Orthopaedic Fellowship Research Articles

Association between personal characteristics and anxiety and burnout in orthopedic residents: a cross-sectional cross-sectional study

ObjectiveBurnout is becoming a major problem in medicine, and some articles have pointed to the link between burnout and anxiety. Several factors can contribute to burnout and anxiety, and recognizing each can improve medical education environments. The purpose of this study is to determine the relationship between personal characteristics, anxiety and burnout of orthopedic residents.MethodIn this cross-sectional study, the anxiety rate, depression, and burnout were evaluated in 94 orthopedic residents above the second year and orthopedic fellowships in three hospitals. Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and Maslach Burnout Inventory—Human Services Survey (MBI-HSS) were used to measure the levels of depression, anxiety, and burnout, respectively. Multivariate logistic regression analysis was used to evaluate predictor variables for burnout.ResultsSevere anxiety and depression were reported in 17% and 12.77% of residents, respectively. The rate of burnout for Emotional Exhaustion (EE), Depersonalization (DP), and low sense of Personal Accomplishment (PA) subscales was 18.09%, 28.72%, and 43.62% of people with high levels of burnout, respectively. Multivariate analysis of logistic regression showed that Works > 60 h per week, Anxiety score > 28, Time spent in the hospital > 9 h per Day, Academic year and Experience being abused by the upstream, Balance between work and life, Feeling the need for support from nurses in the hospital were significantly associated with burnout.Conclusionstress and anxiety can be considered a severe factor in burnout; this issue can provide a clear perspective of the psychological cycle that ultimately leads to a decrease in the efficiency of the medical system and related services.

Nature and Magnitude of Industry Payments to Fellowship Program Directors in Orthopaedic Surgery.

Previous research has highlighted conflicts of interest stemming from industry funding and education of orthopaedic surgeons. This study sought to define the nature and magnitude of industry payments to orthopaedic surgery fellowship program directors (FPDs) in the United States. This was a retrospective cohort study of orthopaedic surgery FPDs during 2021. Data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) and Centers for Medicare and Medicaid Services. Profiles of orthopaedic surgery FPDs were obtained for ACGME-accredited and non-ACGME-accredited training programs. Nonresearch industry payments from 2015 to 2021 were extracted and adjusted for inflation. Temporal trends were analyzed through the calculation of compound annual growth rates. Comparisons were made with nonparametric tests. Of 600 orthopaedic surgery FPDs, 596 received industry funding (99%), which totaled $340.6 million over the study period. A trend toward greater total annual industry payments over the study period was observed (compound annual growth rate = 3.3%, P = 0.009). Most industry payments were for royalties or licensing ($246.6 million, 72.4%) and consulting fees ($53.6 million, 15.7%). The median total payment per orthopaedic surgery FPD was $49,971 (interquartile range [IQR], $291,674), with 22% receiving between $100,000 and $500,000 and 17% receiving more than $500,000. The highest annual industry payments existed in shoulder and elbow ($41,489, IQR, $170,613) and spine surgery ($26,103; IQR, $84,968). ACGME accreditation status did not influence the magnitude of industry compensation to orthopaedic surgery FPDs across subspecialties (P > 0.05). Men had higher total median annual industry payments versus women ($7,799 [IQR, $47,712] versus $1,298 [IQR, $6,169], P < 0.001). Industry payments to orthopaedic surgery FPDs are ubiquitous, but the magnitude varies by subspecialty. Most industry funding was found in shoulder and elbow and spine surgery. Standards for orthopaedic fellowship education, such as those upheld by accrediting bodies, should include guidelines on how FPDs handle and disclose financial relationships with industry.

An automated framework for pediatric hip surveillance and severity assessment using radiographs.

Hip dysplasia is the second most common orthopedic condition in children with cerebral palsy (CP) and may result in disability and pain. The migration percentage (MP) is a widely used metric in hip surveillance, calculated based on an anterior-posterior pelvis radiograph. However, manual quantification of MP values using hip X-ray scans in current standard practice has challenges including being time-intensive, requiring expert knowledge, and not considering human bias. The purpose of this study is to develop a machine learning algorithm to automatically quantify MP values using a hip X-ray scan, and hence provide an assessment for severity, which then can be used for surveillance, treatment planning, and management. X-ray scans from 210 patients were curated, pre-processed, and manually annotated at our clinical center. Several machine learning models were trained using pre-trained weights from Inception ResNet-V2, VGG-16, and VGG-19, with different strategies (pre-processing, with and without region of interest (ROI) detection, with and without data augmentation) to find an optimal model for automatic hip landmarking. The predicted landmarks were then used by our geometric algorithm to quantify the MP value for the input hip X-ray scan. The pre-trained VGG-19 model, fine-tuned with additional custom layers, outputted the lowest mean squared error values for both train and test data, when ROI cropped images were used along with data augmentation for model training. The MP value calculated by the algorithm was compared to manual ground truth labels from our orthopedic fellows using the hip screen application for benchmarking. The results showed the feasibility of the machine learning model in automatic hip landmark detection for reliably quantifying MP value from hip X-ray scans. The algorithm could be used as an accurate and reliable tool in orthopedic care for diagnosing, severity assessment, and hence treatment and surgical planning for hip displacement.

CT of Periarticular Adult Knee Fractures: Classification and Management Implications.

Periarticular knee fractures, which include fractures of the distal femur, tibial plateau, and patella, account for 5%-10% of musculoskeletal injuries encountered in trauma centers and emergency rooms. These injuries are frequently complex, with articular surface involvement. Surgical principles center on reconstruction of the articular surface as well as restoration of limb length, alignment, and rotation to reestablish functional knee biomechanics. Fixation principles are guided by fracture morphology, and thus, CT with multiplanar reformats and volume rendering is routinely used to help plan surgical intervention. Fractures involving the distal femur, tibial plateau, and patella have distinct management considerations. This comprehensive CT primer of periarticular knee fractures promotes succinct and clinically relevant reporting as well as optimized communication with orthopedic trauma surgeon colleagues by tying fracture type and key CT findings with surgical decision making. Fracture patterns are presented within commonly employed fracture classification systems, rooted in specific biomechanical principles. Fracture typing of distal femur fractures and patellar fractures is performed using Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification schemes. Tibial plateau fractures are graded using the Schatzker system, informed by a newer explicitly CT-based three-column concept. For each anatomic region, the fracture pattern helps determine the surgical access required, whether bone grafting is warranted, and the choice of hardware that achieves suitable functional outcomes while minimizing the risk of articular collapse and accelerated osteoarthritis. Emphasis is also placed on recognizing bony avulsive patterns that suggest ligament injury to help guide stress testing in the early acute period. ©RSNA, 2024 Supplemental material is available for this article.

Evaluation and Management of Glenohumeral Instability in Adolescent Patients: An Expert Consensus Statement.

Management of glenohumeral instability in the adolescent population can be both challenging and controversial. There are no current guidelines for optimal management of glenohumeral instability in this population (unidirectional or multidirectional), and the cutoff ages for transition to adult treatment are not known. To develop consensus-based guidelines for the management of glenohumeral instability in adolescents. Consensus statement. A 26-question, multiple-choice survey was developed after 2 rounds of iterations and was submitted to the orthopaedic surgeons of the Pediatric Research in Sports Medicine (PRiSM) Society. The survey comprised 3 sections-demographics, practice setting, and decision-making-and included cutoff ages and management in 5 specific case scenarios. Consensus-based guidelines were generated with 66% response agreement. An indication score was then applied to each response related to more aggressive management to determine if variables related to consensus (or lack thereof) could be identified. A total of 54 responses were returned. Of the respondents, 59% were from academic practice, 84% were pediatric orthopaedic fellowship trained, and 46% performed >25 shoulder instability cases per year. In the setting of first-time anterior shoulder dislocation, nonoperative treatment was preferred for boys aged <14 years and girls aged <13 years. Besides age, proximal humerus physeal status, injury mechanism, sport, and presence of bony injury affected treatment selection. The presence of a Bankart lesion was an indication for stabilization in first-time dislocations for contact athletes with a closing or closed physis, but not in patients with an open physis or noncontact injury mechanisms. For recurrent anterior shoulder dislocation, stabilization was preferred irrespective of physis status. Initial nonoperative treatment was preferred for multidirectional instability. In the setting of first-time anterior shoulder dislocation in patients with open physes, nonoperative treatment was preferred for boys <14 years and girls <13 years. Future multicenter prospective studies focusing on outcomes would help to validate current practice patterns, especially in scenarios for which no consensus was reached.

The Development and Execution of An Orthopaedic Sports Medicine Fellowship Surgical Skills Assessment

Background: Assessment of orthopaedic surgery trainees is traditionally based on subjective evaluation by faculty. The recent push for value-based health care has placed a premium on improving patient outcomes. As a result, surgical training evaluations for orthopaedic trainees are evolving to include more objective measures to evaluate competency. Purpose: To develop and subsequently demonstrate the efficacy of a novel surgical skills assessment for orthopaedic sports medicine fellows. Study Design: Case series; Level of evidence, 4. Methods: A team of 14 fellowship-trained orthopaedic sports medicine surgeons developed objective scoring rubrics for anterior cruciate ligament reconstruction (ACLR) and rotator cuff repair (RCR) using a modified Delphi process. Rubrics were designed based on 10 surgical steps with a grading scale (1-5) based on core competencies with a maximum summative score of 50. Fourteen orthopaedic fellows across a regionally diverse group of sports medicine–accredited fellowship programs were invited to complete both an ACLR and RCR in a surgical skills laboratory at the beginning and end of their fellowship year. Individual surgical steps, overall performance, and total procedure time were evaluated by a single sports medicine surgeon for both sessions. Results: Thirteen of 14 fellows completed both pre- and post-fellowship assessments. For the ACLR procedure, the pre-fellowship mean summative score was 25.4 (SD, 4.4) and the post-fellowship mean summative score was 38.6 (SD, 4.1), which was a statistically significant improvement (P < .001). For the RCR procedure, the pre-fellowship mean summative score was 26.6 (SD, 5.4) and the post-fellowship mean summative score was 38.8 (SD, 4.3), which was also a statistically significant improvement (P < .001). The mean time to completion for the ACLR procedure was 82.3 minutes (SD, 4.3 minutes) pre-fellowship, which improved to 69.7 minutes (SD, 11.6 minutes) post-fellowship (P = .002). The mean time to completion for the RCR procedure was 85.5 minutes (SD, 5.0 minutes) pre-fellowship, which improved to 76.4 minutes (SD, 7.0 minutes) post-fellowship (P < .001). Conclusion: This surgical skills program represents the first standardized and reproducible instrument for the evaluation of 2 arthroscopic sports medicine procedures in the United States. Orthopaedic sports medicine fellows improved significantly in aggregate over their fellowship year with regard to the ACLR and RCR. The described program has the potential to serve as both a training tool and formal orthopaedic sports medicine fellow assessment.

Analysis of Sex Diversity Within Orthopedic Trauma Surgery Fellowship Programs.

Women continue to be underrepresented in orthopedic surgery and in orthopedic fellowship programs, especially in orthopedic trauma. We aimed to assess sex diversity among faculty and trainees in orthopedic trauma surgery fellowship programs and investigate whether the presence of female faculty in those programs is associated with the recruitment of female fellows. This was a cross-sectional analysis of 63 orthopedic trauma surgery fellowship programs. Information regarding program faculty (as of October 2023) and fellows from 2018 to 2024 was gathered. For programs without publicly accessible information, fellowship coordinators were e-mailed for de-identified sex breakdown of fellows categorized by year. The sex of each fellow and faculty member was categorized as male or female and determined by inference from the fellow's first name and confirmed via Internet search using photos, biographies, and preferred pronouns when available. Of 63 programs with 323 orthopedic trauma faculty, 30 (47.6%) programs had at least 1 female faculty member, with only 4 (6.4%) programs having female fellowship directors. Women made up 12% (n = 39) of orthopedic trauma faculty. Of 399 total fellows identified over the 6-year period, 67 (16.7%) were women, with a notable increase in the representation of female fellows over time, from 10.8% in 2018 to 25.4% in 2024. Although programs with female faculty had a similar proportion of female fellows over the 6-year period as those without, in the most recent fellowship year (2023-2024), programs with female faculty had a higher proportion of female fellows than those without (38.2% vs 13.5%, respectively). This cross-sectional, observational study suggests that female surgeons remain underrepresented in orthopedic trauma fellowship director roles, although we observed an increasing number of female trainees entering orthopedic trauma surgery fellowship programs in recent years. In the most recent fellowship class studied, programs with female faculty had more than double the proportion of female fellows compared to programs without any female faculty.

Treatment of clavicle fracture: Interpretation of the 2023 American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines

Clavicle fracture is a common orthopedic injury, accounting for approximately 2.6%-4% of all adult skeletal fractures. In 2023, the American Academy of Orthopaedic Surgeons (AAOS) developed evidence-based treatment guidelines for clavicle fractures, which include 4 recommendations and 10 options. This article, based on a thorough review of the guidelines, discusses the clinical treatment of clavicle fractures, aiming to share advancements and the latest diagnostic and therapeutic considerations with orthopedic colleagues to enhance treatment outcomes.

A Comparison of Demographic Diversity Between Orthopaedic Surgery Residents and ACGME Foot and Ankle Fellows From 2007 to 2022.

Academic medicine emphasizes the need to recruit a diverse workforce in graduate medical education. Orthopaedic surgery residency has demonstrated efforts to model program compositions with evolving US demographics. However, it remains unclear whether orthopaedic fellowships, particularly foot and ankle, also reflect these efforts. Using the publicly available Accreditation Council for Graduate Medical Education (ACGME) Data Resource Book, a census of the gender and racial/ethnic identities of orthopaedic foot and ankle fellows, as well as active orthopaedic surgery residents, were compiled from 2007 to 2022. Linear trend analysis was conducted to evaluate the trends of orthopaedic residents and foot and ankle fellows, with a Pearson correlation for comparison. Prior analysis demonstrated no significant change in sex and ethnic diversity of fellows from 2006 to 2015. The majority of foot and ankle fellows were White (31%-69%) and male (63%-88%). Linear analysis demonstrated growing diversity in female and non-White active orthopaedic surgery residents. Similarly, there was an increasing number of female foot and ankle fellows (0%-38%) reflective of the trend in orthopaedic residency (12%-20%); however, there was no significant change among racial/ethnic identities. Pearson correlation analysis between the trend of orthopaedic residency residents and foot and ankle fellows suggests moderate correlation among female, Asian, and "Unknown" racial/ethnic categories. The proportion of foot and ankle female fellows in ACGME-accredited fellowships has matched or exceeded the percentage of female orthopaedic residents. Despite increased diversity of orthopaedic surgery residents over the past 2 decades, ACGME-accredited foot and ankle fellowships do not yet reflect similar trends among racial/ethnic minorities. Level III, retrospective cohort study.

Intracapsular neck of femur fractures secondary to civilian gunshot injuries: an inter- and intra-observer agreement study on classification and treatment using the AO/OTA classification

PurposeNumerous classification systems have been developed for neck of femur fractures, but none have been tested for reliability in gunshot injuries. Our primary objective was to assess the inter-observer and intra-observer reliability of the AO/OTA classification system when applied to intracapsular neck of femur fractures secondary to low-velocity civilian gunshots wounds (GSWs). Our secondary objective was to test the reliability of the AO/OTA classification system in guiding surgeon treatment choices for these fractures.Patients and methodsEighteen reviewers (six orthopaedic traumatologists, six general orthopaedic surgeons and six junior orthopaedic fellows) were given a set of 25 plain radiographs and CT scans of femur neck fractures secondary to GSW. For each clinical case, all reviewers selected a classification as well as treatment option from a list of given options. Inter-observer reliability was measured at the initial classification. The exercise was repeated 10–12 weeks later by the same 18 reviewers to test intra-observer reliability.ResultsThe Fleiss kappa values indicate only slight agreement amongst raters, across all experience levels, for both injury classification and treatment. Intra-observer agreement was fair across all experience levels for both injury classification and treatment.ConclusionThe AO/OTA classification showed only slight reliability in classification of gunshot fractures of the femur neck. With only fair reliability, it also failed to guide surgical treatment thus rendering its routine use in daily clinical practice of questionable value.

Impact of Program Region and Prestige on Industry Supplemental Earnings for Pediatric Orthopedic Surgery Fellowships in the United States: A Retrospective Analysis

Introduction: With the passage of the Physician Payment Sunshine Act, there has been increased transparency regarding the industrial financial relations that physicians have. Orthopedic surgeons have been highly studied in this domain with approximately 50% of all orthopedic surgeons engaging in industrial financial relationships. Furthermore, an increasing number of orthopedic surgeons are seeking fellowship training with pediatric fellowship programs gaining popularity in recent years. The purpose of this study is to evaluate the impact various pediatric orthopedic fellowship programs have on industry earnings and academic productivity. Methods: Pediatric orthopedic fellowship programs were identified via the Orthopedic Society of North America (POSNA) website. Information on individual fellowship programs was obtained from their respective websites. Academic productivity was measured via an aggregate of all employed physicians’ H-index at a specific fellowship as found on the Scopus website. The Open Payments Database (OPD) website was used to assess lifetime industry earnings. Other variables such as Newsweek or Doximity ranking were taken directly from relevant websites. Statistical analysis was performed using a Kruskal–Wallis test with Bonferroni correction and Mann–Whitney U-test. Results: A total of 43 pediatric orthopedic surgery fellowships in the United States were identified with a total of 392 physicians as fellowship faculty. Complete OPD and H-index information were available for 336 of those physicians (85.7%). On average, there were 7.81 ± 5.18 physicians and 1.56 ± 0.93 fellows per program. The mean combined physician H-index was 117.23 ± 122.51, and the mean combined physician lifetime supplemental earnings in dollars was $646,684.37 ± $1,159,507.17. There was no significant relationship between region of pediatric orthopedic fellowship, Newsweek ranking of affiliated hospital, Doximity ranking of affiliated hospital, presence of MBA program, type of program (public, private, mixed), and the lifetime industry earnings or academic productivity of program graduates. Conclusions: Despite the observed lack of statistical significance, there were clear trends observed with fellowship programs in the northeast and west coast regions being the highest earning and fellowship programs with top 10 Newsweek ranking of affiliated hospital having by far the greatest industry earnings. Sample size limitations likely prevented the detection of statistical significance. Future studies should examine if any relation exists when accounting for type of industry payment received and case volume per fellowship program.

Women in Orthopaedics: 10-Year Trends of Fellowship Match Rate and Subspecialty.

Orthopaedic surgery has consistently remained one of the least diverse specialties in medicine. There are limited data on the match rate by sex into orthopaedic fellowships. The goals of this study were to determine (1) how the percentage of women applying to orthopaedic fellowships has changed from 2011 to 2021, (2) whether there was a correlation between sex and the likelihood of a successful fellowship match, and (3) which subspecialties tend to have a greater proportion of female applicants and fellows. The San Francisco (SF) Match service was used to obtain US orthopaedic fellowship applicant data from 2010 to 2021. San Francisco Match has run the match for the orthopaedic fellowship match since 2010. International medical graduates' applications, incomplete applications, or withdrawn applications were excluded. The following variables were collected and assessed: sex, subspecialty choice (except for hand because they do not use SF Match services), and match outcome. The number of female applicants and matches was recorded by year and compared with the number of male applicants and matches. Chi-square analysis was used to analyze categorical variables. A total of 6969 applicants to all orthopaedic specialties within SF Match were included during the study period. Overall, 859 were female (12.3%), and 6110 were male (87.7%). The number of female applicants had an increasing trend over the 10-year period from 65 applicants in 2011 to 111 in 2021. The overall proportion of female applicants was between 10.1% and 14.4%. The annual match rate for female applicants was 90.7% to 100% during the study period while the match rate for male applicants was 93.7% to 97.3%. Regarding successful matches, pediatrics had the highest proportion of women (range: 30.2% to 46.2%), followed by foot and ankle (range: 9.8% to 26.4%). Spine (range: 3.2 to 10.9%) and adult reconstruction (range: 3.9% to 9%) had the least number of women among matched applicants. This study found that the number of female applicants to orthopaedic fellowships has increased over the past 10 years. The difference in fellowship match rates among male versus female applicants did not statistically differ during this 10-year period; however, the proportion of female fellows is not equally distributed among subspecialties, with a higher proportion of women matching into pediatrics and foot and ankle and lower proportion in reconstruction and spine. These data can provide a benchmark for department chairs and society leadership to ensure they are recruiting, interviewing, and selecting candidates who are representative of the current sex demographics of orthopaedic fellowship graduates.

An In-Depth Analysis of Public and Private Research Funding in Orthopaedic Surgery from 2015 to 2021.

Understanding the trends and patterns of research funding can aid in enhancing growth and innovation in orthopaedic research. We sought to analyze financial trends in public orthopaedic surgery funding and characterize trends in private funding distribution among orthopaedic surgeons and hospitals to explore potential disparities across orthopaedic subspecialties. We conducted a cross-sectional analysis of private and public orthopaedic research funding from 2015 to 2021 using the Centers for Medicare & Medicaid Services Open Payments database and the National Institutes of Health (NIH) RePORTER through the Blue Ridge Institute for Medical Research, respectively. Institutions receiving funds from both the NIH and the private sector were classified separately as publicly funded and privately funded. Research payment characteristics were categorized according to their respective orthopaedic fellowship subspecialties. Descriptive statistics, Wilcoxon rank-sum tests, and Mann-Kendall tests were employed. A p value of <0.05 was considered significant. Over the study period, $348,428,969 in private and $701,078,031 in public research payments were reported. There were 2,229 unique surgeons receiving funding at 906 different institutions. The data showed that a total of 2,154 male orthopaedic surgeons received $342,939,782 and 75 female orthopaedic surgeons received $5,489,187 from 198 different private entities. The difference in the median payment size between male and female orthopaedic surgeons was not significant. The top 1% of all practicing orthopaedic surgeons received 99% of all private funding in 2021. The top 20 publicly and top 20 privately funded institutions received 77% of the public and 37% of the private funding, respectively. Private funding was greatest (31.5%) for projects exploring adult reconstruction. While the amount of public research funding was more than double the amount of private research funding, the distribution of public research funding was concentrated in fewer institutions when compared with private research funding. This suggests the formation of orthopaedic centers of excellence (CoEs), which are programs that have high concentrations of talent and resources. Furthermore, the similar median payment by gender is indicative of equitable payment size. In the future, orthopaedic funding should follow a distribution model that aligns with the existing approach, giving priority to a nondiscriminatory stance regarding gender, and allocate funds toward CoEs. Securing research funding is vital for driving innovation in orthopaedic surgery, which is crucial for enhancing clinical interventions. Thus, understanding the patterns and distribution of research funding can help orthopaedic surgeons tailor their future projects to better align with current funding trends, thereby increasing the likelihood of securing support for their work.

Pedicle screw accuracy placed with assistance of machine vision technology in patients with neuromuscular scoliosis.

Pedicle screws are the primary method of vertebral fixation in scoliosis surgery, but there are lingering concerns over potential malposition. The rates of pedicle screw malposition in pediatric spine surgery vary from 10% to 21%. Malpositioned screws can lead to potentially catastrophic neurological, vascular, and visceral complications. Pedicle screw positioning in patients with neuromuscular scoliosis is challenging due to a combination of large curves, complex pelvic anatomy, and osteopenia. This study aimed to determine the rate of pedicle screw malposition, associated complications, and subsequent revision from screws placed with the assistance of machine vision navigation technology in patients with neuromuscular scoliosis undergoing posterior instrumentation and fusion. A retrospective analysis of the records of patients with neuromuscular scoliosis who underwent thoracolumbar pedicle screw insertion with the assistance of machine-vision image guidance navigation was performed. Screws were inserted by either a staff surgeon, orthopaedic fellow, or orthopaedic resident. Post-operative ultra-low dose CT scans were used to assess pedicle screw accuracy. The Gertzbein classification was used to grade any pedicle breaches (grade 0, no breach; grade 1, <2 mm; grade 2, 2-4 mm; grade 3, >4 mm). A screw was deemed accurate if no breach was identified (grade 0). 25 patients were included in the analysis, with a mean age of 13.6 years (range 11 to 18 years; 13/25 (52.0%) were female. The average pre-operative supine Cobb angle was 90.0 degrees (48-120 degrees). A total of 687 screws from 25 patients were analyzed (402 thoracic, 241 lumbosacral, 44 S2 alar-iliac (S2AI) screws). Surgical trainees (fellows and orthopaedic residents) inserted 46.6% (320/687) of screws with 98.8% (4/320) accuracy. The overall accuracy of pedicle screw insertion was 98.0% (Grade 0, no breach). All 13 breaches that occurred in the thoracic and lumbar screws were Grade 1. Of the 44 S2AI screws placed, one screw had a Grade 3 breach (2.3%) noted on intra-operative radiographs following rod placement and correction. This screw was subsequently revised. None of the breaches resulted in neuromonitoring changes, vessel, or visceral injuries. Machine vision navigation technology combined with careful free-hand pedicle screw insertion techniques demonstrated high levels of pedicle screw insertion accuracy, even in patients with challenging anatomy.

Ortho-plastic approaches to fracture related infection (FRI)

When a plastic surgery opinion is sought to support orthopaedic colleagues, invaluable contributions to decision-making in fracture-related infection (FRI) can be made. We summarise the plastic surgeon's perspective on the most pertinent questions which are relevant when assessing infections as a sequelae of fractures:1.) How to define the soft tissues involved.2.) Local & free tissue cover: options & outcomes.3.) What to do when flaps fail.4.) When simple dressings are an option.

Increasing Value in Subspecialty Training: A Comparison of Variation in Surgical Complications for Pediatric Versus Other Fellowship-trained American Board of Orthopaedic Surgery Candidates in the Treatment of Supracondylar Fractures.

The effect of orthopaedic fellowship subspecialization on surgical complications for patients with supracondylar fracture is unknown. This study seeks to compare the effect of subspecialty training on supracondylar fracture complications. The American Board of Orthopaedic Surgery Part II Examination Case List database was reviewed for all supracondylar fractures from 1999 to 2016. Procedures were divided by fellowship subspecialty (trauma, pediatric, or other) and case volume and assessed by surgeon-reported surgical complications. Predictive factors of complications were analyzed using a binary multivariate logistic regression. Of 10,961 supracondylar fractures identified, 53.47% were done by pediatric fellowship-trained surgeons. Pediatric-trained surgeons had fewer surgical complications compared with their trauma or other trained peers (4.54%, 5.67%, and 6.24%; P = 0.001). Treatment by pediatric-trained surgeons reduced surgical complications (OR = 0.79, 95% CI: 0.66 to 0.94; P = 0.010), whereas increased case volume (31+ cases) showed no significant effect (OR = 0.79, 95% CI: 0.62 to 1.02; P = 0.068). Patient sex, age, and year of procedure did not affect complication rates, while those treated in the Southeast region of the United States and those with a complex fracture type were at increased odds. Treatment of supracondylar fractures by pediatric-trained surgeons demonstrates reduced surgeon-reported complications compared with their other fellowship-trained counterparts, whereas case volume does not. This suggests the value of fellowship training beyond pertinent surgical caseload among pediatric-trained surgeons and may lie in targeted education efforts.

The Effect of Underrepresented Minority Mentorship on Orthopaedic Spine Surgery Recruitment and Diversity: A 20-Year Analysis at a Single Institution.

Despite national efforts to increase diversity and inclusion, underrepresented minority (URM) representation among orthopaedic spine surgery faculty remains low. Research has shown that URM trainees are more likely to pursue surgical careers when they have access to URM mentors. The purpose of this study was to explore the influence of URM representation among spine faculty on the rate of URM orthopaedic residents pursuing spine surgery fellowships. From 2004 to 2023, data were collected from each residency class at our academic institution: residency year, number of residents per class (total and URM), and number of residents applying to spine surgery fellowships. These ethnicities were considered URM: Black or African American, Hispanic or Latino, and Native American. In 2018, two African American spine faculty were hired. Data were compared between Before and After their arrival. A subanalysis was done to include a period of increasing URM recruitment (2012 to 2018). Binary logistic regression analysis evaluated associations between appointment of URM faculty and fellowship choice of URM residents. Two hundred fifty-six residents were included. Thirty-one total URM residents were in the program during the study period (12.1%). Overall, URM representation in the program increased over time [OR: 1.1, 95% CI: 1.1 to 1.2], whereas residents applying to spine surgery fellowships did not change [OR: 1.0, 95% CI: 1.0 to 1.1]. Comparing Before-2012 and 2012 to 2018 groups with the After-2018 group demonstrated a significant difference in the proportion of URM residents applying to spine surgery fellowships after the hiring of URM spine faculty (0.0% versus 23.1% versus 74.1%; P = 0.001). This retrospective study provides empirical evidence of the importance of URM representation among orthopaedic spine surgery faculty and the potential effect on URMs pursuing orthopaedic fellowships. Institutions should consider prioritizing the representation of URM faculty in spine surgery to address the lack of current and future diversity in the field. III.

Treatment Trends in Pediatric Trigger Thumb Among Hand Surgeons, Pediatric Orthopedic Surgeons, and Pediatric Hand Surgeons.

The appropriate initial management of pediatric trigger thumb (PTT) remains controversial. Some providers advocate for prolonged nonoperative management, whereas others may offer surgical release to provide a reliable and expedient resolution. The goal of this study was to elucidate the practice patterns of surgeons with different fellowship training who treat patients with PTT. We hypothesized that an association between surgeon specialty training and treatment algorithm would be identified. A cross-sectional survey was sent to mailing lists of 3 professional organizations whose members represent most providers caring for pediatric hand patients. Respondents were asked their training background and treatment recommendations for several clinical scenarios. Responses were compared across subspecialties. Of the respondents, 444 completed a fellowship in hand surgery, 167 completed a pediatric orthopedic fellowship, and 155 completed an additional congenital hand fellowship. Providers with hand fellowship training were more likely to offer surgical intervention as a first-line treatment for a 3-year-old patient with a flexible trigger thumb than those who completed a pediatric orthopedic fellowship (P = .001), and more likely to offer surgical intervention to a 3-year-old patient with an intermittent (P = .007), painful (P = .015), or locked (P = .012) trigger thumb than those providers who completed additional training in congenital hand surgery. No statistically significant differences in practice patterns were appreciated for children aged 6 and 18 months. Variability was appreciated in practice patterns for initial treatment recommendation for a patient presenting with PTT. Subspecialty training does appear to affect treatment recommendations for clinical scenarios involving a 3-year-old patient with PTT, although this trend is not observed when treating younger patients.

Trends in Osteopathic Authorship in Orthopedic Publications and Its Impact on Adult Reconstruction Match Rates

BackgroundDoctors of osteopathy (D.O.) have historically been underrepresented in the orthopedic literature. As adult reconstruction (AR) continues to rank among the most competitive orthopedic fellowships, participation in research likely serves a key role for successfully matching. This study sought to identify trends in D.O. orthopedic publications and assess for correlations between these trends and osteopathic AR match results. MethodsThe top 10 orthopedic surgery journals based on impact factor were selected for analysis. Articles published between 2010 and 2021 were screened to assess for publications with a D.O. author, as well as authorship position. A total of 29,499 articles were available for final analysis. Data from the San Francisco Residency and Fellowship Match Services were also reviewed to evaluate the number of osteopathic applicants and their match rates during the same study period. Trends in D.O. publications and osteopathic AR match rates were then assessed for any correlations. ResultsFrom 2010 to 2021, there was a significant increase in orthopedic and arthroplasty-related publications with a D.O. author (P < .0001), as well as D.O. first (P = .0006) and senior authorship positions (P = .009). Osteopathic match rate significantly increased during the study period (P = .003). There was a strong correlation between the increase in osteopathic match rate and arthroplasty-related publications with a D.O. author (r = 0.76). ConclusionsFrom 2010 to 2021, there was an upward trend of osteopathic orthopedic publications. This increase is strongly correlated with an increase in osteopathic AR match rate. Our findings suggest that authorship in publications may play a key role in successfully matching into an AR fellowship.

Nationwide Effect of COVID-19 on Cases Performed During Pediatric Orthopaedic Surgery Fellowship Training in the United States.

The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak. The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes. A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year. A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks.