Faculty Bibliography

BACKGROUND:Resident burnout-the state of exhaustion, maladaptive detachment, and low sense of accomplishment-is a widely documented phenomenon that affects between 27% and 75% of residents in the United States. To our knowledge, no previous study has examined the relationship between resident burnout and performance on the Orthopaedic In-Training Examination (OITE). The current investigation sought to evaluate whether an association exists between indices of orthopaedic surgery resident burnout as assessed by the Maslach Burnout Inventory (MBI) and performance on the OITE. METHODS:In a cross-sectional study of the orthopaedic surgery residents at a single large academic institution, the MBI was completed by all trainees in May 2016. The results of the 2016 OITE were documented for each resident, including the percentage of correctly answered questions and OITE percentile ranking. To control for individual test-taking skills, United States Medical Licensing Examination (USMLE) Step-1 and Step-2 scores also were documented for each resident. The relationship between the MBI subscale scores and OITE performance was evaluated. RESULTS:The analysis included 100% of the 62 orthopaedic surgery residents in training at our institution. Sixteen (25.8%) of the residents experienced at least moderate emotional exhaustion, while 32 (51.6%) of the residents experienced at least moderate depersonalization and 8 (12.9%) of the residents experienced a moderate sense of impaired personal accomplishment. Postgraduate year (PGY)-2 residents had the highest emotional exhaustion and depersonalization scores compared with residents in other years of training. Each of the 3 MBI indices of burnout was associated with worse OITE performance when controlling for general test-taking ability. CONCLUSIONS:In this study of orthopaedic surgery residents at a large academic training program, burnout was present among residents in all PGYs of training; it was most prevalent during the second year of training. Increased levels of the 3 components of burnout were associated with worse performance on the OITE. While there is a lack of consensus in the existing literature, this study provides additional evidence that burnout is negatively associated with 1 aspect of overall resident performance. CLINICAL RELEVANCE/CONCLUSIONS:Orthopaedic surgery residency training is challenging; residents are tasked to acquire a considerable amount of knowledge, develop complex surgical skills, and hone critical clinical thinking in a relatively short period of time. Identifying modifiable contributors to resident burnout and the development of strategies to promote resident wellness during training are important as we strive toward developing the next generation of capable, competent, and well-balanced orthopaedic surgeons.

BACKGROUND:Synovial fluid biomarkers can highlight the molecular milieu associated with knee pathology and have been shown to be significantly different in patients with anterior cruciate ligament (ACL) injuries compared to uninjured controls. The purpose of the current study was to establish how synovial fluid biomarker concentrations change in patients undergoing ACL reconstruction between the immediate preoperative period to the acute postoperative period. METHODS:Patients were prospectively enrolled at the time of surgery from September 2016 to March 2017. Patients who had an operative knee synovial fluid sample obtained at the time of ACL reconstruction and provided a synovial fluid sample at their first postoperative appointment were included. The concentrations of 10 biomarkers were determined using a multiplex magnetic bead immunoassay. Biomarker concentrations before and after surgery were compared using a paired sample t-test. RESULTS:Eight patients with mean age of 33.4 years who underwent isolated ACL reconstruction using a bonepatellar tendon-bone autograft were included. The mean time between surgery and postoperative office visit was 10.4 days. There was a statistically significant increase in the concentrations of interleukin-6 (IL-6, p = 0.014), monocyte chemoattractant protein-1 (MCP-1, p = 0.024), human matrix metalloproteinase 3 (MMP-3, p = 0.00002), macrophage inflammatory protein-1 beta (MIP-1β, p = 0.006), human interleukin-1 receptor antagonist (IL-1Ra, p = 0.017), and vascular endothelial growth factor (VEGF, p = 0.023) between the time of surgery and the first postoperative visit and a decrease in the concentration of tissue inhibitor of metalloproteinase-2 (p = 0.050). CONCLUSION/CONCLUSIONS:The molecular profile of the synovial fluid changes in the early postoperative period following arthroscopic ACL reconstruction. The concentration of proinflammatory markers (such as IL-6, MCP-1, MMP-3, and MIP-1β) and growth factors including VEGF increases. The concentration of the anti-inflammatory marker tissue inhibitor of metalloproteinase-2 (TIMP-2) appears to decrease postoperatively.

PURPOSE/OBJECTIVE:This study attempts to establish whether local adiposity of the knee at the level of the joint line is associated with alterations in synovial fluid biomarker concentrations in patients undergoing ACL reconstruction with or without an associated meniscectomy. METHODS:Patients undergoing ACL reconstruction were prospectively enrolled at the time of surgery from July 2011 to January 2015. Synovial fluid samples were collected just prior to incision and the concentrations of 10 biomarkers of interest were determined using a multiplex magnetic bead immunoassay. Knee adiposity was assessed via measures of leg fat area using magnetic resonance axial T2 images at the level of the joint line. Measurement was determined by subtracting the sum of the joint area, consisting of bony and muscle areas, from the total leg area with six different ratios assessed. Groups were evaluated by injury type (isolated ACL, ACL + meniscal injury, and total cohort). The correlation between synovial fluid biomarker levels and leg fat area ratios was evaluated using Spearman's correlation. RESULTS:There were 22 females and 26 males, with a mean age of 33.8 years (± 10.5) and a mean BMI of 25.3 (± 4.0). In the setting of isolated ACL injury, there was a statistically significant correlation between leg fat ratios and interleukin- 6, vascular endothelial growth factor, and interleukin-1 receptor antagonist. In patients with concomitant meniscal tears, there was an inverse correlation between leg fat ratios and monocyte chemoattractant protein-1. CONCLUSION/CONCLUSIONS:The leg fat to total leg volume ratio and leg fat to joint space volume ratio were the most consistent measures for alterations in post-injury synovial fluid biomarker concentrations. Analysis of synovial fluid at the time of ACL reconstruction demonstrated significant correlations between specific leg-fat area ratios and synovial fluid biomarker concentrations. Local adiposity around the knee joint appears to modulate the biochemical environment of the joint and can clinically help guide prognostic discussions with the patient.

Background: Pectoralis major ruptures are increasing in incidence primarily due to an increase in awareness, activity level among young males between 20 - 40 years of age, and use of anabolic steroids. Although the majority of pectoralis major ruptures are acute injuries, many chronic ruptures are unrecognized and it is imperative to understand proper evaluation of these injuries, as well as the appropriate treatment for acute and chronic ruptures. Purpose: Pectoralis major ruptures can lead to deformity and physical disability if left untreated. This review paper discusses the both acute and chronic ruptures as well as indications for nonoperative treatment and operative treatment to give the reader the best understanding of this diagnosis and proper management. Methods: A systematic review of the literature was performed using a search of electronic databases. Search terms such as pectoralis major rupture, pectoralis major repair, pectoralis major tendon transfer and pectoralis major nonoperative treatment were used. Case reports, systematic reviews, prospective and retrospective studies were included to provide a comprehensive review. The only exclusion criteria consisted of studies not published in English. This review article includes the anatomy and biomechanics of the pectoralis major muscle, proper evaluation of the patient, operative and nonoperative treatment of acute and chronic pectoralis major ruptures, and outcomes of the recommended treatment. Conclusion: Nonoperative treatment is indicated for patients with medical comorbidities, older age, incomplete tears, or irreparable damage. Patients treated non-operatively have been shown to lose strength, but regain full range of motion. Patients with surgery before 6 weeks reported better outcomes than patients with surgery between 6-8 weeks. The chronicity of the rupture (>8 weeks) increases likelihood of reconstruction, involving the use of autografts or allografts. Patients treated with delayed repair had significantly better strength, satisfaction and outcomes than patients with nonoperative treatment. The pectoralis tendon can also be transferred in patients with rotators cuff tears, atrophy, or significant functional limitation. Tendon transfers have been shown to have unpredictable outcomes, but overall satisfactory results.

Objectives: The current opioid epidemic necessitates physicians to seek ways to decrease patients' requirements of narcotic medications without sacrificing their postoperative comfort level. This study evaluated patients' pain following arthroscopic shoulder instability repair and compared the use of narcotic medications between patients prescribed NSAIDs with rescue opioid prescription to those prescribed opioids alone. We hypothesized there would not be a significant difference in postoperative pain and addition of NSAIDs would result in decreased opioid use.
Method(s): Forty patients scheduled to undergo an arthroscopic shoulder instability repair were randomized to receive Ibuprofen 600mg and a 10-pill rescue prescription of Percocet 5/325mg (n=20) or Percocet 5/325mg (n=20). Primary outcomes were the amount of Percocet tablets used in the first week and VAS on postoperative day (POD) 1, 4, and 7. Statistical analysis was done using independent t-tests and bivariate analysis for correlation. Findings were considered significant at p<0.05.
Result(s): Forty patients with a mean age of 35.08 (+/- 8.48)were enrolled between December 2017 and May 2018. The total amount of opioid consumption was statistically significantly lower in the multimodal group compared to the opioid group (p <0.04) as well as Percocet consumption between POD 0-4 (p <0.04). There were no significant differences in VAS at any point between the two groups. One patient in the Ibuprofen cohort experienced dizziness on POD 1. Two patients in the Percocet cohort experienced nausea and vomiting on POD 1 and POD 4.
Conclusion(s): Multimodal analgesia using NSAIDs with an opioid rescue prescription has resulted in significant reduction in postoperative narcotic consumption. As both cohorts showed similar pain levels, it is possible to alleviate postoperative pain with lower amounts of opioids than are currently being prescribed. The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of post-operative narcotics distribution

Objectives: Changes in the joint microenvironment following an intra-articular injury have been implicated in the pathogenesis of knee osteoarthritis. Few studies have evaluated alterations in the joint microenvironment in the setting of meniscus injury. The purpose of the current study was to determine the changes in synovial fluid biomarker concentrations caused by meniscus pathology by comparing samples from injured, symptomatic knees to samples from asymptomatic contralateral knees.
Method(s): Patients undergoing surgery for unilateral meniscus injury were prospectively enrolled in this institutional review board approved study from October 2011 to December 2016. A cohort was formed consisting of patients that had synovial fluid samples collected from both the injured and contralateral uninjured knee at the time of arthroscopic surgery. Patients with ligamentous injury of the knee were excluded from the current analysis. Synovial fluid samples were collected just prior to incision and the concentrations of 10 biomarkers of interest were determined using a multiplex magnetic bread immunoassay.
Result(s): The current analysis included synovial fluid samples from 82 knees (41 operative and 41 contralateral knees) from 41 patients undergoing arthroscopic surgery to treat a symptomatic meniscus injury. The mean age of patients was 49.86 +/- 11.75 years. Based on linear mixed effects models, there were significantly greater concentrations of 4 of the 5 pro-inflammatory biomarkers in symptomatic knees compared to asymptomatic knees when controlling for the duration of symptoms, BMI, age, and the random effects of by-patient variability. Knees with symptomatic meniscus injuries had 126.8 times greater concentration of IL-6, 2.7 times greater concentration of MCP-1, 2.0 times greater concentration of MIP-1beta, and 5.4 times greater concentration of MMP-3 compared to the contralateral, asymptomatic knee (Table 1). When controlling for the chronicity of the injury, presence of synovitis, and age of the patient, knees with concomitant high-grade cartilage lesions (ICRS 3 or 4) were associated with 2.1 times greater concentration of MCP-1, 1.9 times greater concentration of MIP-1beta, and 3.4 times greater concentration of VEGF compared to knees with concomitant low-grade cartilage lesions (ICRS 1 or 2). When controlling for the other variables, the presence of synovitis was associated with an 89.5% lower concentration of TIMP-1 compared to operative knees without synovitis. The age of the patient was found to affect the concentrations of IL-6, MCP-1, and VEGF. For all knees included in the study, each 1 year increase in age was associated with a 6% increase in IL-6, 3% increase in MCP-1, and 4% increase in VEGF (Figure 1).
Conclusion(s): This study is the first that examines the synovial fluid biomarker concentrations in the setting of a symptomatic isolated meniscus injury. We demonstrated that 4 of the 5 proinflammatory biomarkers that were tested are found in greater concentration in the symptomatic knee. Furthermore, we described the effects of associated cartilage damage, synovitis, and patient age on biomarker concentrations. Understanding the implication of these alterations in the intra-articular microenvironment in the setting of meniscal pathology may hold the key to identifying treatment targets in an effort to prevent the onset of post-meniscectomy osteoarthritis. (Table Presented)

Cartilage injury, such as full-thickness lesions, predisposes patients to the premature development of osteoarthritis, a degenerative joint disease. While surgical management of cartilage lesions has improved, long-term clinical efficacy has stagnated, owing to the lack of hyaline cartilage regeneration and inadequate graft-host integration. This study tests the hypothesis that integration of cartilage grafts with native cartilage can be improved by enhancing the migration of chondrocytes across the graft-host interface via the release of chemotactic factor from a degradable polymeric mesh. To this end, a polylactide-co-glycolide/poly-ε-caprolactone mesh was designed to localize the delivery of insulin-like growth factor 1 (IGF-1), a well-established chondrocyte attractant. The release of IGF-1 (100 ng/mg) enhanced cell migration from cartilage explants, and the mesh served as critical structural support for cell adhesion, growth, and production of a cartilaginous matrix in vitro, which resulted in increased integration strength compared with mesh-free repair. Further, this neocartilage matrix was structurally contiguous with native and grafted cartilage when tested in an osteochondral explant model in vivo. These results demonstrate that this combined approach of a cell homing factor and supportive matrix will promote cell-mediated integrative cartilage repair and improve clinical outcomes of cartilage grafts in the treatment of osteoarthritis.

PURPOSE/OBJECTIVE:To evaluate the efficacy of oral nonsteroidal anti-inflammatory drugs (NSAIDs) as the primary postoperative pain medication compared with standard oral opioids following arthroscopic partial meniscectomy. METHODS:This was a single-center, prospective, nonrandomized, comparative observational study. Patients ages 18 to 65 years who were indicated for arthroscopic meniscectomy were included. Postoperatively, patients were prescribed 1 of 2 analgesic regimens: (1) ibuprofen (600 mg every 6-8 hours as needed) and 10 tablets of oxycodone/acetaminophen (5/325 mg as needed for breakthrough pain) or (2) 30 to 40 tablets oxycodone/acetaminophen (5/325 mg every 6 hours as needed). Subjects completed questionnaires at 8 hours, 24 hours, 48 hours, and 1 week after surgery, which included medication usage, visual analog scale pain score, incidence of adverse events, and patient satisfaction. RESULTS:Sixty-eight patients with mean age 51.2 years (±10.4 years) were enrolled between October 2016 and February 2017. Enrollment in the opioid group continued until 30 patients were enrolled in the NSAID group, and at final analysis there were 28 patients in the NSAID group and 40 in the opioid group. There were no significant differences in sex, visual analog scale pain score, or patient satisfaction between the 2 groups at any time point. Patients in the opioid group had a significantly higher mean opioid consumption on postoperative day 1 (1.1 vs 0.5 tablets, P < .03) and postoperative days 3 to 7 (2.6 vs 0.5 tablets, P < .02) compared with NSAID group patients. There was a trend toward greater total (1 week) opioid usage (4.7 vs 2.0 tablets) in the opioid group; however, this was not statistically significant (P < .08). Fifty-three percent of opioid group patients independently chose to forego their opioid medication for an over-the-counter NSAID and/or acetaminophen instead. No patients requested a medication refill. CONCLUSIONS:We found no significant difference in pain control, satisfaction, and total 1-week opioid use between patients prescribed NSAIDs with opioids and those prescribed opioids alone. All patients used only limited amounts of opioids to control postoperative pain, suggesting we are currently overprescribing opioids after arthroscopic partial meniscectomy. LEVEL OF EVIDENCE/METHODS:Level II, prospective comparative study.

BACKGROUND:Despite advances in technology, graft rupture rates reported in the literature following anterior cruciate ligament (ACL) surgery range from 1.8% to 18%. Recent anatomical studies have identified a lateral structure, the anterolateral ligament (ALL), as a potential source of residual pivoting following ACL reconstruction. The purpose of this report is to review the history surrounding the ALL and recent anatomic studies, identify its biomechanical and clinical implications, and develop a practical approach to utilizing it during ACL reconstruction. METHODS:An extensive review of the historical and current literature surrounding the identification of the ALL, its biomechanical function, reconstruction, and outcomes of ALL reconstruction was performed. DISCUSSION/CONCLUSIONS:After the storm of media coverage surrounding the "new ligament" known as the ALL, much attention was focused on cadaveric dissection, biomechanical analysis, and reconstruction of this structure. Several techniques have been described, and currently studies are being performed both retrospectively and prospectively to evaluate the added benefit of ALL reconstruction to the rotational stability of the knee and outcomes after ACL reconstruction. CONCLUSION/CONCLUSIONS:The ALL is a lateral-based structure that provides rotational stability to the knee in the presence of ACL deficiency. Reconstruction of this ligament may provide added benefit to stability and outcomes following ACL reconstruction in certain patient populations. Further randomized controlled trials are needed to elucidate the true benefit of ALL reconstruction and those patients who should undergo this added procedure.

OBJECTIVE:An important part of clinical training is learning how to identify and prevent hospital-acquired conditions or injuries. Despite this, there are few standardized methods in graduate medical education (GME) for teaching and assessing resident patient safety skills. Residents often do not report safety events, and increasing resident engagement can positively impact patient safety. In the current study, we sought to apply such a tool in gauging the capacity of orthopedic surgery interns at a large academic medical center to identify patient safety hazards and begin a discussion regarding the management of potential patient safety issues. METHODS:A total of 27 orthopedic surgery interns at a single large academic medical center participated in the current observational study divided into two distinct groups in the summers of 2016 and 2017. A patient room was simulated with a training mannequin lying supine in a hospital bed. A mock patient chart and handoff were created in the electronic medical record (EMR) on the bedside computer. Patient safety hazards and errors of care were placed around the room and in the EMR, including several derived from the Joint Commission's National Patient Safety Goals. Each intern was given a maximum of 20 minutes to identify as many of the simulated patient safety hazards as possible. A debrief was conducted at the end of the exercise to discuss their responsibility to speak up when hazards are identified in a non-simulated patient room. For analysis, the hazards were distributed into four categories: room organization, EMR, patient care, and white board. Each intern's individual score (number of complete identifications/total number of hazards) and the group's performance as a whole in each category were calculated. RESULTS:The mean individual score was 51.54% (26.67% to 70.00%) in group A and 40.41% (25.71% to 54.29%) in group B. In group A, room organization hazards were identified more than any other category (74.62%), followed by patient care errors (40.38%), EMR hazards (40.17%), and white board errors (38.46%). In group B, room organization was identified the most (57.74%), followed by EMR (50%), and patient care and white board hazards (28.57% each). Certain critical safety hazards were identified by a small number of interns. For example, the inadequate handoff was only identified by four interns in each group. CONCLUSIONS:Hazards related to room cleanliness were easier to identify than hazards related to specific errors in patient care. A wide variation in the identification of critical safety issues was observed among the trainees assessed. This type of simulated educational experience provides important opportunities for resident-specific education in the realm of patient safety and health care quality.