Board-certified Surgeons Research Articles

Compressive force and valgus torque are the predominant applied loads during the pivot shift exam: An in vitro study.

Despite the clinical utility of the pivot shift exam, the requisite applied forces and torques to elicit a pivot shift remain unclear. The purposes of this study are (1) to identify the greatest forces and torques applied to the knee during the pivot shift exam and (2) to evaluate if the applied loads differ among experienced surgeons. Three cadaveric hemipelvis-to-toe specimens (ages 53, 36 and 31 years; two males and one female) with no history of knee or hip injury were utilized. The experimental setup consisted of securing the hemipelvis to a mounting frame via an external fixator to simulate patient positioning during the clinical exam. The hemipelvis, femur, and tibia were spatially tracked by motion capture and the applied loads were measured using a 6-axis force-torque sensor. After sectioning the anterior cruciate ligament (ACL), three board-certified sports medicine surgeons then performed the pivot shift exam on each specimen utilizing their preferred technique. Forces (compression-distraction, anterior-posterior, and medial-lateral) and torques (varus-valgus, internal-external rotation, and flexion-extension) applied to the knee joint immediately preceding the reduction of the proximal lateral tibia during each pivot shift exam were calculated. Compression was the largest applied force averaging 95 N ± 15 N for all surgeons and knees, which was at least 4.5 times greater, on average, than the applied anterior and applied medial tibial forces (p < 0.0001). Valgus was the largest of the three applied torques, averaging 8.5 ± 2.1 Nm. Internal rotation torque was 3.7 times less, on average, than the applied valgus torque (p < 0.0001). Each surgeon applied compressive force. However, anterior force was more variable among surgeons, with one of the three surgeons applying minimal anterior force (p ≤ 0.024). The magnitude of applied torques was similar among examiners (n.s). Compressive force and valgus torque were the predominant applied loads during the pivot shift exam. A lower magnitude of internal rotation torque was also applied. The anterior force was not consistently applied among examiners. These data can better inform clinical, cadaveric, and computational studies utilizing the pivot shift exam to assess knee biomechanics and can be used to educate trainees in conducting this complex manoeuvre. An in vitro biomechanic study.

Radiographically Apparent Acetabular Sourcil Landmarks Are Created by Comparable Regions of the Pelvis With Extraarticular Bone Variably Confounding Estimates of Joint Coverage.

The severity of hip dysplasia is characterized by radiographic measurements that require user definition of the acetabular sourcil edge, a bony landmark for which the corresponding three-dimensional (3D) anatomy is not well defined in any imaging plane. To use digitally reconstructed radiographs to determine: (1) What 3D anatomy is contributing to the "acetabular sourcil" location used to make lateral center-edge angle (LCEA) and anterior center-edge angle (ACEA) measurements in standing AP and false-profile radiographic views, respectively? (2) How do intraobserver and interobserver agreement in LCEA and ACEA translate into agreement of the 3D anatomy being evaluated? (3) How distinct are regions around the acetabular rim circumference that are evaluated by LCEA and ACEA measurements on radiographs? Between January 2018 and May 2019, 72 patients were indicated for periacetabular osteotomy to treat hip dysplasia or acetabular retroversion at our institution. From these patients, a series of 10 patients were identified of the first 12 patients in 2018 who were treated with periacetabular osteotomy, excluding two with missing or low-quality clinical imaging. A second series of 10 patients was identified of the first 11 patients in 2019 who were treated with periacetabular osteotomy and concurrent hip arthroscopy, excluding one who was missing clinical imaging. Pelvis and femoral bone surface models were generated from CT scans of these two series of 10 patients. There were 15 female and five male patients, with a median patient age of 18 years (IQR 17 to 23 years), a preoperative LCEA of 22° (IQR 18° to 24°), and a preoperative ACEA of 23° (IQR 18° to 27°). Exclusion criteria included missing preoperative CT or standard clinical radiographic imaging or severe joint incongruity. To address our first study question, digitally reconstructed radiographs matching each patient's standing AP and false-profile clinical radiographs were created from the segmented CT volumes. A board-certified orthopaedic surgeon and three trained researchers measured LCEA and ACEA on the digitally reconstructed radiographs, and the selected sourcil points were projected back into coordinates in the 3D anatomic space. To address our second study question, intraobserver and interobserver agreement in radiographic coverage angles were related to variations in 3D coordinates of the selected bony anatomy. Lastly, to address our third study question, 3D locations around the acetabular rim identified as contributing to the lateral and anterior sourcil points were summarized across patients in a clockface coordinate system, and statistical analysis of the "time" separating the 3D acetabular contributions of the sourcil edges was performed. The 3D anatomy contributing to the lateral sourcil was a variable length (27 mm [IQR 15 to 34 mm]) span of the laterosuperior acetabular edges, with contributions by the anterior inferior iliac spine in 35% (7 of 20) of hips. The anterior sourcil reflected a 28-mm (IQR 25 to 31 mm) span of bone from the medial ilium (posterior-medial to the anterior-inferior iliac spine and anterior-lateral to the arcuate line) to the anterior and lateral edges of the acetabulum. Interobserver variability was good for LCEA (intraclass correlation coefficient [ICC] 0.82 to 0.83) and moderate to good for ACEA (ICC 0.73 to 0.79), whereas the agreement in identified 3D sourcil locations varied widely (ICC 0.32 to 0.95). The acetabular edge of the 3D anatomy contributing to the anterior sourcil overlapped the circumferential range of the acetabular rim contributing to the lateral sourcil. Projection of two-dimensional radiographic landmarks contributing to the diagnosis of structural hip deformity into 3D allowed for the identification of the overlapping bony anatomy contributing to radiographically visible anterior and lateral sourcil edges. This work leveraging digitally reconstructed radiographs and 3D pelvis anatomy has found that bone outside the joint contributes to the radiographic appearance of the sourcil and may variably confound estimates of joint coverage. Furthermore, the substantial overlap between the acetabular bone contributing to measurement of the LCEA and ACEA would indicate that these angles measure similar acetabular deformity, and that additional measures are needed to assess anterior coverage independent of lateral coverage.

Clinical experience and outcomes using a commercially available micro-plating system for metabone fractures in dogs and cats: 10 cases (2019-2023).

To report the clinical experience and long-term outcome following metabone fracture stabilisation using a commercially available micro-plating system (VetKISS, 1.0-mm, IMEX Veterinary, USA). Consecutive, client-owned cats and dogs weighing <7 kg, with traumatic metabone fractures stabilised using VetKISS micro-plates were prospectively enrolled with informed owner consent. Clinical and radiographic parameters were recorded. Either short-term or long-term clinical and radiographic follow-up was required for study inclusion. Four cats and six dogs were enrolled and operated by one of two board-certified surgeons. Bodyweight ranged from 1.9 to 6.6 kg. Number of metabones fractured: all four (60%), three (30%) and two (10%). Anatomical alignment was restored for each metabone. External coaptation was not used in any case. Radiographic follow-up documented clinical or bony union in all cases. Mean time to clinical union was 51 days. One major complication (screw removal) and two minor complications (partial construct failure) were observed. All patients made a complete functional recovery at the time of documented union. Long-term follow-up was available in five cases. No lameness (evaluated independently by both surgeons) or plate sensitivity was noted. This is the first clinical evaluation of the VetKISS for metabone fracture repair, and includes long-term follow-up. Results demonstrated complete functional recovery and 100% clinical union rates in all patients, with acceptable complication rates. This system can be considered for metabone repair in patients weighing <7 kg without the use of external coaptation.

Can ChatGPT Reliably Answer the Most Common Patient Questions Regarding Total Shoulder Arthroplasty?

BackgroundIncreasingly, patients are turning to artificial intelligence (AI) programs such as ChatGPT to answer medical questions either before or after consulting a physician. Although ChatGPT’s popularity implies its potential in improving patient education, concerns exist regarding the validity of the chatbot’s responses. Therefore, the objective of this study was to evaluate the quality and accuracy of ChatGPT’s answers to commonly asked patient questions surrounding total shoulder arthroplasty (TSA). MethodsEleven trusted healthcare websites were searched to compose a list of the 15 most frequently asked patient questions about TSA. Each question was posed to the ChatGPT user interface, with no follow-up questions or opportunity for clarification permitted. Individual response accuracy was graded by three board-certified orthopedic surgeons using an alphabetical grading system (i.e., A-F). Overall grades, descriptive analyses, and commentary were provided for each of the ChatGPT responses. ResultsOverall, ChatGPT received a cumulative grade of B-. The question responses surrounding general/preoperative and postoperative questions received a grade of B- and B-, respectively. ChatGPT’s responses adequately responded to patient questions with sound recommendations. However, the chatbot neglected recent research in its responses, resulting in recommendations that warrant professional clarification. The interface deferred specific questions to orthopedic surgeons in 8/15 questions, suggesting its awareness of its own limitations. Moreover, ChatGPT often went beyond the scope of the question after the first two sentences, and generally made errors when attempting to supplement its own response. ConclusionOverall, this is the first study to our knowledge to utilize AI to answer the most common patient questions surrounding TSA. ChatGPT achieved an overall grade of B-. Ultimately, while AI is an attractive tool for initial patient inquiries, at this time it cannot provide responses to TSA-specific questions that can substitute the knowledge of an orthopedic surgeon.

Multimodal Analgesia and Small Opioid Prescriptions are the New Standard in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership

BackgroundThe purpose of this survey study was to assess the current analgesia and anesthesia practices used by total joint arthroplasty surgeon members of the American Association of Hip and Knee Surgeons (AAHKS) as well as identify changes in practice made by AAHKS members over time. MethodsA survey of 37 questions was created and approved by the AAHKS Research Committee. The survey was distributed to all 3,243 practicing adult reconstruction surgeon members of AAHKS in May 2023. Results were compared to a nearly identical survey sent out to all board-certified adult reconstruction surgeon members of AAHKS 5 years previously in November 2018. ResultsThere were 527 responses (16%) to the survey. Since 2018, the mean number of opioid pills prescribed after total joint arthroplasty has declined significantly from 49 to 32 pills after total knee arthroplasty (TKA) and from 44 to 18 pills after total hip arthroplasty (THA). The use of multimodal analgesics in addition to opioids has also increased over the past 5 years from 74 to 93%. The most common medications utilized include nonsteroidal anti-inflammatories (98%), acetaminophen (80%), and gabapentinoids (32%). A majority of surgeons (78%) still use a spinal for TKA and THA. However, there has been an increase in the number of surgeons using peripheral nerve blocks for TKA from 69% in 2018 to 84% in 2023. The routine use of periarticular injection or local infiltration anesthesia in THA and TKA has also increased over the past 5 years from 80 to 86%. ConclusionsSince 2018, there has been increased adoption of multimodal analgesia and anesthesia, and improved consensus regarding the optimal regimen among surveyed arthroplasty surgeon members of AAHKS. The number of opioid pills prescribed after THA and TKA has declined significantly over the past 5 years.

The Geographic Distribution of Vascular Surgeons and Trainees by State in 2023

Approximately 1.4 vascular surgeons/100,000 persons are estimated to fulfill current patient needs in the United States (US), but an ongoing shortage exists. The aims of this study are to provide an updated nationwide state-by-state workforce analysis and compare the distribution of practicing vascular surgeons and training opportunities. Vascular surgeons in the US were identified using the National Provider Identifier registry in 2023. Only board-certified and actively licensed vascular surgeons were included. To estimate the number of vascular surgery graduates per year in each state, integrated residency and fellowship-matched positions (trainees) were ascertained from the National Resident Matching Program website. Surgeons and trainees were totaled by state, and densities were calculated using the 2020 US Census Bureau state populations. These two cohorts were also examined together using simple linear regression and geographic mapping. This study included 3399 board-certified vascular surgeons and 228 newly matched trainees. The average densities of vascular surgeons and trainees in the US are 1/100,000 persons and 0.06/100,000 persons, respectively. The five states with the lowest densities of vascular surgeons are AR, ND, NV, OK, and WY, averaging 0.4/100,000 persons. Eight states (AK, ID, KS, ND, NM, NV, RI, WY) had zero training programs offering positions in 2023 and ranked in the lowest quartile for the number of practicing vascular surgeons (Figure 1). Simple linear regression demonstrated a statistically significant correlation between state rates of vascular surgeons and trainees (p < 0.001). States with zero training positions also have the fewest vascular surgeons per capita. Statewide attention to expanding vascular surgery training opportunities targeted in these areas could positively impact the current maldistribution and shortage of vascular surgeons.

ChatGPT and trainee performances in the management of maxillofacial patients

IntroductionChatGPT is an artificial intelligence based large language model with the ability to generate human-like response to text input, its performance has already been the subject of several studies in different fields. The aim of this study was to evaluate the performance of ChatGPT in the management of maxillofacial clinical cases. Materials and methodsA total of 38 clinical cases consulting at the Stomatology-Maxillofacial Surgery Department were prospectively recruited and presented to ChatGPT, which was interrogated for diagnosis, differential diagnosis, management and treatment. The performance of trainees and ChatGPT was compared by three blinded board-certified maxillofacial surgeons using the AIPI score. ResultsThe average total AIPI score assigned to the practitioners was 18.71 and 16.39 to ChatGPT, significantly lower (p < 0.001). According to the experts, ChatGPT was significantly less effective for diagnosis and treatment (p < 0.001). Following two of the three experts, ChatGPT was significantly less effective in considering patient data (p = 0.001) and suggesting additional examinations (p < 0.0001). The primary diagnosis proposed by ChatGPT was judged by the experts as not plausible and /or incomplete in 2.63 % to 18 % of the cases, the additional examinations were associated with inadequate examinations in 2.63 %, to 21.05 % of the cases and proposed an association of pertinent, but incomplete therapeutic findings in 18.42 % to 47.37 % of the cases, while the therapeutic findings were considered pertinent, necessary and inadequate in 18.42 % of cases. ConclusionsChatGPT appears less efficient in diagnosis, the selection of the most adequate additional examination and the proposition of pertinent and necessary therapeutic approaches.

Enhanced safety in central venous catheterization performed by Japanese board-certified pediatric surgeons: a retrospective single-center study.

Board certification by the Japanese Society of Pediatric Surgeons is awarded to pediatric surgeons with substantial surgical experience and academic achievement. However, to date, the surgical performance or outcomes of certified surgeons have not been reported. This study examined the relationship between board certification and surgical outcomes of central venous catheterization. This retrospective single-center study was conducted between April 2017 and May 2024. Patients were classified based on whether their procedures were performed by board-certified or non-certified surgeons, and their backgrounds and surgical outcomes were compared. In addition, multivariate analysis was performed to identify the factors associated with prolonged operative time. This study included 112 procedures: 26 performed by board-certified surgeons and 86 performed by non-certified surgeons. There were no significant differences in the age, sex, weight, or primary diagnosis between the groups; however, surgery-associated complications were significantly more common in the non-certified surgeon group than in the board-certified surgeon group (15.1% vs. 0%, P = 0.036). In addition, factors independently associated with a prolonged operative time included weight < 10kg, left-sided approach, implantable port device use, and < 7years of postgraduate experience for the surgeon. Board certification was associated with a significant reduction in surgery-associated complications during central venous catheterization.

Evaluation of Osteotomy Healing in Boxer Dogs Undergoing Tibial Plateau Levelling Osteotomy Using Two Radiographic Scoring Systems.

The aim of this study was to (1) compare 5-point and 10-point bone healing radiographic scoring systems using postoperative tibial plateau levelling osteotomy (TPLO) radiographs and (2) determine whether Boxer osteotomy healing time differs from age-matched Labrador Retrievers. This was a multicentre retrospective study. Fifty-eight client-owned dogs undergoing TPLO (29 Boxers and 29 Labrador Retrievers) were included. Five board-certified surgeons evaluated the radiographs three independent times. Osteotomy healing approximately 8 weeks postoperatively was graded using previously reported 5-point and 10-point scoring systems and immediate postoperative radiographs were assessed for the presence of an osteotomy gap of ≥1 mm. Both scoring systems had good consistency among observers. Intraobserver consistency was good in three out of five observers using the 5-point system and in four out of five observers using the 10-point system. Boxers had significantly lower radiographic healing scores at 8 weeks postoperatively compared with Labrador Retrievers using both scoring systems (p ≤ 0.001). The presence of an osteotomy gap postoperatively resulted in significantly lower healing scores at 8 weeks using both scoring systems (p < 0.001) in both breeds. No difference was found in inter- and intraobserver variability between scoring systems. Boxer dogs had lower healing scores at 8 weeks after TPLO compared with Labrador Retrievers. An osteotomy gap of ≥1 mm was associated with lower healing scores.

A Sustainable Solution for Reducing Draping Waste in Cleft Surgeries.

This study aims to reduce the waste generated from primary cleft lip and/or palate (CL/P) repair. A retrospective chart review examined a single surgeon's experience with CL/P repair using standard draping technique and reduced draping technique. Fisher's exact tests were performed comparing complication rates between techniques. All procedures were conducted at a single academic medical center under the care of a board-certified pediatric plastic surgeon and fellowship-trained pediatric anesthesiologists. The study included all patients ≤ 24 months of age who underwent primary CL/P repair using a reduced draping technique at the senior author's institution. An equivalent number of patients who underwent CL/P repair by the senior author immediately prior to implementation of the reduced draping technique were included for comparison. Patients undergoing CL/P repair before the change in technique were draped using the standard CL/P draping. The senior author then switched to using a reduced draping on all CL/P repairs afterwards. Weights and costs of both draping sets were obtained and differences calculated. A manual chart review was performed to assess rates of accidental intraoperative extubation, postoperative infection, fistula formation, and wound dehiscence. The implementation of a reduced draping technique resulted in a 530 gram weight savings and $7.49 cost savings per procedure. Fisher's exact tests revealed no statistically significant differences in complication rates except for oral mucosal dehiscence, which was lower in the reduced draping group. Reduced draping in CL/P repairs significantly reduces operative waste without compromising surgical outcomes.

Influenced: Exploring the Effect of Social Media on Medical Students' Perceptions of Plastic Surgery.

Medical students rarely receive dedicated education in plastic surgery, exposing them to influence from the internet or television programming that is frequently skewed toward cosmetic procedures. Additionally, social media posts from board-certified plastic surgeons make up a small portion of available content. These biased representations may impact students' perceptions, narrowing the scope of referrals and limiting career exploration. Medical students at two academic medical centers were surveyed. Blinded data were collected on exposure to plastic surgery, social media usage, observed content, and perceptions of the specialty. Students' understanding of plastic surgery was evaluated using clinical scenarios. The response rate was 24.3%. Social media and television were the primary contributors to understanding of plastic surgery in 51.6% of students, especially for those who had not completed a surgical clerkship (P < 0.026). Students most frequently viewed plastic surgery content posted by influencers (28.1%), followed by board-certified plastic surgeons (24.1%), patients (21.2%), and nonplastic surgeon physicians (19.7%). Posts relating to cosmetic procedures (44.3%) were viewed most frequently. Students who followed board-certified plastic surgeons performed better when answering clinical vignettes (64.8% versus 50.9%). Social media and television play a significant role in medical students' perceptions of plastic surgery. Students are also more likely to see posts from influencers than board-certified plastic surgeons, furthering potential bias. Quality content from board-certified surgeons and professional societies may improve scope of practice creep and student interest.

Male National Basketball Association G-League and Collegiate Basketball Athletes Have a High Prevalence of Radiographic Ankle Abnormalities

PurposeThe purposes of this study were to characterize radiographic foot/ankle bony abnormalities in elite-level, asymptomatic male basketball athletes, and to investigate the association between anthropometric (age, height, weight) or sport-specific characteristics (total exposures, player position, pregame ankle taping) and the prevalence of abnormal radiographic findings in asymptomatic basketball athletes MethodsElite-level basketball players who underwent routine, pre-season static radiographic imaging, including antero-posterior, lateral, and mortise views of the ankle were included. Radiographs were collected from asymptomatic athletes participating in pre-season history and physical with negative anterior drawer/talar tilt test. Radiographs were evaluated by a musculoskeletal radiologist and board-certified orthopedic surgeon; kappa statistics were used to evaluate agreement. ResultsFifty-four basketball players (34 collegiate, 20 professional; mean age 21.5 years) were included, totaling 5,148 player exposures from 2017-2019. 106 ankles presented with radiographic findings (98.15%). The most prevalent radiographic finding was pes planus (47.22%), followed by degenerative joint disease (DJD) (33.33%), talonavicular sclerosis (28.70%), prominent stieda process (25.93%), os trigonum (20.93%), os subfibulare (11.11%), pes cavus (5.56%), subtalar coalition (2.78%), and cavovarus (0.93%). Height ≥ 80” was significantly associated with talonavicular sclerosis and Kellgren-Lawrence 1 changes. ConclusionsThis study demonstrated a strong association between height and talonavicular sclerosis and DJD, as well as a relatively high prevalence of pes planus and DJD in asymptomatic collegiate and professional basketball players.

The implementation status of prehabilitation during neoadjuvant chemotherapy for patients with locally advanced esophageal cancer: a questionnaire survey to the board-certified facilities in Japan.

Prehabilitation during neoadjuvant therapy has the potential to improve clinical outcomes. However, information on its global dissemination status is limited. This Japanese nationwide survey investigated the implementation status of and barriers to prehabilitation during neoadjuvant chemotherapy (NAC) for patients with locally advanced esophageal cancer in hospitals. This multicenter nationwide survey was conducted by post. The eligible facilities were 155 Japanese hospitals that had been certified within the last 10years as authorized institutes for board-certified esophageal surgeons by the Japan Esophageal Society. We administered an original questionnaire to investigate the current status of prehabilitation during NAC. The response rate was 75% (117/155 facilities). Forty-six facilities (39%) provided prehabilitation during NAC. The most frequently selected reasons for not providing or providing insufficient prehabilitation were lack of human resources, issues with the reimbursement of medical fees, difficulty in providing continuous prehabilitation during repeated inpatient and outpatient care, the lack of established standard prehabilitation programs, challenges in providing multidisciplinary prehabilitation, and difficulty in managing physical symptoms. We observed that the implementation rate of prehabilitation during NAC was low. Critical reasons were not only the lack of medical resources but also the lack of evidence-based standard prehabilitation programs during NAC and the lack of evidence for how to continuously deliver prehabilitation during NAC to patients with physical symptoms.

An ultrasound-guided supraclavicular approach for tunneled central venous catheter insertion can be safely performed by junior residents.

Ultrasound-guided supraclavicular catheterization (UGSC) of the brachiocephalic vein (BCV) for long-term tunneled central venous catheter (tCVC) insertion may be safer than the internal jugular vein approach due to its superior field of view. We examined the clinical outcomes of tCVC insertions performed by junior residents through UGSC of the BCV. From January 2018 to December 2023, we assessed clinical outcomes and compared the experience levels of surgeons conducting tCVC insertions. Surgeons were categorized into three groups: junior residency (JR), senior residency (SR), and board-certified pediatric surgeons (BCPS). 177 tCVC insertions were done on 146 patients. Intraoperative complications included 6 cases of arterial puncture, 1 case of pneumothorax, 1 case of over insertion of catheter tip, and 1 case of suspected hemothorax. Distribution across groups was as follows: 28 cases (15.8%) in JR group, 92 (52.0%) in SR group, and 57 (32.2%) in BCPS group. Although the JR group exhibited longer operation times than the BCPS group, no significant differences in intraoperative complications were noted. Junior residents can safely perform UGSC for tCVC insertion. However, careful consideration of complications such as arterial or thoracic puncture is essential and case selection should be based on experience.

Complications and putative risk factors for cecal or colonic surgery in dogs: 79 cases (2002-2015).

To evaluate the complication rate, mortality rate and putative risk factors for cecal or colonic surgery in dogs. A multi-institutional retrospective study including dogs that had undergone surgery that involved the cecum or the colon. Medical records from three referral hospitals were reviewed for patient demographics and clinical data. The association between putative risk factors and survival to discharge or complications was assessed using univariable and multivariable analysis. Seventy-nine dogs met the criteria to be included in this study. Fifty-five dogs had full thickness incision surgeries, while 24 dogs had partial thickness surgeries. The complication and mortality rates for full thickness and partial thickness cecal/colonic surgeries were not statistically different. The dehiscence rate of colonic anastomosis in this study was four of 47 (8.5%). On univariate analysis, performing full thickness procedures out of hours had an association with increased complications and mortality. On multivariable analysis, no factors were associated with survival to discharge or complications. There was no association of board-certified surgeon presence in surgery with complications or mortality. The performance of full thickness cecal/colonic surgery is not associated with a statistically significant increased risk for complications or mortality compared to partial thickness procedures, with a possible increased risk of complications and mortality in full thickness procedures out of hours.

Reliability of a Modified Watson-Jones Classification for Tibial Tubercle Fractures in Children.

The first case report describing a pediatric fracture of the tibial tubercle was published in 1852 in the Medical Times and Gazette, a Journal of Medical Science, literature, criticism, and news. A century later, in 1955, Sir Watson-Jones introduced the first classification system for this fracture. Despite the existence of several classification systems for pediatric tibial tubercle fractures in the medical literature, a crucial aspect of their validation-reliability and reproducibility-has not yet been systematically evaluated. In this study, a modified Watson-Jones (mWJ) classification system of tibial tubercle fractures in children was assessed for intraobserver and interobserver variability. Using the mWJ classification, 3 board-certified pediatric orthopaedic surgeons and 3 orthopaedic surgery residents, classified thirty tibial tubercle fractures based on anteroposterior and lateral radiographs on 2 separate occasions in a 2-week duration. Further comparison was made to evaluate the impact of advanced imaging, specifically computed tomography or magnetic resonance imaging, on diagnostic reliability and reproducibility. The study found substantial intraobserver reliability of the mWJ classification based on radiographs alone, with a Cohen weighted kappa (κ w ) coefficient of 0.733. When advanced imaging was utilized, the reliability of the classification improved to κ w = 0.783. Similarly, interobserver reliability demonstrated substantial consistency among observers when using radiographs alone (κ w = 0.69) and improved agreement with advanced imaging (κ w = 0.75). Notably, there was no significant difference in reliability scores between senior-level attendings and residents when analyzed as separate groups. Fracture classification systems are clinically relevant tools that help organize and transfer knowledge efficiently, provide treatment guidance, propose prognostic expectations, and improve communication in academic literature. The present study demonstrated substantial reproducibility of an mWJ fracture classification system both between and within individual surgeon raters. Level III-diagnostic.

Balancing Expectations: Navigating Medically Necessary Torso Procedures with Cosmetic Components in the Military Healthcare System.

Surgeons performing federal insurance-financed procedures involving medically necessary and cosmetic components must navigate patient expectations to avoid postoperative disappointment. This challenge is amplified in military healthcare, where different surgical specialties concurrently address the same diagnosis, while the Department of Defense policy on cosmetic fees and TRICARE's definition of excluded services adds further complexity. With the increasing prevalence of elevated body mass index, focus is directed toward diagnoses involving the torso, specifically gynecomastia in male individuals, and diastasis of the rectus abdominis muscles (DRAM) in female individuals. The study involves a team of experienced board-certified surgeons conducting a narrative review of surgical procedures addressing gynecomastia and DRAM. Relevant literature from 2000 to 2023 is reviewed, focusing on patient satisfaction regarding outcome of medically necessary and cosmetic aspects. For gynecomastia, distinguishing between true and pseudogynecomastia is critical. A protocol is presented based on the Simon classification, offering evidence-based guidelines for surgical interventions. Similarly, for DRAM, a minimally invasive approach balances deployment readiness and surgical recovery. The presence of a symptomatic panniculus, however, requires more invasive intervention. The downstream ramification of limited Current Procedural Terminology codes for these interventions is discussed. In medically necessary procedures funded through federal health plans such as TRICARE, the primary goal is functional improvement, not the final torso contour. Clear communication and preoperative counseling are crucial to managing patient expectations. Providers in military healthcare must navigate the complex landscape of patient expectations, policy guidelines, and duty readiness while maintaining the standard of care.

Trained to cut? A literature review of veterinary surgical resident training.

A surgical residency trains veterinary graduates to a higher level of expertise in surgical procedures than is possible during veterinary school and prepares a resident to pursue board certification in surgery. The education of veterinary surgical residents has changed minimally since its inception in the twentieth century, and there are insufficient studies to determine if residency programs are producing surgeons with competence in each of the necessary procedural categories. The aims of this review were to report the current theory and methods used to provide surgical education to residents, to discuss the training most likely to create a competent, board-certified surgeon and to review assessment methods used during training. Several literature searches using broad terms such as "veterinary surgery residency," "veterinary surgery resident," and "veterinary surgical training" were performed using PubMed, CAB abstracts, and Google Scholar. Literature pertinent to theory, methods, training, and assessment of veterinary surgical residents was included. The reviewed literature demonstrated the need for research-based learning curves for specific procedures. Simulation training is known to facilitate deliberate practice and should be leveraged where possible to reach competency. The creation of validated assessment methods should be pursued as it enables assessment of competency instead of inferring its development from case logs. Understanding and supporting learner cognition and providing sufficient feedback remain important issues in the field. Surgical educators are urged to continue to search for innovative and evidence-based ways to train competent surgical residents.

Quantitative assessment of the troCarWash™ system for automated laparoscopic camera cleaning.

Soilage of the surgical endoscope occurs frequently during minimally invasive surgery. The resultant impairment of visualization of the surgical field compromises patient safety, prolongs operative times, and frustrates surgeons. The standard practice for cleaning the surgical camera involves a disruption in the conduct of surgery by completely removing the endoscope from the field, manually cleaning its lens, treating it with a surfactant, and reinserting it into the patient; after which the surgeon resumes the procedure. We developed an automated solution for in vivo endoscope cleaning in minimally invasive surgery- a port that detects the position of the endoscope in its distal lumen, and precisely and automatically delivers a pressurized mist of cleaning solution to the lens of the camera. No additions to the scope and minimal user interaction with the port are required. We tested the efficacy of this troCarWash™ device in a porcine model of laparoscopy. Four board-certified general surgeons were instructed to soil and then clean the laparoscope using the device. Representative pre- and post-clean images were exported from the surgical video and clarity was graded (1) digitally by a canny edge detection algorithm, and (2) subjectively by 3 blinded, unbiased observers using a semi-quantitative scale. We observed statistically significant improvements in clarity by each method and for each surgeon, and we noted significant correlation between digital and subjective scores. Based on these data, we conclude that the troCarWash™ effectively restored impaired visualization in a large animal model of laparoscopy.

Challenges in multi-centric generalization: phase and step recognition in Roux-en-Y gastric bypass surgery.

Most studies on surgical activity recognition utilizing artificial intelligence (AI) have focused mainly on recognizing one type of activity from small and mono-centric surgical video datasets. It remains speculative whether those models would generalize to other centers. In this work, we introduce a large multi-centric multi-activity dataset consisting of 140 surgical videos (MultiBypass140) of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgeries performed at two medical centers, i.e., the University Hospital of Strasbourg, France (StrasBypass70) and Inselspital, Bern University Hospital, Switzerland (BernBypass70). The dataset has been fully annotated with phases and steps by two board-certified surgeons. Furthermore, we assess the generalizability and benchmark different deep learning models for the task of phase and step recognition in 7 experimental studies: (1) Training and evaluation on BernBypass70; (2) Training and evaluation on StrasBypass70; (3) Training and evaluation on the joint MultiBypass140 dataset; (4) Training on BernBypass70, evaluation on StrasBypass70; (5) Training on StrasBypass70, evaluation on BernBypass70; Training on MultiBypass140, (6) evaluation on BernBypass70 and (7) evaluation on StrasBypass70. The model's performance is markedly influenced by the training data. The worst results were obtained in experiments (4) and (5) confirming the limited generalization capabilities of models trained on mono-centric data. The use of multi-centric training data, experiments (6) and (7), improves the generalization capabilities of the models, bringing them beyond the level of independent mono-centric training and validation (experiments (1) and (2)). MultiBypass140 shows considerable variation in surgical technique and workflow of LRYGB procedures between centers. Therefore, generalization experiments demonstrate a remarkable difference in model performance. These results highlight the importance of multi-centric datasets for AI model generalization to account for variance in surgical technique and workflows. The dataset and code are publicly available at https://github.com/CAMMA-public/MultiBypass140.