Orthopaedic Surgeons Research Articles

Understanding the Landscape of Spinal Injections: Insights and Challenges from Latin America

IntroductionLow back pain (LBP) and neck pain (NP) are primary causes of disability, with LBP being a frequent reason for medical consultations. After conservative and pharmacological treatments, spinal injections are considered the next option. Despite multiple guidelines, spinal blocks remain controversial in terms of indication, technique, and operator, leading to considerable inter-institutional variability. The absence of regional studies in Latin America on how spinal surgeons handle spinal injections prompts the objectives of this study: to evaluate spinal surgeons' knowledge and experience, analyze techniques, and identify barriers and challenges in implementing spinal injections, including resource limitations, technology access, and training. MethodsA cross-sectional survey was performed using a questionnaire specifically designed by the authors. Results260 spinal surgeons from Latin America participated and answered a 17-question questionnaire. 75% performed their own spinal blocks and they are willing to keep on learning new techniques on the field. The most frequent block, was the lumbar facet injection (80%). And the great majority (76%) used fluoroscopy in their practice. ConclusionThe study addresses a critical gap in the literature by focusing on spinal interventions in Latin America, where there is a notable lack of regional studies. The majority of the surgeons enrolled perform their own spinal injections, and they are interested in keep on learning. The findings not only contribute to the global discourse on spinal care but also offer a basis for the development of region-specific guidelines and educational initiatives.

Dropped head syndrome suspected due to oxaliplatin used in adjuvant chemotherapy for gastric cancer: a case report

BackgroundDropped head syndrome (DHS) is caused by dysfunction of the cervical musculature. It is classified into two groups according to the cause: one is weakness of the neck extensors and the other is hypercontraction of the cervical flexors associated with Parkinson’s disease and other disorders. Although some drugs have previously been reported as suspected causes of DHS, we are unaware of any reports in which oxaliplatin was suspected. In this report, we describe a case of DHS during adjuvant chemotherapy for gastric cancer, along with a review of the relevant literature.Case presentationA 72-year-old man was diagnosed with gastric cancer, cT3N0M0 cStage IIB, and underwent laparoscopic total gastrectomy with D2 lymphnode dissection and Roux-en-Y reconstruction. The operative time was 311 min, intraoperative blood loss was 40 g, and he was discharged without any post-operative complications. The histopathological diagnosis was pT4aN2M0 pStage IIIA, and S-1 + oxaliplatin (SOX) therapy was started as adjuvant chemotherapy. On the 4th course of SOX, he complained of neck heaviness and a blood test revealed that his creatine kinase (CK) level was elevated to 2464 IU/L. After consultation with an orthopedic surgeon and a neurologist, DHS due to localized cervical extensor myositis was suspected. Therefore, the 6th course of SOX was postponed, and 30 mg of oral steroids were initiated. His symptoms improved, and his CK level decreased within 2 weeks. After resuming S-1 monotherapy and tapering off oral steroids, no recurrence of symptoms has been observed.ConclusionsWe experienced one case of DHS during adjuvant chemotherapy for gastric cancer. If DHS develops after starting oxaliplatin, involvement of the drug should be suspected, and discontinuation of chemotherapy and introduction of oral steroids should be considered.

The critical importance of recognition, evaluation, and management of mental health on outcomes following hip arthroscopy – A synthetic narrative review: Current concepts

Mental health and wellness influence patients with hip pain and dysfunction secondary to Femoroacetabular Impingement Syndrome, acetabular dysplasia, and labral injury. Disorders of mental wellness may impact hip preservation surgery patients both before and after surgery. Major depression and generalized anxiety are the two most common diagnoses that affect hip preservation surgery patients. There are dozens of unique questionnaires that can subjectively and objectively characterize the mental health of patients with hip pain. Pain threshold and pain tolerance are two issues that must be recognized to optimally predict treatment outcome in an informed consent shared decision-making discussion. Patient expectations may also significantly influence preoperative symptoms and postoperative outcome. Pain threshold, pain tolerance, and patient expectations are entities traditionally viewed as qualitative and unmeasurable. However, many valid and reliable methods exist to quantitatively assess these patient-specific variables. Recent original research and synthetic review publications have consistently concluded similar findings: patients with disorders of mental wellness generally have lower preoperative patient-reported outcome scores, do improve following surgery, albeit to a lesser magnitude than non-mental disorder patients, and ultimately have lower postoperative scores at their final follow. As with most Orthopedic Surgery literature, the investigation of mental health and hip preservation is primarily via retrospective level four evidence with small numbers of patients from a single-center and single-surgeon at short-term follow-up. Although hip preservation surgeons are Orthopedic Surgeons by training and practice, they must be able to recognize mental wellness disorders and either treat or refer when suspected or identified.

Sex Diversity and Equity Among Fellows of the American Orthopaedic Association.

We hypothesized that women are underrepresented among fellows of the American Orthopaedic Association (AOA) relative to their prevalence among faculty at departments of orthopaedic surgery. Clinical faculty at departments of orthopaedic surgery that are affiliated with residency training programs were analyzed for AOA membership. Participation-to-prevalence ratios (PPRs) were calculated for men and women with AOA membership relative to their prevalence among orthopaedic surgeon faculty. A PPR of <0.8 or >1.2 indicated under- or overrepresentation, respectively. PPR values between 0.8 and 1.2 indicated equivalent representation. Sex disparities in AOA membership were explored by academic rank and orthopaedic subspecialty. There were 4,310 orthopaedic surgery faculty, and 998 (23.2%) had AOA membership. Overall, women formed the minority of members in the AOA study cohort (11.4%), but they had equivalent representation relative to their prevalence among faculty (10.0%, PPR = 1.14, p = 0.210). In the AOA study cohort, women were the minority at each academic rank, including assistant professor (20.2% versus 79.8%, p < 0.001), associate professor (16.8% versus 83.2%, p < 0.001), and full professor (7.0% versus 93.0%, p < 0.001). However, women had greater representation in the AOA study cohort at each academic rank than would be expected based on their prevalence among faculty, including the assistant (PPR = 1.45), associate (PPR = 1.56), and full (PPR = 1.27) professor levels. Similarly, in the AOA study cohort, women were the minority in each orthopaedic subspecialty, but were only underrepresented in pediatric orthopaedics (PPR = 0.74). Women had greater representation in the AOA study cohort than would be expected by their prevalence among faculty in hand surgery (PPR = 1.51) and orthopaedic sports medicine (PPR = 1.33). In contrast, men had equivalent representation in each orthopaedic subspecialty. Women form a minority group in the AOA, but they exhibit greater representation in the AOA than would be expected based on their prevalence among faculty at each academic rank, and they have greater representation than men, who exhibit equivalent representation across all academic ranks. Collectively, these results disproved our hypothesis, and suggest that women are participating in the AOA at rates that are greater than their prevalence among faculty. Equitable participation of women in orthopaedic surgery is necessary to promote diversity and inclusion in the specialty. The AOA may be an important catalyst for future positive diversity and inclusion efforts within orthopaedic surgery.

Evaluation of the effectiveness of the femoro-sacral posterior angle system for measuring spino-pelvic morphology in high-dysplastic developmental spondylolisthesis.

The Femoro-Sacral Posterior Angle (FSPA) system and the pelvic incidence (PI) system are utilized for measuring sagittal spino-pelvic morphology in patients with high-dysplastic developmental spondylolisthesis (HDDS). This study aimed to analyze the accuracy and stability of these two systems. A retrospective analysis was conducted on 45 patients diagnosed with HDDS who underwent surgical treatment at our hospital (HDDS group), along with 45 patients without spondylolisthesis (normal group). Three orthopedic surgeons utilized the FSPA and PI systems to measure various parameters, including FSPA, pelvic angle(PA), sacral incidence (SI), PI, pelvic tilt (PT), and sacral slope (SS), respectively. The intraclass correlation coefficient (ICC) was employed to assess the inter-observer consistency of measurements. There was significant differences in all the parameters between the normal and HDDS groups (p < 0.05), except for SS (p = 0.508). Specifically, SI was lower in HDDS group than in the normal group (23.0 ± 13.4 vs. 38.6 ± 7.1), whereas SS was higher (35.3 ± 15.7 vs. 33.6 ± 7.4). Within HDDS group, there was no statistically significant difference in PI (p = 0.159), SS (p = 0.319), and FSPA (p = 0.173) between pre- and post-surgery measurements. The ICC results indicated superior reliability for the FSPA system (0.842-0.885) compared to the PI system (0.682-0.720) within the HDDS group. Compared with the PI system, the FSPA system demonstrated higher accuracy in evaluating spino-pelvic morphology in HDDS patients. Moreover, it exhibited higher ICC values, indicating higher inter-observer reliability, thus serving as an effective method for assessing spino-pelvic morphology in HDDS patients.

Anesthetic considerations for joint replacement surgery in hemophilic arthropathy: a comprehensive review.

Managing hemophilia in patients undergoing joint replacement surgery requires a comprehensive approach encompassing preoperative assessment, meticulous intraoperative care, and tailored postoperative management. Evaluation of joint integrity, bleeding history, and inhibitor presence guides surgical planning and hemostatic therapy selection to optimize outcomes. During surgery, careful attention to factor replacement, antibiotic prophylaxis, anesthetic techniques, and orthopedic strategies minimizes bleeding risk and enhances surgical success. Postoperatively, effective pain management, continued hemostatic therapy, and individualized rehabilitation programs are vital for facilitating recovery and preventing complications. Close monitoring for potential complications, such as periprosthetic joint infection and recurrent hemarthrosis, allows for prompt intervention when necessary. Overall, a collaborative approach involving hematologists, orthopedic surgeons, anesthesiologists, and rehabilitation specialists ensures comprehensive care tailored to the unique needs of patients with hemophilia undergoing joint replacement surgery, ultimately optimizing outcomes and improving quality of life. This holistic approach addresses the multifaceted challenges posed by hemophilia and joint replacement surgery, providing patients with the best possible chance for successful outcomes and long-term joint function. By integrating specialized expertise from multiple disciplines and implementing evidence-based strategies, healthcare providers can effectively manage hemophilia in the context of joint replacement surgery, mitigating risks and maximizing benefits for patients.

Development of a deep learning-based fully automated segmentation of rotator cuff muscles from clinical MR scans.

The fatty infiltration and atrophy in the muscle after a rotator cuff (RC) tear are important in surgical decision-making and are linked to poor clinical outcomes after rotator cuff repair. An accurate and reliable quantitative method should be developed to assess the entire RC muscles. To develop a fully automated approach based on a deep neural network to segment RC muscles from clinical magnetic resonance imaging (MRI) scans. In total, 94 shoulder MRI scans (mean age = 62.3 years) were utilized for the training and internal validation datasets, while an additional 20 MRI scans (mean age = 62.6 years) were collected from another institution for external validation. An orthopedic surgeon and a radiologist manually segmented muscles and bones as reference masks. Segmentation performance was evaluated using the Dice score, sensitivities, precision, and percent difference in muscle volume (%). In addition, the segmentation performance was assessed based on sex, age, and the presence of a RC tendon tear. The average Dice score, sensitivities, precision, and percentage difference in muscle volume of the developed algorithm were 0.920, 0.933, 0.912, and 4.58%, respectively, in external validation. There was no difference in the prediction of shoulder muscles, with the exception of teres minor, where significant prediction errors were observed (0.831, 0.854, 0.835, and 10.88%, respectively). The segmentation performance of the algorithm was generally unaffected by age, sex, and the presence of RC tears. We developed a fully automated deep neural network for RC muscle and bone segmentation with excellent performance from clinical MRI scans.

COMPLIANCE WITH THE SUSPECTED CAUDA EQUINA SYNDROME (CES) PATHWAY IN BETSI CADWALADR UNIVERSITY HEALTH BOARD (BCUHB) WEST: A RETROSPECTIVE AUDIT AGAINST NATIONAL STANDARDS

ObjectiveGuidelines published by the British Association of Spine Surgeons (BASS) and Society of British Neurological Surgeons (SBNS) recommend urgent MRI imaging and intervention in individuals suspected of having CES. The need for an evidence based protocol is driven by a lack of 24/7 MRI services and centralisation of neurosurgery to tertiary centres, compounded by CES's significant medico-legal implications. We conducted an audit to evaluate the pathway for suspected CES in BCUHB West between 2018 and 2021.MethodsA retrospective audit of patients managed for suspected CES between 01/11/2018 and 01/05/2021 was performed, using the SBNS/BASS guidelines as the standard.ResultsA total of 252 patients received an emergency MRI for suspected CES between 2018 and 2021. 99% of patients were scanned in compliance with SBNS/BASS standards. Radiological evidence of CES was found in 18% of patients. 33% of emergency scans were performed by out-of-hours services. 4% of patients had repeated scans within the same 6-month period. The majority of referrals originated from Orthopaedics surgeons (78%), or staff in the Emergency Department (8%). 92% of ambulatory patients were not admitted to hospital. During the peak of the COVID-19 pandemic, referrals increased from 2.5 to 3.5 per week.ConclusionSBNS/BASS standards were largely met, avoiding life changing disability and medico-legal consequences. The department should continue to follow SBNS/BASS guidance on the management of individuals with suspected CES. Challenges regarding the use of repeated scans should be addressed to avoid unnecessary costs. Introduction of new early recognition guidelines and Same Day Emergency Care (SDEC) has likely driven an increase in suspected CES referrals, and subsequent MRI demand. This audit should be utilised as an ongoing tool to ensure best practice continues, and to implement simple measures which may improve compliance with the pathway.

THE USE OF A TIBIA REDUCTION DEVICE IN THE TREATMENT OF FRACTURES UNDERGOING TIBIAL NAILING AT A DISTRICT GENERAL HOSPITAL: A PARALLEL CASE SERIES

Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced.A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case.Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11.The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08)The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04).This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time.

Are There Differences in Short-Term Postoperative Outcomes Among Surgical Subspecialists Performing Lower Extremity Flap Procedures? A National Surgical Quality Improvement Project (NSQIP) Analysis of 1324 Patients

Introduction: Soft tissue flaps are an integral and versatile tool to help manage soft tissue defects of varying severities. These complex procedures can be done by a variety of specialties and can lead to a variety of postoperative complications. Locoregional flaps are the middle rung of the reconstructive ladder and can be performed by surgeons of various training pathways. The profile of patients and their complications when stratified by surgical specialty is unknown. The purpose of this study was to compare short-term postoperative outcomes between surgical subspecialists performing a locoregional flap of the lower extremity to determine factors influencing complication rates. Methods: The National Surgical Quality Improvement Project (NSQIP) database was queried using Current Procedural Terminology code 15,738 to identify adult patients undergoing a muscle, myocutaneous, or fasciocutaneous lower extremity flap procedure from 2016 to 2019. We examined the primary outcome of a pooled wound complication rate with secondary outcomes including the individual NSQIP wound- and nonwound complications. Results: A total of 1324 patients were identified. Plastic surgeons performed 926 (70%) procedures, general surgeons performed 243 (18%) procedures, orthopedic surgeons performed 89 (7%) procedures, and vascular surgeons performed 66 (5%) procedures. On multivariate analysis, surgical subspecialty was not associated with the primary outcome, but malignancy-related operations and nonelective status were considered significant. Conclusions: Patient characteristics, but not surgeon subspecialty, account for the variation in patient outcomes in lower extremity flap reconstruction. Larger, prospective studies examining these outcomes are needed to further characterize complication risk factors in this patient population.

The hidden value of MRI: modifying treatment decisions in C-spine injuries

Background dataComputed Tomography (CT) is the gold standard for cervical spine (c-spine) evaluation. Magnetic resonance imaging (MRI) emerges due to its increasing availability and the lack of radiation exposure. However, MRI is costly and time-consuming, questioning its role in the emergency department (ED). This study investigates the added the value of an additional MRI for patients presenting with a c-spine injury in the ED.MethodsWe conducted a retrospective monocenter cohort study that included all patients with neck trauma presenting in the ED, who received imaging based on the NEXUS criteria. Spine surgeons performed a full-case review to classify each case into “c-spine injured” and “c-spine uninjured”. Injuries were classified according to the AO Spine classification. We assessed patients with a c-spine injury detected by CT, who received a subsequent MRI. In this subset, injuries were classified separately in both imaging modalities. We monitored the treatment changes after the additional MRI to evaluate characteristics of this cohort and the impact of the AO Spine Neurology/Modifier modifiers.ResultsWe identified 4496 subjects, 2321 were eligible for inclusion and 186 were diagnosed with c-spine injuries in the retrospective case review. Fifty-six patients with a c-spine injury initially identified through CT received an additional MRI. The additional MRI significantly extended (geometric mean ratio 1.32, p < 0.001) the duration of the patients’ stay in the ED. Of this cohort, 25% had a change in treatment strategy and among the patients with neurological symptoms (AON ≥ 1), 45.8% experienced a change in treatment. Patients that were N-positive, had a 12.4 (95% CI 2.7–90.7, p < 0.01) times higher odds of a treatment change after an additional MRI than neurologically intact patients.Conclusion and relevanceOur study suggests that patients with a c-spine injury and neurological symptoms benefit from an additional MRI. In neurologically intact patients, an additional MRI retains value only when carefully evaluated on a case-by-case basis.

The Development of Spinal Endoscopic Ultrasonic Imaging System with an Automated Tissue Recognition Algorithm.

Preclinical experimental study. To develop an intraoperative ultrasound-assisted imaging device, which could be placed at the surgical site through an endoscopic working channel and which could help surgeon recognition of different tissue types during endoscopic spinal surgery (ESS). ESS remains a challenging task for spinal surgeons. Great proficiency and experience are needed to perform procedures such as intervertebral discectomy and neural decompression within a narrow channel. The limited surgical view poses a risk of damaging important structures, such as nerve roots. We constructed a spinal endoscopic ultrasound system, using a 4-mm custom ultrasound probe, which can be easily inserted through the ESS working channel, allowing up to 10 mm depth detection. This system was applied to ovine lumbar spine samples to obtain ultrasound images. Subsequently, we proposed a two-stage classification algorithm, based on a pretrained DenseNet architecture for automated tissue recognition. The recognition algorithm was evaluated using accuracy and consistency. The probe can be easily used in the ESS working channel and produce clear and characteristic ultrasound images. We collected 367 images for training and testing of the recognition algorithm, including images of the spinal cord, nucleus pulposus, adipose tissue, bone, annulus fibrosus and nerve roots. The algorithm achieved over 90% accuracy in recognizing all types of tissues with a Kappa value of 0.875. The recognition times were under 0.1 s using the current configuration. Our system was able to be used in existing ESS working channels and clearly identified at-risk spinal structures in vitro. The pretrained algorithms could identify six intraspinal tissue types accurately and quickly. The concept and innovative application of intraoperative ultrasound in ESS may shorten the learning curve of ESS and improve surgical efficiency and safety.

Minimal-invasive pain procedures are effective in different degenerative pain generators in CLBP: A prospective cohort study.

It is estimated that a significant number of spinal surgeries are performed, but many patients do not often benefit. Our aim was to determine how effective minimally invasive pain procedures (MIP) are in chronic low back pain (CLBP) patients with proven degenerative causes (specific low back pain). 386 eligible patients with CLBP/sciatica resistant to conservative therapy and scheduled for open surgery were screened, and 167 could be enrolled in this study. Indications for MIP in the remaining 150 individuals were made by one experienced spinal surgeon. Before and 6 months after the intervention, the numeric rating scale (NRS) and Oswestry Disability Index (ODI) were recorded. MIP was performed, such as radiofrequency of the facet and SI-joint, intradiscal electrothermal therapy in case of discogenic pain, as well as epidural neuroplasty in patients with disc herniation/epidural fibrosis. There was a statistically significant decrease in NRS (p< 0.05), as well as a significant increase in ODI (p< 0.001) 6 months after the procedures. This was also true for the results of all different pain generators and subsequent performed procedures alone. The indication of MIP should be routinely reviewed in patients with CLBP to avoid potentially open surgery and a burden on healthcare costs.

Lumbar spine fusion surgery versus best conservative care for patients with severe, persistent low back pain.

People with severe, persistent low back pain (LBP) may be offered lumbar spine fusion surgery if they have had insufficient benefit from recommended non-surgical treatments. However, National Institute for Health and Care Excellence (NICE) 2016 guidelines recommended not offering spinal fusion surgery for adults with LBP, except as part of a randomized clinical trial. This survey aims to describe UK clinicians' views about the suitability of patients for such a future trial, along with their views regarding equipoise for randomizing patients in a future clinical trial comparing lumbar spine fusion surgery to best conservative care (BCC; the FORENSIC-UK trial). An online cross-sectional survey was piloted by the multidisciplinary research team, then shared with clinical professional groups in the UK who are involved in the management of adults with severe, persistent LBP. The survey had seven sections that covered the demographic details of the clinician, five hypothetical case vignettes of patients with varying presentations, a series of questions regarding the preferred management, and whether or not each clinician would be willing to recruit the example patients into future clinical trials. There were 72 respondents, with a response rate of 9.0%. They comprised 39 orthopaedic spine surgeons, 17 neurosurgeons, one pain specialist, and 15 allied health professionals. Most respondents (n = 61,84.7%) chose conservative care as their first-choice management option for all five case vignettes. Over 50% of respondents reported willingness to randomize three of the five cases to either surgery or BCC, indicating a willingness to participate in the future randomized trial. From the respondents, transforaminal interbody fusion was the preferred approach for spinal fusion (n = 19, 36.4%), and the preferred method of BCC was a combined programme of physical and psychological therapy (n = 35, 48.5%). This survey demonstrates that there is uncertainty about the role of lumbar spine fusion surgery and BCC for a range of example patients with severe, persistent LBP in the UK.

Exploring the viability of Virtual Reality as a teaching method for knee aspiration

Knee arthrocentesis is a simple procedure commonly performed by general practitioners and junior doctors. As such, doctors should be competent and comfortable in performing the technique by themselves; however, they need to be adequately trained. The best method to ensure practitioner proficiency is by optimizing teaching at an institutional level, thus, educating all future doctors in the procedure. However, the Coronavirus Disease 19 (COVID-19) pandemic caused significant disruption to hospital teaching for medical students which necessitated investigating the effectiveness of virtual reality (VR) as a platform to emulate hospital teaching of knee arthrocentesis. A workshop was conducted with 100 fourth year medical students divided into three Groups: A, B and C, each receiving a pre-reading online lecture. Group A was placed in an Objective Structured Clinical Examination (OSCE) station where they were assessed by a blinded orthopaedic surgeon using the OSCE assessment rubric. Group B undertook a hands-on practice station prior to assessment, while Group C received a VR video (courtesy of the University of Adelaide’s Health Simulation) in the form of VR headset or 360° surround immersion room and hands-on station followed by the OSCE. Upon completion of the workshop, students completed a questionnaire on their confidence with the procedure and the practicality of the VR station. OSCE scores were compared between Groups B and C to investigate the educational value of VR teaching. On average, students with VR headsets reported higher confidence with the procedure and were more inclined to undertake it on their own. Students in Group C who used the VR station prior to assessment scored higher than the non-VR Groups (Group A, 56%; Group B, 67%; Group C 83%). Students in Group A had statistically significant results on average compared to those in Group B (t(69) = 3.003, p = 0.003), as do students in Group B compared to Group C (t(62) = 5.400, p < 0.001). Within Group C students who were given VR headsets scored higher than immersion room students. The VR headset was beneficial in providing students with a representation of how knee arthrocentesis may be conducted in the hospital setting. While VR will not replace conventional in-hospital teaching, given current technological limitations, it serves as an effective teaching aid for arthrocentesis and has many other potential applications for a wide scope of medicine and surgical training.

Artificial Intelligence Portrayals in Orthopaedic Surgery: An Analysis of Gender and Racial Diversity Using Text-to-Image Generators.

The increasing accessibility of artificial intelligence (AI) text-to-image generators offers a novel avenue for exploring societal perceptions. The present study assessed AI-generated images to examine the representation of gender and racial diversity among orthopaedic surgeons. Five prominent text-to-image generators (DALL·E 2, Runway, Midjourney, ImagineAI, and JasperArt) were utilized to create images for the search queries "Orthopedic Surgeon," "Orthopedic Surgeon's Face," and "Portrait of an Orthopedic Surgeon." Each query produced 80 images, resulting in a total of 240 images per generator. Two independent reviewers categorized race, sex, and age in each image, with a third reviewer resolving discrepancies. Images with incomplete or multiple faces were excluded. The demographic proportions (sex, race, and age) of the AI-generated images were then compared with those of the 2018 American Academy of Orthopaedic Surgeons (AAOS) census. In our examination across all AI platforms, 82.8% of the images depicted surgeons as White, 12.3% as Asian, 4.1% as Black, and 0.75% as other; 94.5% of images were men; and a majority (64.4%) appeared ≥50 years old. DALL·E 2 exhibited significantly increased diversity in representation of both women and non-White surgeons compared with the AAOS census, whereas Midjourney, Runway, and ImagineAI exhibited significantly decreased representation. The present study highlighted distortions in AI portrayal of orthopaedic surgeon diversity, influencing public perceptions and potentially reinforcing disparities. DALL·E 2 and JasperArt show encouraging diversity, but limitations persist in other generators. Future research should explore strategies for improving AI to promote a more inclusive and accurate representation of the evolving demographics of orthopaedic surgery, mitigating biases related to race and gender. This study is clinically relevant as it investigates the accuracy of AI-generated images in depicting diversity among orthopaedic surgeons. The findings reveal significant discrepancies in representation by race and gender, which could impact societal perceptions and exacerbate existing disparities in health care.

Knowledge and Utilization of Sex-Specific Lead Aprons Among Pediatric Orthopaedic Surgeons.

Orthopaedic surgeons routinely face exposure to ionizing radiation during intraoperative use of fluoroscopy. Lead personal protective equipment reduces occupational radiation exposure. Female-specific lead aprons are designed with expanded lateral coverage to improve protection of breast tissue against radiation beams. The purpose of this study was to identify current trends in knowledge and utilization of female-specific lead aprons as well as any barriers to utilization. An anonymous electronic survey including 20 multiple choice and multiple selection responses was distributed to all members of the Pediatric Orthopaedic Society of North America (POSNA). Respondents who reported the use of intraoperative fluoroscopy in their practice were included in the study. Most respondents were attending surgeons (91%) and practiced in an academic setting (85%) in an urban environment (75%). Most respondents reported using a lead apron for every case (76%) and a thyroid shield for every case (75%), while most respondents reported they do not wear lead glasses (73%). Fifty-one percent of respondents were aware of female-specific lead aprons. The majority of respondents reported female-specific lead is unavailable (45%) or available in insufficient quantities (5.5%) at their institution. Ninety percent of females reported they do not wear female-specific lead with the common reasons being lack of availability and discomfort. Knowledge of female-specific lead is low with lack of availability as a common barrier to utilization. As female presence in the field of orthopaedic surgery expands, efforts should be made to improve education and availability of sex-specific lead aprons.

Is Close Supervision by a Senior Surgeon Necessary During the Initial Days of Performing Endoscopic Lumbar Discectomy? A Retrospective Comparative Study between Two Fellowship Trained Surgeons to Assess the Learning Curve.

Endoscopic lumbar discectomy is a minimally invasive technique with a steep learning curve. The studies in the literature base the learning curve on the operative duration. We conducted this study to determine the learning curve based on the presence or absence of supervision by an experienced surgeon. This study involved two spine surgeons (surgeon A and surgeon B), who after their fellowship training from the same institute started practising in two different hospitals with different settings. The data of the first 80 patients operated by these two surgeons were extracted, and the patients were followed up for a minimum of 1 year. The data were split into first 30 cases and late 50 cases, which were compared to see the difference between the two surgeons. The first 30 cases were evaluated between the two surgeons, and the most significant difference between the two was the operative duration. There was difference between the two surgeons in approach towards migrated and foraminal/extra foraminal discs (P = 0.02). The surgeon B started operating on upper lumbar levels in his later 50 cases, but the foraminal and extraforaminal disc herniations were rarely treated by surgeon B. Endoscopic discectomy when supervised by senior faculty helps to reduce the operative duration especially in the initial phases of a surgeon's career. The surgeon under the supervision of a senior faculty performs more of migrated and foraminal herniated discs.

Mid-Term Functional Outcomes Of Arthroscopic Rotator Cuff Repair In Patients With Or Without Frozen Shoulder: A Single-Center Retrospective Cohort Study

Rotator cuff tear (RCT) accompanied by frozen shoulder is a challenge for orthopedic surgeons as RCTs are often treated with surgical repair which need protection of repair, whereas the treatment for frozen shoulder is physical therapy to restore the range of motion of the shoulder joint. There is no consensus for the ideal treatment if those pathologies occur at the same time. The primary aim of the study is to compare the mid-term functional surgical outcomes of RCT repair in patients with or without frozen shoulder. Patients who underwent arthroscopic repair for full-thickness RCT in our institution between January 2021 and January 2023 were retrospectively reviewed. Patients were divided into two groups: with or without frozen shoulder at the time of arthroscopic repair. Patients with frozen shoulder underwent manipulation under general anesthesia and their rotator interval was released with a radiofrequency prior to RCT repair. Patients’ visual analog pain score (VAS), Constant score, ASES score, and University of California Los Angeles (UCLA) scores were compared at their latest follow-up. A total of 39 patients (19 frozen and 20 non-frozen shoulders) with a mean 23.9 ± 2.7 months of follow-up were included in the study. At the latest follow-up, there was no statistical difference in frozen and non-frozen groups in the mean VAS, ASES, UCLA, and Constant scores. The findings of the present study suggest that preoperative frozen shoulder does not have a negative impact on arthroscopic RCT repair, if frozen shoulder pathology is addressed during surgery.

Vesico-obturator venous plexus - a rare termination of obturator vein.

Obturator vein usually terminates into the internal iliac vein. Its variations are the cause major bleeding problems in pelvic surgeries. We observed a rare variation in the termination of the right obturator vein. There was a duplication of right obturator vein. Both obturator veins entered the pelvic cavity through the obturator foramen and joined with two vesical veins to form a vesico-obturator plexus. This plexus surrounded the internal iliac artery and terminated into the internal iliac vein. Awareness of this rare variation could be of importance to anatomists, radiologists, gynaecologists, urologists, and orthopaedic surgeons. The plexus might lead to hazardous bleeding in pelvic lymph node clearance procedures, hernia surgeries, gynaecological and orthopaedic procedures in this region. The pelvic fractures too can provoke dramatic retroperitoneal hematomas related to these veins injuries.