Faculty Bibliography

BACKGROUND:Children and adolescents are vulnerable to the ongoing opioid overdose epidemic in the United States. To minimize pediatric patients' exposure to opioids, efforts are underway to reduce opioid prescriptions after closed reduction and percutaneous pinning (CRPP) for supracondylar humerus fractures. Standardized pain management protocols preferentially using opioid-free analgesics are reported to be effective in managing postoperative pain and limiting the utilization of opioids. This study compares retrospective data collected before and after the implementation of a standardized postoperative pain management protocol at a large academic children's hospital. The primary aim of this study was to compare opioid prescription patterns during the 2 periods. The secondary aim of the study was to determine the effect of the protocol on minimizing prescription errors. METHODS:This Institutional Review Board-approved study was a retrospective review of pediatric patients who underwent CRPP for supracondylar humerus fractures between January 2019 and December 2021. A control cohort of patients treated before the implementation of a department-approved pain management protocol was compared with a cohort of patients treated after the implementation of a standardized postoperative pain management protocol. We compared the number of opioid prescriptions provided to patients before and after the implementation of the protocol. Descriptive statistics and chi-square analyses were used to evaluate prescribing patterns. RESULTS:After the implementation of the standardized pain medication control protocol, we observed a successful decrease in pediatric patients receiving postoperative opioids from 49.6% to 13.6% and in opioid prescribing errors from 38.6% to 12.5%. In addition, there was reduced variability in the type of narcotics prescribed. After the protocol's implementation, the most common combination of medication prescribed for postoperative pain control was acetaminophen and ibuprofen (69.5%). The chi-square test demonstrated no significant association between postoperative opioid prescription and fracture classification or length of stay. CONCLUSION/CONCLUSIONS:Opioid prescription patterns for postoperative pain management after CRPP for supracondylar humerus fractures were highly variable before the introduction of a standardized pain management protocol. The introduction of the standardized guideline effectively decreased the number of opioids prescribed at discharge, resulted in fewer opioid prescribing errors, and reduced variability in prescribing patterns among providers. LEVEL OF EVIDENCE/METHODS:Level IV-retrospective case series.

OBJECTIVE:The purpose of this study was to describe our experience using superiorly applied low-profile locking plates for the operative fixation of displaced midshaft clavicle fractures (MCFs). STUDY DESIGN/METHODS:This was a retrospective analysis performed at an academic institution. RESULTS:Eighty-three patients who presented with displaced, shortened MCFs were treated operatively by a single surgeon at our institution over a 10-year period. All patients received a precontoured low-profile locking plate applied in the superior position. A displaced midshaft clavicle fracture was fixed operatively using a precountered low-profile 2.7/3.5 mm locking plate applied in the superior position. Data were analyzed to evaluate time to union, final shoulder range of motion, incidence of hardware removal, and rate of postoperative complications. The cohort was 66.2% male with an average age at initial injury of 36.5 ± 14.1 years. At a mean of 3.6 ± 1.9 months, 99% of patients had united their fracture. At an average of 7.37-month follow-up, mean range of motion was 174° forward elevation, 173° abduction, 82° external rotation, and internal rotation to T7. Using the short musculoskeletal functional assessment (SMFA), the mean functional outcome index score was 4.12, bothersome index was 1.94, activity index was 1.55, emotion index was 2.51, arm and hand index was 1.14, mobility index was 0.68, and total index was 1.56. Ninety-two percent of patients had retained their hardware. There was 1 incidence of each of the following complications: infection, nonunion, hardware failure, and deep vein thrombosis. CONCLUSION/CONCLUSIONS:Superior clavicle plating using precontoured low-profile locking plates is an acceptable treatment modality for displaced MCF. This method yields excellent results regarding time to union, shoulder range of motion, incidence of hardware removal, and the rate of postoperative complications. Patients considering operative fixation of displaced MCF should be counseled accordingly.

IMPORTANCE/UNASSIGNED:First-generation undergraduate students are underrepresented in medicine and face challenges that affect their application and matriculation to medical school. OBJECTIVE/UNASSIGNED:To understand the barriers and available support at the individual, interpersonal, and organizational levels for first-generation students in premedical programs. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This qualitative study was part of a larger project on professional identity formation among US medical students from low socioeconomic backgrounds with a focus on first-generation undergraduate students. Semistructured online interviews of 48 students (37 of whom were first-generation students) from 27 US medical schools were conducted from November 1, 2021, through April 30, 2022, and secondary analyses regarding their premedical experiences were performed. Interviews were recorded, transcribed, deidentified, assigned an alphanumeric code, and analyzed using an inductive thematic approach from June 1 through December 30, 2024. Participants were offered a $20 gift card in appreciation for their time. EXPOSURE/UNASSIGNED:Experiences of students identifying as first-generation college students in premedical training. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Main outcomes included themes and subthemes at the individual, interpersonal, and organizational levels constructed from interview data. Bronfenbrenner's ecological systems theory was used as a guiding interpretive framework to analyze participants' experiences within their broader social and environmental contexts. This model allowed examination of how individual perspectives were shaped by interactions across personal, social, and structural contexts. The team engaged in reflexive discussions, memos, and consensus-based refinement to identify key themes. RESULTS/UNASSIGNED:Among 37 participants identified as first-generation students, 21 (56.8%) identified as female (mean [SD] age, 27.3 [2.8] years). One participant (2.7%) identified as American Indian or Alaska Native; 7 (18.9%) as Hispanic, Latino, or Spanish origin; 8 (21.6%) as non-Hispanic Asian or Asian American; 9 (24.3%) as non-Hispanic Black or African American; and 12 (32.4%) as non-Hispanic White. Analyses revealed key themes across all 3 levels of the ecological systems model: individual, interpersonal, and organizational. Individual themes included personal and family background, such as financial instability and lack of clinical exposure. Interpersonal themes included access to premedical advisors, faculty mentors, and peer networks. Organizational themes included limited institutional resources and pathway programs. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this qualitative study of first-generation students, financial instability, limited medical school-related social connections and resources, and unfamiliarity with academic systems were found to uniquely burden these students. By identifying and improving resources such as tailored mentorship, individualized advising, and participation in pathway programs, medical schools can help reduce structural barriers for aspiring physicians who are first-generation college students.

INTRODUCTION/BACKGROUND:The integration of computer-assisted navigation systems (CASs) in total knee arthroplasty (TKA) procedures has gained popularity in recent years. However, additional validation of the accuracy of CAS feedback is necessary. We used short-length and full-length postoperative radiographs to quantify the differences between alignment parameters measured by a novel imageless CAS and alignment outcomes as evidenced on postoperative radiographs. MATERIALS AND METHODS/METHODS:A retrospective analysis was conducted on prospectively collected data from a cohort of patients undergoing navigated primary TKA. Fifty-eight patients had met inclusion criteria, and intraoperative CAS measurements were obtained from device recordings. Alignment parameters were measured digitally and included femorotibial angle on short-length films and hip-knee-ankle axis, mechanical lateral distal femoral angle (mLDFA), and mechanical medial proximal tibial angle (mMPTA) on full-length films. These were compared between CAS and radiograph measurements using a 2-tailed t test. RESULTS:The mean mLDFA measured by the CAS was 0.7° ± 1.1°, compared with 1.3° ± 1.4° as measured on full-body radiographs (P = .1). The mean mMPTA measured by the CAS was 0.2° ± 1.0°, compared with 0.9° ± 1.4° as measured on full-body radiographs (P = .06). On average, radiograph and CAS measurements differed by 0.5° ± 1.5° for mLDFA and 0.7° ± 1.5° for mMPTA. The average postoperative hip-knee-ankle axis was 177.6° ± 2.1°, and the average femorotibial angle was 176.0° ± 9.6° as measured on radiographs. CONCLUSION/CONCLUSIONS:No significant differences in either average or individual measured values for mLDFA or mMPTA were observed between the intraoperative CAS measurements and alignment outcomes postoperatively. Our data highlight the clinical utility of CASs to accurately achieve intended TKA alignment objectives.

The scapholunate ligament (SLL) is a critical stabilizer of the wrist joint. Disruption of the SLL leads to altered wrist kinematics, including scaphoid flexion, lunate extension, and increased stress on surrounding cartilage and ligaments, which can progress to dorsal intercalated segment instability and scapholunate advanced collapse. Despite predictable biomechanical changes, clinical outcomes vary widely because some patients develop significant functional limitations, whereas others remain asymptomatic. Nonoperative management, including immobilization, therapy, and bracing, remains the first-line treatment for partial tears or stable injuries. Surgical intervention, such as SLL repair with capsulodesis or reconstruction, is indicated for cases with persistent pain, instability, or functional deficits. Capsulodesis is a commonly used adjunct to SLL repair. Multiple surgical techniques exist for SLL repair in the acute setting and for reconstruction in the chronic setting when SLL is deemed irreparable. Although several surgical techniques are available for chronic injuries, a gold standard has not yet been established.

The need to perform revision anterior cruciate ligament reconstruction (ACLR) has several etiologies such as infection, arthrofibrosis, cyclops lesions, and graft failure, which should be distinguished before revision ACLR. Even the definition of graft failure varies within the literature. ACLR graft failure falls into modifiable, surgeon-controlled factors, such as tunnel position, graft choice, and alignment, and nonmodifiable factors, such as patient age, tissue quality, or secondary traumatic reruptures. In this review, we describe a facile framework for the workup of modifiable ACLR graft failure.

BACKGROUND:Policymakers need research-informed guidance on leveraging national government funding to promote evidence-based practice (EBP) implementation, however empirical studies of policy financing strategies in implementation science remain limited. Major investments are already being made. Starting in 2012, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) funded state substance use service agencies to implement EBPs for youth substance use. We examined 19 states funded to implement the Adolescent Community Reinforcement Approach (A-CRA), an exemplar EBP selected by most states. Using the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework, we sought to explain state-level variation in A-CRA reach (defined as the proportion of A-CRA certified providers) and to identify policy implications for improving EBP financing strategies. METHODS:We conducted an explanatory sequential mixed-method (QUAN→QUAL) comparative case study, treating each state as a case. States were categorized as achieving high, medium, and low reach during their grant periods using A-CRA certification records and state demographic data. We then synthesized available data (i.e., interviews with 33 state agency administrators, grant administrative records, other documents describing A-CRA implementation) to summarize grant activities completed and their quality, and factors potentially influencing reach in each state. Finally, we compared and contrasted state cases to identify policy implications through pattern matching techniques. RESULTS:We characterized the 19 states' reach levels as high (n = 7), medium (n = 5), and low (n = 7) and identified an average of 5 grant-related activities completed per state; the most common being A-CRA training to treatment organizations. Six states were case anomalies (e.g., low quantity and quality of activities, while achieving high reach). Most notably, we found that high-reach states had more specific, intentional, and explicit A-CRA implementation requirements for treatment organizations than did low- and medium-reach states. States were also more successful in achieving A-CRA reach when they reported proactively addressing implementation barriers (e.g., provider turnover, state leadership buy-in and support). CONCLUSIONS:Our mixed-method comparative case study advances policy-focused implementation research related to EBP financing strategies, demonstrating how examination of large-scale real-world funding initiatives can produce generalizable lessons. Our findings have implications for how future funding initiatives can facilitate EBP delivery to maximize reach.

Despite bone's robust regenerative capacity, complications such as delayed union and nonunion affect 5-10% of fractures, with significant clinical and economic burdens. The rising incidence of fractures, particularly in an aging population, highlights the importance of optimizing fracture healing strategies. This review explores current therapies aimed at enhancing bone regeneration, focusing on 2 main categories: local biologic therapies and mechanical therapies. Local biologic treatments, including concentrated bone marrow aspirate, platelet-rich plasma, bone morphogenetic proteins, and platelet-derived growth factor, aim to stimulate osteogenesis at the fracture site. Therapies, such as electrical stimulation, low-intensity pulsed ultrasound, and extracorporeal shockwave therapy, are theorized to modify the mechanical environment to promote healing. Although these therapies show promise, variability in clinical outcomes emphasizes the need for further research to standardize protocols and refine treatment strategies. Overall, advancing our understanding of bone healing mechanisms will continue to drive innovation in fracture management, improving patient outcomes and reducing health care costs.

Genetics is a burgeoning field within adult reconstructive surgery. Genome-wide sequencing has identified genetic variants found to be associated with not only the development of osteoarthritis but also arthroplasty-related complications, such as aseptic loosening, prosthetic joint infection, arthrofibrosis, and postoperative pain. Examples include newer technology, such as next-generation sequencing, in diagnosing culture-negative prosthetic joint infection. Genetics drives new therapeutic technologies, such as gene therapy, gene-editing, and bacteriophage treatment. Although still rare, a handful of phase 3 clinical trials of gene therapy for osteoarthritis have begun to demonstrate efficacy with low-risk profiles. As the field continues to grow, public and professional buy-in as well as cost present challenges.