The Iowa orthopaedic journal最新文献

Background: Dedifferentiated chondrosarcoma (DCS) is a highly malignant variant that portends a poor prognosis. Although factors such as clinico-pathological characteristics, surgical margin, and adjuvant modalities likely play a role in overall survival, debate continues with varying results on the importance of these indicators. The purpose of this study is (1) To delineate the characteristics, local recurrence (LR), and survival of patients with intermediate (IGCS), high (HGCS) and dedifferentiated (DCS) chondrosarcoma of the extremity by utilizing detailed cases at one tertiary institution. (2) To assess survival between high grade chondrosarcoma and DCS utilizing a less detailed but large cohort from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods: Twenty-six cases of high-grade (conventional FNCLCC grades 2 and 3, dedifferentiated) chondrosarcoma were identified from an ongoing prospective cohort of 630 sarcoma patients managed surgically at a tertiary referral university hospital between 9/1/2010-12/30/2019. A retrospective review of demographics, tumor characteristics, surgical procedure, treatment course, and survival data was performed to determine prognostic factors for survival. An additional 516 cases of chondrosarcoma were identified from the SEER database. Using the Kaplan-Meier method, both the large database and case series were evaluated, and estimated cause-specific survival was calculated at 1, 2, and 5 years.

Results: There were 12 IGCS, 5 HGCS, and 9 DCS patients in the single institution cohort. DCS had a higher stage at diagnosis (p=0.04). Limb salvage was the most common procedure performed in every group (11/12 IGCS, 5/5 HGCS, and 7/9 DCS; p=0.56). Margins included 8/12 wide and 3/12 intralesional for IGCS. For HGCS, there were 3/5 wide, 1/5 marginal, and 1/5 intralesional. A majority of DCS margins were wide (8/9) with only 1 marginal. There was no difference of associated margins between the groups (p=0.85), however there was a difference when margins were classified based on numerical measurement (IGCS: 0.125cm (0.1-0.35); HGCS: 0cm (0-0.1); DCS: 0.2cm (0.1-0.5); p=0.03). The overall median follow-up was 26 months (IQR:16.1-70.8). The time interval from resection to death was lower in DCS (11.5 months (10.7-12.2)), followed by IGCS (30.3 months (16.2-78.2)), and HGCS (55.1 months (32.0-78.2; p=0.047). LR occurred in 5/9 DCS, 1/5 HGCS, and 1/14 IGCS patients. Of the DCS patients only 2/6 who received systemic therapy had LR, while all 3/3 who did not receive systemic therapy had LR. Overall systemic therapy and radiation did not impact incidence of LR (p=0.67; p=0.34). However, patients who had LR were 17.5 times more likely to die within one year (HR=17.5, 95%CI (1.01-303.7), p=0.049), after adjusting for the age at the surgery. There was no correlation with the utilization of systemic therapy, radiation therapy, or margin and o

Background: The Lane plate was one of the first widely used bone plates, utilized in the first decades of the twentieth century. Here we present the results of a retrieval analysis on a Lane plate, and a review of the history of these plates. Our patient underwent plating of her femur with a Lane plate in 1938. She developed a sciatic nerve palsy, managed surgically later that year by Dr. Arthur Steindler at the University of Iowa. Her femur healed, her nerve recovered, and she did well until 2020, at age 94, when she presented to the University of Iowa with a draining sinus that appeared to communicate with the plate. She underwent irrigation and debridement with hardware removal. The plate was sectioned, and its composition and structure characterized.

Methods: We retrieved hard copies of the patient's archived medical records from 1938, which document in detail the treatments performed by Dr. Steindler. The plate was analyzed using scanning electron microscopy (SEM) to characterize the surface of the plate. A cross section was taken from the plate, and the composition of the alloy was determined using energy dispersive x-ray spectroscopy (EDS). A review of the literature surrounding early plating techniques was conducted.

Results: Our patient recovered from her surgery and soon returned to her baseline state of health. Intraoperative cultures grew C. acnes. Analysis of the surface of the plate demonstrated significant corrosion, and the crystal structure seen on SEM suggested a strong alloy that is prone to corrosion. Analysis of the cross section with EDS demonstrated an alloy containing 94.9% iron, 1.7% aluminum, 1.2% chromium, and 1.1% manganese.

Conclusion: The Lane plate was introduced around 1907 by Sir William Arbuthnot Lane, a British surgeon, and was one of the first widely used devices for the plating of fractures. Given that this patient was likely one of the last to be treated with a Lane plate, this may be the final opportunity for such a retrieval analysis. Level of Evidence: IV.

Background: Antegrade femoral intramedullary nailing (IMN) is a common orthopedic procedure that residents are exposed to early in their training. A key component to this procedure is placing the initial guide wire with fluoroscopic guidance. A simulator was developed to train residents on this key skill, building off an existing simulation platform originally developed for wire navigation during a compression hip screw placement. The objective of this study was to assess the construct validity of the IMN simulator.

Methods: Thirty orthopedic surgeons participated in the study: 12 had participated in fewer than 10 hip fracture or IMN related procedures and were categorized as novices; 18 were faculty, categorized as experts. Both cohorts were instructed on the goal of the task, placing a guide wire for an IM nail, and the ideal wire position reference that their wire placement would be graded against. Participants completed 2 assessments with the simulator. Performance was graded on the distance from the ideal starting point, distance from the ideal end point, wire trajectory, duration, fluoroscopy image count, and other elements of surgical decision making. A two-way ANOVA analysis was used to analyze the data looking at experience level and trial number.

Results: The expert cohort performed significantly better than the novice cohort on all metrics but one (overuse of fluoroscopy). The expert cohort had a more accurate starting point and completed the task while using fewer images and less overall time.

Conclusion: This initial study shows that the IMN application of a wire navigation simulator demonstrates good construct validity. With such a large cohort of expert participants, we can be confident that this study captures the performance of active surgeons today. Implementing a training curriculum on this simulator has the potential to increase the performance of the novice level residents prior to their operating on a vulnerable patient. Level of Evidence: III.

Background: The COVID-19 pandemic and its effects on the orthopaedic match process are yet to be fully understood and should be explored. We hypothesize that the cancellation of away rotations due to the COVID-19 pandemic would decrease the variability of where students matched into orthopaedic residency compared to pre-pandemic years.

Methods: Accredited orthopaedic programs were collected from the Accreditation Council for Graduate Medical Education (ACGME) database. Rosters of orthopaedic residency classes for the years 2019, 2020, and 2021 were compiled across all orthopaedic programs in the United States. Data collection for the incoming 2021 orthopaedic surgery residents was carried out by reviewing each program's website, Instagram, and Twitter.

Results: Data for the incoming orthopaedic surgery residents from the 2021 National Residency Match Program (NRMP) were collected. 25.7% of incoming residents matched at their home institution. Data collection for the 2020 and 2019 orthopaedic residency classes yielded 19.2% and 19.5% home institution match rates, respectively. When examining likelihood to match into an orthopaedic residency program in ones own's state, we found that in the 2021 match cycle, 39.3% of applicants matched within their state, while 34.3% and 33.4% of incoming residents matched in 2020 and 2019, respectively.

Conclusion: To keep our patients and staff safe, visiting externship rotations were suspended in the 2021 Match cycle. As we continue to navigate the shifting waters of the COVID-19 pandemic, it is important to understand how our choices affect the dynamics of applying into residency training and beyond. This study demonstrates that a higher percentage of applicants that matched into orthopaedic residency remained at their home program compared to the previous two years before the pandemic. This indicates that programs tended to rank their home applicants, and that applicants tended to rank their home programs, higher than those that were less familiar. Level of Evidence: IV.

Background: Orthopaedic surgeons debate the timing of and necessity for surgical intervention when treating displaced midshaft clavicle fractures (MCFs). This systematic review evaluates the available literature regarding functional outcomes, complication rates, nonunion, and reoperation rates between patients undergoing early versus delayed surgical management of MCFs.

Methods: Search strategies were applied in PubMed (Medline), CINAHL (EBSCO), Embase (Elsevier), Sport Discus (EBSCO), and Cochrane Central Register of Controlled Trials (Wiley). Following an initial screening and full-text review, demographic and study outcome data was extracted for comparison between the early fixation and delayed fixation studies.

Results: Twenty-one studies were identified for inclusion. This resulted in 1158 patients in the early group and 44 in the delayed. Demographics were similar between groups except for a higher percentage of males in the early group (81.6% vs. 61.4%) and longer time to surgery in the delayed group (4.6 days vs. 14.5 months). Disability of the arm, shoulder, and hand scores (3.6 vs. 13.0) and Constant-Murley scores (94.0 vs. 86.0) were better in the early group. Percentages of initial surgeries resulting in complication (33.8% vs. 63.6%), nonunion (1.2% vs. 11.4%), and nonroutine reoperation (15.8% vs. 34.1%) were higher in the delayed group.

Conclusion: Outcomes of nonunion, reoperation, complications, DASH scores, and CM scores favor early surgery over delayed surgery for MCFs. However, given the small cohort of delayed patients who still achieved moderate outcomes, we recommend a shared decision-making style for treatment recommendations regarding individual patients with MCFs. Level of Evidence: II.

Family planning is a challenge for physicians at all stages of their careers, but particularly difficult during residency. Residency commonly occurs during prime childbearing years and is associated with long work hours and inflexible schedules. A commonly cited deterrent for women entering orthopaedic surgery is the inability to achieve a healthy and fulfilling work-life balance.¹ Further, those women who pursue starting a family during residency have been shown to have higher rates of pregnancy-related complications including infertility with complications rates as high as 30%.^2,3 In a recent AAOS article, a call to action for modified policies to prioritize the health of pregnant orthopaedic surgeons and their unborn children was made to decrease the overall risk to women who wish to have children during residency and early practice.⁴ The University of Iowa has a history of attracting women into the orthopedic training program. We asked past graduates of the University of Iowa Orthopedic Residency program who had children during residency to share their personal experiences and opinions. We asked past graduates to answer five questions surrounding their pregnancy during residency. We have included the good, the bad, and the ugly with real-life testimonies in hopes that despite the statistics, women in our field considering pregnancy will find comfort in those that have been through it. Four prior residents were kind enough to share their experiences. Dr. Sarah Schippers (SS) completed residency in 2021 and is currently finishing a hand and upper extremity fellowship and will soon be starting private practice in Kansas. She shares on her experience regarding two pregnancies during residency. Dr. Tina Hajewski (TH) completed residency in 2021 and is also currently finishing a spine fellowship and will soon be starting private practice in Washington, sharing on her experience having two children during residency. Dr. Elizabeth Weldin (EW) completed residency in 2018 and is a current hand and upper extremity attending in Oklahoma and shares her experience having a child during residency and the contrast to having children during practice. Finally, Dr. Heather Campion (HW) completed residency in 2012 and is a current hand and upper extremity attending in Oregon and shares her experience as being the first Iowa orthopaedic resident to have a child during residency. Level of Evidence: V.

Background: The purpose of this study was to determine risk factors for blood transfusion in primary anatomic and reverse total shoulder arthroplasty (TSA) performed for osteoarthritis.

Methods: Patients who underwent anatomic or reverse TSA for a diagnosis of primary osteoarthritis were identified in a national surgical database from 2005 to 2018 by utilizing both CPT and ICD-9/ICD-10 codes. Univariate analysis was performed on the two transfused versus non-transfused cohorts to compare for differences in comorbidities and demographics. Independent risk factors for perioperative blood transfusions were identified via multivariate regression models.

Results: 305 transfused and 18,124 nontransfused patients were identified. Female sex (p<0.001), age >85 years (p=0.001), insulin-dependent diabetes mellitus (p=0.001), dialysis dependence (p=0.001), acute renal failure (p=0.012), hematologic disorders (p=0.010), disseminated cancer (p<0.001), ASA ≥ 3 (p<0.001), and functional dependence (p=0.001) were shown to be independent risk factors for blood transfusions on multivariate logistic regression analysis.

Conclusion: Several independent risk factors for blood transfusion following anatomic/reverse TSA for osteoarthritis were identified. Awareness of these risk factors can help surgeons and perioperative care teams to both identify and optimize high-risk patients to decrease both transfusion requirements and its associated complications in this patient population. Level of Evidence: III.

Background: The purpose of this study was to determine how orthopedic residency program directors (PDs) evaluate residency applicants who participated in a research gap-year (RGY).

Methods: A 23 question electronically administered survey was created and emailed to all Accreditation Council for Graduate Medical Education (ACGME) orthopedic residency PDs for the 2020-21 application cycle. PDs were emailed directly if active contact information was identifiable. If not, program coordinators were emailed. The survey contained questions regarding the background information of programs and aimed at identifying how PDs view and evaluate residency applicants who participated in a RGY. Descriptive statistics for each question were performed.

Results: Eighty-four (41.8%) of 201 PDs responded. Most respondent programs (N=62, 73.8%) identified as an academic center. The most common geographic region was the Midwest, N=33 (39.3%). Few programs (N=3, 3.8%) utilize a publication "cut-off" when screening residency applicants. When asked how many peer-reviewed publications were necessary to deem a RGY as "productive," responses ranged from 0-15 publications (median interquartile range 4.5 [3-5]). Forty-one (53.3%) PDs stated they would council medical students to take a RGY with USMLE Step 1 scores being the #1 factor guiding that advice. More PDs disagree than agree (N=35, 43.6%; vs N=22, 28.2%) that applicants who complete a RGY are more competitive applicants, and 35 PDs (45.5%) agree research experiences will become more important in resident selection as USMLE Step 1 transitions to Pass/Fail.

Conclusion: Program directors have varying views on residency applicants who did a RGY. While few programs use a publication cutoff, the median number of publications deemed as being a "productive" RGY was approximately 5. Many PDs agree that research experiences will become more important as USMLE Step becomes Pass/Fail. This information can be useful for students interested in pursuing a RGY and for residency programs when evaluating residency applicants. Level of Evidence: IV.

Background: Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra-articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization.

Methods: The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination database was queried to identify all candidates performing at least one ankle fracture ORIF from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy. Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05.

Results: During the study period, there were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained ABOS Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeons (293/6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to arthroscopic cases, 293 cases (75.5%) were performed by foot and ankle fellowship trained surgeons, 29 (7.5%) sports medicine, and 4 (1.0%) trauma. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151).

Conclusion: Ankle arthroscopy utilization during ankle fracture ORIF has increased over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend. Level of Evidence: IV.

Background: Avascular necrosis (AVN) is a rare albeit serious condition that has a high risk for long term morbidity given the risk of chronic pain and arthroplasty after diagnoses. The recent rise in sports participation in the pediatric population demonstrates the importance of evaluating functional limitations after AVN treatment. Return to sport (RTS) rates after treatment for AVN have not been evaluated in pediatric or adolescent populations.It is necessary to evaluate all joints impacted by AVN due to heterogenous nature of the disease and the variety of sports that could be impacted by disease specific activity restrictions. Thus, this present study aimed to characterize RTS rate after AVN treatment, determine if there was a difference in RTS rates after operative versus nonoperative management, and identify demographic and treatment factors associated with RTS rates.

Methods: This retrospective cohort study evaluated patients ages eight to twenty years old who were treated for symptomatic AVN of any joint between January 2005 and August 2021. Patient records were reviewed for demographic, disease, and treatment variables. Standard descriptive statistics and bivariate analyses were performed to describe and compare groups who did and did not RTS. A generalized estimating model was used to determine variables that were associated with better RTS rates.

Results: A total of 144 patients and 190 lesions were evaluated in the study, 60 patients (43%) were female with a mean age of 14.36+/-3.24 years. The overall RTS rate after AVN treatment was 67% (64/96). Roughly 8% of patients (5/64) were able to return to multiple sports, however of those that returned to sports, 6% (4/64) reported playing at a lower level of competition. There was not a significant difference between the RTS rate for those who underwent operative versus nonoperative management (70% versus 62%, p=0.38). Males were almost 2.5 times more likely to return to sport than females (OR: 2.46, p=0.018).

Conclusion: The ability to return to sports after AVN treatment has largely remained unknown in the pediatric and adolescent populations. Our data suggests that a majority of patients are able to RTS in the short term follow up with males being twice as likely to RTS compared to females. Physicians should maintain awareness of the long-term morbidity of AVN and understand the unique patient and disease characteristics that optimize functional outcomes in this population. Level of Evidence: III.