Faculty Bibliography

INTRODUCTION/BACKGROUND:To aid implementing an ethics curriculum in an orthopaedic residency program, the American Academy of Orthopaedic Surgeons (AAOS) created 14 ethics scenarios. Because delivery of this curriculum could be burdensome, an online module-based curriculum might be optimal. METHODS:Two cohorts of orthopaedic residents participated: cohort I completed 14 online ethics modules converted from the 14 AAOS ethics scenarios. For each module, we gave a multiple-choice assessment immediately before the module, immediately afterward, and 3 months afterward. Cohort II completed only the 14-module assessments at similar time intervals without any educational content. RESULTS:Cohort I demonstrated improvement in 3-month postmodule assessment scores in 11 of the 14 modules, 3 of which had statistical differences in baseline scores for cohort I and cohort II. We observed no statistical difference in scores within cohort II on repeat testing. DISCUSSION/CONCLUSIONS:This study demonstrates that 11 of the 14 AAOS ethics scenarios, converted to online modules, teach ethical concepts to orthopaedic residents. Orthopaedic residency programs may find it valuable to engage their residents in the ethics scenarios created by the AAOS to complement their ethics curriculum.

The aim of this investigation was to examine graduating orthopedic resident case logs to evaluate trends in performing pediatric orthopedic procedures and compare pediatric orthopedic case volume among residents in the 90th, 50th, and 10th percentiles (by case volume) to identify caseload variation. Accreditation Council for Graduate Medical Education orthopedic resident case logs were examined for graduating years 2007-2013. Linear regression analyses were carried out to assess temporal trends in pediatric orthopedic case volume. Subgroup analyses were carried out to assess trends in cases by anatomic location. Comparisons of the number of pediatric cases performed by the 90th, 50th, and 10th percentiles of graduating residents were also performed. Pediatric orthopedic case volume increased significantly per graduating resident (295.9-373.2; P<0.001) from 2007 to 2013. Graduating residents in the 90th (494-573; P=0.001), 50th (264-334; P<0.001), and 10th (144-216; P=0.003) percentiles of case volume all sustained significant increases in the number of pediatric orthopedic cases performed. Subgroup analyses showed significant increases in pediatric orthopedic shoulder (4.8-7.3; P<0.001), humerus/elbow (25.9-32.7; P<0.001), forearm/wrist (28.6-40.4; P<0.001), hand/finger (15-16.9; P=0.005), femur/knee (44.5-51.9; P=0.002), leg/ankle (39.4-41.1; P=0.004), and spine case volume (24.9-33.6; P<0.001). On average, graduating residents in the 90th, 50th, and 10th percentiles performed 524, 302, and 169 cases, respectively. The current investigation shows significant growth in the number of pediatric orthopedic cases performed by graduating residents, particularly among upper extremity procedures. However, considerable variation in pediatric orthopedic case volume exists among residents. Although the educational effects of this case volume variation are incompletely understood, the current investigation may be beneficial in efforts to improve pediatric orthopedic educational quality.

OBJECTIVES/OBJECTIVE:1) Demonstrate that a validated trauma triage score for middle-aged and geriatric patients could identify those at high risk for mortality within the first two days of hospitalization and 2) determine the cost of care for this cohort of patients DESIGN:: Prospective cohort study SETTING:: Single Level 1 Trauma Center PATIENTS:: Patients 55 years and older who were evaluated in the emergency department setting by Orthopaedics or who met American College of Surgeons Tier 1-3 criteria INTERVENTION:: Calculation of validated trauma triage score, Score for Trauma Triage in Geriatric and Middle Aged (STTGMA), using patient's demographic, injury severity, and functional statusMain Outcome Measurements: length of stay, inpatient mortality, time between presentation and time of death, and direct variable costs of hospitalization RESULTS:: A total of 1470 consecutive patients (mean age of 72.2±11.9 years) were enrolled in this study, 17 of whom expired within 48 hours of presentation to the emergency department. These patients had a significantly higher trauma triage score than the rest of the cohort with a score of 50.9%±37.2% vs. 3.3%±9.5%, p<0.001 indicating that they had a mean risk of inpatient mortality of over 50%. Mean total cost/day was much higher in the cohort of patients who died within 48 hours of admission compared to all other trauma patients ($49,367±$79,057 vs. $3,966±$2,897 (p=0.031)). CONCLUSION/CONCLUSIONS:To achieve value-based care in this high-risk cohort, targeted cost-savings while improving patient outcomes and/or expediting goals-of-care and end-of-life goals is necessary and the STTGMA score allows for stratification of these patients in both mortality risk and cost profile. LEVEL OF EVIDENCE/METHODS:Prognostic, Level III.

BACKGROUND:Clinician-scientist numbers have been stagnant over the past few decades despite awareness of this trend. Interventions attempting to change this problem have been seemingly ineffective, but research residency positions have shown potential benefit. OBJECTIVE:We sought to evaluate the effectiveness of a clinician-scientist training program (CSTP) in an academic orthopedic residency in improving academic productivity and increasing interest in academic careers. METHODS:Resident training records were identified and reviewed for all residents who completed training between 1976 and 2014 (n = 329). There were no designated research residents prior to 1984 (pre-CSTP). Between 1984 and 2005, residents self-selected for the program (CSTP-SS). In 2005, residents were selected by program before residency (CSTP-PS). Residents were also grouped by program participation, research vs. clinical residents (RR vs. CR). Data were collected on academic positions and productivity through Internet-based and PubMed search, as well as direct e-mail or phone contact. Variables were then compared based on the time duration and designation. RESULTS:Comparing all RR with CR, RR residents were more likely to enter academic practice after training (RR, 34%; CR, 20%; p = 0.0001) and were 4 times more productive based on median publications (RR, 14; CR, 4; p < 0.0001). Furthermore, 42% of RR are still active in research compared to 29% of CR (p = 0.04), but no statistical difference in postgraduate academic productivity identified. CONCLUSIONS:The CSTP increased academic productivity during residency for the residents and the program. However, this program did not lead to a clear increase in academic productivity after residency and did not result in more trainees choosing a career as clinician-scientists.

INTRODUCTION: Much has been studied with reference to methicillin resistant Staphylococcus aureus (MRSA) and methicillin sensitive S. aureus (MSSA) colonization and associated outcomes and comorbidities. In the area of Orthopedic surgery, literature predominantly comes from the field of arthroplasty. Little is known about outcomes of fracture and Orthopedic trauma patients in the setting of S. aureus colonization. We believe that MRSA/MSSA colonization in and of itself may be a weak marker for generally poor protoplasm, potentially with complex medical history including previous hospitalization or rehab placement. This milieu of risk factors may or may not contribute to poorer outcomes after fracture and fracture nonunion surgery. The purpose of this study is to determine if nasal swabbing for S. aureus (MRSA or MSSA) carriage can predict operative culture, complications, or outcomes following fracture nonunion surgery. METHODS: Sixty-two consecutive patients undergoing surgery for fracture nonunion were prospectively followed. Data analyses were performed using grouped MRSA and MSSA carriers (Staphylococcus carriers: SC). Outcomes analyzed included time to healing, need for additional surgery, and persistent nonunion. RESULTS: Twenty-six percent of patients (16/62) were identified as MSSA carriers, an additional 6.5% (4/62) carried MRSA. Follow-up of at least 12-months was obtained on 90% (56/62) of patients. White blood cell counts, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values did not differ between SCs and non-carriers pre-operatively. Carriers were just as likely as non-carriers to culture positively for any pathogen at the time of surgery. Although SC's were three times as likely as non-carriers to grow S. aureus (15% vs. 5%), this difference did not reach statistical significance (p=0.3). Post-operative wound complications, antibiotic use, pain at follow-up and progression to healing did not differ between groups. CONCLUSIONS: Ultimately, pre-operative nasal swabbing for S. aureus is a simple and non-invasive diagnostic tool with prognostic implications in patients undergoing fracture nonunion surgery. This study found that MRSA and MSSA colonized patients with fracture nonunion of long bones do not have an increased association with positive cultures or a predisposition towards greater post-operative infectious complications.

PURPOSE/OBJECTIVE:To describe one center's experience with nonunion of one or both bones of the forearm and report on the functional recovery of patients treated for a single- or 2-bone forearm nonunion. METHODS:We performed a retrospective analysis of 23 patients who presented to our institution over an 11-year period and underwent surgical repair of a forearm nonunion (radius, ulna, or both bones). The main outcome measurements included time to union, visual analog scale pain scores, range of motion, Short Musculoskeletal Function Assessment scores, and postoperative complications. RESULTS:Of the 23 patients, 21 (91.3%) healed their nonunion after a single surgical procedure. All patients ultimately healed their nonunion; 7 patients were healed at 3-month follow-up, 11 healed at 6-month follow-up, and 5 healed at 12-month follow-up. Mean visual analog scale pain scores improved considerably from presentation to latest follow-up. The mean range of motion at the latest follow-up was as follows: elbow 130.9° flexion-extension arc, forearm 78.5° pronation/77.8° supination, and wrist 76.1° palmar flexion/74.3° dorsiflexion. Mean Short Musculoskeletal Function Assessment arm and hand index scores improved significantly from baseline to the latest follow-up. Mean Short Musculoskeletal Function Assessment function, activity, and bothersome indices demonstrated improvement, though this was not statistically significant. Two patients required further surgery to achieve osseous union. One patient sustained an iatrogenic posterior interosseous nerve palsy, which resolved spontaneously. CONCLUSIONS:Repair of forearm nonunion with compression plating and bone grafting provides reliable clinical and functional outcomes. Patients treated surgically for nonunion of one or both of the forearm bones can expect to heal with the potential for considerable improvements in pain and function postoperatively. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic IV.

Sharps-related injuries represent a significant occupational hazard to orthopedic surgeons. Despite increased attention and targeted interventions, evidence suggests that the majority of incidents continue to go unreported. The purpose of this study was to examine the incidence, attitudes, and factors that affect the reporting of sharps injuries among orthopedic surgery residents at a large academic teaching hospital in an effort to increase reporting rates and design effective interventions. This study administered an anonymous cross-sectional survey regarding intraoperative sharps exposures to current orthopedic house staff, with an 87% (54/62) response rate. Overall, 76% of surveyed residents (41/54) had at least one sharps exposure during residency. The majority of these incidents (55%) were never reported. The most common reason cited for not reporting was a "perception of low risk." Residents whose exposures were witnessed by others on the surgical team were more likely to report the incident (57% vs. 23%, p = 0.043), suggesting that peer pressure acts to improve reporting rates. While the implementation of a "needlestick hotline" and increased education has led to improved reporting rates at our institution, further improvements aimed at reducing unwitnessed incidents, and therefore unreported incidents, could comprise an increased emphasis on surgical team vigilance, positive peer pressure, the incorporation of sharps-specific surgical debriefing statements and anonymous tip lines.

OBJECTIVES/OBJECTIVE:To assess the role self-reported treatment for a psychiatric diagnosis may play in long-term functional outcomes after operatively managed tibial plateau fractures. DESIGN/METHODS:Prospective cohort study. SETTING/METHODS:Academic medical center. PATIENTS/METHODS:Over an 11-year period, patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an IRB-approved registry. A total of 245 patients were included in the study. Twenty-one patients reported treatment for a psychiatric diagnosis. INTERVENTION/METHODS:Surgical repair of tibial plateau fractures. MAIN OUTCOME MEASURE/METHODS:Patients were divided into 2 cohorts; 1 cohort being those who self-reported receiving treatment of a psychiatric diagnosis (PI); the other group being those who did not self-report receiving treatment of a psychiatric diagnosis (NPI). Three-month, 6-month, and long-term outcomes (mean = 18 months) were evaluated using the Short Musculoskeletal Function Assessment (SMFA), pain scores, and postoperative complications (infection, VTE, nonunion, and necessity for secondary operations). RESULTS:Pain scores were higher in patients who self-reported receiving treatment for a psychiatric diagnosis (P = 0.012). Long-term functional outcomes as measured by the SFMA were demonstrated to be worse in patients who self-reported treatment for a psychiatric diagnosis (P = 0.034). No differences existed between groups in regards to postoperative complications. Multiple linear regression analysis revealed that being treated for diagnosis of a mental health illness was an independent predictor of worse functional outcomes at long-term follow-up [B = 8.874, 95% confidence interval (CI) = 0.354-17.394, P = 0.041]. CONCLUSIONS:Mental health plays a crucial role in long-term outcomes after operative fixation of tibial plateau fractures. Patients who have been diagnosed with a mental health illness have significantly worse outcomes at long-term follow-up. LEVEL OF EVIDENCE/METHODS:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES/OBJECTIVE:To assess clinical and hospital quality outcomes of patients receiving the previously reported Reduced Effective Dose Using Computed Tomography In Orthopaedic iNjury (REDUCTION) imaging protocol. DESIGN/METHODS:Retrospective Chart review SETTING:: Level I Trauma Center and affiliated Tertiary Care Hospital CenterPatients/Participants: fifty patients who received this protocol for acute traumatic fracture evaluation and met inclusion criteria were compared to a cohort of fifty patients matched for age and fracture type who previously received conventional CT scanning for acute traumatic fracture evaluation. INTERVENTION/METHODS:Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol for diagnostic fracture evaluation. MAIN OUTCOME MEASURES/METHODS:Estimated effective radiation doses were calculated and compared using Digital Imaging and Communications in Medicine (DICOM) information from all included studies. Patient outcomes between groups were compared with time to fracture union as the primary outcome. Secondary outcome measures included: presence of complication defined as infection, malunion, nonunion, failure of non-operative treatment, painful implants, and implant failure. Other secondary quality outcomes that were recorded included readmission within 30 days and hospital length of stay. Functional quality measures included joint range of motion. Statistical analyses were conducted to identify significant differences between cohorts (significance designated as p<0.05). RESULTS:Patient characteristics between cohorts were not significantly different with respect to age, gender, body mass index, comorbidities, injury mechanism or injury location. Fractures of the elbow, hip, knee, and foot/ankle were evaluated. Mean clinical follow-up was 9.5 ± 4.9 months for the REDUCTION cohort and 12.4 ± 5.3 months for conventional CT cohort. Mean estimated effective dose for all REDUCTION scans was 0.15 milliSieverts (mSv) as compared to 1.50 mSv for the conventional CT cohort (p=0.037). Pre-operative diagnosis was confirmed intra-operatively in 49/50 cases in the REDUCTION cohort compared to 48/50 cases in the conventional CT cohort (p=0.79). Outcomes including time to union, range of motion, complications, readmission, treatment failure, reoperation, and length of stay were not significantly different between groups. CONCLUSIONS:The REDUCTION protocol represents an ultra low dose CT scan developed for minimizing radiation exposure to patients presenting with traumatic fractures. This protocol resulted in a ten-fold reduction in radiation exposure. No difference in clinical or hospital quality outcomes was detected between patients who received this protocol as compared to those receiving automated dose CT scans. The REDUCTION protocol is a safe and effective method of performing CT scans for extremity fractures with significantly reduced radiation risk. LEVEL OF EVIDENCE/METHODS:Retrospective Case-Control Study, Level III Evidence.