation continue to mature, our success in preventing posttraumatic osteoarthritis has not kept pace. Advances in research in the subchondral bone, inflammatory response, and joint mechanics continue to open our understanding of this posttraumatic process. In addition, there are possibilities emerging as biological agents to therapeutically alter the progression of PTOA.

The Evolution, Current State and Clinical Benefits of Far Cortical Fracture Fixation

Treatment of distal femur fractures have reported high fracture healing complications in several studies. The development of far cortical locking (FCL) technology results in improved fracture healing outcomes. There are biomechanical and animal studies demonstrating that the locked plating incorporating FCL screws provides a more flexible form of fixation compared to traditional locking plates (LP). Clinical studies have shown that the commercially available Zimmer Motionloc system with FCL screws provide good results in distal femur fractures and periporsthetic distal femur fractures. FCL constructs may help resolve fracture healing problems in the future. However, there is not enough available clinical evidence to conclusively indicate whether clinical healing rates are improved with FCL screw constructs compared to traditional LP's. Therefore, further prospective study designs are needed to compare FCL to LP constructs and to investigate the role of interfragmentary motion on callus formation. Level of Evidence: V.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 1: Epidemiology, Pathophysiology, and Current Imaging Approaches

This first of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey the state of scientific knowledge related to incidence, diagnosis, pathologic mechanisms, and injection treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 3, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Part 1 overviews areas of epidemiology and pathophysiology, current approaches in imaging, diagnostic and therapeutic injections, and genetics. Opportunities for future research are discussed. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the needs of patients that suffer from arthritis of foot and ankle. The foot and ankle contain a myriad of interrelated joints and tissues that together provide a critical functionality. When this functionality is compromised by OA, significant disability results, yet the foot and ankle are generally understudied by the research community. Level of Evidence: Level V - Review Article/Expert Opinion.

Summary Report of the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society's Symposium on Targets for Osteoarthritis Research: Part 2: Treatment Options

This second of a 2-part series of articles recounts the key points presented in a collaborative symposium sponsored jointly by the Arthritis Foundation and the American Orthopaedic Foot & Ankle Society with the intent to survey current treatment options for osteoarthritis (OA) of the foot and ankle. A meeting was held virtually on December 10, 2021. A group of experts were invited to present brief synopses of the current state of knowledge and research in this area. Topics were chosen by meeting organizers, who then identified and invited the expert speakers. Part 2 overviews the current treatment options, including orthotics, non-joint destructive procedures, as well as arthroscopies and arthroplasties in ankles and feet. Opportunities for future research are also discussed, such as developments in surgical options for ankle and the first metatarsophalangeal joint. The OA scientific community, including funding agencies, academia, industry, and regulatory agencies, must recognize the importance to patients of addressing the foot and ankle with improved basic, translational, and clinical research.

LEVEL OF EVIDENCE

Level V, review article/expert opinion.

Gut Bacteria Regulate the Pathogenesis of Huntington's Disease in Drosophila Model

Changes in the composition of gut microbiota are implicated in the pathogenesis of several neurodegenerative disorders. Here, we investigated whether gut bacteria affect the progression of Huntington’s disease (HD) in transgenic Drosophila melanogaster (fruit fly) models expressing full-length or N-terminal fragments of human mutant huntingtin (HTT) protein. We find that elimination of commensal gut bacteria by antibiotics reduces the aggregation of amyloidogenic N-terminal fragments of HTT and delays the development of motor defects. Conversely, colonization of HD flies with Escherichia coli (E. coli), a known pathobiont of human gut with links to neurodegeneration and other morbidities, accelerates HTT aggregation, aggravates immobility, and shortens lifespan. Similar to antibiotics, treatment of HD flies with small compounds such as luteolin, a flavone, or crocin a beta-carotenoid, ameliorates disease phenotypes, and promotes survival. Crocin prevents colonization of E. coli in the gut and alters the levels of commensal bacteria, which may be linked to its protective effects. The opposing effects of E. coli and crocin on HTT aggregation, motor defects, and survival in transgenic Drosophila models support the involvement of gut-brain networks in the pathogenesis of HD.

Significant Loss of Skeletal Muscle Mass Occurs After Femoral Fragility Fracture

Objectives

Femoral fragility fractures in the elderly result in devastating loss of physical function and muscle mass, which is a direct result of immobilization and nutrient deficiencies during healing. A better understanding of how muscle mass responds to injury is needed to critically evaluate nutrition interventions designed to prevent muscle loss and optimize function. The purpose of this study was to document sarcopenia, nutrition status, and changes in muscle mass after femoral fragility fractures.

Methods

A two-center prospective observational study enrolled individuals ≥65 years old admitted for operative fixation of a low-energy femoral fracture. Body composition was assessed within 72 hours of admission using bioelectrical impedance and repeated 6 and 12 weeks after injury. Sarcopenia was defined by gender-specific cutoffs for appendicular skeletal muscle mass index. Malnutrition was defined by Mini Nutritional Assessment®. Wilcoxon Signed Rank test was used to assess 6 and 12-week change from baseline in skeletal muscle mass (SMM). Wilcoxon Rank Sum test was used to compare the change in SMM in those with vs without malnutrition and sarcopenia. SMM results are presented as median (interquartile range).

Results

Thirty participants (27% male) age 76.9 ± 8.9 years were enrolled. At baseline, 11 (37%) were sarcopenic, and 17 (59%) were at risk of malnutrition. SMM decreased 1.75kg (−3.30 to −0.40, p < 0.001) by 6 weeks post-injury. By 12 weeks, participants lost 3.04 kg of SMM (−4.49 to −1.45), p < 0.001). Participants with adequate baseline nutrition status lost more SMM at 6 weeks compared to those with at risk of malnutrition (−3.56 kg (−4.65 to −1.60) versus −1.22 kg (−2.00 to −0.20), P = 0.01). No difference was observed in SMM loss between those with vs without sarcopenia at baseline.

Conclusions

Femoral fragility fractures result in devastating losses of skeletal muscle mass. Most were at risk of malnutrition, but participants with adequate baseline nutrition lost more muscle mass, indicating that future investigations of interventions to prevent muscle loss should focus on all fragility fracture patients regardless of nutrition status. These results highlight the need for further investigation into interventions to mitigate muscle loss after injury.

Funding Sources

Orthopedic Trauma Association.

Conditionally Essential Amino Acid Supplementation Reduces Postoperative Complications and Muscle Wasting After Fracture Fixation: A Randomized Controlled Trial

BACKGROUND

Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures.

METHODS

Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM.

RESULTS

Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points.

CONCLUSIONS

Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Contemporary Issues in the Acquisition of Orthopaedic Surgical Skills During Residency: Competency-Based Medical Education and Simulation

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Orthopaedic education should produce surgeons who are competent to function independently and can obtain and maintain board certification.

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Contemporary orthopaedic training programs exist within a fixed 5-year time frame, which may not be a perfect match for each trainee.

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Most modern orthopaedic residencies have not yet fully adopted objective, proficiency-based, surgical skill training methods despite nearly 2 decades of evidence supporting the use of this methodology.

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Competency-based medical education backed by surgical simulation rooted in proficiency-based progression has the potential to address surgical skill acquisition challenges in orthopaedic surgery.

American Board of Orthopaedic Surgery’s Initiatives Toward Competency-Based Education

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

Effects of flanking sequences and cellular context on subcellular behavior and pathology of mutant HTT

Huntington's disease (HD) is caused by an expansion of a poly glutamine (polyQ) stretch in the huntingtin protein (HTT) that is necessary to cause pathology and formation of HTT aggregates. Here we ask whether expanded polyQ is sufficient to cause pathology and aggregate formation. By addressing the sufficiency question, one can identify cellular processes and structural parameters that influence HD pathology and HTT subcellular behavior (i.e. aggregation state and subcellular location). Using Drosophila, we compare the effects of expressing mutant full-length human HTT (fl-mHTT) to the effects of mutant human HTTexon1 and to two commonly used synthetic fragments, HTT171 and shortstop (HTT118). Expanded polyQ alone is not sufficient to cause inclusion formation since full-length HTT and HTTex1 with expanded polyQ are both toxic although full-length HTT remains diffuse while HTTex1 forms inclusions. Further, inclusions are not sufficient to cause pathology since HTT171-120Q forms inclusions but is benign and co-expression of HTT171-120Q with non-aggregating pathogenic fl-mHTT recruits fl-mHTT to aggregates and rescues its pathogenicity. Additionally, the influence of sequences outside the expanded polyQ domain is revealed by finding that small modifications to the HTT118 or HTT171 fragments can dramatically alter their subcellular behavior and pathogenicity. Finally, mutant HTT subcellular behavior is strongly modified by different cell and tissue environments (e.g. fl-mHTT appears as diffuse nuclear in one tissue and diffuse cytoplasmic in another but toxic in both). These observations underscore the importance of cellular and structural context for the interpretation and comparison of experiments using different fragments and tissues to report the effects of expanded polyQ.

Surgical Skill Can be Objectively Measured From Fluoroscopic Images Using a Novel Image-based Decision Error Analysis (IDEA) Score

BACKGROUND

To advance orthopaedic surgical skills training and assessment, more rigorous and objective performance measures are needed. In hip fracture repair, the tip-apex distance is a commonly used summative performance metric with clear clinical relevance, but it does not capture the skill exercised during the process of achieving the final implant position. This study introduces and evaluates a novel Image-based Decision Error Analysis (IDEA) score that better captures performance during fluoroscopically-assisted wire navigation.

QUESTIONS/PURPOSES

(1) Can wire navigation skill be objectively measured from a sequence of fluoroscopic images? (2) Are skill behaviors observed in a simulated environment also exhibited in the operating room? Additionally, we sought to define an objective skill metric that demonstrates improvement associated with accumulated surgical experience.

METHODS

Performance was evaluated both on a hip fracture wire navigation simulator and in the operating room during actual fracture surgery. After examining fluoroscopic image sequences from 176 consecutive simulator trials (performed by 58 first-year orthopaedic residents) and 21 consecutive surgical procedures (performed by 19 different orthopaedic residents and one attending orthopaedic surgeon), three main categories of erroneous skill behavior were identified: off-target wire adjustments, out-of-plane wire adjustments, and off-target drilling. Skill behaviors were measured by comparing wire adjustments made between consecutive images against the goal of targeting the apex of the femoral head as part of our new IDEA scoring methodology. Decision error metrics (frequency, magnitude) were correlated with other measures (image count and tip-apex distance) to characterize factors related to surgical performance on both the simulator and in the operating room. An IDEA composite score integrating decision errors (off-target wire adjustments, out-of-plane wire adjustments, and off-target drilling) and the final tip-apex distance to produce a single metric of overall performance was created and compared with the number of hip wire navigation cases previously completed (such as surgeon experience levels).

RESULTS

The IDEA methodology objectively analyzed 37,000 images from the simulator and 688 images from the operating room. The number of decision errors (7 ± 5 in the operating room and 4 ± 3 on the simulator) correlated with fluoroscopic image count (33 ± 14 in the operating room and 20 ± 11 on the simulator) in both the simulator and operating room environments (R2 = 0.76; p < 0.001 and R2 = 0.71; p < 0.001, respectively). Decision error counts did not correlate with the tip-apex distance (16 ± 4 mm in the operating room and 12 ± 5 mm on the simulator) for either the simulator or the operating room (R2 = 0.08; p = 0.15 and R2 = 0.03; p = 0.47, respectively), indicating that the tip-apex distance is independent of decision errors. The IDEA composite score correlated with surgical experience (R2 = 0.66; p < 0.001).

CONCLUSION

The fluoroscopic images obtained in the course of placing a guide wire contain a rich amount of information related to surgical skill. This points the way to an objective measure of skill that also has potential as an educational tool for residents. Future studies should expand this analysis to the wide variety of procedures that rely on fluoroscopic images.

CLINICAL RELEVANCE

This study has shown how resident skill development can be objectively assessed from fluoroscopic image sequences. The IDEA scoring provides a basis for evaluating the competence of a resident. The score can be used to assess skill at key timepoints throughout residency, such as when rotating onto/off of a new surgical service and before performing certain procedures in the operating room, or as a tool for debriefing/providing feedback after a procedure is completed.

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs

Background

The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism.

Methods

Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results.

Results

Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%).

Conclusions

The ABOSBT was able to identify 2.4% low score evaluations (<level 3) for all residents. The tool was concordant with the PD for 81% of the residents considered low performers or "outliers" for professional behavior. The 5-domain construct makes it an effective actionable tool that can be used to help develop performance improvement plans for residents.

Level of Evidence

Level II.

Trends and Complications of Arthroscopic-Assisted Tibial Plateau Fracture Fixation: A Matched Cohort Analysis

Purpose

To determine trends in arthroscopic-assisted tibial plateau fracture fixation (AATPFF), to evaluate trends in the overall rate of tibial plateau fracture fixation, and to compare postoperative complications between AATPFF and traditional tibial plateau fixation.

Methods

A retrospective review of patients undergoing AATPFF and traditional tibial plateau fixation was conducted using the Humana Inc. administrative database from 2007 to 2016. A 1:1 propensity match was utilized to match patients in the 2 study groups based on age, sex, obesity, diabetes, hypertension, chronic obstructive pulmonary disease, depression or anxiety, and smoking history. Postoperative complications were grouped as minor medical complications, major medical complications, surgical complications, emergency department visits, and reoperation. Linear regression analysis was used to assess trends and Pearson's χ² test was used to compare postoperative complications with statistical significance defined as P < .05.

Results

In total, 522 patients underwent AATPFF and 3920 patients underwent traditional tibial plateau fracture fixation. There was a 4-fold increase in the use of AATPFF over the study period (P = .0173). Similarly, there was an increase in the utilization of traditional tibial plateau fracture fixation, although to a lesser extent (1.33-fold). After propensity matching, the traditional fixation group demonstrated significantly higher rates of minor medical complications (8.2% vs 2.7%, P = .0002), major medical complications (9.9% vs 4.6%, P = .0018), surgical complications (13.2% vs 2.7%, P < .0001), and emergency department visits (21.4% vs 13.5%, P < .0001) within 90 days of surgery compared with the AATPFF group. There was no difference in reoperation rates within 90 days between the 2 groups (2.9% vs 3.6%, P = .85).

Conclusions

The incidence of tibial plateau fracture fixation is increasing, however, use of AATPFF is increasing at a faster rate compared to traditional techniques. Furthermore, the addition of knee arthroscopy to fracture fixation does not increase the risk of complication, reoperation, or emergency department visit within 90 days.

Level of Evidence

III, retrospective matched cohort.

Serine residues 13 and 16 are key modulators of mutant huntingtin induced toxicity in Drosophila

Poly-glutamine expansion near the N-terminus of the huntingtin protein (HTT) is the prime determinant of Huntington's disease (HD) pathology; however, post-translational modifications and protein context are also reported to influence poly-glutamine induced HD toxicity. The impact of phosphorylating serine 13/16 of mutant HTT (mHTT) on HD has been documented in cell culture and murine models. However, endogenous processing of the human protein in mammalian systems complicates the interpretations. Therefore, to study the impact of S13/16 phosphorylation on the subcellular behavior of HTT under a controlled genetic background with minimal proteolytic processing of the human protein, we employed Drosophila as the model system. We ectopically expressed full-length (FL) and exon1 fragment of human HTT with phosphomimetic and resistant mutations at serines 13 and 16 in different neuronal populations. Phosphomimetic mHTT aggravates and the phosphoresistant mutation ameliorates mHTT-induced toxicity in the context of both FL- and exon1- mHTT in Drosophila although in all cases FL appears less toxic than exon1. Our observations strongly indicate that the phosphorylation status of S13/16 can affect HD pathology in Drosophila and these residues can be potential targets for affecting HD pathogenesis.

Correlation of 3D Joint Space Width From Weightbearing CT With Outcomes After Intra-articular Calcaneal Fracture

BACKGROUND

Posttraumatic osteoarthritis (PTOA) of the subtalar joint is a serious, disabling, and frequent complication following intra-articular calcaneal fractures (IACFs). Using plain radiographs to assess the subtalar joint for PTOA is imprecise and insensitive, hindering progress toward improving treatment and assessing outcomes. This study explored how low-dose weightbearing computed tomography (WBCT) can be used to provide reliable, quantitative 3D measures of subtalar joint space width (JSW) following IACF and correlated the 3D JSW with clinical outcomes.

METHODS

After institutional review board approval, 21 patients (15 male; age, 28-70 years) who sustained IACFs and were treated with percutaneous surgical reduction underwent WBCT scans at follow-up visits 2 to 15 years (average, 7.8 years) after surgical treatment. Subtalar joint 3D JSW was computed after a semiautomated protocol was used to segment the talus and calcaneus from the WBCT data. Mean and minimum 3D JSW measurements were calculated and compared with Kellgren-Lawrence (KL) radiographic osteoarthritis grade, RAND-36 Physical (PCS) and Mental (MCS) Component Scores, and visual analog scale (VAS) pain scores. Spearman's rank correlation was used to detect the strength of association between variables, with significance set at P < .05.

RESULTS

Mean 3D JSW values measured from WBCT for patients with IACFs ranged from 0.9 to 2.5 mm (1.7 ± 0.4 mm) over the entire subtalar joint. Intra- and interrater reliabilities for the WBCT-based JSW measurement technique were 0.95 (95% CI, 0.91-0.97) and 0.97 (95% CI, 0.95-0.98), respectively. Mean and minimum 3D JSW values correlated inversely with VAS pain scores and KL grade (P < .05), particularly in central and posterior subtalar regions.

CONCLUSION

WBCT-based methods were used to quantify the preservation/loss of JSW in patients with IACFs, enabling more accurate, definitive measurement of subtalar PTOA. The results of this study demonstrate that WBCT can be utilized to objectively assess subtalar PTOA and help us to better understand how arthritic changes affect actual patient experience.

LEVEL OF EVIDENCE

Level III, prognostic comparative study.

Weight-Bearing CT Scan After Tibial Pilon Fracture Demonstrates Significant Early Joint-Space Narrowing

BACKGROUND

Posttraumatic osteoarthritis (PTOA) is a common and early sequela of tibial pilon fractures resulting in substantial long-term disability. New approaches are needed to objectively and reliably quantify early disease progression in order to critically assess the impact of interventions aimed at preventing or mitigating PTOA. Weight-bearing computed tomography (WBCT) scans provide a means for measuring joint space while the ankle is in a loaded, functional position. We assessed the interrater and intrarater reliability of a standardized, regional method to quantify joint-space loss following tibial pilon fracture compared with the uninjured contralateral ankle.

METHODS

We prospectively enrolled 20 patients with intra-articular tibial pilon fractures that were surgically treated at 1 of 2 level-I trauma centers. Six months after injury, bilateral ankle WBCT scans were obtained. Joint space was measured by 4 reviewers at 9 discrete regions of the tibiotalar articulation on sagittal images. Measurements were repeated by reviewers 2 weeks later. To characterize the measurement method, interrater correlation coefficient estimates and test-retest reproducibility were calculated.

RESULTS

The mean tibiotalar joint space was 21% less in the injured ankles compared with the contralateral uninjured ankles (p < 0.0001). The middle-lateral and middle-central regions of the joint demonstrated the greatest decrease in joint space between injured and uninured ankles. The interrater correlation coefficient of the measurement technique was 0.88, and the test-retest reproducibility was 0.80, indicating good reliability and reproducibility of the method.

CONCLUSIONS

We developed a simple, standardized, and reliable technique to quantify tibiotalar joint space following tibial pilon fracture on WBCT. Significant loss of joint space is seen 6 months after the injury. This tool can be used to longitudinally quantify loss of joint space following pilon fracture and assess the impact of interventions to reduce PTOA.

Update on Mentorship in Orthopaedic Resident Education: A Report from the American Orthopaedic Association

BACKGROUND

Mentorship has been identified as an important element of educational and professional development for surgeons. An assessment that was conducted and reported through the American Association of Orthopaedic Surgeons (AAOS) in 2008 showed variability among U.S. residencies regarding the structure and requirements for mentorship during orthopaedic training; the assessment also demonstrated variability in residents' satisfaction with mentorship opportunities during their surgical training.

METHODS

An updated survey was developed and distributed via e-mail to residents attending the Resident Leadership Forum at the 2015 American Orthopaedic Association Annual Meeting to determine their views regarding the importance of mentorship, as well as their assessments of formal mentorship programs within their residencies. The updated data were compared with the prior survey results from 2008.

RESULTS

A total of 149 (87.6%) of 170 residents responded to the survey. Of these, 34.9% (51 of 146) reported the existence of a formal mentorship program within their residency, as compared with 26.0% of residencies as stated in the 2008 report. One hundred percent of residents indicated that having a mentor during orthopaedic residency was either critical (63.7%, 93 of 146) or advantageous (36.3%, 53 of 146) to professional development as a surgeon; 74.7% (109 of 146) of residents reported currently having mentors, which appears to represent an increase from the prior report (51%, 258 of 506). However, the percentage of residents who reported being "very" satisfied (17.9%, 25 of 140) or "somewhat" satisfied (43.6%, 61 of 140) with their mentorship opportunities was almost identical to the prior report (61.9% [86 of 139] versus 61.0%, respectively). Overall, residents from programs with formal mentorship programs in place reported significantly higher satisfaction with their mentoring program/environment compared with those from programs without formal mentorship programs in place (3.98 versus 3.54, p = 0.026).

CONCLUSIONS

Orthopaedic residents continue to overwhelmingly indicate that mentorship is an important component of residency education: 34.9% of residencies have a formal mentorship program, compared with 26.0% in the prior survey. Additionally, 74.7% of current residents reported having a mentor compared with 51% of residents in the prior study. Despite this difference, a very similar percentage of residents indicated that they were either "very" or "somewhat" satisfied with their mentorship experience. Residents from programs with formal mentorship programs reported significantly higher satisfaction with their mentorship programs compared with those without formal programs. These results support continued efforts toward improving mentorship opportunities within U.S. orthopaedic residency programs.

A Vision for Using Simulation & Virtual Coaching to Improve the Community Practice of Orthopedic Trauma Surgery

BACKGROUND

Many orthopedic surgeries involve the challenging integration of fluoroscopic image interpretation with skillful tool manipulation to enable procedures to be performed through less invasive approaches. Simulation has proved beneficial for teaching and improving these skills for residents, but similar benefits have not yet been realized for practicing orthopedic surgeons. A vision is presented to elevate community orthopedic practice and improve patient safety by advancing the use of simulators for training and assessing surgical skills.

METHODS

Key elements of this vision that are established include 1) methods for the objective and rigorous assessment of the performance of practicing surgeons now exist, 2) simulators are sufficiently mature and sophisticated that practicing surgeons will use them, and 3) practicing surgeons can improve their performance with appropriate feedback and coaching.

RESULTS

Data presented indicate that surgical performance can be adequately and comparably measured using structured observations made by experts or non-expert crowds, with the crowdsourcing approach being more expedient and less expensive. Rigorous measures of the surgical result and intermediate objectives obtained semi-automatically from intra-operative fluoroscopic image sequences can distinguish performances of experts from novices. Experience suggests that practicing orthopedic surgeons are open to and can be constructively engaged by a family of mature simulators as a means to evaluate and improve their surgical skills.

CONCLUSIONS

The results presented support our contention that new objective assessment measures are sufficient for evaluating the performance of working surgeons. The novel class of orthopedic surgical simulators available were tested and approved by practicing physicians. There exists a clear opportunity to combine purpose-designed simulator exercises with virtual coaching to help practicing physicians retain, retrain, and improve their technical skills. This will ultimately reduce cost, increase the quality of care, and decrease complication rates.

CLINICAL RELEVANCE

This vision articulates a means to boost the confidence of practitioners and ease their anxiety so that they perform impactful procedures more often in community hospitals, which promises to improve treatment and reduce the cost of care while keeping patients closer to their homes and families.

Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures: A Randomized Controlled Trial

BACKGROUND

Pain management following surgical treatment of an ankle fracture is an under-studied area of clinical practice. The present study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with an operatively treated, closed, rotational ankle fracture.

METHODS

Patients indicated for operative fixation of a rotational ankle fracture were randomized to receive multimodal surgical-site injection (ropivacaine 200 mg, epinephrine 0.6 mg, and morphine 5 mg) or no injection (control). Visual analog scale (VAS) pain and opioid consumption data were collected every 4 hours until discharge from the hospital. Length of stay and discharge destination were recorded. Patients were sent automated text messages to report VAS pain and opioid usage during the first 2 weeks after discharge.

RESULTS

One hundred patients (49 injection and 51 control) were enrolled. Demographic data were similar between the 2 groups. Mean VAS scores over the first 24 and 48 hours postoperatively were slightly lower in the injection group (42 ± 3 and 41 ± 3, respectively) compared with the control group (52 ± 3 and 50 ± 3, respectively; p = 0.01 and p < 0.01, respectively). The median opioid usage, in terms of morphine equivalent dose, was similar over the first 24 hours between the injection group (25.5; range, 0 to 74.7) and the control group (28.3; range, 2.5 to 91.0; p = 0.35). The median opioid usage from recovery room admission to discharge was also similar between the injection group (29.0; range, 0 to 85.3) and the control group (32.7; range, 4.3 to 215.0; p = 0.35). There were no differences in outpatient VAS scores or opioid consumption during the first 2 weeks postoperatively as assessed with use of automated text messaging. Median length of stay was 22.3 hours (range, 1.7 to 182.3 hours) for the injection group and 22.5 hours (range, 2.2 to 123.3 hours) for the control group (p = 0.71). The response rate for the post-discharge automated text messages was 85.1%. Complication rates were similar.

CONCLUSIONS

The use of multimodal surgical-site injections in operatively treated rotational ankle fractures is associated with a reduction in immediate in-hospital pain scores that is statistically significant but below the minimal clinically important difference.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Correlation of Fracture Energy With Sanders Classification and Post-traumatic Osteoarthritis After Displaced Intra-articular Calcaneus Fractures

OBJECTIVES

To quantify fracture severity for a series of displaced intra-articular calcaneal fractures (DIACFs) and to correlate it with Sanders classification, post-traumatic osteoarthritis (PTOA), and patient outcomes.

DESIGN

Retrospective review and fracture severity analysis.

SETTING

Level 1 trauma center affiliated with the University of Iowa in Iowa City, IA.

PATIENTS/PARTICIPANTS

Thirty-six patients with 48 DIACFs were selected from 153 patients previously treated. All patients 18 years of age and older who had available electronic preop and postop computed tomography (CT) scans, good-quality postop and follow-up radiographs, and a follow-up ≥18 months were selected for study.

INTERVENTION

Fractures were treated with percutaneous reduction, using multiple small stab incisions and fluoroscopy to guide manipulation of articular fragments using cork screws or Steinmann pins, with subsequent fixation using 3.5- and 4.0-mm screws.

MAIN OUTCOME MEASUREMENTS

Preop CT scans were used to grade fractures according to the Sanders classification and to quantify fracture severity. Fracture severity was objectively quantified using a CT-based measure of fracture energy. PTOA was assessed on follow-up radiographs using the Kellgren-Lawrence scale. Patient outcomes were assessed using the Short Form 36 (SF-36) questionnaire and a visual analog scale pain score.

RESULTS

Fracture energies for the 48 DIACFs ranged from 14.1 to 26.2 J (19.3 ± 3.1 J) and correlated with Sanders classification (rho = 0.53, P = 0.0001); type I (16.3 ± 0.9 J); type II (18.0 ± 2.7 J); type III (20.8 ± 2.8 J); and type IV (22.0 ± 0.7 J). Fracture energy was higher for fractures in which the subtalar joint developed PTOA (19.5 ± 2.7 J) than for those that did not (18.9 ± 3.3 J), but the difference did not reach statistical significance. The Sanders classification predicted PTOA risk [odds ratio (OR) = 4.04, 95% confidence interval = 1.43-11.39, P = 0.0084]. No relationship was observed between fracture energy and visual analog scale pain scores. Higher fracture energy correlated with lower SF-36 scores.

CONCLUSIONS

Fracture energy positively correlates with Sanders classification for DIACFs, which can be used to identify more severe fractures at greater risk of progressing to PTOA.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Resident Surgical Skills Web-Based Evaluation: A Comparison of 2 Assessment Tools

BACKGROUND

Evaluation of surgical skill competency is necessary as graduate medical education moves toward a competency-based curriculum. This study by the American Board of Orthopaedic Surgery (ABOS) and the Council of Orthopaedic Residency Directors (CORD) compares 2 web-based evaluation tools that assess the level of autonomy that is demonstrated by residents during surgical procedures in the operating room as measured by faculty.

METHODS

Two hundred and ninety-four residents from 16 orthopaedic surgery residency programs were evaluated by 370 faculty using 2 web-based evaluation tools in a crossover design in which residents requested faculty review of their surgical skills before starting a case. One thousand, one hundred and fifty Ottawa Surgical Competency Operating Room Evaluation (O-Score) assessments, which included a 9-question evaluation of 8 steps of the surgical procedure, were compared with 1,186 P-score evaluations, which included a single-question summative evaluation. Twenty-five different surgical procedures were evaluated.

RESULTS

There were no significant differences in rates of resident requests or faculty completion of the 2 scores. The most common surgical procedures that were assessed were total knee arthroplasty (n = 254, 11%), carpal tunnel release (n = 191, 8%), open reduction and internal fixation (ORIF) of stable hip fractures (n = 170, 7%), ORIF of simple ankle fractures (n = 169, 7%), and total hip arthroplasty (n = 166, 7%). Both instruments disclosed significant differences in competency among entry, intermediate, and advanced-level residents. The findings support the construct validity of the evaluation method. The survey results indicated that >70% of the faculty were confident that use of either the P-score or the O-score allowed them to distinguish a resident who can perform the surgery independently from one who needs additional training.

CONCLUSIONS

This research has led to the modification of the O-score and the P-score into a combined OP-score instrument. The ABOS envisions that the OP-score instrument can be used with an expanded number of surgical procedures as a required element of residency training in the near future.

CLINICAL RELEVANCE

This study allows the profession of orthopaedic surgery education to take a leadership role in the measurement of competence for surgical skills for orthopaedic surgeons in residency training, an important clinically relevant topic to the practice of orthopaedic surgery.

Perioperative nutrition assessment in musculoskeletal trauma patients: Dietitian evaluation is superior to serum chemistries or modified screening questionnaire for risk stratification

INTRODUCTION

Malnutrition is a potentially modifiable risk factor associated with increased hospital charges, major wound complication, and fracture non-union after orthopaedic surgery. The goal of this study was to examine the relationship between three nutrition screening tools and postoperative complications in patients undergoing acute fracture fixation.

METHODS

Patients aged 18 or older undergoing acute operative fracture fixation at a Level I academic trauma center were screened upon admission using a malnutrition screening questionnaire (MSQ), and classified as low-, moderate- or high risk. Patients at moderate-to-high risk were assessed for clinical malnutrition by dietitian. Serum albumin, transferrin, total lymphocyte count, and 25(OH) Vitamin D were measured preoperatively. Primary outcome measures included twelve-month postoperative surgical and medical complications obtained by retrospective chart review.

RESULTS

Of 373 patients, 17% were moderate-to-high risk of malnutrition by MSQ. Clinical malnutrition was diagnosed by dietitian in 4.3% of patients assessed. Nearly half of all subjects had deficiency in one or more serum biomarkers. Cost of biomarker assays was $624 per patient. Medical or surgical complications occurred in 19% of patients. Dietitian diagnosed malnutrition (clinical malnutrition) was the strongest predictor of complication (OR 3.49, p = 0.017). Hypoalbuminemia was also associated with increased complication risk (OR 1.79, p = 0.045). MSQ score was not correlated with postoperative complication.

CONCLUSIONS

Among the examined malnutrition screening tools, clinical malnutrition had the strongest association with postoperative complication. Hypoalbuminemia was associated with increased odds of complication, however there was a large false positive rate with all tested serum chemistries and high associated hospital charges compared to dietitian assessment. MSQ was a poor predictor of malnutrition and clinical outcome. Dietetic assessment is advised for orthopaedic trauma patients.

Systematic genetic interaction studies identify histone demethylase Utx as potential target for ameliorating Huntington's disease

Huntington's disease (HD) is a dominantly inherited neurodegenerative disease caused by alterations in the huntingtin gene (htt). Transcriptional dysregulation is an early event in HD progression. Protein acetylation and methylation particularly on histones regulates chromatin structure thereby preventing or facilitating transcription. Although protein acetylation has been found to affect HD symptoms, little is known about the potential role of protein methylation in HD pathology. In recent years, a series of proteins have been described that are responsible for methylating and demethylating histones as well as other proteins. We carried out systematic genetic interaction studies testing lysine and arginine methylases and demethylases in a Drosophila melanogaster HD model. We found that modulating methylation enzymes that typically affect histone positions H3K4, H3K36 or H3K79 had varying effects on HD pathology while modulating ones that typically affect constitutive heterochromatin marks at H3K9 and H4K20 generally had limited impact on HD pathology. In contrast, modulating enzymes acting on the facultative heterochromatin mark at H3K27 had specific effects on HD pathology, with reduction of the demethylase Utx rescuing HTT-induced pathology while reducing Polycomb Repressive Complex2 core methylase components led to more aggressive pathology. Further exploration of the mechanism underlying the methylation-specific interactions suggest that these lysine and arginine methylases and demethylases are likely exerting their influence through non-histone targets. These results highlight a novel therapeutic approach for HD in the form of Utx inhibition.

Early Subspecialization in Orthopedic Surgery Training

Recent studies have shown that applicants to the American Board of Orthopaedic Surgery Part II examination are performing fewer procedures outside of their chosen subspecialty. In this study, the authors assessed whether trainees are beginning their subspecialization during residency. The authors reviewed the chosen fellowships and case logs of 231 residents graduating from 5 academic orthopedic residency training programs from 2002 to 2017. The number of cases logged by residents who chose a specialty was then compared with the number of cases logged by residents who chose other specialties. Residents who chose spine surgery (108.4±50.7 vs 74.4±60.2, P<.01), hand surgery (242.2±92.9 vs 194.3±78.2, P<.01), and sports medicine (278.5±105.8 vs 229.0±93.9, P<.01) performed significantly more procedures in their chosen fields than their colleagues. In contrast, for total joint arthroplasty (P=.18) and foot and ankle surgery (P=.46), there was no significant difference in the number of cases between residents who chose the sub-specialty and those who did not. Residents pursuing careers in spine surgery, hand surgery, and sports medicine obtained additional operative exposure to their chosen field during residency. Formalizing this early experience with specialization tracks during the chief year may be considered. [Orthopedics. 2019; 42(1):e39-e43.].

Miles to go (mtgo) encodes FNDC3 proteins that interact with the chaperonin subunit CCT3 and are required for NMJ branching and growth in Drosophila

Analysis of mutants that affect formation and function of the Drosophila larval neuromuscular junction (NMJ) has provided valuable insight into genes required for neuronal branching and synaptic growth. We report that NMJ development in Drosophila requires both the Drosophila ortholog of FNDC3 genes; CG42389 (herein referred to as miles to go; mtgo), and CCT3, which encodes a chaperonin complex subunit. Loss of mtgo function causes late pupal lethality with most animals unable to escape the pupal case, while rare escapers exhibit an ataxic gait and reduced lifespan. NMJs in mtgo mutant larvae have dramatically reduced branching and growth and fewer synaptic boutons compared with control animals. Mutant larvae show normal locomotion but display an abnormal self-righting response and chemosensory deficits that suggest additional functions of mtgo within the nervous system. The pharate lethality in mtgo mutants can be rescued by both low-level pan- and neuronal-, but not muscle-specific expression of a mtgo transgene, supporting a neuronal-intrinsic requirement for mtgo in NMJ development. Mtgo encodes three similar proteins whose domain structure is most closely related to the vertebrate intracellular cytosolic membrane-anchored fibronectin type-III domain-containing protein 3 (FNDC3) protein family. Mtgo physically and genetically interacts with Drosophila CCT3, which encodes a subunit of the TRiC/CCT chaperonin complex required for maturation of actin, tubulin and other substrates. Drosophila larvae heterozygous for a mutation in CCT3 that reduces binding between CCT3 and MTGO also show abnormal NMJ development similar to that observed in mtgo null mutants. Hence, the intracellular FNDC3-ortholog MTGO and CCT3 can form a macromolecular complex, and are both required for NMJ development in Drosophila.

A Survey on Recent Medical School Graduate Comfort With the Level 1 Milestones

OBJECTIVE

The Next Accreditation System implemented 5 levels of milestones for orthopedic surgery residents in 2013. The Level 1 milestones were noted as those "expected of an incoming resident." While the milestones were intended for assessing resident progression and readiness for independent practice, this designation can also be used to assess how well prepared graduating medical students are for beginning an orthopedic surgery residency. The primary objective of this paper is to measure recent medical school graduate comfort with the Level 1 milestones.

DESIGN, SETTING, AND PARTICIPANTS

In June 2015, the program directors for the Midwest Orthopaedic Surgical Skills (MOSS) Consortium affiliated residency programs were sent an online survey for distribution to the recent medical school graduates who matched at their respective programs. The survey was about recent graduate comfort with the Level 1 milestone handles associated with 16 orthopedic milestones spanning multiple subspecialties. Responses were grouped based on comfort with individual milestone handles with orthopedic conditions (e.g., carpal tunnel) or with broader categories spanning orthopedic milestones (e.g., imaging).

RESULTS

In all, 66 of 112 graduates (58.9%) responded. Of 60 milestone handles surveyed, respondents were "Comfortable" with an average of 31.6 ± 14.2 handles with some conditions performing much better than others. The median "Comfortable" response rate was 31 handles. The 8 broader categories had "Comfortable" response rates between 35% and 70%. All 8 orthopedic conditions had significantly higher "Comfortable" response rates for "Evaluation & Knowledge" handles than for "Decision Making & Treatment" handles.

CONCLUSIONS

Most recent medical student graduates who matched into an orthopedic surgery residencies are only comfortable with about half of the Level 1 milestone handles even though they are expected to meet the Level 1 milestones upon beginning residency. This finding suggests the development of an assessment based on the Level 1 milestones would be appropriate to better inform both graduate and undergraduate medical education in orthopedic surgery.

Operative Experience During Orthopaedic Residency Compared with Early Practice in the U.S

BACKGROUND

The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice.

METHODS

This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents.

RESULTS

The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice.

CONCLUSIONS

Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice.

Nonmammalian Models of Huntington's Disease

Flies, worms, yeast and more recently zebra fish have all been engineered to express expanded polyglutamine repeat versions of Huntingtin with various resulting pathologies including early death, neurodegeneration, and loss of motor function. Each of these models present particular features that make it useful in studying the mechanisms of polyglutamine pathology. However, one particular unbiased readout of mHTT pathology is functional loss of motor control. Loss of motor control is prominent in patients, but it remains unresolved whether pathogenic symptoms in patients result from overt degeneration and loss of neurons or from malfunctioning of surviving neurons as the pathogenic insult builds up. This is why a functional assay such as motor control can be uniquely powerful in revealing early as well as late neurological deficits and does not rely on assumptions such as that the level of inclusions or the degree of neuronal loss can be equated with the level of pathology. Drosophila is well suited for such assays because it contains a functioning nervous system with many parallels to the human condition. In addition, the ability to readily express mHTT transgenes in different tissues and subsets of neurons allows one the possibility of isolating a particular effect to a subset of neurons where one can correlate subcellular events in response to mHTT challenge with pathology at both the cellular and organismal levels. Here we describe methods to monitor the degree of motor function disruption in Drosophila models of HD and we include a brief summary of other nonmammalian models of HD and discussion of their unique strengths.

Communication with Orthopedic Trauma Patients via an Automated Mobile Phone Messaging Robot

BACKGROUND

Communication with orthopedic trauma patients is traditionally problematic with low response rates (RRs). The purpose of this investigation was to (1) evaluate the feasibility of communicating with orthopedic trauma patients postoperatively, utilizing an automated mobile phone messaging platform; and (2) assess the first 2 weeks of postoperative patient-reported pain and opioid use after lower extremity orthopedic trauma procedures.

MATERIALS AND METHODS

This was a prospective investigation at a Level 1 trauma center in the United States. Adult patients who were capable of mobile phone messaging and were undergoing common, lower extremity orthopedic trauma procedures were enrolled in the study. Patients received a daily mobile phone message protocol inquiring about their current pain level and amount of opioid medication they had taken in the past 24 h starting on postoperative day (POD) 3 and continuing through POD 17. Our analysis considered (1) Patient completion rate of mobile phone questions, (2) Patient-reported pain level (0-10 scale), and (3) Number and percentage of daily prescribed opioid medication patients reported taking.

RESULTS

Twenty-five patients were enrolled in this investigation. Patients responded to 87.5% of the pain and opioid medication inquiries they received over the 2-week study period. There were no differences in RRs by patient age, sex, or educational attainment. Patient-reported pain decreased over the initial 2-week study period from an average of 4.9 ± 1.7 on POD 3 to 3 ± 2.2 on POD 16-17. Patients took an average of 68% of their maximum daily narcotic prescription on POD 3 compared with 35% of their prescribed pain medication on POD 16-17.

CONCLUSIONS

We found that in orthopedic trauma patients, an automated mobile phone messaging platform elicited a high patient RR that improved upon prior methods in the literature. This method may be used to reliably obtain pain and medication utilization data after trauma procedures.

Long-term consequences of landmine injury: A survey of civilian survivors in Bosnia-Herzegovina 20 years after the war

INTRODUCTION

Bosnia-Herzegovina is one of the most landmine-contaminated countries in Europe. Since the beginning of the war in 1992, there have been 7968 recorded landmine victims, with 1665 victims since the end of the war in 1995. While many of these explosions result in death, a high proportion of these injuries result in amputation, leading to a large number of disabled individuals.

OBJECTIVE

The purpose of this study is to conduct a survey of civilian landmine victims in Bosnia-Herzegovina in order to assess the effect of landmine injuries on physical, mental, and social well-being.

METHODS

Civilian survivors of landmine injuries were contacted while obtaining care through local non-governmental organizations (NGOs) throughout Bosnia-Herzegovina to inquire about their current level of independence, details of their injuries, and access to healthcare and public space. The survey was based upon Physicians for Human Rights handbook, "Measuring Landmine Incidents & Injuries and the Capacity to Provide Care."

RESULTS

42 survivors of landmines completed the survey, with an average follow up period of 22.0 years (±1.7). Of civilians with either upper or lower limb injuries, 83.3% underwent amputations. All respondents had undergone at least one surgery related to their injury: 42.8% had at least three total operations and 23.8% underwent four or more surgeries related to their injury. 26.2% of survivors had been hospitalized four or more times relating to their injury. 57.1% of participants reported they commonly experienced anxiety and 47.6% reported depression within the last year. On average, approximately 3% of household income each year goes towards paying medical bills, even given governmental and non-governmental assistance. Most survivors relied upon others to take care of them: only 41.5% responded they were capable of caring for themselves. 63.4% of respondents reported their injury had limited their ability to gain training, attend school, and go to work.

CONCLUSION

The majority of civilian landmine survivors report adverse health effects due to their injuries, including anxiety, depression, multiple surgeries, and hospitalizations. The majority also experience loss of independence, either requiring care of family members for activities of daily living, disability, and inability to be employed. Further research is required to determine effective interventions for landmine survivors worldwide.

Polyglutamine expansion affects huntingtin conformation in multiple Huntington's disease models

Conformational changes in disease-associated or mutant proteins represent a key pathological aspect of Huntington’s disease (HD) and other protein misfolding diseases. Using immunoassays and biophysical approaches, we and others have recently reported that polyglutamine expansion in purified or recombinantly expressed huntingtin (HTT) proteins affects their conformational properties in a manner dependent on both polyglutamine repeat length and temperature but independent of HTT protein fragment length. These findings are consistent with the HD mutation affecting structural aspects of the amino-terminal region of the protein, and support the concept that modulating mutant HTT conformation might provide novel therapeutic and diagnostic opportunities. We now report that the same conformational TR-FRET based immunoassay detects polyglutamine- and temperature-dependent changes on the endogenously expressed HTT protein in peripheral tissues and post-mortem HD brain tissue, as well as in tissues from HD animal models. We also find that these temperature- and polyglutamine-dependent conformational changes are sensitive to bona-fide phosphorylation on S13 and S16 within the N17 domain of HTT. These findings provide key clinical and preclinical relevance to the conformational immunoassay, and provide supportive evidence for its application in the development of therapeutics aimed at correcting the conformation of polyglutamine-expanded proteins as well as the pharmacodynamics readouts to monitor their efficacy in preclinical models and in HD patients.

Can We Agree on Expectations and Assessments of Graduating Residents?: 2016 AOA Critical Issues Symposium

Orthopaedic educators are responsible for training a prepared and competent workforce that will provide effective care for a growing number of patients with musculoskeletal conditions. Currently, there are both internal and external forces that pose substantial challenges to medical students, residents, program directors, faculty members, and chairs in achieving this goal. One area of particular concern is the education of surgeons, whose knowledge and professional behavior must be matched by their ability to acquire procedural skills. In order to address this issue, many training systems have implemented a competency-based training approach into their curricula. This article discusses the efforts that orthopaedic training bodies in Canada and Australia have taken toward competency-based education and what steps the American Board of Orthopaedic Surgery (ABOS), the Council of Orthopaedic Residency Directors (CORD), the American Orthopaedic Association (AOA), the American Academy of Orthopaedic Surgeons (AAOS), and the Accreditation Council for Graduate Medical Education (ACGME) are considering to improve residency education in the current and future environments.

Orthopaedic education in the era of surgical simulation: Still at the crawling stage

Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulation-based curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.

Efficacy of Surgical-Site, Multimodal Drug Injection Following Operative Management of Femoral Fractures: A Randomized Controlled Trial

BACKGROUND

Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures.

METHODS

There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored.

RESULTS

The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic.

CONCLUSIONS

Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Complementary models reveal cellular responses to contact stresses that contribute to post-traumatic osteoarthritis

Two categories of joint overloading cause post-traumatic osteoarthritis (PTOA): single acute traumatic loads/impactions and repetitive overloading due to incongruity/instability. We developed and refined three classes of complementary models to define relationships between joint overloading and progressive cartilage loss across the spectrum of acute injuries and chronic joint abnormalities: explant and whole joint models that allow probing of cellular responses to mechanical injury and contact stresses, animal models that enable study of PTOA pathways in living joints and pre-clinical testing of treatments, and patient-specific computational models that define the overloading that causes OA in humans. We coordinated methodologies across models so that results from each informed the others, maximizing the benefit of this complementary approach. We are incorporating results from these investigations into biomathematical models to provide predictions of PTOA risk and guide treatment. Each approach has limitations, but each provides opportunities to elucidate PTOA pathogenesis. Taken together, they help define levels of joint overloading that cause cartilage destruction, show that both forms of overloading can act through the same biologic pathways, and create a framework for initiating clinical interventions that decrease PTOA risk. Considered collectively, studies extending from explants to humans show that thresholds of joint overloading that cause cartilage loss can be defined, that to at least some extent both forms of joint overloading act through the same biologic pathways, and interventions that interrupt these pathways prevent cartilage damage. These observations suggest that treatments that decrease the risk of all forms of OA progression can be discovered. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:515-523, 2017.

Fractures of the tibial plateau involve similar energies as the tibial pilon but greater articular surface involvement

Patients with tibial pilon fractures have a higher incidence of post-traumatic osteoarthritis than those with fractures of the tibial plateau. This may indicate that pilon fractures present a greater mechanical insult to the joint than do plateau fractures. We tested the hypothesis that fracture energy and articular fracture edge length, two independent indicators of severity, are higher in pilon than plateau fractures. We also evaluated whether clinical fracture classification systems accurately reflect severity. Seventy-five tibial plateau fractures and 52 tibial pilon fractures from a multi-institutional study were selected to span the spectrum of severity. Fracture severity measures were calculated using objective CT-based image analysis methods. The ranges of fracture energies measured for tibial plateau and pilon fractures were 3.2-33.2 Joules (J) and 3.6-32.2 J, respectively, and articular fracture edge lengths were 68.0-493.0 mm and 56.1-288.6 mm, respectively. There were no differences in the fracture energies between the two fracture types, but plateau fractures had greater articular fracture edge lengths (p < 0.001). The clinical fracture classifications generally reflected severity, but there was substantial overlap of fracture severity measures between different classes. Similar fracture energies with different degrees of articular surface involvement suggest a possible explanation for dissimilar rates of post-traumatic osteoarthritis for fractures of the tibial plateau compared to the tibial pilon. The substantial overlap of severity measures between different fracture classes may well have confounded prior clinical studies relying on fracture classification as a surrogate for severity. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:618-624, 2017.

Tibial Plateau Fractures: A New Rank Ordering Method For Determining To What Degree Injury Severity Or Quality Of Reduction Correlate With Clinical Outcome

BACKGROUND

Injury severity may be the most important factor in determining outcome after articular fractures, but there is a surprising paucity of clinical evidence to support this assertion. The purpose of this study was to utilize a new method for rank ordering a group of patient radiographs to assess the effect of injury severity and quality of reduction on patient outcomes after tibial plateau fractures.

METHODS

Tibial plateau fractures in 64 patients were treated operatively or non-operatively based on physician preference from standard of care techniques. Fracture severity and reduction quality were stratified from radiographs by four expert clinicians using an iTunes-based rank ordering methodology. The images were distributed electronically, and the ranks were performed on local computers at three different institutions. Clinical outcomes were measured with the SF-12 health questionnaire and the Knee injury and Osteoarthritis Outcome Score (KOOS).

RESULTS

There was excellent or very good agreement between raters for injury severity ranking (correlation 0.77-0.91) and quality of reduction (correlation 0.66-0.82). There was no correlation between the injury severity nor quality of reduction and general or joint-specific clinical outcomes.

CONCLUSIONS

Expert orthopaedic traumatologists strongly agree on how to rank order tibial plateau fractures based both on injury severity and quality of reduction. The novel electronic interface utilized allows an ever-expanding series of cases to be ranked quickly, conveniently, and across multiple centers. This interface holds great promise for establishing prospective, continuously expanding rank orders of various fracture types, which may have great value for clinical research, education about fracture severity, and for prognosis and treatment decisions. In the present study, neither injury severity nor quality of reduction correlated with the clinical outcomes. Other patient- and injury-related factors may be more important in determining clinical outcome of tibial plateau fractures than the appearances of the radiographs at the time of injury or after reduction. Level of Evidence: level III evidence.