Faculty Bibliography

Osteotomies around the knee are an effective procedure that shifts the weight-bearing axis from the pathologic side to the uninvolved side to alleviate pain, unload cartilage transplantations, slow down the progression of arthritis, and protect ligament reconstructions. The advancement in plates from nonlocking to locking have increased the stability of constructs to allow for early mobilization and maintained corrections. Further developments with patient-specific instrumentation have made these techniques more reproducible and accurate. Bone grafting and biologics remain a topic of debate but likely a helpful adjuvant in the context of larger corrections or joint preservation surgeries.

Tibial tuberosity osteotomy (TTO) is a well-described treatment option for a broad range of patellofemoral joint disorders, including patellofemoral instability, focal chondral lesions of the patellofemoral joint, and patellofemoral arthritis. The purpose of this article is to review the indications and highlight the surgical technique for the more commonly performed TTO procedures and discuss outcomes, as well as surgical pearls for this technique.

BACKGROUND/UNASSIGNED:The majority of orthopaedic residents match into fellowship in the subspecialty they are most interested in at the start of residency, however there is a lack of understanding of medical student interest in orthopaedic subspecialties. Our objective was to determine interest in arthroplasty among medical students interested in orthopaedic surgery, and to identify factors contributing to student interest and disinterest.. METHODS/UNASSIGNED:An anonymous online survey was developed and distributed to medical students interested in orthopaedic surgery at 23 United States allopathic and osteopathic medical schools through their school administrators. Descriptive statistics were calculated, and a Fisher's exact test was used for categorical variables. RESULTS/UNASSIGNED:183 medical students (56% female) completed the survey for an estimated 29% response rate. Significantly fewer female medical students were interested in adult reconstruction compared to their male counterparts (10% versus 29%, p = 0.004). The most commonly identified factors contributing to interest by female students were interest in the subject matter (100%) and patient population (70%), while male students most commonly identified clinical experience (74%) and presence of a mentor (63%). Significantly fewer female medical students received the suggestion to pursue arthroplasty compared to males (0% versus 11%, p = 0.002). CONCLUSION/UNASSIGNED:V.

OBJECTIVES/OBJECTIVE:Diabetes mellitus is a complex heterogenous metabolic disease that significantly affects the world population. Although many treatments exist, including medications such as metformin, sulfonylureas, and glucagon-like peptide-1 (GLP) receptor agonist, there is growing interest in finding alternative methods to noninvasively treat this disease. It has been previously shown that low-intensity ultrasound stimulation of pancreatic β-cells in mice can elicit insulin secretion as a potential treatment for this disease. This is desirable as therapeutic ultrasound has the ability to induce bioeffects while selectively focusing deep within tissues, allowing for modulation of hormone secretion in the pancreas to mitigate insufficient levels of insulin. METHODS:was administered 5 minutes continuously, that is, 100% duty cycle, to donor pancreatic human islets, followed by 1 hour incubation and RT-qPCR to assess the effect of ultrasound stimulation on gene expression. The genes were insulin (INS), glucagon (Glu), amylin (Amy), and binding immunoglobulin protein (BiP). Nine donor pancreatic human islets were used to assess insulin and glucagon secretion, while eight samples were used for amylin and BiP. Fold change (FC) was calculated to analyze the effect of ultrasound stimulation on the gene expression of the donor islet cells. High-glucose and thapsigargin-treated islets were utilized as positive controls. Cell viability testing was done using a Trypan Blue Exclusion Test. RESULTS:Ultrasound stimulation did not cause a statistically significant upregulation in any of the tested genes (INS FC = 1.15, P-value = .5692; Glu FC = 1.60, P-value = .2231; Amy FC, P-value = .2863; BiP FC = 2.68, P-value = .3907). CONCLUSIONS:The results of this study show that the proposed ultrasound treatment parameters do not appear to significantly affect gene expression of any gene tested.

BACKGROUND:The orthopaedic surgery residency match is becoming increasingly more competitive with a disproportionate number of applicants to positions. As the residency application process has become more competitive, applicants have resorted to applying broadly to improve their chance of a successful match. Preference signaling was implemented for orthopaedic surgery for the 2022-2023 match cycle which allowed applicants to "signal" 30 programs of their choosing. METHODS:The purpose of this study was to assess the impact of preference signaling on orthopaedic surgery applicant experiences and outcomes in the 2023 residency application cycle and match. An anonymous electronically based survey study developed using Research Electronic Data Capture (REDCap) was send to 895 applicants to a single orthopedic residency program. 148 applicants filled out some portion of the survey for a 16.5% response rate. RESULTS:51% of applicants applied to 61-100 programs. Applicants received more interview offers from programs they signaled compared to programs they did not signal. 50% of applicants responded that the number of allotted signals was "just right", with more applicants responding that the number of signals allotted was "too many" rather than "too few". 62% of applicants agreed that signaling increased his/her chances of receiving an interview offer at a signaled program, 66% were satisfied with the results of the match, and 50% thought signaling had a positive impact on the application process. CONCLUSION:.

INTRODUCTION:There is concern that the direct anterior (DA) approach is associated with a steeper learning curve than the posterolateral (PL) approach in total hip arthroplasty (THA). The purpose of this study was to investigate if the learning curve is similar for newly trained arthroplasty fellowship-trained surgeons using the DA and PL approaches. METHODS:The first 100 primary THA cases of six DA and PL fellowship-trained arthroplasty surgeons were identified and divided into 50 case cohorts. Demographics, indications for surgery, and 90-day Hip Society standardized complications were collected. Variables were analyzed using independent sample t tests, chi-square tests, or Fisher exact tests. RESULTS:In total, there were 600 patients, and no notable differences were observed in revision surgeries, surgical complications, and total complications between the DA and PL groups. Both groups had lower revision surgery rates, surgical complications, and total complications during their second 50 cases. Higher revision surgeries, and surgical and total complication rates were observed among all surgeons during the first 50 cases. DISCUSSION AND CONCLUSION:No differences were observed in the learning curve when comparing the DA and PL approach. With proper training, early-career surgeons can safely perform THA with similar complication rates regardless of the approach.

Understanding global body balance can optimize the postoperative course for patients undergoing spinal or lower limb surgical realignment. This observational cohort study aimed to characterize patients with reported imbalance and identify predictors. The CDC establishes a representative sample annually via the NHANES. All participants who said "yes" (Imbalanced) or "no" (Balanced) to the following question were identified from 1999-2004: "During the past 12 months, have you had dizziness, difficulty with balance or difficulty with falling?" Univariate analyses compared Imbalanced versus Balanced subjects and binary logistic regression modeling predicted for Imbalance. Of 9964 patients, imbalanced (26.5%) were older (65.4 vs. 60.6 years), with more females (60% vs. 48%). Imbalanced subjects reported higher rates of comorbidities, including osteoporosis (14.4% vs. 6.6%), arthritis (51.6% vs. 31.9%), and low back pain (54.4% vs 32.7%). Imbalanced patients had more difficulty with activities, including climbing 10 steps (43.8% vs. 21%) and stooping/crouching/kneeling (74.3% vs. 44.7%), and they needed greater time to walk 20 feet (9.5 vs. 7.1 s). Imbalanced subjects had significantly lower caloric and dietary intake. Regression revealed that difficulties using fingers to grasp small objects (OR: 1.73), female gender (OR: 1.43), difficulties with prolonged standing (OR: 1.29), difficulties stooping/crouching/kneeling (OR: 1.28), and increased time to walk 20 feet (OR: 1.06) were independent predictors of Imbalance (all p < 0.05). Imbalanced patients were found to have identifiable comorbidities and were detectable using simple functional assessments. Structured tests that assess dynamic functional status may be useful for preoperative optimization and risk-stratification for patients undergoing spinal or lower limb surgical realignment.

BACKGROUND/UNASSIGNED:A Substantial Clinical Benefit (SCB) value is the amount of change in a patient-reported outcome measure required for a patient to feel they significantly improved from an intervention. Previously published SCB values are often cited by researchers when publishing outcomes data. Where these SCB values are set can have a large impact on the conclusions drawn from a study citing them. As such, the goal of this study was to determine the generalizability of SCB values for a procedure when stratified by time from surgery and geographic region. METHODS/UNASSIGNED:A nationwide outcomes database was utilized to obtain preoperative, one-year, and two-year postoperative outcome measurements for patients who underwent anatomic total shoulder arthroplasty (TSA) or reverse TSA. The data were divided into three geographic regions: the South, the Midwest, and the West. An East region was not included due to its limited number of patients. SCB values were calculated for four outcomes measures: Single Assessment Numeric Evaluation score, American Shoulder Elbow Surgeons score, Visual Analog Scale, and Western Ontario Osteoarthritis of the Shoulder score. SCB values were calculated for each region, for each procedure, and at both one and two years postoperatively. To determine the variability of potential SCBs within each region, simulated datasets were created to determine a distribution of possible calculated SCBs. RESULTS/UNASSIGNED:A total of 380 anatomic TSA patients and 543 reverse TSA patients were included for analysis. There was a high degree of variability of SCB values when stratified by procedure, time, and region. While some simulated datasets did produce homogenous SCB distributions among regions, some outcome measures demonstrated a large heterogeneity in distribution among regions, with concomitant large distributions of values within individual regions. CONCLUSIONS/UNASSIGNED:There is notable heterogeneity of SCB values when stratified by region or time. The current method of citing previously published SCB values for determining the efficacy of an intervention may be inappropriate. It is likely that this variability holds true in other areas of orthopedics.

BACKGROUND:Superior capsular reconstruction (SCR) can be used for massive irreparable rotator cuff tears in the absence of significant degenerative changes; however, those who fail an SCR may require reverse shoulder arthroplasty (RSA). The effect of a previously performed SCR on outcomes following RSA remains unknown. METHODS:Subjects who underwent RSA from May 2015 to January 2021 at 2 separate institutions were retrospectively identified through prospectively collected databases. Patients who underwent RSA after failed SCR were matched to those who underwent RSA after failed rotator cuff repair (RCR) based on the number of previous ipsilateral shoulder procedures (n = 1, 2, ≥3) and secondarily by age within 5 years. American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and Western Ontario Osteoarthritis of the Shoulder index (WOOS) scores were compared between groups. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) thresholds were calculated to determine clinically relevant differences between groups. RESULTS:Forty-five patients were included (32 RSA following RCR, 13 following SCR). There were more smokers (P = .001) and worker's compensation cases (P = .034) in the SCR group. The RCR cohort was older (P = .007) and had a greater incidence of mental health (P > .999) and somatic disorders (P = .698), although these did not reach statistical significance. The mean follow-up for the RCR and SCR groups were 24.2 ± 23.3 and 20.4 ± 14.9 months following RSA, respectively (P = .913). The time from index RCR or SCR to RSA were 94.4 ± 22.2 and 89.2 ± 5.3 months, respectively (P = .003). Pre- and postoperative range of motion were similar between groups, as was the overall change in forward flexion (P = .879), abduction (P = .971), and external rotation (P = .968) following RSA. The RCR group had lower postoperative VAS pain (P = .009), higher SANE (P = .015), higher ASES (P = .008), and higher WOOS (P = .018) scores. The percentage achieving the MCID (P = .676) and SCB (P > .999) were similar; however, 56.7% of the RCR group met the SANE PASS threshold compared with 0.0% in the SCR group (P = .005). There were no differences in postoperative complications (P = .698) or revision rates (P = .308) following RSA between cohorts. CONCLUSION/CONCLUSIONS:When matched for number of previous procedures to the ipsilateral extremity and age, patients who underwent RSA following failed SCR had worse clinical outcome scores than their RSA following failed RCR counterparts. No patient in the SCR group met the SANE PASS threshold, whereas more than half of the RCR group did.

The purpose of this study is to determine if arthroscopic shavers can effectively collect and process connective tissue progenitor (CTP) cells from subacromial bursal tissue for utilization in rotator cuff repair augmentation. Subacromial bursal tissue was collected and processed using two arthroscopic shavers, Shaver A and Shaver B, in 10 patients undergoing arthroscopic rotator cuff repair. Each shaver was used in a random order for the same patient. Tissue samples underwent testing for cellular proliferation, cellular concentration, number of colony-forming units (CFU), live/dead assay, fluorescence-activated cells sorting (FACS) analysis, cytokine analysis, and growth factor analysis. Shaver A produced more CFUs compared to Shaver B (210.3 vs. 125.9; p < 0.001). At 3 weeks, cells collected via Shaver A had greater cellular proliferation (0.35 vs. 0.51; p < 0.001) as well as more viable cells (214,773 vs. 132,356 cells/gram; p < 0.001). Tissue collected with Shaver B had greater amounts of the cytokines MMP-1 (3741 vs. 5500 pg/mL; p < 0.001), MMP-3 (1131 vs. 1871 pg/mL; p < 0.001), and MMP-13 (179 vs. 401 pg/mL; p < 0.001), while those collected with Shaver A had greater vascular endothelial growth factor (VEGF) (47.8 vs. 9.0 pg/mL; p < 0.05). Arthroscopic shavers are capable of harvesting and processing CTP cells from subacromial bursal tissue. Different shavers may produce different yields of viable CTP cells.