Fellowship-trained Surgeons Research Articles

Stemless components lead to improved radiographic restoration of humeral head anatomy compared with short-stemmed components in total shoulder arthroplasty.

Restoring the native center of rotation (COR) in total shoulder arthroplasty (TSA) has been shown to improve postsurgical function, subjective outcomes, and implant longevity. The primary purpose of this study was to compare postoperative radiographic restoration of the humeral COR between short-stem and stemless humeral implants by evaluating the mean COR shift between the 2 techniques. Secondary outcomes evaluated were comparisons of COR shift outliers, humeral head implant thickness and diameter, direction of COR shift, and neck-shaft angle (NSA). This study was a multicenter retrospective comparative study using a consecutive series of primary anatomic TSA patients who received either a short-stem or stemless humeral implant. Radiographically, COR and NSA were measured by 2 fellowship-trained surgeons using the best-fit circle technique on immediate postoperative Grashey radiographs. A total of 229 patients formed the final cohort for analysis that included 89 short stems and 140 stemless components. The mean COR shift for short stems was 2.7 mm (±1.4 mm) compared with 2.1 mm (±0.9 mm) for stemless implants (P<.001). The percentage of short-stem implant patients with a >2 mm COR difference from native was 66.0% (n=62) compared with 47.4% (n=64) for stemless (P=.006). The percentage of short-stem patients with a >4 mm COR difference from native was 17.0% (n=16) compared with 3.0% (n=4) for stemless (P<.001). The mean humeral implant head thickness for short stems was 18.7±2.2 mm compared with 17.2±1.3 mm for stemless implants (P<.001). The mean humeral head diameter for short stems was 48.7±4.4 mm compared with 45.5±3.5 mm for stemless implants (P<.001). The NSA for the short-stem cohort was 136.7° (±3.6°) compared with 133.5° (±6.0°) for stemless (P<.001). Stemless prostheses placed during TSA achieved improved restoration of humeral head COR and were less likely to have significant COR outliers compared with short-stem implants.

Stemless total shoulder arthroplasty using a novel multiplanar osteotomy and elliptical humeral head results in both improved early range of motion and radiographic center of rotation compared with standard total shoulder arthroplasty.

Restoration of the native glenohumeral anatomy is an important consideration in obtaining optimal range of motion (ROM) after anatomic total shoulder arthroplasty (TSA). Recently, a new stemless TSA system has been developed that uses both a multiplanar osteotomy (MPO), to improve the surgeon's ability to restore humeral center of rotation (COR), and an elliptical humeral head to improve ROM. The purpose of our study was to compare the difference in early postoperative ROM and restoration of radiographic COR, between this stemless TSA and standard stemmed TSAs. This was a retrospective review of 50 consecutive primary TSAs performed by a single surgeon for glenohumeral osteoarthritis. The initial cohort underwent TSA with a standard stemmed humeral component with a circular humeral head (n=25), whereas the subsequent cohort underwent stemless TSA using an MPO and an elliptical humeral head (n=25). Postoperative data collection included active shoulder ROM as measured by goniometer, complications or revision surgery, and measurements of radiographic COR. Patients were assessed at 6 weeks, 12 weeks, 6 months, and 12 months after surgery. Change in COR was determined on postoperative radiographs by 2 fellowship-trained surgeons on 2 separate occasions. Intra- and interrater reliability were computed using intraclass correlation coefficients. For both mean forward flexion (FF) and external rotation (ER), there was greater ROM in the MPO-elliptical group at all time points, which was statistically significant. Mean change in FF favored the MPO group at 6 and 12 weeks and was statistically significant and above the minimal clinically important difference (MCID): 6 weeks, standard -15.8° vs. MPO 8.4° (P=.004); 12 weeks, standard 6.4° vs. MPO 29.2° (P=.001). Mean change in ER favored the MPO group at 6 weeks and was statistically significant: standard 5.4° vs. MPO 14.0° (P=.02). There were no revision surgeries in either group. Average change in COR was 2.7 mm in the standard group and 1.8 mm in the MPO-elliptical group, which was statistically significant (P<.001). Number of patients with >3 mm of difference in COR was 10 (40%) in the standard group and 1 (5%) in the MPO-elliptical group, which was statistically significant (P=.002). Average intraclass correlation coefficient was 0.75, indicating good reliability within and between surgeon measurements. The use of a multiplanar osteotomy and elliptical humeral head was associated with improved early range of motion and better reproduction of the radiographic COR compared with standard stemmed TSA.

Reliability of Current Classification Systems for Periprosthetic Fractures of the Humerus.

Numerous classification systems exist to evaluate periprosthetic humerus fractures, although most are based on limited patient numbers. The Wright & Cofield system is the most widely used classification system. We sought to evaluate the inter-observer and intra-observer reliabilities of this system compared to the Unified Classification System (UCS) using the largest patient sample to date. This retrospective study identified patients between December 2011 and January 2021 with a periprosthetic fracture of the humerus around the stem of a shoulder arthroplasty component. Three upper extremity trained surgeons evaluated all radiographs for stem stability, evidence of pre-injury stem loosening, Wright & Cofield classification, UCS classification, and recommended treatment for each case at two timepoints separated by two months. The kappa statistic for inter-observer and intra-observer reliability was calculated. Seventy-six patients were included. There was moderate inter-observer (kappa 0.53) and substantial intra-observer (kappa 0.69) agreement when classifying stem stability after fracture. There was moderate inter-observer (kappa 0.48) and intra-observer (kappa 0.60) agreement when evaluating for stem loosening prior to fracture. There was fair inter-observer (kappa 0.29) and moderate intra-observer (kappa 0.51) agreement regarding the UCS class. There was moderate inter-observer (kappa 0.41) and intra-observer (kappa 0.57) agreement regarding the proposed treatment. There was slight inter-observer (kappa 0.04) and moderate intra-observer (kappa 0.44) agreement regarding the Wright & Cofield classification. The Wright & Cofield system is less reliable than the UCS classification. A more reliable and clinically relevant classification system is needed to standardize discussion of periprosthetic proximal humerus fractures. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database.

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

Special Report: The Moore Pediatric Surgery Center: An Evolving Model for Pediatric Orthopaedic Surgical Care in a Limited Resource Environment

The authors describe their 11-year experience with 1 model for providing short-term (about 1wk/y in country) pediatric orthopaedic surgical care in a limited resource environment. This paper provides a detailed narrative of 1 team's pediatric orthopaedic work at the Moore Pediatric Surgery Center in Guatemala City, how it has evolved over these 11 years, financial aspects of the model, and examines patient follow-up data for a consecutive 8-year period. The authors have reviewed financial records, case lists, patient charts from 2014 to 2022, and patient photographic records from The Moore Center and as provided via internet by a local contracted Guatemalan pediatric orthopaedic fellowship-trained surgeon to present a complete picture of how the service functions. Specific follow-up data included: last follow-up date, date discharged from follow-up, and major complications including infection, surgical wound dehiscence, return for unplanned surgery, major nerve injury, and recurrent hip dislocation for cases of closed or open reduction of developmental hip dislocation. A total of 297 consecutive pediatric orthopaedic surgical patients were identified from 2014 to 2022. Of these, charts were found for 235 patients (135 female, 110 male), of which 43% were from the urban Guatemala City region. Two hundred sixteen (72%) had at least 1 follow-up clinic visit, and 87 (37%) had at least 1-year follow-up or were discharged. All complications identified by this retrospective chart review included 4 recurrent hip dislocations (3 after closed reduction), 1 femur fracture after implant removal, 1 superficial infection requiring antibiotics, 1 partial dehiscence treated only with dressings, 1 thumb subluxation, and 1 failed graft with internal fixation for congenital pseudoarthrosis of tibia. The Moore Pediatric Surgery Center is a financially viable, sustainable, safe, and effective model for delivering short-term surgical care for many pediatric orthopaedic conditions in a limited resource environment. None (descriptive).

Short-term radiographic analysis of a stemless humeral component for anatomic total shoulder arthroplasty

Standard stemmed humeral implants have traditionally been utilized for total shoulder arthroplasty (TSA) with a recent trend to implant smaller stems including short and stemless humeral designs. However, the rate of stress shielding after stemless TSA has not been primarily studied. Therefore, the objective of this study is to report the short-term survivorship and radiographic analysis of a stemless humeral implant. A retrospective cohort review of a prospectively collected, multicenter database for patients undergoing total shoulder arthroplasty with a stemless humeral design (Equinoxe Stemless; Exactech, Inc., Gainesville, FL, USA) with a minimum of 2 years clinical and radiographic follow-up was performed. The primary outcomes were to report the location and rate of stress shielding from a radiographic analysis of the humeral stem. Additionally, the revision rate of the humeral stem is reported. The secondary outcomes included ASES scores, visual analog scale (VAS) pain scores, and range of motion (ROM). Radiographs (anterior-posterior/Grashey and axillary) were reviewed blindly by two fellowship trained shoulder surgeons. Radiographic analysis included stress shielding (partial or complete cortical resorption) and subsidence or shift in component position. Fifty four patients were included in this study with an average follow-up of 27 months (range 24-32 months). The average age of this cohort was 65 years (range 57-73 years) with 23 patients (43%) being female. Stress shielding was observed in 4 patients (7%) with the medial calcar being the most common location of stress shielding. Three of the 4 patients (75%) had evidence of partial resorption while 1 patient (25%) had evidence of complete resorption. No humeral component shift or subsidence was observed. There were no revisions due to humeral component complications. There was 1 revision surgery for aseptic glenoid loosening. A significant improvement for all clinical outcome measures was seen including with respect to VAS pain, which improved from 6.2 to 1.8 (P<.05), ASES, which improved from 38.2 to 81.8 (P<.05), and ROM which forward flexion improved from 120 degrees to 153 degrees (P<.05) and external rotation improved from 29 degrees to 49 degrees (P<.05). This ongoing study demonstrates a low rate of stress shielding for a stemless design humeral implant at short-term follow-up without any revision surgery due to humeral component complications. Longer term radiographic and clinical analysis with this cohort will be needed to confirm these findings and theoretical benefits for future revision surgeries.

Results of single-incision distal biceps tendon repair for early-career upper-extremity surgeons.

The purpose of this investigation was to assess surgical outcomes after distal biceps tendon (DBT) repair for upper-extremity surgeons at the beginning of their careers, immediately following fellowship training. We aimed to determine if procedure times, complication rates, and clinical outcomes differed during the learning curve period for these early-career surgeons. All cases of DBT repairs performed by 2 fellowship-trained surgeons from the start of their careers were included. Demographic data as well as operative times, complication rates, and patient reported outcomes were retrospectively collected. A cumulative sum chart (CUSUM) analysis was performed for the learning curve for both operative times and complication rate. This analysis continuously compares performance of an outcome to a predefined target level. A total of 78 DBT repairs performed by the two surgeons were included. In the CUSUM analysis of operative time for surgeon 1 and 2, both demonstrated a learning curve until case 4. In CUSUM analysis for complication rates, neither surgeon 1 nor surgeon 2 performed significantly worse than the target value and learning curve ranged from 14 to 21 cases. Mean Disabilities of Arm, Shoulder, and Hand score (QuickDASH) (10.65±5.81) and the pain visual analog scale scores (1.13±2.04) were comparable to previously reported literature. These data suggest that a learning curve between 4 and 20 cases exists with respect to operative times and complication rates for DBT repairs for fellowship-trained upper-extremity surgeons at the start of clinical practice. Early-career surgeons appear to have acceptable clinical results and complications relative to previously published series irrespective of their learning stage.

8715 Enhancing Quality of Recovery and Satisfaction in Minimally Invasive Gynecologic Surgery - Utility of Structured Perioperative Education

<h3>Study Objective</h3> Determine if additional structured perioperative education improves patient quality of recovery (QoR) and satisfaction in patients undergoing minimally invasive gynecologic surgery (MIGS). <h3>Design</h3> Two-phased quality improvement initiative. <h3>Setting</h3> Academic institution. <h3>Patients or Participants</h3> All patients undergoing MIGS with fellowship-trained surgeons. <h3>Interventions</h3> Patient educational video and informational handout. <h3>Measurements and Main Results</h3> Atotal of 126 patients received standard of care (SoC) counseling with their individual surgeon and 96 patients received standard of care plus additional education (SoC+E). Thirty SoC patients and 31 SoC+E patients met criteria. There were no significant differences in age, BMI, and duration of surgery between our two cohorts, however we observed longer duration of surgery in the SoC+E group. Approximately 75% of all cases were performed via multi-port laparoscopy. When examining our primary outcome, QoR between the cohorts was significantly different (p=0.03). Interestingly, while we hypothesized that QoR would be better in patients receiving additional education, the opposite was true in our study population. There were no significant differences when patients were asked to rate their recovery and preoperative counseling. Patient satisfaction did not differ between SoC and SoC+E groups with 80% and 74% as "very satisfied" in each cohort respectively. When patients in the SoC+E group were asked to rate the preoperative video and handout, 45% of patients and 32% of patients "strongly agreed" and "agreed" that the video was helpful, respectively. <h3>Conclusion</h3> Current literature supports the safety and feasibility of same-day-discharge in MIGS. This places the patient in a unique position to self-manage their recovery at home. There is a paucity of data suggesting ways to actually enhance peri-operative counseling beyond individual surgeon counseling (SoC). We demonstrate a significant difference between QoR scores. Interestingly, those who only received surgeon counseling demonstrated higher QoR scores. Additional studies are needed to determine effective tools that will serve as an adjunct to each surgeon's standard of care

Gender and Generational Divide Between Surgeons Regarding Preoperative Palliative Care Referral for Patients with Resectable Pancreatic Cancer: Results from an International Survey

INTRODUCTION: Preoperative palliative care (PC) consultation has been proposed for patients with resectable gastrointestinal cancer. Two randomized trials are evaluating PC and surgeon comanagement in the perioperative setting. We hypothesized that pancreatic surgeons harbor significant reservations regarding providing palliative care in parallel with potentially curative surgery. METHODS: An anonymous international web-based survey was conducted in 2021. Chi-square test or Fisher’s exact test were used for categorical questions, and the Wilcoxon test was used for Likert-scaled questions. Statistical significance was set at p < 0.05. RESULTS: A total of 138 surveys were completed. Of these, 83% of surgeons were male, 85% completed a fellowship, 80% practiced in academia, 46% performed more than 30 annual curative-intent operations for PDAC, and 90% had been in practice 30 or fewer years. Of those surveyed, 88% of surgeons were from the US. Of those surveyed, 65% of surgeons supported introducing PC preoperatively; female surgeons (p = 0.018) and fellowship-trained surgeons (p = 0.002) significantly more likely supported this practice; however, surgeons in practice more than 30 years did not support preoperative PC referral (p = 0.003). Of those surveyed, 94% of surgeons identified benefits associated with preoperative PC consultation; female surgeons (p = 0.048; odds ratio 3.03; CI 097. to 9.45) and fellowship-trained surgeons (p = 0.016; odds ratio 4.17; CI 1.30 to 13.33), were more likely to report that preoperative PC consultation may improve symptoms management. US surgeons identified more benefits and challenges related to preoperative PC consultation compared with non-US surgeons. CONCLUSION: Most surgeons recognize the potential benefit of preoperative PC consultation and comanagement. However, gender, fellowship training, and years in practice impact surgeons’ preference. Further studies are needed to elucidate patient and other stakeholder perspectives on preoperative PC-surgeon comanagement.

Does the Reduction Matter? Non-Emergent Ankle Fractures and the Effect of Near-Anatomic Reduction

Category: Ankle; Other Introduction/Purpose: Ankle fractures are a common orthopedic injury observed in a wide variety of patient populations. Prior to being seen by an orthopedic specialist, patients with ankle fractures may have already undergone several procedures in the field or in the emergency department to stabilize or reduce the injured bone. While a paradigm that near-anatomic reduction improves outcomes in non-urgent ankle fractures exists, no study to date has shown objective evidence of this in postoperative patient- reported outcomes. The present study aims to evaluate whether adequate reduction of non-emergent ankle fractures within 24 hours of inciting injury influenced postoperative outcomes. Methods: All non-emergent ankle fractures treated by a single foot and ankle, fellowship-trained surgeon were queried over a period of 5 years and retrospectively evaluated through the electronic medical record. 97 patients over the age of 18 years with traumatic ankle fracture etiologies were considered. Plain film radiographs from initial presentation to the emergency department or first visit to orthopedics clinic were evaluated by the attending physician for adequate reduction based on AP and lateral tibiotalar congruency. Patient demographics and surgical outcomes data were collected from electronic medical record review. In the cases deemed to be dislocated or subluxated on initial injury films, the days until adequate reduction were calculated along with patient-reported VAS and SF-36 scores. Non-continuous data were compared using chi-squared tests, while continuous, non- normally distributed data were compared utilizing a Mann-Whitney U test. Alpha and beta for this study were assumed to be 0.05 and 0.8, respectively. Results: The average age was 46, with 68.9% of the patient population that was female. 51 patients were found to be adequately reduced within 24 hours, while 39 were not. The average time to final PRO follow-up was 12.6 months +- 1.9. No differences in preoperative VAS, SF-36 physical nor mental scores were noted between adequately and inadequately reduced cohorts (p= 0.654, p=0.262, p=0.760 respectively). Similarly, no differences in final postoperative follow up VAS, SF-36 physical nor mental scores were observed (p=0.503, p=0.252, p=0.296 respectively). VAS pain scores in both cohorts also improved to a similar degree over the preoperative to final postoperative follow up time point (p=0.261). Conclusion: These data show no difference in patient-reported pain or physical and mental functioning scores over 1 year after surgical fixation of the ankle, regardless of whether the ankle joint was adequately reduced within 24 hours of injury. We assert that anatomic reduction of the ankle joint following traumatic, non-emergent ankle fracture does not play a significant role in overall patient outcomes over 1 year following surgical correction.

Are Complications and Survival of Total Ankle Arthroplasty Influenced by Hospital Setting? An Analysis of 189 Cases Performed in Community and County Hospitals

Category: Ankle Arthritis; Ankle; Other Introduction/Purpose: Total ankle arthroplasty is a notoriously challenging operation typically reserved for well-resourced academic tertiary care facilities. Limited studies support its safety in a community hospital setting, while outcomes in a county hospital setting have not been previously described. Demonstrating that TAA can be performed effectively and safely in broader hospital settings is critical given the importance of access to care, the prevalence of tibiotalar arthritis, and known efficacy of TAA for pain management, ankle stability, and preservation of functional ambulation. The purpose of this study was to investigate the differences in post-operative complications, revision rates, and implant survival of TAA performed in the community versus county hospital setting. Methods: A total of 189 patients that underwent TAA between January 2014 and May 2021 were retrospectively evaluated. 149 cases (79%) were performed in a community hospital setting, and 40 cases (21%) were performed in a county hospital setting. Surgeries were completed by a single fellowship-trained surgeon utilizing the same Stryker STAR implant for all cases. Patient demographics, postoperative complications, and revision surgery profiles were collected with a mean follow-up of 22.3 +- 21.1 months. Logistic regression was used to analyze the relationships between complications and osteoarthritis etiology, age, smoking history, diabetes, obesity, and hospital setting. Categorical variables were compared with Chi-square tests, means were compared with a two-tailed Student's t-test, and implant survival was assessed with a Kaplan-Meier analysis. Significance was defined as p&lt;.05 for all statistical analyses. Results: Controlling for osteoarthritis etiology and patient demographics, TAA performed in the county setting was a significant predictor of aseptic loosening (b=2.25, SE=1.01, p=.025; OR=9.5, 95% CI: 1.3-68.1) and posterior tibial tendon (PTT) dysfunction (b=2.76, SE=1.3, p=.034; OR=16, 95% CI: 1.2-204). Rate of aseptic loosening was significantly higher in the county as compared to the community setting (10% vs. 1.3%) (p=.006), as was PTT dysfunction (10% vs. 0.7%) (p=.001). All other complications were comparable between settings (p&gt;.05) (Figure 1). At 7 years, TAA survival with any reoperation as an endpoint was comparable between community (88.6%) and county (87.5%) settings (p=.872), with no difference in mean time to reoperation between community (11.2 months) and county (22.3 months) settings (p=.25). With explant surgery as an endpoint, survival was similarly comparable between community (97.3%) and county (95%) settings (p=.677). Overall mean time to explant surgery was 24.4 months with no difference between settings (p=.10). Conclusion: Total ankle arthroplasty has a similar reoperation rate and implant survival in community and county hospital settings. Our mid-term results compare favorably with outcomes reported from academic tertiary care facilities and suggest that total ankle arthroplasty is an effective intervention across hospital settings when performed by an experienced surgeon. However, certain complications, including symptomatic aseptic loosening and PTT dysfunction, were found to be more common when performed in the county hospital setting. Future studies are necessary to investigate the impact of the increased complication rate on long-term outcomes of total ankle arthroplasty in the county hospital setting.

Total Ankle Arthroplasty for Post-Traumatic Fracture vs Primary Osteoarthritis: An Analysis of Complications, Revisions, and Implant Survival

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle arthroplasty (TAA) has been shown to provide satisfactory clinical outcomes for the treatment of end-stage tibiotalar arthritis. However, most outcome studies do not discriminate by arthritis etiology, and there are currently no large-scale studies comparing outcomes of TAA performed for primary osteoarthritis (POA) versus post-traumatic osteoarthritis secondary to fracture sequelae (PTOA). The purpose of this study was to investigate the effect of arthritis etiology on post-operative complications, revision rates, and implant survival of TAA. Methods: 143 patients that underwent TAA for POA (n=68) and PTOA (n=75) between January 2014 and May 2021 were retrospectively evaluated. Surgeries were completed by a single fellowship-trained surgeon utilizing the same Stryker STAR implant for all cases. Patient demographics, postoperative complications, and revision surgery profiles were collected with a mean follow-up of 21 +- 19 months (Range 1.4 months-6.4 years). Based on a severity classification proposed by Gadd et al, complications were divided into low and high risk for TAA failure. Other complications (arthrofibrosis, impingement, periprosthetic cystic changes, Achilles tendinitis, persistent instability, and PTT dysfunction) were also collected. Logistic regression was used to analyze the relationship between patient demographics, osteoarthritis etiology, and complications. Categorical variables were compared with Chi-square tests, means with a two-tailed Student's t-test, and implant survival was assessed with a Kaplan-Meier analysis and Mantel-Cox logrank test. Significance was defined as p&lt;.05 for all statistical analyses. Results: Cohort demographics were comparable except that POA patients were significantly older (65+-9 years) than PTOA patients (57+-13 years) (p&lt;.001). There was no difference in rate of low risk (16.2% vs. 9.3%) (p=.218), high risk (13.2% vs. 16%) (p=.641), or other complications (14.7% vs 22.7%) (p=.224) between POA and PTOA. This remained true when controlling for patient demographics. At 7 years, TAA survival with implant retention revision as an endpoint was comparable between POA (91.2%) and PTOA (93.3%) (p=.615), with no difference in mean time to revision between POA (5+-4 months) and PTOA (16+-21 months) (p=.27). With TAA explant as an endpoint, greater survival trended in POA (100%) as compared to PTOA (94.6%) (p=.056) (Figure 1). Mean time to TAA explant for PTOA was 13+-7 months. Failure etiologies included symptomatic arthrofibrosis, component subsidence, periprosthetic fracture, and aseptic loosening. Conclusion: The complications, revision rates, and 7-year survivorship of TAA using a single prosthesis for PTOA secondary to fracture sequelae were no different when compared to TAA for POA. However, there was a non-significant trend for an increased rate of implant failure requiring TAA explant in PTOA compared to POA (Figure 1). Given this trend, further investigation is warranted to assess the long-term outcomes and implant survival of total ankle arthroplasty for post-traumatic fracture osteoarthritis.

Value of Hospice and Palliative Medicine Fellowship After Surgical Training: Bridging the Gap for Improved Patient Care.

Objective: Surgeons comprise 2% of HPM-trained physicians. Little is known about the perceived value of HPM training to the surgeon or medical community. We aim to demonstrate the value of HPM fellowship training to surgeons and surgical practice from the point of view of HPM fellowship trained surgeons. Design: A qualitative analysis was performed using semi-structured zoom interviews that elicited the lived experiences of HPM trained surgeons. Data was analyzed using descriptive statistics and thematic analysis. Setting: Researchers were from the University of Kansas School of Medicine and the University of Alabama at Birmingham. Participants were trained and worked across the United States in a variety of settings. Participants: Eligibility included training in general surgery, obstetrics and gynecology, or affiliated subspecialties and completion of a 1-year HPM fellowship. Results: 17 interviews were performed. Several themes emerged regarding the transformative value of HPM training to their medical and surgical practice: (1) Learning to apply shared decision making and goal-concordant care to surgical decision making, and (2) Decreasing personal bias in medical decision making, and (3) Enabling wellness in surgeons. Two themes emerged regarding the perceived value to both the surgical community and the HPM community: (1) Value of the HPM Fellowship Trained Surgeon to the Surgical Community, and (2) Value of the HPM Fellowship Trained Surgeon to the HPM Community. All study participants valued their HPM training and felt highly valued by the healthcare team. Conclusion: HPM trained surgeons are highly valued on the healthcare team and improve patient-centered surgical care.

Incidence of attrition among early-career abdominal transplant surgeons

BackgroundThe prevalence of burnout and depression among abdominal transplant surgeons has been well described. However, the incidence of early-career transplant surgeons leaving the field is unknown. The objective of this study was to quantify the incidence of attrition among early-career abdominal transplant surgeons. MethodsA custom database from the Organ Procurement and Transplantation Network with encrypted surgeon-specific identifiers was queried for transplant surgeons who entered the field between 2008 and 2019. Surgeons who experienced attrition, defined as not completing a subsequent transplant after a minimum of 5, were identified. Surgeon-specific case volumes, case mix, and recipient outcomes were modeled to describe their association with attrition. ResultsBetween 2008 and 2018, 496 abdominal transplant surgeons entered the field and performed 76,465 transplant procedures. A total of 24.4% (n = 121) experienced attrition, with a median time to attrition of 2.75 years. Attrition surgeons completed fewer kidney (7 vs 21, P < .01), pancreas (0.52 vs 1.43, P < .01), and liver transplants (1 vs 4, P < .01) in their first year of practice. Attrition surgeons completed a smaller proportion of their transplant center’s volume (9% vs 18%, P < .01) and were less likely to participate in pediatric transplants (26.5% vs 52.5%, P < .01) and living donor kidney transplants (64.5% vs 84.5%, P < .01). On multivariable analysis, performing fewer kidney (odds ratio: 0.98, 95% confidence interval: 0.98–0.99) and liver transplants (odds ratio: 0.98, 95% confidence interval: 0.97–0.98) by year 5 and completing a smaller proportion of their centers’ volume (odds ratio: 0.96, 95% confidence interval: 0.94–0.98) were associated with attrition. Furthermore, attrition surgeons had worse allograft and patient survival for liver transplant recipients (both log-rank P < .01). ConclusionThis investigation was the first to quantify the high incidence of attrition experienced by early-career abdominal transplant surgeons and its association with surgeon-specific case volumes, case mix, and worse recipient outcomes. These findings suggested the abdominal transplant workforce is struggling to retain their fellowship-trained surgeons.

Treatment patterns of ABOS part II candidates: A decline of operative management among geriatric proximal humerus fractures over the decade (2010–2020)

BackgroundThe purpose of this study was to assess trends in ABOS part II candidate's operative management of geriatric (≥65 years) proximal humerus fractures over the 2010–2020 decade. MethodsThis retrospective database cohort study utilized the American Board of Orthopaedic Surgery (ABOS) database for candidates taking Part II of their boards. Surgical coding was reviewed and the ICD10 data was correlated to the CPT code for shoulder arthroplasty or open reduction internal fixation. We investigated the number of proximal humerus fracture operative cases per year, the percent arthroplasty used per year, the stratification of percent arthroplasty per orthopaedic fellowship subspecialty and geographic region. ResultsA total of 2,409 operative cases for proximal humerus fractures in patients 65 years of age and older were submitted by 1,420 ABOS candidates. There was a 37% reduction in operatively managed proximal humerus fractures among ABOS part II candidates between the first half of the decade (2010–2015, 263.2 +/- 13.4) and the second half of the decade (2016–2020, 166 +/- 31.2; p<.05). There also was a downward trend with a 53% reduction in percent treated with arthroplasty as compared to ORIF during those same windows (2010–2015, 34.4 +/-11.7) and (2016–2020, 16.2 +/- 6.4; p<.5). Partitioned by single fellowship training, Shoulder and Elbow (S&E) surgeons performed the highest percent arthroplasty at 25.2%, followed by Sports at 23.1% and the lowest percent arthroplasty was Trauma at 11.7%. The Southeast United States had the lowest percentage arthroplasty at 15.8% as compared to the Midwest (23.8%) and Northeast (25.8%). ConclusionDespite the rapid growth of both the elderly population and related geriatric proximal humerus fractures, ABOS candidates are treating less with surgery. There has been approximately a 37% decrease in the total number of operatively treated proximal humerus fractures between the first and second half 2010–2020 decade. When operative treatment is performed, there is a trend towards ORIF over an arthroplasty. Trauma fellowship trained surgeons are less likely to perform an arthroplasty as compared to other subspecialties. The Southeast region is least likely to perform an arthroplasty as compared to the Midwest or Northeast.

P150. Differences in survivorship between elderly patients with odontoid and hip fractures: a retrospective cohort study

<h3>BACKGROUND CONTEXT</h3> Both odontoid fractures and hip fractures often occur from a standing height and are thus categorized as fragility fractures. Studies have reported a 1-year mortality rate of 37.5% for patients with odontoid fractures in comparison to a 1-year mortality rate of 32% for those with hip fractures within the same age-matched cohort. However, an evaluation of comorbidities' influence on the relative mortality of hip and odontoid fractures is lacking. <h3>PURPOSE</h3> The purpose of this study is to compare the mortality and risk factors of isolated odontoid fractures to those with isolated hip fractures among the elderly population (>65 years). <h3>STUDY DESIGN/SETTING</h3> A single institution 14-year retrospective review of a level 1 trauma center with six fellowship trained spine surgeons. <h3>PATIENT SAMPLE</h3> This study included elderly patients (>65 years at the time of injury) who sustained either an isolated hip fracture or isolated odontoid fracture. <h3>OUTCOME MEASURES</h3> Primary outcomes were age at time of injury, comorbidities (Charlson Comorbidity Index (CCI)) and time from injury to mortality. <h3>METHODS</h3> Patients greater than 65 years with an isolated odontoid fracture or hip fracture from 2006 to 2020 were identified. Data collected include demographic information, time from injury to death, and living status. Death was assessed using a national social security database. Patients were matched on a 4:1 basis on both age and CCI. A Kaplan-Meier table was used to analyze survivorship from the date of fracture between age- and CCI score-matched patients with an odontoid fracture or hip fracture. A Cox regression analysis was used to assess the effect of age and CCI score on survival. <h3>RESULTS</h3> A total of 1,234 patients with isolated hip fractures and 133 patients with isolated odontoid fractures were identified. After matching, a total of 532 hip fracture patients and 133 odontoid fracture patients were included in the analysis. A Kaplan-Meier estimate analysis revealed that survivorship for elderly patients with isolated odontoid fractures was longer compared to elderly patients with isolated hip fractures (p<0.0001). Furthermore, patients with isolated hip fractures experienced an increased risk of death compared to patients with isolated odontoid fractures (hazard ratio [HR] = 1.47, p = 0.03), regardless of CCI score. Although risk of death was greater following hip fractures, CCI scores were independently associated with an increased risk of death in both patient groups (HR = 1.43, p = 0.004). <h3>CONCLUSIONS</h3> Survivorship following isolated hip or odontoid fractures decreases substantially over time. Elderly patients who suffer isolated odontoid fractures have a lower risk of death compared to elderly patients who suffer isolated hip fractures. The presence of comorbidities significantly increases the risk of death in patients with isolated hip or odontoid fractures. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Assessment of Rod Bending Accuracy for Sagittal Spinal Deformity Correction on 3D Printed Moulage

Background: One of the most important objectives in the deformity correction surgery of spine is to achieve appropriate sagittal alignment, to improve patient outcome and reduce the risk of junctional failure. Intra-operative rod bending is crucial to achieve desired alignment. Objectives: Assessment of accuracy of rod bending by spine surgeons with or with-out template and/or correction. Methods: Spine surgeons were asked to bend two rods; one in-situ on three-dimensional (3D) printed moulage, designed based on schematic representation of a patient with Kyphoscoliosis, the other rod was asked to bend with correction angles. The differences were measured and correlated with experience and specialty. Results: 21 fellowship trained spine surgeons participated in this study, for in-situ rod, mean thoracic and lumbar bend were 65.2 (P = 0.033) and 49.3 (P = 0.077) degrees, respectively and for the correction rod, mean bend in thoracic and lumbar were 53.8 (P = 0.001) and 51.8 (P = 0.004) degrees, respectively, with significant difference from cut-off point. Each curve was over-bend and it was more pronounce in thoracic, both on in-situ and correction rods, 61.9 and 71.1 %, respectively. Level of experience showed positive correlation with degree of rod bending more than five years in thoracic in-situ bend (P = 0.003) and thoracic bend with correction (P = 0.004). Field of specialty showed positive correlation as well; with orthopedic in-situ bend (P = 0.002) and with correction (P = 0.003). Conclusions: Spine surgeons tend to over-bend rods, when given target angles and when correction is needed. However, when provided with template, a 3D printed moulage in our study, accuracy of rod bending improved significantly.

Trends in Facial Paralysis Management: A National Survey Study.

Advances in operative management, minimally invasive procedures, and physical therapy have allowed for dramatic improvements in functional and cosmetic outcomes in patients with facial paralysis. Our goal was to evaluate the current trends and practice patterns in the diagnosis and management of facial paralysis by provider demographics. An electronic questionnaire was distributed to members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Practice patterns in the diagnosis and treatment were compared by level of training (fellowship-trained facial plastic and reconstructive surgeon versus non-fellowship trained), practice type (academic and private), practice length, patient volume, and presence of a dedicated facial nerve clinic. The bivariate associations of the outcome variables and the stratification factors were analyzed using 2-way contingency tables and Fisher's exact tests. The survey was sent to 1129 members of the AAFPRS. The response rate was 11.7% (n=132). Most respondents were fellowship-trained surgeons (79%) in the academic setting (55%), and most have been in practice for more than 10 years (53%). Practice setting and patient volume were the factors most associated with significant variations in management, including the use of facial paralysis grading scales, photography/videography, patient-reported outcome metrics, as well as differences in both noninvasive and surgical management. Based on the present study, several physician demographic factors may play a role in choosing which diagnostic and treatment options are employed for facial paralysis, with practice setting and patient volume appearing to be the 2 variables associated with the most significant differences.

Distribution of the head and neck surgical oncology workforce in the United States.

The recent trends in education and geographic distribution of the head and neck surgery workforce have not been studied extensively. We reviewed publicly available sources to locate all fellowship-trained head and neck surgeons and recent graduates. The number of surgeons in each state was compared against head and neck cancer incidence data from the Centers for Disease Control. The number of graduates increased annually by 1 per 100 000 000 people from 2011-2020. The average number of fellowship-trained surgeons per state was 10 (SD: 12). The average number of new head and neck cancer cases per surgeon was 247 (SD: 135). Ten states (20%) had cases >1 SD above the national average/surgeon, while 3 (6%) had cases >1 SD below the national average. Head and neck surgeons are located in most states, but not uniformly. Most states have approximately average density of surgeons; however, several states are outliers.

High rate of return to sport and excellent patient-reported outcomes after an open Latarjet procedure.

The purpose of this study was to report return to sport, patient-reported outcomes (PROs), subjective outcomes, and complications or failures in patients who underwent open Latarjet surgery. Patients who underwent open Latarjet surgery performed by 2 fellowship-trained surgeons between August 2006 and November 2018 were included. Prospectively collected data were reviewed. Recurrent instability and revision surgical procedures were recorded. Subjective outcomes included return to sport and fear of reinjury or activity modification as a result of patients' instability history. PROs included the American Shoulder and Elbow Surgeons (ASES) score, Short Form 12 Physical Component Summary score, Single Assessment Numeric Evaluation score, Quick Disabilities of the Arm, Shoulder and Hand score, and satisfaction. Age, sex, sports participation, pain, primary vs. revision surgery (prior failed arthroscopic or open Bankart repair), dislocation number, glenoid bone loss, glenoid track concept, and projected glenoid track were evaluated. Failure was defined as an ASES score <70, recurrent dislocation, or revision instability surgery. A total of 126 shoulders (125 patients) met the inclusion criteria, with a mean age of 28.1 years (range, 15-57 years). Of 126 shoulders, 7 (5.5%) underwent additional procedures prior to final follow-up and were excluded from outcome analyses; failure occurred in 6 of these shoulders. Mean follow-up data at 3.7 years (range, 2-9.3 years) were attained in 86.6% of patients (103 of 119). All PROs significantly improved from preoperative baseline (ASES score, from 69.7 to 90.2; Single Assessment Numeric Evaluation score, from 55.8 to 85.9; and Quick Disabilities of the Arm, Shoulder and Hand score, from 28.4 to 10.5). PROs did not differ based on sex, sports participation type, dislocation with or without sports, primary vs. revision procedure, and preoperative dislocation number. No correlations existed between PROs and age, glenoid bone loss, or number of previous surgical procedures. On-track lesions (50 of 105, 47.6%) and projected on-track lesions (90 of 105, 85.7%) correlated with better patient satisfaction but not PROs. Despite not having recurrences, 63 of 99 patients (63.6%) reported activity modifications and 44 of 99 patients (44.4%) feared reinjury. These groups had statistically worse PROs, although the minimal clinically important difference was not met. Return to sport was reported by 97% of patients (86 of 89), with 74% (66 of 89) returning at the same level or slightly below the preinjury level. Revision stabilization surgery was required 6 of 126 cases (4.8%), and 6 of 103 shoulders (5.8%) had ASES scores <70. The open Latarjet procedure led to significant improvements in all PROs, and overall, 97% of patients returned to sport. Fear of reinjury and activity modifications were common after open Latarjet procedures but did not appear to affect clinical outcomes. On-track and projected on-track measurements correlated with better patient satisfaction but not improved PROs.