bluuebunny/crossref_metadata_2025 huggingface dataset:
Time Out for Teaching: Implementing a Post-Procedure Time Out to Improve Surgical Evaluations
Authors: Straney Jennifer , Gala Rajiv , Ranger Caitlyn , Blosser Emily
Published: September 2018

Faculty Advisor:

Arthur Ollendorff, MD

PURPOSE:

To increase surgical evaluations by implementing a post-procedure Time Out for teaching.

BACKGROUND:

Compliance with intra-operative resident feedback and use of myTIPreport evaluations is poor. Feedback with completed evaluations is vital to improving surgical competence and compliance with ACGME milestones.

METHODS:

Post procedure Time Out for Teaching was implemented after gynecologic surgery to remind faculty to complete evaluations. A paper myTIPreport evaluation was provided in each operating room. Compliance goal was 80%. Evaluations were completed prior to leaving the operating room. PDSA cycles were used to introduce and evaluate this process. Using T-test, we compared completion rates prior to implementation of the Time Out. We removed the paper evaluations and continued PDSA cycles with the Time Out and electronic evaluations only. We compared completion rates of Time Out with paper evaluations to those with electronic evaluations.

RESULTS:

Implementing the Time Out with paper evaluations significantly improved compliance from 6/101 (5.9%) to 74/90 (82%, P<.01). When paper was removed, there was no significant difference in completed evaluations with Time Out alone (P=.14). Evaluation using chi squared and Fisher's exact tests showed completion rates with paper to be 11.36 times higher than with electronic evaluations (P<.0001).

DISCUSSION:

Adding a Post-procedure Time Out to remind faculty to complete intra-operative evaluations did improve compliance. However, having a paper evaluation proved to increase compliance more than the Time Out with electronic evaluations. We plan to continue the Time Out for Teaching process, but will give faculty the option to complete evaluations on paper.
Assessing the Effectiveness of Using Mechanistic Concept Maps in Case-Based Collaborative Learning
Authors: Fischer Krisztina , Sullivan Amy M. , Krupat Edward , Schwartzstein Richard M.
Published: September 2018

Problem

Despite the advantages of using mechanistic concept maps (MCMs)—diagrams created individually or collaboratively by a team to foster inductive analysis of a clinical problem—in individual learning, very little is known about their benefits in collaborative learning.

Approach

First-year medical and dental students (n = 170) were assigned to one of four learning groups in the Homeostasis I course, Harvard Medical School, February–March 2016. One group (n = 43) was randomly assigned to the MCM intervention; students in the remaining groups (n = 127) served as controls. Outcomes included pre- and postcourse surveys on, among other things, reasoning skills, attitudes toward teamwork, and tolerance of ambiguity; final exam scores; and qualitative responses to three open-ended questions on students’ perceptions of the effects of MCMs on their learning.

Outcomes

Response rates for pre- and postcourse surveys were 87/170 (51%) and 91/170 (54%). Compared with students in the control groups, students in the MCM group reported better reasoning skills (P = .01) and attitudes toward teamwork (P = .02). There were no significant differences in final exam scores between the groups. Students in the intervention group found MCMs more helpful in conceptual learning than their own notes and flashcards (P = .0001) or the readiness assessment quizzes (P = .0009). Qualitative analysis indicated MCM students routinely overcame team-learning obstacles through strategies aimed at prioritizing collaborative inductive reasoning.

Next Steps

Ongoing studies are evaluating the contextual elements and best practices for optimal employment of MCMs in promoting collaborative inductive reasoning.
Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents’ Practice and Fellowship Intentions
Authors: Phillips Julie P. , Peterson Lars E. , Fang Bo , Kovar-Gough Iris , Phillips Robert L.
Published: September 2018

Purpose

Educational debt is increasing and may affect physicians’ career choices. High debt may influence family medicine residents’ initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents’ practice and fellowship intentions.

Method

The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents’ practice (ownership and type) and fellowship intentions.

Results

Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000–$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41–0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36–0.85 and OR 0.62, CI 0.40–0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20–0.67 and OR 0.29, CI 0.15–0.55, respectively).

Conclusions

High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.
The Effects of Motor Imagery on Pain and Range of Motion in Musculoskeletal Disorders
Authors: Yap Benjamin Wei Da , Lim Edwin Choon Wyn
Published: September 2018

Introduction:

In recent years, there has been an increase in the use of motor imagery (MI) in the rehabilitation of musculoskeletal pain conditions. Across the literature, most reviews have yet to consider Laterality Judgement Task training as a form of MI method. This review aimed to evaluate the effectiveness of using MI as an adjunct to standard rehabilitation on the improvement of pain and range of motion parameters when managing patients with musculoskeletal pain conditions.

Methods:

Searches of 8 major electronic databases were conducted. Data for pain and range of motion were extracted. Meta-analyses (where possible) with either a fixed or random-effect(s) model, standardized mean differences (SMDs), and tests of heterogeneity were performed.

Results:

Eight clinical controlled trials were identified and included in the meta-analyses. When compared with standard rehabilitation alone, the adjunctive role of MI provided superior pain relief (pooled SMD, −2.25; 95% confidence interval, −4.11 to −0.4; P=0.02), and greater improvement in range of motion (pooled SMD, 3.04; 95% confidence interval, 0.66-5.43; P=0.01) in chronic musculoskeletal pain disorders.

Discussion:

The results suggest that MI may be effective for pain relief and improvement in range of motion among chronic musculoskeletal pain conditions, although conclusion is based on a limited certainty of evidence as assessed using the GRADES (Grading of Recommendation, Assessment, Development and Evaluation) approach.
Associations Between Musculoskeletal Pain Experience and Pressure and Cold Pain Sensitivity
Authors: Waller Robert , Smith Anne J. , O’Sullivan Peter B. , Slater Helen , Sterling Michele , Straker Leon M.
Published: September 2018

Objectives:

To investigate the cross-sectional associations between musculoskeletal pain experience and measures of pressure and cold pain sensitivity in young adults from the Western Australian Pregnancy Cohort (Raine) Study.

Participants and Methods:

In total, 917 participants were eligible for analysis if they provided data pertaining to musculoskeletal pain status at the 22-year follow-up and had data for at least 1 valid pain sensitivity test. Standardized protocols were used to assess pressure pain threshold (4 sites: lumbar spine, tibialis anterior, upper trapezius, and wrist) and cold pain threshold (wrist). Four pain experience groups (“No pain” [n=562, 61.3%], “Low” [n=84, 9.2%], “Medium” [n=147, 16.0%], “High” [n=124, 13.5%]) were determined by latent class analysis using parameters of pain chronicity, frequency, intensity, and number of pain areas. Variables considered as confounders included sex, age, ethnicity, waist-hip ratio, psychological symptoms, sleep quality, physical activity, sedentary behavior, smoking, and income.

Results:

There were no associations between pain experience and pressure pain sensitivity after adjusting for confounders. The “Medium” and “High” pain experience groups demonstrated heightened cold pain sensitivity compared with the “No pain” group (P=0.023), adjusted for sex and smoking.

Discussion:

This study provides the most extensive investigation of the relationship between musculoskeletal pain experience and pressure and cold pain sensitivity in young adults. Heightened cold pain sensitivity in those classified as “Medium” and “High” pain experience may suggest altered nociceptive processing and has implications for clinical management.
Evaluation of Digital Face Recognition Technology for Pain Assessment in Young Children
Authors: Sakulchit Teeranai , Kuzeljevic Boris , Goldman Ran D.
Published: September 2018

Objectives:

Accurate assessment of pain in young children is challenging. An Emotion Application Programing Interface (API) can analyze and report 8 emotions from facial images. Each emotion ranges between 0 (no correlation) to 1 (greatest correlation). We evaluated correlation between the Emotion API with the FLACC scale (face, lets, activity, cry, and consolability) among children younger than 6 years old during blood sampling.

Methods:

Prospective pilot exploratory study in children during blood sampling. Pictures with facial expressions were uploaded to Emotion API program. Primary outcome was the correlation coefficient between FLACC scale and emotions. Secondary outcomes included maximal correlation of each emotion for 3 pictures—before, during and after needle penetration; and the average of each emotion for 9 pictures—4 before, 1 during and 4 after needle penetration to the skin.

Results:

A total of 77 children were included. During needle penetration, SADNESS was significantly correlated (0.887, P<0.05), and NEUTRAL was negative correlated with the FLACC scale (−0.841; P<0.05). The maximal correlation of each emotion showed increase in SADNESS and decrease in NEUTRAL emotions during, compared to before, needle penetration. Similar findings were observed when the average of each emotion was compared during to before needle penetration.

Discussion:

During a blood test procedure, young children show higher SADNESS and lower NEUTRAL emotions as reported by the Emotion API. This software program may be useful in reporting emotions related to pain in young children, and more research is needed to compare its validity, reliability and real-time application compared to the FLACC scale.
Trends in Fellow Education Research Among Obstetric and Gynecologic Subspecialties
Authors: Buckheit Caledonia , Willis-Gray Marcella , Dotters-Katz Sarah
Published: September 2018

OBJECTIVE:

To evaluate the frequency at which fellow education-related abstracts are presented at national meetings and compare presentation rates before and after the accreditation transition.

METHODS:

This cross-sectional study evaluated abstracts from the five most recent national meetings of the Society for Maternal-Fetal Medicine (SMFM), the Society of Gynecologic Oncology, the American Society for Reproductive Medicine (ASRM), the American Urogynecologic Society (AUGS), and the Council on Resident Education in Obstetrics and Gynecology (CREOG) and Association of Professors of Gynecology and Obstetrics (APGO). Three independent reviewers assessed abstracts for education-specific content. Abstracts were included if two or greater reviewers identified them as related to fellow education. Descriptive statistics were used for data analysis.

RESULTS:

Fourteen thousand six hundred thirty abstracts were presented at obstetric and gynecologic subspecialty meetings between 2012 and 2017. Of these, 29 (0.20%) pertained to fellows' education. The percent of total abstracts that were fellow-related remained relatively constant over time. Of the four subspecialties, the AUGS presented fellow education research almost five times more frequently than ASRM (P<.01) or SMFM (P<.01). Over the study period, 1,283 abstracts were presented at the CREOG and APGO meeting, with four (0.31%) pertaining to fellows' education. At the CREOG and APGO meeting, fellow-related abstracts did not appear to increase over the period studied.

CONCLUSION:

Research regarding fellows' education is rarely presented at national meetings, representing less than 1% of all abstracts, and has not substantially increased since the transition to the Accreditation Council for Graduate Medical Education.
Validation of a Simulation Model for Laparoscopic Myomectomy Developed with 3D-Printed Molds
Authors: Singleton Miller , Behr Amanda , Braun Kelli , Stager Robert
Published: September 2018

PURPOSE:

To develop a model that can be used by Ob-Gyn residents when performing simulation for laparoscopic myomectomy.

BACKGROUND:

Laparoscopic myomectomy (LM) is a challenging procedure encountered by Ob-Gyn residents during residency training. Limited commercial simulation products exist but are cost-prohibitive for consistent use.

METHODS:

Uterine and fibroid molds were generated using Pixelogic® Z-brush design software and printed from a 3D printer using polylactic acid filament. Smooth-On® Dragon Skin silicone of varying densities was used for the uterus and fibroids. The model consisted of a uterine body with four fundal subserosal fibroids – two placed anteriorly and two placed posteriorly—fallopian tubes, and round ligaments. Residents evaluated the model and its effectiveness in simulating LM upon simulation completion.

RESULTS:

Five uterine models with four fibroids each were constructed for a total cost of $318 (printed molds, silicone, and pigment); replacement models cost $30 (silicone and pigment only). The model functioned well within the trainer box using surgical instruments and suture; however, the base of the fibroid adhered to the myometrium making excision of the entire specimen difficult. All residents (N=13) used the model. Residents felt the model was realistic (4/5), helps develop skills needed for LM (4.5/5), and will increase resident competency in laparoscopy (4.8/5).

DISCUSSION:

Our model provides a realistic simulation of LM at low cost. One model can be used by up to four residents. We can repair previously used models with silicone allowing them to be reused. We have updated the model to decrease fibroid adherence to the myometrium and facilitate complete excision.
Acute Respiratory Distress Syndrome After Uterine Artery Embolization
Authors: Nguyen Dong Bach , How Jeffrey , Ziegler Cleve , Madar Jaclyn
Published: September 2018

INTRODUCTION:

Although uterine artery embolization has been established as a less invasive alternative to hysterectomy or myomectomy for the treatment of uterine leiomyomas, it is not devoid of life-threatening complications.

CASE:

We present the case of a 44-year-old patient who developed a severe systemic inflammatory response and acute respiratory distress syndrome 5 weeks after uterine artery embolization of a large multileiomyomatous uterus. Deterioration of her clinical status prompted an emergency hysterectomy that led to rapid improvement.

CONCLUSION:

Although fatalities from septicemia after uterine artery embolization have been reported, aseptic inflammatory responses to uterine degeneration can also lead to multiorgan failure. With recent studies refuting uterine size and leiomyoma location as risk factors, further research is needed to help select appropriate uterine artery embolization candidates.
Cervical Pessary Compared With Vaginal Progesterone for Preventing Early Preterm Birth
Authors: Cruz-Melguizo Sara , San-Frutos Luis , Martínez-Payo Cristina , Ruiz-Antorán Belén , Adiego-Burgos Begoña , Campillos-Maza José Manuel , García-González Celso , Martínez-Guisasola Javier , Pérez-Carbajo Esther , Teulón-González María , Avendaño-Solá Cristina , Pérez-Medina Tirso ,   on behalf of the PESAPRO Study Group
Published: September 2018

OBJECTIVE:

To compare the effectiveness of a cervical pessary and vaginal progesterone to prevent spontaneous preterm births in pregnant women with cervical lengths 25 mm or less as measured by transvaginal ultrasonography.

METHODS:

This was a multicenter, open-label, randomized, noninferiority trial. Women with singleton pregnancies and a short cervix (25 mm or less) measured transvaginally at the second-trimester ultrasonogram were invited to participate. They were computer-randomized (one to one) into cervical pessary placement or treatment with vaginal progesterone (200 mg/24 hours). The primary outcome was spontaneous preterm delivery before 34 weeks of gestation. The noninferiority margin was set at 4% with a 0.025 one-sided α level and a statistical power of 80%. That is, if the 95% CI upper bound exceeded 4%, the pessary could not be deemed noninferior. A sample size of 254 women was required to show noninferiority of the pessary to progesterone.

RESULTS:

The trial was conducted from August 2012 to April 2016 with the participation of 27 Spanish hospitals. A total of 254 patients were enrolled and 246 included in the intention-to-treat analysis. Demographic and baseline characteristics were similar across groups. The rate of spontaneous delivery before 34 weeks of gestation was 14% (n=18/127) in the pessary group and 14% (n=17/119) in the progesterone group with a risk difference of −0.11% (95% CI −8.85% to 8.62%; P=.99), that is, noninferiority was not shown for the pessary. The incidence of increased vaginal discharge (87% vs 71%, P=.002) and discomfort (27% vs 3%, P<.001) was significantly higher in the pessary group.

CONCLUSION:

A cervical pessary was not noninferior to vaginal progesterone for preventing spontaneous birth before 34 weeks of gestation in pregnant women with short cervixes.

CLINICAL TRIAL REGISTRATION:

EU Clinical Trials Register, 2012-000241-13; ClinicalTrials.gov, NCT01643980.
Innate immunity and Toll-like receptor signaling in the pathogenesis of scleroderma: advances and opportunities for therapy
Authors: Brown Max , O’Reilly Steven
Published: September 2018

Purpose of review

Systemic sclerosis (SSc) is an autoimmune connective tissue disease in which inflammation and cytokine dysregulation leads to skin fibrosis. Toll-like receptors (TLRs) are conserved pattern recognition receptors, recognizing pathogens danger-associated molecular patterns (DAMPs) that elicit a cascade of proinflammatory signaling. Recently, TLRs have been found to be critically important in SSc pathogenesis, with increased levels of the TLRs and their ligands present in the disease. Animal models have also been pivotal in delineating the role of these innate immune receptors in SSc. This current review examines the role of TLRs and the most recent evidence of the role of DAMPs and how these may be exploited therapeutically.

Recent findings

Increasingly, studies have demonstrated the key roles of TLR4 and other intracellular TLRs in mediating fibrosis in SSc patients and animal models. TLR4 activation appears a key point and novel DAMPs, expressed upon tissue damage, appear critical in mediating the profibrotic effect through a downstream enhancement of transforming growth factor β. Deletion of Tenascin-C or a splice variant of fibronectin ameliorates animal models of skin fibrosis. Intracellular, nucleic acid sensing, TLR8 is critical in activating macrophages to secrete profibrotic molecules. The mechanism involves histone modification through epigenetic modifying enzymes.

TLRs are key therapeutic targets in SSc.
Malnutrition and the Orthopaedic Trauma Patient: A Systematic Review of the Literature
Authors: Ernst Alexandra , Wilson Jacob M. , Ahn Jaimo , Shapiro Marc , Schenker Mara L.
Published: September 2018

Objectives:

To evaluate the available literature for associations between nutrition and outcomes after operative treatment of long bone and long bone periarticular fractures.

Data Sources:

Systematic review of English-language articles in the MEDLINE, Embase, PubMed, and Cochrane computerized literature databases (through December 2015) using PRISMA guidelines.

Study Selection:

Randomized controlled trials, quasi-randomized controlled trials, case–control studies, and cohort studies (retrospective and prospective) involving long bone and long bone periarticular fractures that included the effect of nutritional status on fracture union, time to union, and any related soft-tissue complication were eligible for review.

Data Extraction:

Two authors independently extracted data from the selected studies using a standardized data collection form with predefined data fields for demographics, interventions, study methods, complications, and management outcomes.

Data Synthesis:

Although one of the original aims of the study was to conduct a meta-analysis, the available literature did not offer sufficient data for meta-analysis.

Conclusions:

Although our systematic review demonstrates a possible role for oral nutritional supplementation and vitamin supplementation in the orthopaedic trauma patient, there remains a need for well-designed trials to clarify this role. There is likely benefit to multidisciplinary approaches to nutritional optimization in the orthopaedic trauma patient, and this should be explored further in forthcoming work.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Clamshell Osteotomy for Acute Fractures in the Malunion Setting: A Technical Note
Authors: Pires Robinson Esteves , Gausden Elizabeth B. , Sanchez Gustavo Tadeu , Wajnsztejn André , Teixeira Thiago Martins , Soares Marcelo da Silva , Pesantez Rodrigo , Lorich Dean G.
Published: September 2018

Surgical management of lower extremity malunions and acute fractures in the setting of lower extremity deformities presents a unique challenge for orthopaedic surgeons. The objective of this study was to evaluate the outcomes of using the clamshell osteotomy in patients with acute fractures involving a malunion or deformity. A retrospective review of the cases performed by various orthopaedic traumatologists at 4 different trauma centers was performed to identify cases using the clamshell osteotomy from January 2012 to January 2016. Nine clamshell osteotomy cases were identified, 4 presenting fractures in the setting of previous malunions. All osteotomies healed within 15 months (average 6.8 ± 4.4 SD). In this multicenter case series, we demonstrate that using clamshell osteotomies can result in excellent outcomes for permitting intramedullary nailing of acute fractures in patients with lower extremity deformity.
International Orthopaedic Multicenter Study in Fracture Care: Coordinating a Large-Scale Multicenter Global Prospective Cohort Study
Authors: Sprague Sheila , McKay Paula , Li Chuan Silvia , Ivers Rebecca , Moroz Paul J. , Jagnoor Jagnoor , Bhandari Mohit , Miclau Theodore ,   on behalf of the INORMUS Investigators
Published: September 2018

Traditionally, the orthopaedic trauma literature has been dominated by small studies that were largely single-center initiatives. More recently, there has been a paradigm shift toward larger, multicenter studies because the orthopaedic community embraced the concepts of evidence-based medicine and the need for high-quality research to guide clinical practice. The International Orthopaedic Multicenter Study in Fracture Care is a large multicenter international cohort study in musculoskeletal trauma in Africa, Asia, and Latin America. This is the first study of this magnitude within the global orthopaedic trauma community. The International Orthopaedic Multicenter Study in Fracture Care study has provided an opportunity to form new international collaborative relationships and to develop new research capacity and global collaborative relationships that will provide the foundation for future studies in injury prevention and management.

Levels of Evidence:

IV.
Role of North-South Partnership in Trauma Management: Uganda Sustainable Trauma Orthopaedic Program
Authors: O'Brien Peter , Kajja Isaac , Potter Jeffrey M. , O'Hara Nathan N. , Kironde Edward , Petrisor Brad
Published: September 2018

Uganda, as do many low–middle income countries, has an overwhelming volume of orthopaedic trauma injuries. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) is a partnership between the University of British Columbia, McMaster University and Makerere University that was initiated in 2007. The goal of the project is to reduce the disabilities that occur secondary to musculoskeletal trauma in Uganda. USTOP works with local collaborators to build orthopaedic trauma capacity through teaching, innovation, and research. USTOP has maintained a multidisciplinary approach to training, involving colleagues in anesthesia, nursing, rehabilitation, and sterile reprocessing. The project was initiated at the invitation of the Department of Orthopaedics at Makerere University and Mulago Hospital in Kampala. The project is a collaboration between Canadian and Ugandan orthopaedic surgeons and is driven by the needs identified by the Ugandan surgeons. The program has also worked with collaborators to develop several technologies aimed at reducing the cost of providing orthopaedic care without compromising quality. As orthopaedic trauma capacity in Uganda advances, USTOP strives to continually evolve and provide relevant support to colleagues in Uganda to ensure that changes result in sustainable improvements in patient care.
Current Status of Musculoskeletal Trauma Care Systems Worldwide
Authors: Miclau Theodore , Hoogervorst Paul , Shearer David W. , El Naga Ashraf N. , Working Zachary M. , Martin Claude , Pesántez Rodrigo , Hüttl Tobias , Kojima Kodi E. , Schütz Michael ,   on behalf of the International Orthopaedic Trauma Study Consortium
Published: September 2018

Background and Rationale:

Although general trauma care systems and their effects on mortality reduction have been studied, little is known of the current state of musculoskeletal trauma delivery globally, particularly in low-income (LI) and low middle-income (LMI) countries. The goal of this study is to assess and describe the development and availability of musculoskeletal trauma care delivery worldwide.

Materials & Methods:

A questionnaire was developed to evaluate different characteristics of general and musculoskeletal trauma care systems, including general aspects of systems, education, access to care and pre- and posthospital care. Surgical leaders involved with musculoskeletal trauma care were contacted to participate in the survey.

Results:

Of the 170 surveys sent, 95 were returned for use for the study. Nearly 30 percent of surgeons reported a formalized and coordinated trauma system in their countries. Estimates for the number of surgeons providing musculoskeletal trauma per one million inhabitants varied from 2.6 in LI countries to 58.8 in high-income countries. Worldwide, 15% of those caring for musculoskeletal trauma are fellowship trained. The survey results indicate a lack of implemented musculoskeletal trauma care guidelines across countries, with even high-income countries reporting less than 50% availability in most categories. Seventy-nine percent of the populations from LI countries were estimated to have no form of health care insurance. Formalized emergency medical services were reportedly available in only 33% and 50% of LI and LMI countries, respectively. Surgeons from LI and LMI countries responded that improvements in the availability of equipment (100%), number and locations of trauma-designated hospitals (90%), and physician training programs (88%) were necessary in their countries. The survey also revealed a general lack of resources for postoperative and rehabilitation care, irrespective of the country's income level.

Conclusion:

This study addresses the current state of musculoskeletal trauma care delivery worldwide. These results indicate a greater need for trauma system development and support, from prehospital through posthospital care. Optimization of these systems can lead to better outcomes for patients after trauma. This study represents a critical first step toward better understanding the state of musculoskeletal trauma care in countries with different levels of resources, developing strategies to address deficiencies, and forming regional and international collaborations to develop musculoskeletal trauma care guidelines.
Asociación de Cirujanos Traumatólogos de las Américas: Development of a Latin American Research Consortium
Authors: Miclau Theodore , MacKechnie Madeline C. , Shearer David W. ,   on behalf of the ACTUAR group
Published: September 2018

Trauma continues to be a leading cause of mortality and morbidity in lower to middle-income countries. To meet the ever-growing need of musculoskeletal care in trauma patients, orthopaedic surgeons play an instrumental role in providing care, guided by relevant clinical research studies. Promoting research and publishing results are both crucial to influencing trauma-related skeletal injury treatment in lower to middle-income countries. Currently, few opportunities exist for trauma surgeons in Latin America to participate in clinical research or to contribute to academic publications, thereby limiting their ability to address potentially critical treatment questions faced by their specific patient populations. In response to these obstacles, in 2017, a group of 60 surgeon leaders representing 18 countries throughout Latin America developed the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR; www.actuarla.org). The ACTUAR supports investigative opportunities for Latin American orthopaedic trauma surgeons who want to contribute through collaborative research work. This pioneering initiative aims to improve trauma-related research, clinical care, and health care policies through the development of an international network across the Americas.
Nonoperative versus operative treatment for displaced midshaft clavicle fractures in adolescents: a comparative study
Authors: Song Mi Hyun , Yun Yeo-Hon , Kang Kimoon , Hyun Myung Jae , Choi Sungwook
Published: September 2018

We aimed to compare the outcomes and complications of nonoperative and operative treatment for displaced midshaft clavicle fractures in adolescents. Radiological and functional evaluations and complications for 23 patients with nonoperative treatment were compared with those for 18 patients with operative treatment. No nonunion developed in either group. No significant intergroup differences were observed for occurrence of delayed union or time to union (P=0.851 and 0.887, respectively). Both groups showed excellent functional outcomes on the basis of Disabilities of the Arm, Shoulder and Hand scores and Constant Shoulder Scores. Shoulder abduction strength and range of motion were also well restored in both treatment groups. However, recovery of shoulder range of motion was significantly faster in the operative group (mean: 5.3 weeks; range: 4.0–7.0 weeks) than in the nonoperative group (mean: 9.9 weeks; range: 8.0–19.0 weeks) (P<0.001). There were no patients in either treatment group who needed revisional surgery to address complications with functional deficits. Both nonoperative and operative treatments yielded excellent outcomes, without severe complications. On the basis of our results, nonoperative treatment is recommended as a primary treatment option for displaced midshaft clavicle fractures in adolescents. However, operative treatment can be considered in selected patients who require early functional recovery or have a high activity level.
Optimizing the use of fibula in type II tibial hemimelia: early results
Authors: Radhakrishna Veerappa N. , Madhuri Vrisha , Palocaren Thomas
Published: September 2018

We describe a technique for optimal use of fibula in reconstruction of type II tibial hemimelia. Six affected children with mean age of 1.4 years and treated over a 5-year period were reviewed. All underwent staged reconstruction by lowering the fibula to below knee level using Ilizarov soft tissue distraction, transfer of distal fibula under proximal tibia, and foot centralization. Mean follow-up period was 3.6 years (range: 1.6–6.05 years). Mean age at follow-up was 4.4 years, and increase in length was 4.08 cm. Tibiofibular union and foot centralization were universally achieved. Mild residual equinovarus deformity was present in three children and braced. Our technique allowed significant length gain and foot centralization in toddlers without distraction osteogenesis.
Foot size asymmetry following Ponseti treatment versus comprehensive surgical releases for unilateral clubfeet
Authors: Wallace Juanita J. , White Hank D. , Augsburger Samuel F. , Talwalkar Vishwas R. , Muchow Ryan D. , Iwinski Henry J. , Walker Janet L.
Published: September 2018

Using age and height matched cohorts with unilateral idiopathic clubfeet (n=40 each), we retrospectively reviewed pedobarographic studies to determine the impact of treatment, Ponseti versus comprehensive surgical releases (CSR), on the foot length, width, and contact area. The foot pressures were determined by self-selected walking across a force plate. Ponseti treatment results in more symmetrical foot lengths, widths, and total contact areas with an improvement of 1.3 shoe sizes difference compared with treatment with CSR. This suggests that there is improved growth in the clubfoot in those treated with Ponseti management compared with those treated with CSR.
Standardized traction versus side-bending radiographs in adolescent idiopathic scoliosis: a preliminary study
Authors: O’Neill Cathleen J. , Brennan Stephen A. , Quinn Cian , Brabazon Dermot , Kiely Patrick J.
Published: September 2018

The aim of this study was to develop a new type of preoperative flexibility test for adolescent idiopathic scoliosis. The objective was to develop a test that was standardized and allow for the measurement of in-vivo forces required for curve correction. It was undertaken to compare the results of this new test with side-bending radiographs. Various preoperative radiographic techniques have been used to assess flexibility in patients awaiting scoliosis correction surgery. The major limitation of these investigations is a lack of standardization. The side-bending radiograph is the current gold standard, against which this new test was compared. A prospective clinical study was conducted. An axial traction force of 1.5 times body weight was applied through the spine of patients using a traction jig. Posteroanterior, side-bending and traction radiographs were taken. Cobb angle and apical vertebra axial rotation measurements were obtained. Flexibility indices in the coronal and axial planes were calculated. Cobb angle reduction and axial derotation were compared between the two methods. A total of 15 (12 female and three male) patients, with a mean age of 15.1 years, were assessed. The mean force imparted on traction films was 800 N. The major curve Cobb angle measurements were 60.4° on standing posteroanterior radiograph, 52.7° on side-bend film and 44.5° on traction at 1.5 times body weight. The corresponding apical vertebrae axial rotations were 23.9°, 22.2° and 16.5°, respectively. The mean Cobb angle reduction was 15.9 for traction and 7.7 for side-bend radiographs (P<0.0001). The mean apical vertebra derotation was 7.4 for traction and 1.7° for side-bend radiographs (P=0.0083). The mean flexibility index in the coronal plane was 0.479. The mean flexibility index in the axial plane was 0.240. Our novel method of traction radiographs at 1.5 times body weight is a safe and reproducible method of assessing curve flexibility in patients with scoliosis. This method achieves a larger Cobb angle and axial derotation when compared with side-bending radiographs.
Management of Irreducible Hip Dislocations in Infants With Developmental Dysplasia of the Hip Diagnosed Below 6 Months of Age
Authors: Aarvold Alex , Schaeffer Emily K. , Kelley Simon , Clarke Nicholas M.P. , Herrera-Soto Jose A. , Price Charles T. , Mulpuri Kishore
Published: September 2018

Background:

Infants with dislocated irreducible (D/I) hips can be substantially harder to treat than infants with dislocated but reducible hips. The purpose of this study was to compare treatment methods and outcomes for infants with D/I hips in order to optimize management of this difficult patient cohort.

Methods:

A multicenter prospective hip dysplasia study database was analyzed from 2010 to 2016. Infants aged below 6 months with clinically and radiologically confirmed D/I hips were included in the study. Teratological hips (syndromic/neuromuscular) were excluded.

Results:

In total, 59 hips in 52 patients were included. All hips were clinically Ortolani negative and radiologically dislocated but irreducible on presentation and had at least 20 months of follow-up. Mean age at diagnosis was 1.9 months (range, 0.1 to 5.9 mo). There were 33 left hips, 12 right hips, and 14 bilateral hips (7 patients). In total, 48 of 59 hips were treated in Pavlik harness. The remainder were treated by alternative braces or primary closed or open reductions. Pavlik treatment was successful in 27 of 48 hips. Pavlik treatment was abandoned in 21 D/I hips, 3 due to femoral nerve palsy and the remainder due to failure to achieve reduction. There was no statistical correlation between Pavlik success and age at diagnosis (P=0.22), patient sex (P=0.61), or bilateral compared with unilateral D/I hips (P=0.07). Left hips were more likely to be successfully reduced in Pavlik harness than right hips (P=0.01). Five complications occurred: 3 patients developed femoral nerve palsy in Pavlik harness, while 2 patients developed avascular necrosis, both after failed Pavlik treatment and subsequent surgery.

Conclusions:

Pavlik harness treatment has been demonstrated to be a safe and sensible first-line treatment for infants with D/I hips. Left hips were more likely to be successfully reduced in Pavlik harness than right hips, but age, sex, and bilaterality were not correlated. The outcomes demonstrated from this multicentre prospective database inform management of this complex patient cohort.

Level of Evidence:

Level II—prognostic study: less-quality prospective study.
Changes in Proximal Femoral Shape During Fetal Development
Authors: Li Don T. , Cui Jonathan J. , Henry Havalee T. , Cooperman Daniel R.
Published: September 2018

Background:

Walker and Goldsmith's classic article on fetal hip joint development reported that neck/shaft angle did not change from 12 weeks of gestational age through term while version increased from 0 to 40 degrees. This suggests no change in coronal alignment during development, a conclusion we dispute. By re-examining their data, we found that the true neck/shaft angle (tNSA) decreased by 7.5 degrees as version increased by 40 degrees from 12 weeks of gestational age to term.

Methods:

Four investigators measured both femoral version and neck-shaft angle from photographs published by the authors of femurs at multiple stages of maturation from 12 weeks of gestational age to term. The tNSAs and inclination angles were calculated for each femur illustrated using previously validated formula. Changes in the morphology of the femur over time were analyzed using a Student t test. Interobserver and intraobserver reliability were also determined by the Pearson R coefficient.

Results:

As reported by Walker and Goldsmith, apparent neck/shaft angle (aNSA) did not significantly change during maturation, whereas version increased by 40 degrees. However, tNSA decreased by 7.5 degrees during maturation, while the inclination increased by 32 degrees over the same period. This paper demonstrates angular changes in both the coronal and transverse planes with a 4:1 ratio of angular change in the transverse and coronal planes respectively. Interobserver Pearson coefficient R=0.98 and an intraobserver Pearson coefficient R=0.99.

Conclusions:

Although Walker and Goldsmith reported angular changes only in the transverse plane, we conclude that they identified angular changes in both the coronal and transverse planes. Here we show it is mathematically necessary for tNSA to decrease, if aNSA remains constant as version increases.

Clinical Relevance:

A reader who is not well versed in the difference between aNSA and tNSA or version and inclination cannot appreciate what Walker and Goldsmith presented. Surgeons operating on the proximal femur also benefit from understanding these distinctions.
Understanding Respiratory Restrictions as a Function of the Scoliotic Spinal Curve in Thoracic Insufficiency Syndrome: A 4D Dynamic MR Imaging Study
Authors: Udupa Jayaram K. , Tong Yubing , Capraro Anthony , McDonough Joseph M. , Mayer Oscar H. , Ho Suzanne , Wileyto Paul , Torigian Drew A. , Campbell Robert M.
Published: September 2018

Background:

Over the past 100 years, many procedures have been developed for correcting restrictive thoracic deformities which cause thoracic insufficiency syndrome. However, none of them have been assessed by a robust metric incorporating thoracic dynamics. In this paper, we investigate the relationship between radiographic spinal curve and lung volumes derived from thoracic dynamic magnetic resonance imaging (dMRI). Our central hypothesis is that different anteroposterior major spinal curve types induce different restrictions on the left and right lungs and their dynamics.

Methods:

Retrospectively, we included 25 consecutive patients with thoracic insufficiency syndrome (14 neuromuscular, 7 congenital, 4 other) who underwent vertical expandable prosthetic titanium rib surgery and received preimplantation and postimplantation thoracic dMRI for clinical care. We measured thoracic and lumbar major curves by the Cobb measurement method from anteroposterior radiographs and classified the curves as per Scoliosis Research Society (SRS)-defined curve types. From 4D dMRI images, we derived static volumes and tidal volumes of left and right lung, along with left and right chest wall and left and right diaphragm tidal volumes (excursions), and analyzed their association with curve type and major curve angles.

Results:

Thoracic and lumbar major curve angles ranged from 0 to 136 and 0 to 116 degrees, respectively. A dramatic postoperative increase in chest wall and diaphragmatic excursion was seen qualitatively. All components of volume increased postoperatively by up to 533%, with a mean of 70%. As the major curve, main thoracic curve (MTC) was associated with higher tidal volumes (effect size range: 0.7 to 1.0) than thoracolumbar curve (TLC) in preoperative and postoperative situation. Neither MTC nor TLC showed any meaningful correlation between volumes and major curve angles preoperatively or postoperatively. Moderate correlations (0.65) were observed for specific conditions like volumes at end-inspiration or end-expiration.

Conclusions:

The relationships between component tidal volumes and the spinal curve type are complex and are beyond intuitive reasoning and guessing. TLC has a much greater influence on restricting chest wall and diaphragm tidal volumes than MTC. Major curve angles are not indicative of passive resting volumes or tidal volumes.

Level of Evidence:

Level II—diagnostic.
Abstract Submission and Acceptance Rates for Men and Women in Academic Pediatric Orthopaedic Surgery: An Analysis of POSNA Annual Meeting Abstract Submissions 2012-2015
Authors: Sharkey Melinda S. , Feinn Richard S. , Cahill Sean V. , Batter Alexandra , Nduaguba Afamefuna M. , Cassese Todd , Carter Cordelia W.
Published: September 2018

Background:

It has recently been demonstrated that women members of the Pediatric Orthopaedic Society of North America (POSNA) participate at the Annual Meeting at disproportionately lower rates than men members, as defined by accepted abstract(s). We hypothesize that this discrepancy is associated with lower abstract submission rates by women members.

Methods:

POSNA membership directories for the years 2012-2015 were used to record the name, sex, membership category, and years of membership for each member. Final programs for Annual Meetings and abstract submission records for the same time period were used to record the number of accepted and rejected abstracts for each member. General estimating equations with a binomial model and logit link were used to compare the proportion of abstract acceptances between sexes across years.

Results:

During the period 2012-2015, active members included 534 men (83.8%) and 103 women (16.2%), whereas candidate members included 207 men (64.7%) and 113 women (35.3%). When active and candidate members were considered collectively, men were significantly more likely to have an accepted abstract (P=0.009) and this significant difference did not change over the 4-year period (P=0.627). However, men submitted significantly more abstracts per member per year than women (means: 1.5 abstracts/man/y; 0.8 abstracts/woman/y; P<0.001). This held true for both candidate members (early career) (P=0.001) as well as active members (mid-career) (P<0.001). When the total number of abstract submissions per year per member was taken into account, the percentage of abstract acceptances was similar for men and women (men=42%, women=40%; P=0.847).

Conclusions:

Abstract acceptance rates were similar for women and men members of POSNA for the 2012-2015 Annual Meetings. However, men had a significantly greater number of abstract submissions per member than women, and consequently, men presented a higher proportion of abstracts relative to their membership numbers. This supports our hypothesis that the disproportionately lower rate of active participation amongst women members at POSNA Annual Meetings, defined as abstract acceptance, is due to lower rates of abstract submissions, rather than to lower rates of acceptances.

Level of Evidence:

It is not applicable as it is not a clinical or basic science study.