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Background: Femoral fragility fractures in older adults can result in devastating loss of physical function and independence. Skeletalmuscle atrophy likely contributes to disability. The purpose of this study was to characterize the change in skeletalmuscle mass, investigate the relationship with malnutrition and physical function, and identify risk factors for skeletal muscle loss. Methods: Adults ≥65 years of age who were treated with operative fixation of an isolated femoral fragility fracture were enrolled in this multicenter, prospective observational study. Skeletal muscle mass was assessed within 72 hours of admission using multifrequency bioelectrical impedance analysis, which was repeated at 6 weeks, 3 months, and 6 months. Sarcopenia was defined by sex-specific cutoffs for the appendicular skeletal muscle mass index. The Mini Nutritional Assessment was used to measure nutritional status at the time of injury. Physical function was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function domain. Linear mixed models were used to evaluate changes in skeletal muscle mass and PROMIS Physical Function scores over time and to evaluate factors associated with skeletal muscle mass changes. Results: Ninety participants (74% female) with a mean age of 77.6 ± 9.0 years were enrolled. At the time of injury, 30 (33%) were sarcopenic and 44 (49%) were at risk for malnutrition or had malnutrition. Older age was associated with lower skeletal muscle mass (age of ≥75 versus <75 years: least squares mean [and standard error],23.3 ± 1.6 kg; p = 0.042). From the time of injury to 6 weeks, participants lost an average of 2.4 kg (9%) of skeletal muscle mass (95% confidence interval [CI] = -3.0 to -1.8 kg; p < 0.001). This early loss did not recover by 6 months (1.8 kg persistent loss compared with baseline [95% CI = -2.5 to -1.1 kg]; p < 0.001). Participants with normal nutritional status lost more skeletal muscle mass from baseline to 6 weeks after injury compared with those with malnutrition (1.3 kg more loss [standard error, 0.6 kg]; p = 0.036). A 1-kg decrease in skeletal muscle mass was associated with an 8-point decrease in the PROMIS Physical Function (model parameter estimate, 0.12 [standard error, 0.04]; p = 0.002). Conclusions: We found that older adults with femoral fragility fractures lost substantial skeletal muscle mass and physical function. Participants with adequate baseline nutrition actually lost more muscle mass than those who were malnourished, indicating that future investigations of interventions to prevent muscle loss should focus on older adults regardless of nutritional status. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Postoperative complications and substantial loss of physical function are common after musculoskeletal trauma. We conducted a prospective randomized controlled trial to assess the impact of conditionally essential amino acid (CEAA) supplementation on complications and skeletal muscle mass in adults after operative fixation of acute fractures.Methods: Adults who sustained pelvic and extremity fractures that were indicated for operative fixation at a level-I trauma center were enrolled. The subjects were stratified based on injury characteristics (open fractures and/or polytrauma, fragility fractures, isolated injuries) and randomized to standard nutrition (control group) or oral CEAA supplementation twice daily for 2 weeks. Body composition (fat-free mass [FFM]) was measured at baseline and at 6 and 12 weeks postoperatively. Complications were prospectively collected. An intention-to-treat analysis was performed. The relative risk (RR) of complications for the control group relative to the CEAA group was determined, and linear mixed-effects models were used to model the relationship between CEAA supplementation and changes in FFM.Results: Four hundred subjects (control group: 200; CEAA group: 200) were enrolled. The CEAA group had significantly lower overall complications than the control group (30.5% vs. 43.8%; adjusted RR = 0.71; 95% confidence interval [CI] = 0.55 to 0.92; p = 0.008). The FFM decreased significantly at 6 weeks in the control subjects (-0.9 kg, p = 0.0205), whereas the FFM was maintained at 6 weeks in the CEAA subjects (-0.33 kg, p = 0.3606). This difference in FFM was not seen at subsequent time points.Conclusions: Our results indicate that CEAA supplementation has a protective effect against common complications and early skeletal muscle wasting after operative fixation of extremity and pelvic fractures. Given the potential benefits of this inexpensive, low-risk intervention, multicenter prospective studies in focused trauma populations are warranted.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Posttraumatic osteoarthritis (PTOA) is a common and early sequela of tibial pilon fractures resulting in substantial long-term disability. New approaches are needed to objectively and reliably quantify early disease progression in order to critically assess the impact of interventions aimed at preventing or mitigating PTOA. Weight-bearing computed tomography (WBCT) scans provide a means for measuring joint space while the ankle is in a loaded, functional position. We assessed the interrater and intrarater reliability of a standardized, regional method to quantify joint-space loss following tibial pilon fracture compared with the uninjured contralateral ankle.Methods: We prospectively enrolled 20 patients with intra-articular tibial pilon fractures that were surgically treated at 1 of 2 level-I trauma centers. Six months after injury, bilateral ankle WBCT scans were obtained. Joint space was measured by 4 reviewers at 9 discrete regions of the tibiotalar articulation on sagittal images. Measurements were repeated by reviewers 2 weeks later. To characterize the measurement method, interrater correlation coefficient estimates and test-retest reproducibility were calculated.Results: The mean tibiotalar joint space was 21% less in the injured ankles compared with the contralateral uninjured ankles (p < 0.0001). The middle-lateral and middle-central regions of the joint demonstrated the greatest decrease in joint space between injured and uninured ankles. The interrater correlation coefficient of the measurement technique was 0.88, and the test-retest reproducibility was 0.80, indicating good reliability and reproducibility of the method.Conclusions: We developed a simple, standardized, and reliable technique to quantify tibiotalar joint space following tibial pilon fracture on WBCT. Significant loss of joint space is seen 6 months after the injury. This tool can be used to longitudinally quantify loss of joint space following pilon fracture and assess the impact of interventions to reduce PTOA. [ABSTRACT FROM AUTHOR]

Background: Mentorship has been identified as an important element of educational and professional development for surgeons. An assessment that was conducted and reported through the American Association of Orthopaedic Surgeons (AAOS) in 2008 showed variability among U.S. residencies regarding the structure and requirements for mentorship during orthopaedic training; the assessment also demonstrated variability in residents' satisfaction with mentorship opportunities during their surgical training.Methods: An updated survey was developed and distributed via e-mail to residents attending the Resident Leadership Forum at the 2015 American Orthopaedic Association Annual Meeting to determine their views regarding the importance of mentorship, as well as their assessments of formal mentorship programs within their residencies. The updated data were compared with the prior survey results from 2008.Results: A total of 149 (87.6%) of 170 residents responded to the survey. Of these, 34.9% (51 of 146) reported the existence of a formal mentorship program within their residency, as compared with 26.0% of residencies as stated in the 2008 report. One hundred percent of residents indicated that having a mentor during orthopaedic residency was either critical (63.7%, 93 of 146) or advantageous (36.3%, 53 of 146) to professional development as a surgeon; 74.7% (109 of 146) of residents reported currently having mentors, which appears to represent an increase from the prior report (51%, 258 of 506). However, the percentage of residents who reported being "very" satisfied (17.9%, 25 of 140) or "somewhat" satisfied (43.6%, 61 of 140) with their mentorship opportunities was almost identical to the prior report (61.9% [86 of 139] versus 61.0%, respectively). Overall, residents from programs with formal mentorship programs in place reported significantly higher satisfaction with their mentoring program/environment compared with those from programs without formal mentorship programs in place (3.98 versus 3.54, p = 0.026).Conclusions: Orthopaedic residents continue to overwhelmingly indicate that mentorship is an important component of residency education: 34.9% of residencies have a formal mentorship program, compared with 26.0% in the prior survey. Additionally, 74.7% of current residents reported having a mentor compared with 51% of residents in the prior study. Despite this difference, a very similar percentage of residents indicated that they were either "very" or "somewhat" satisfied with their mentorship experience. Residents from programs with formal mentorship programs reported significantly higher satisfaction with their mentorship programs compared with those without formal programs. These results support continued efforts toward improving mentorship opportunities within U.S. orthopaedic residency programs. [ABSTRACT FROM AUTHOR]

Background: Pain management following surgical treatment of an ankle fracture is an under-studied area of clinical practice. The present study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with an operatively treated, closed, rotational ankle fracture.Methods: Patients indicated for operative fixation of a rotational ankle fracture were randomized to receive multimodal surgical-site injection (ropivacaine 200 mg, epinephrine 0.6 mg, and morphine 5 mg) or no injection (control). Visual analog scale (VAS) pain and opioid consumption data were collected every 4 hours until discharge from the hospital. Length of stay and discharge destination were recorded. Patients were sent automated text messages to report VAS pain and opioid usage during the first 2 weeks after discharge.Results: One hundred patients (49 injection and 51 control) were enrolled. Demographic data were similar between the 2 groups. Mean VAS scores over the first 24 and 48 hours postoperatively were slightly lower in the injection group (42 ± 3 and 41 ± 3, respectively) compared with the control group (52 ± 3 and 50 ± 3, respectively; p = 0.01 and p < 0.01, respectively). The median opioid usage, in terms of morphine equivalent dose, was similar over the first 24 hours between the injection group (25.5; range, 0 to 74.7) and the control group (28.3; range, 2.5 to 91.0; p = 0.35). The median opioid usage from recovery room admission to discharge was also similar between the injection group (29.0; range, 0 to 85.3) and the control group (32.7; range, 4.3 to 215.0; p = 0.35). There were no differences in outpatient VAS scores or opioid consumption during the first 2 weeks postoperatively as assessed with use of automated text messaging. Median length of stay was 22.3 hours (range, 1.7 to 182.3 hours) for the injection group and 22.5 hours (range, 2.2 to 123.3 hours) for the control group (p = 0.71). The response rate for the post-discharge automated text messages was 85.1%. Complication rates were similar.Conclusions: The use of multimodal surgical-site injections in operatively treated rotational ankle fractures is associated with a reduction in immediate in-hospital pain scores that is statistically significant but below the minimal clinically important difference.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Evaluation of surgical skill competency is necessary as graduate medical education moves toward a competency-based curriculum. This study by the American Board of Orthopaedic Surgery (ABOS) and the Council of Orthopaedic Residency Directors (CORD) compares 2 web-based evaluation tools that assess the level of autonomy that is demonstrated by residents during surgical procedures in the operating room as measured by faculty.Methods: Two hundred and ninety-four residents from 16 orthopaedic surgery residency programs were evaluated by 370 faculty using 2 web-based evaluation tools in a crossover design in which residents requested faculty review of their surgical skills before starting a case. One thousand, one hundred and fifty Ottawa Surgical Competency Operating Room Evaluation (O-Score) assessments, which included a 9-question evaluation of 8 steps of the surgical procedure, were compared with 1,186 P-score evaluations, which included a single-question summative evaluation. Twenty-five different surgical procedures were evaluated.Results: There were no significant differences in rates of resident requests or faculty completion of the 2 scores. The most common surgical procedures that were assessed were total knee arthroplasty (n = 254, 11%), carpal tunnel release (n = 191, 8%), open reduction and internal fixation (ORIF) of stable hip fractures (n = 170, 7%), ORIF of simple ankle fractures (n = 169, 7%), and total hip arthroplasty (n = 166, 7%). Both instruments disclosed significant differences in competency among entry, intermediate, and advanced-level residents. The findings support the construct validity of the evaluation method. The survey results indicated that >70% of the faculty were confident that use of either the P-score or the O-score allowed them to distinguish a resident who can perform the surgery independently from one who needs additional training.Conclusions: This research has led to the modification of the O-score and the P-score into a combined OP-score instrument. The ABOS envisions that the OP-score instrument can be used with an expanded number of surgical procedures as a required element of residency training in the near future.Clinical Relevance: This study allows the profession of orthopaedic surgery education to take a leadership role in the measurement of competence for surgical skills for orthopaedic surgeons in residency training, an important clinically relevant topic to the practice of orthopaedic surgery. [ABSTRACT FROM AUTHOR]

Background: Mechanotransduction is theorized to influence fracture-healing, but optimal fracture-site motion is poorly defined. We hypothesized that three-dimensional (3-D) fracture-site motion as estimated by finite element (FE) analysis would influence callus formation for a clinical series of supracondylar femoral fractures treated with locking-plate fixation.Methods: Construct-specific FE modeling simulated 3-D fracture-site motion for sixty-six supracondylar femoral fractures (OTA/AO classification of 33A or 33C) treated at a single institution. Construct stiffness and directional motion through the fracture were investigated to assess the validity of construct stiffness as a surrogate measure of 3-D motion at the fracture site. Callus formation was assessed radiographically for all patients at six, twelve, and twenty-four weeks postoperatively. Univariate and multivariate linear regression analyses examined the effects of longitudinal motion, shear (transverse motion), open fracture, smoking, and diabetes on callus formation. Construct types were compared to determine whether their 3-D motion profile was associated with callus formation.Results: Shear disproportionately increased relative to longitudinal motion with increasing bridge span, which was not predicted by our assessment of construct stiffness alone. Callus formation was not associated with open fracture, smoking, or diabetes at six, twelve, or twenty-four weeks. However, callus formation was associated with 3-D fracture-site motion at twelve and twenty-four weeks. Longitudinal motion promoted callus formation at twelve and twenty-four weeks (p = 0.017 for both). Shear inhibited callus formation at twelve and twenty-four weeks (p = 0.017 and p = 0.022, respectively). Titanium constructs with a short bridge span demonstrated greater longitudinal motion with less shear than did the other constructs, and this was associated with greater callus formation (p < 0.001).Conclusions: In this study of supracondylar femoral fractures treated with locking-plate fixation, longitudinal motion promoted callus formation, while shear inhibited callus formation. Construct stiffness was found to be a poor surrogate of fracture-site motion. Future implant design and operative fixation strategies should seek to optimize 3-D fracture-site motion rather than rely on surrogate measures such as axial stiffness. [ABSTRACT FROM AUTHOR]

Background: The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice.Methods: This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents.Results: The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice.Conclusions: Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice. [ABSTRACT FROM AUTHOR]

Orthopaedic educators are responsible for training a prepared and competent workforce that will provide effective care for a growing number of patients with musculoskeletal conditions. Currently, there are both internal and external forces that pose substantial challenges to medical students, residents, program directors, faculty members, and chairs in achieving this goal. One area of particular concern is the education of surgeons, whose knowledge and professional behavior must be matched by their ability to acquire procedural skills. In order to address this issue, many training systems have implemented a competency-based training approach into their curricula. This article discusses the efforts that orthopaedic training bodies in Canada and Australia have taken toward competency-based education and what steps the American Board of Orthopaedic Surgery (ABOS), the Council of Orthopaedic Residency Directors (CORD), the American Orthopaedic Association (AOA), the American Academy of Orthopaedic Surgeons (AAOS), and the Accreditation Council for Graduate Medical Education (ACGME) are considering to improve residency education in the current and future environments. [ABSTRACT FROM AUTHOR]

Background: Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures.Methods: There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored.Results: The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic.Conclusions: Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: The evolving surgical skills education paradigm in orthopaedics has generated a strong demand for validated educational tools and methodologies. This study aimed to confirm that a one-on-one faculty coaching review of the head-mounted video recording of a resident's surgical performance on a validated articular fracture simulation trainer would substantially improve subsequent performance. Methods: Fifteen first-year or second-year orthopaedic surgery residents reduced and fixed a standardized intra-articular tibial plafond fracture model under fluoroscopic guidance. Their performances were recorded by a head-mounted video camera. Prior to repeating the procedure six weeks later, eight subjects (the intervention group) reviewed the video of their performance with an orthopaedic traumatologist, and seven subjects (the control group) did not. Cohort performance was compared with respect to task duration, number of fluoroscopic images, and scores on the Objective Structured Assessment of Technical Skills (OSATS) as evaluated by fellowship-trained orthopaedic traumatologists blinded to the residents' year in training and prior surgical experience. Results: The initial performance OSATS scores were not significantly different (p ⩾ 0.05) between the control and intervention groups. Assessments of their repeat performance showed a significant net interval improvement (p < 0.05) in OSATS scores in the intervention group (mean [and standard deviation], 21 ± 8 points) compared with the control group (6 ± 3 points). The mean fluoroscopy utilization had a significant net decrease (p < 0.05) in the intervention group (25.4 ± 11.7 points) compared with the control group (5.3 ± 7.0 points). Task duration in the repeat performance was similar between both groups. Conclusions: Personalized video-based feedback improved performance on a standardized articular fracture trainer for first-year and second-year residents. The described technique may further enhance resident surgical skills education. [ABSTRACT FROM AUTHOR]

The article presents a speech by J. Lawrence Marsh, president of the nonprofit American Orthopaedic Association (AOA), delivered at the combined meeting of the AOA and the nonprofit Canadian Orthopaedic Association (COA) held in Montreal, Quebec on June 20, 2014. The speech focused on the importance of surgical graduate medical education (GME) and surgical skills training for orthopaedic surgeons.

Background: The purpose of this study was to investigate the trends in operative management of femoral neck fractures by orthopaedic surgeons applying for board certification. Methods: We queried the American Board of Orthopaedic Surgery database to identify all femoral neck fractures that had been treated and reported by candidates taking Part II of the licensing examination from 1999 to 2011 to determine the utilization of internal fixation, hemiarthroplasty, and total hip arthroplasty. The longitudinal trends were then stratified by patient age (younger than sixty-five, sixty-five to seventy-nine, eighty and older) and the declared subspecialty of the candidate. Results: There were 19,541 femoral neck fractures that had been treated by 4450 board certification candidates. The use of total hip arthroplasty increased over time (0.7% of fractures in 1999, 7.7% in 2011, p < 0.001); use of hemiarthroplasty (67.1% in 1999, 63.1% in 2011, p = 0.020) and internal fixation (32.2% in 1999, 29.2% in 2011, p = 0.064) declined slightly. All geographic regions showed an increase in utilization of total hip arthroplasty, with substantial variation between locations. The proportion of patients younger than age sixty-five who were managed with total hip arthroplasty increased from 1.4% to 13.1% (p < 0.001). Candidates with a declared subspecialty of ‘‘adult reconstruction’’ showed a strong trend toward the use of total hip arthroplasty (4.3% from 1999 to 2002, 21.1% from 2009 to 2011, p < 0.001), while ‘‘trauma’’ subspecialty candidates demonstrated decreasing utilization of internal fixation (40.9% from 1999 to 2002, 32.9% from 2009 to 2011, p = 0.012). The percentage of candidates treating at least one femoral neck fracture decreased from 54.8% from 1999 to 2002 to 46.3% from 2009 to 2011 (p < 0.001). Conclusions: The most substantial changes in treatment of femoral neck fractures were seen in the younger group of patients. Currently, a smaller percentage of board certification candidates are treating femoral neck fractures than those in the past, possibly reflecting a trend toward specialty care. [ABSTRACT FROM AUTHOR]

The article focuses on the efforts of the Department of Orthopaedics and Rehabilitation at the University of Iowa Hospitals and Clinics to develop a one-month surgical skills course with a structured curriculum for PGY-1 orthopaedic residents. It says that the program includes multiple instructional elements like background reading and didactic teaching, and opportunities for assessment and critical feedback.

The article discusses the changes in accreditation system of the Next Accreditation System (NAS) in July 2013. It says that NAS vision will be interesting at future to assess the reality rather than speculation on changes in accreditation program. It mentions that it is easier for many programs due to less review requirements.

Fracture types that were excluded were diaphyseal fractures and any fractures that involved the fourth-fifth metatarsal articulation. In recent decades, surgical treatment has become more common for many fracture types, such as tibial fractures, unstable ankle fractures, and fractures with a displaced calcaneus; however, among fractures that have been and continue to be treated nonoperatively,suchtreatmenthasbecomesimplerandlessrestrictive. Simpler Treatment Is Often Better: Commentary on an article by Young Rak Choi, MD, et al.: "Hard-Soled Shoe Versus Short Leg Cast for a Fifth Metatarsal Base Avulsion Fracture. [Extracted from the article]

Background: Recent studies have shown that it is difficult to accurately reduce and assess the reduction of the syndesmosis after ankle injury. The syndesmosis is most commonly reduced with use of reduction clamps to compress across the tibia and fibula. However, intraoperative techniques to optimize forceps reductions to restore syndesmotic relationships accurately have not been systematically studied. The purpose of the present study was to evaluate the accuracy of syndesmosis reduction with different rotational vectors of clamp placement.Methods: Ten through-the-knee cadaveric specimens were used. Markers were placed on the tibia and fibula to produce consistent clamp placement and radiographic evaluation. A computed tomographic scan of the ankle was made to serve as a control, followed by a stepwise destabilization of the anterior inferior tibiofibular ligament, syndesmosis, deltoid ligament, small posterior malleolus fracture, and large posterior malleolus fracture. Following each step in the destabilization, clamps were applied to compress the syndesmosis at varying angles and computed tomography was performed to measure the alignment of the syndesmosis as compared with that on the control scan.Results: In all degrees of induced instability, and for all vectors of clamp placement, a small but consistent amount of overcompression of the syndesmosis was observed. The average overcompression (and standard deviation) for all samples was 0.93 ± 0.70 mm. Both obliquely oriented clamp arrangements consistently caused fibular malreductions in the sagittal plane. Placing the clamp in the neutral anatomical axis reduced the syndesmosis most accurately, with an average displacement of 0.1 ± 0.77 mm compared with control through all degrees of instability.Conclusions: Clamp placement in the neutral anatomical axis reduced the syndesmosis most accurately in our cadaveric model, although slight overcompression was frequently observed. Placing the clamp obliquely malreduced the unstable syndesmosis. [ABSTRACT FROM AUTHOR]

The article presents a research study on the effects of construct stiffness in promoting fracture-healing by the use of locking plates such as locked-plate constructs and far-cortical-locking fixator. Far-cortical-locking fixator is believed to promote fracture-healing by decreasing construct stiffness without reducing the strength and durability of the fixator. On the other hand, a clinical evidence is presented that locked-plate constructs may be too rigid to promote fracture-healing.

Background: Lecture-based courses are common in orthopaedic surgery; however, their effectiveness in improving medical knowledge has not been widely assessed. The Orthopaedic Trauma Association conducts a resident trauma course that occurs four to six weeks prior to the Orthopaedic In-Training Examination (OITE). The purposes of this study were to determine whether residents who had taken this course performed better on the trauma domain of the OITE and to compare the effect of the course with the effect of a focused rotation in orthopaedic trauma. Methods: The percentile scores on the trauma domain of the OITE for forty-seven residents in postgraduate year (PGY) 2 were reviewed. Twenty-nine residents who took a trauma course within six weeks before the OITE were compared with eighteen residents who took the course after the OITE. As a secondary analysis, the effect of a trauma rotation for the same PGY-2 residents before and after the OITE was also assessed. Baseline orthopaedic knowledge was assessed with use of the overall OITE percentage scores. Results: The trauma domain scores were not significantly better among the residents who took the course (mean and standard deviation, 62.2 ± 9.9) compared with those who had not taken it (mean, 59.2 ± 6.2) (p = 0.2). A significant difference (p = 0.04) was found for a trauma rotation, with the residents who had a trauma rotation scoring better (mean, 64.5 ± 6.8) than the residents who had not (mean, 58.8 ± 8.9). The subgroup of residents who had both a course and a trauma rotation before the test scored significantly better (p = 0.01) than the subgroup that had neither of these experiences before the test (mean, 65.6 ± 8.0 and 56.9 ± 6.4, respectively). Conclusions: An orthopaedic trauma course alone does not enhance an orthopaedic resident's trauma medical knowledge as assessed on a standardized test. However, a trauma rotation before, and in particular the combination of both a course and a trauma rotation, can improve trauma test scores. [ABSTRACT FROM AUTHOR]

Background: Locked bridge plating relies on secondary bone healing, which requires interfragmentary motion for callus formation. This study evaluated healing of fractures stabilized with a locked plating construct and a far cortical locking construct, which is a modified locked plating approach that promotes interfragmentary motion. The study tested whether far cortical locking constructs can improve fracture-healing compared with standard locked plating constructs. Methods: In an established ovine tibial osteotomy model with a 3-mm gap size, twelve osteotomies were randomly stabilized with locked plating or far cortical locking constructs applied medially. The far cortical locking constructs were designed to provide 84% lower stiffness than the locked plating constructs and permitted nearly parallel gap motion. Fracture-healing was monitored on weekly radiographs. After the animals were killed at week 9, healed tibiae were analyzed by computed tomography, mechanical testing in torsion, and histological examination. Results: Callus on weekly radiographs was greater in the far cortical locking constructs than in the locked plating constructs. At week 9, the far cortical locking group had a 36% greater callus volume (p = 0.03) and a 44% higher bone mineral content (p = 0.013) than the locked plating group. Callus in the locked plating specimens was asymmetric, having 49% less bone mineral content in the medial callus than in the lateral callus (p = 0.003). In far cortical locking specimens, medial and lateral callus had similar bone mineral content (p = 0.91). The far cortical locking specimens healed to be 54% stronger in torsion (p = 0.023) and sustained 156% greater energy to failure in torsion (p < 0.001) than locked plating specimens. Histologically, three of six locked plating specimens had deficient bridging across the medial cortex, while all remaining cortices had bridged. Conclusions: Inconsistent and asymmetric callus formation with locked plating constructs is likely due to their high stiffness and asymmetric gap closure. By providing flexible fixation and nearly parallel interfragmentary motion, far cortical locking constructs form more callus and heal to be stronger in torsion than locked plating constructs. Clinical Relevance: Far cortical locking fixation may be advisable for stiffness reduction of locked bridge plating constructs to improve fracture-healing. [ABSTRACT FROM AUTHOR]

The article presents an overview of barriers to clinical research which were reported by attendees of a symposium which was presented at the annual meeting of the American Orthopedic Association which was held on June 16, 2007 in Asheville, North Carolina. A discussion of the impact the barriers have had on clinical research is presented.

Focuses on six cases of pubic ramus insufficiency fractures following total hip arthroplasty. Symptoms exhibited by patients; Effect of treatments provided to each patient; Evidence revealed by radiography of all patients.

Background: The intermediate outcome of fractures of the tibial plafond treated with current techniques has not been reported, to our knowledge. The purpose of this study, performed at a minimum of five years after injury, was to determine the effect of these fractures on ankle function, pain, and general health status and to determine which factors predict favorable and unfavorable outcomes. Methods: Fifty-six ankles (fifty-two patients) with a tibial plafond fracture were treated with a uniform technique consisting of application of a monolateral hinged transarticular external fixator coupled with screw fixation of the articular surface. Thirty-one patients with thirty-five involved ankles returned between five and twelve years after the injury for a physical examination, assessment of ankle pain and function with the Iowa Ankle Score and Ankle Osteoarthritis Scale, assessment of general health status with the Short Form-36 (SF-36), and radiographic examination of the ankle. Results: Arthrodesis had been performed on five of the forty ankles for which the outcome was known at a minimum of five years after the injury. Other than removal of prominent screws (two patients), no other surgical procedure had been performed on any patient. The average Iowa Ankle Score was 78 points (range, 28 to 96 points). The scores on the SF-36 and Ankle Osteoarthritis Scale demonstrated a long-term negative effect of the injury on general health and on ankle pain and function when compared with those parameters in age-matched controls. The degree of osteoarthrosis was grade 0 in three ankles, grade 1 in six, grade 2 in twenty, and grade 3 in six. The majority of patients had some limitation with regard to recreational activities, with an inability to run being the most common complaint (twenty-seven of the thirty-one patients). Fourteen patients changed jobs because of the ankle injury. Fifteen ankles were rated by the patient as excellent; ten, as good; seven, as fair; and one,... [ABSTRACT FROM AUTHOR]

Background: Studies of the long-term outcomes of treatment of fractures of the tibial plateau have included wide mixtures of fracture types and mostly low-energy split and split-depression fractures. The long-term results of treatment of high-energy intra-articular proximal tibial fractures are unknown. The purpose of this study was to assess the function of the knee and the development of arthrosis at a minimum of five years after injury in a consecutive series of patients in whom a high-energy fracture of the tibial plateau had been treated with a uniform technique of external fixation.Methods: Between July 1988 and December 1994, thirty patients with a total of thirty-one fractures of the tibial plateau were treated with a monolateral external fixator and limited internal fixation of the articular surface. Follow-up data on twenty-four knees in twenty-three patients were obtained at a mean of ninety-eight months. Twenty patients (twenty knees) returned specifically for the study, at which time they completed an Iowa Knee Score questionnaire and a Short Form-36 (SF-36) general health survey, a physical examination was performed, and weight-bearing radiographs were made. The results of the SF-36 evaluations for fourteen patients and the Knee Scores for twelve were compared with those obtained five years previously, at two to four years after the injury.Results: After healing, no patient required a secondary reconstructive procedure. The range of motion of the knee averaged 3 degrees of extension to 120 degrees flexion, which was an average of 87% of the total arc of the contralateral knee. The average Iowa Knee Score was 90 points (range, 72 to 100 points). For twelve patients, the Iowa Knee Score previously recorded at two to four years averaged 92 points, as did the score at the time of the latest follow-up. Thirteen patients rated their outcome as excellent; six, as good; and three, as fair. Fifteen patients were working, and ten of them were performing strenuous labor. Radiographs showed no evidence of arthrosis in fourteen knees, grade-1 arthrosis in three, grade-2 in three, and grade-3 in two. Compared with the radiographic appearance two to four years after injury, there was no evidence of progression of arthrosis in eighteen knees and one grade of progression in four. The SF-36 subscale scores were similar to those of age-matched controls. The fourteen patients who had previous SF-36 scores had no deterioration of these scores.Conclusions: Patients with a high-energy fracture of the tibial plateau treated with external fixation have a good prognosis for satisfactory knee function in the second five years after injury. The knee joint cartilage appears to be tolerant of both the injury and mild-to-moderate residual articular displacement, which was associated with a low rate of severe arthrosis. [ABSTRACT FROM AUTHOR]

Background: During routine follow-up of patients treated with a three-piece stainless-steel modular femoral nail, osteolysis and periosteal reaction around the modular junctions of some of the nails were noted on radiographs. The purpose of this study was to evaluate the prevalence, etiology, and clinical relevance of these radiographic findings. Methods: Forty-four femoral fractures or nonunions in forty-two patients were treated with a modular stainlesssteel femoral intramedullary nail. Seventeen nails were excluded, leaving twenty-seven intramedullary nails in twenty-seven patients for this study. All patients had had a femoral diaphyseal fracture; nineteen had had an acute fracture and eight, a nonunion. These twenty-seven patients returned for radiographs, a physical examination, assessment of functional outcomes, assessment of thigh pain with a visual analog scale, determination of serum chromium levels, and nail removal if desired. A control group of sixteen patients treated with a one-piece stainless-steel femoral intramedullary nail was evaluated with use of the same outcome measures and was compared with the group treated with the modular femoral nail with regard to prevalence of thigh pain and serum chromium levels. Twelve modular femoral nails were removed according to the study protocol. The modular nail junctions were analyzed for corrosion products, and histopathologic analysis of tissue specimens from the femoral canal was performed. Results: The twenty-seven patients were seen at a mean of twenty-one months after fracture fixation; twenty-six of the twenty-seven fractures healed. Twenty-three femora had at least one of three types of abnormalities—osteolysis, periosteal reaction, or cortical thickening—localized to one or both modular junctions. Eighteen patients had severe reactions, defined as osteolysis of ≥2 mm, cortical thickening of ≥5 mm, and/or a periosteal reaction (group 1). Nine patients had mild or no reactions... [ABSTRACT FROM AUTHOR]

A review of the article "Dynamic Stress Testing Is Unnecessary for Unimalleolar Supination-External Rotation Ankle Fractures with Minimal Fracture Displacement on Lateral Radiographs" by Simo Nortunen is presented.

An introduction is presented in which the editor discusses reports within the issue on topics including end resident training, competency-based training, and Graduate Medical Education.

An abstract of the article "A Simulation Trainer for Complex Articular Fracture Surgery," by Tameem M. Yehyawi and colleagues is presented.

Background: Residency programs commonly use performance on the Orthopaedic In-Training Examination (OITE) developed by the American Academy of Orthopaedic Surgeons (AAOS) to identify residents who are lagging behind their peers and at risk for failing Part I of the American Board of Orthopaedic Surgery (ABOS) Certifying Examination. This study was designed to investigate the utility of the OITE score as a predictor of ABOS Part I performance.Method: Results for 3132 examinees who took Part I of the ABOS examination for the first time from 2002 to 2006 were matched with records from the 1997 to 2006 OITE tests; at least one OITE score was located for 2852 (91%) of the ABOS Part I examinees. After OITE performance was rescaled to place scores from different test years on comparable scales, descriptive statistics and correlations between ABOS and OITE scores were computed, and regression analyses were conducted to predict ABOS results from OITE performance.Results: Substantial increases in the mean OITE score were observed as residents progressed through training. Stronger correlations were observed between OITE and ABOS performance during later years in training, reaching a maximum of 0.53 in years 3 and 4. Logistic regression results indicated that residents with an OITE score below the 10th percentile were much more likely to fail Part I compared with those with an OITE score above the 50th percentile.Conclusions: OITE performance was a good predictor of the ABOS score and pass-fail outcome; the OITE can be used effectively for early identification of residents at risk for failing the ABOS Part I examination. [ABSTRACT FROM AUTHOR]

The article focuses on the national survey conducted by the American Academy of Orthopaedic Surgeons (AAOS) on the use of surgical skills in orthopaedic resident education. The survey was conducted through the use of two online versions of Surgical Skills Simulation Survey. The results of the survey reveal that both program directors and residents agree on the role of surgical skills laboratories on orthopaedic resident training.

Background: The primary influence on medical students' career choice is their third-year clerkship. However, orthopaedics is not a required rotation in the curriculum of most medical schools. Our goals were to identify factors that motivate students to choose an orthopaedic career and to compare these with the factors that influence students to choose nonorthopaedic disciplines. Methods: Fourth-year medical students and orthopaedic residents at the postgraduate year (PGY)-l level at eight orthopaedic training programs in the United States were surveyed to determine the reasons that they chose orthopaedics instead of other medical or surgical fields. Results: Of the 622 individuals who responded to our survey, 125 were entering orthopaedics and 497 were not. Although career choice in both groups was most heavily influenced by third and fourth-year clinical rotations and faculty contacts, orthopaedics-bound respondents were more likely than non-orthopaedics-bound respondents to be strongly influenced by experiences and people prior to medical school. Orthopaedics-bound respondents were less likely to report a faculty member as the most important person influencing career choice. Fifty-one percent (sixty-three) of 124 students who selected orthopaedics had already decided to pursue this field prior to their third-year rotation. Patient care was chosen by 71% (347) of490 non-orthopaedics-bound respondents and 75% (ninety-four) of 125 orthopaedics-bound respondents as the most important factor for pursuing a particular field. Income was not selected as the deciding factor by respondents in either group. Conclusions: Although faculty contacts and third-year clinical rotations played an important role in student selection of specialty training, they were less influential for those choosing an orthopaedic career than for those choosing other disciplines. Many students choosing orthopaedics made this decision prior to medical school. We believe that increased exposure to positive clinical role models and experiences during medical school would enhance medical students' options for choosing orthopaedic surgery as a career. Anticipated income did not play a deciding role in career selection. [ABSTRACT FROM AUTHOR]