Point-of-Care Ultrasound Curriculum for Internal Medicine Residents During the COVID-19 Era: A Pilot Study.

INTRODUCTION: The use of point-of-care ultrasound (POCUS) by internal medicine physicians and residents is increasing. We present the results of a pilot study to implement a POCUS curriculum that was interrupted by the Coronavirus Disease 2019 (COVID-19) pandemic at an internal medicine residency program at a community hospital. The purpose of this study is to inquire about the attitude and interest of our medical residents in POCUS. Additionally, we also plan to examine whether a curriculum that lacks some practical aspects due to COVID-19 restrictions can still improve the residents' confidence in recognizing common POCUS applications and improve image interpretation skills. METHODS: We conducted a prospective, pre-, and post-curriculum pilot study to examine the POCUS skills of categorical internal medicine residents in Post-Graduate Years (PGY) 1 through 3 at a community hospital. The two POCUS-related skills examined were self-reported confidence level in recognizing certain POCUS examination findings and POCUS image interpretation skills. Due to social distancing guidelines, we were unable to host hands-on sessions as originally planned, but residents did receive lectures via Zoom regarding POCUS training and also organ-specific diagnoses. Three primary outcomes were measured: (1) baseline difference in confidence level between interns (PGY-1) and senior residents (PGY-2 and 3) at the beginning of the curriculum, (2) improvement in POCUS confidence level before and after the curriculum considering interns and senior residents all together and also separately, and (3) improvement in image interpretation skills before and after the curriculum. RESULTS: Of 41 residents, 23 participants completed the pre- and post-curriculum test. Of the 23 participants, 12 participants were interns, and 11 were senior residents. Overall, interns showed a statistically significant improvement in the confidence level in almost all diagnoses except pulmonary embolism (p = 0.084). For image interpretation tests, significant improvement was found only in recognizing the two signs of pneumothorax: pleural line absent sliding (X2 = 4.00, p < 0.05) and the barcode sign (X2 = 6.13, p < 0.05). The pre-curriculum confidence level questionnaire included a question about residents' interest in learning POCUS during residency. It showed that the vast majority of residents (21 residents [91%]) are either extremely or mostly interested in POCUS. Most of our residents (18 [78%]) did not have formal exposure to POCUS during medical school. CONCLUSION: A POCUS curriculum that lacks hands-on workshops and longitudinal image saving and reviewing due to the COVID-19 pandemic restrictions did not improve the residents' image interpretation skills, although the confidence levels of the interns statistically improved. After the pandemic, we plan to implement the full curriculum and examine whether it will improve the residents' image acquisition and interpretation skills.

Modern total ankle arthroplasty versus ankle arthrodesis: A systematic review and meta-analysis.

The controversy in surgical management of end-stage tibiotalar arthritis with Total Ankle Arthroplasty (TAA) versus Ankle Arthrodesis (AA) has grown in parallel with the evolution of both procedures. No randomized controlled trials exist due to the vast differences in surgical goals, patient expectations, and complication profiles between the two procedures. This makes high quality systematic reviews necessary to compare outcomes between these two treatment options. The aim of this study was to provide a systematic review with meta-analysis of publications reporting outcomes, complications, and revision data following third-generation TAA and/or modern AA published in the past decade. Thirtyfive articles met eligibility criteria, which included 4312 TAA and 1091 AA procedures. This review reports data from a mean follow-up of 4.9 years in the TAA cohort and 4.0 years in the AA cohort. There was no significant difference in overall complication rate following TAA compared to AA (23.6% and 25.7% respectively, P-value 0.31). Similarly, there was no significant difference in revision rate following TAA compared to AA (7.2% and 6.3% respectively, P-value 0.65). Successful treatment of end-stage tibiotalar arthritis requires an understanding of a patients' goals and expectations, coupled with appropriate patient selection for the chosen procedure. The decision to proceed with TAA or AA should be made on a case-by-case basis following an informed discussion with the patient regarding the different goals and complication profiles for each procedure.

Pelvic incidence in a femoroacetabular impingement population.

OBJECTIVE: We aim to determine if pelvic incidence (PI) differed between a symptomatic femoroacetabular impingement (FAI) population and a control. METHODS: We retrospectively identified a cohort of symptomatic FAI patients and compared measured PI to a control group. RESULTS: The PI was significantly lower in the FAI group compared to the control (51.32±1.07 vs. 55.63±1.04; P < 0.01). CONCLUSION: The mean PI was significantly decreased in the FAI population compared to a control.

Assessment of Flexion Strength Following Single- Versus Double-Hamstring Tendon Harvest for Anterior Cruciate Ligament Reconstruction.

PURPOSE: To compare isometric hamstring strength deficits, knee laxity, functional outcomes, and patient-reported outcomes between patients who underwent anterior cruciate ligament (ACL) reconstruction with doubled semitendinosus and gracilis tendon autograft (ST/G) versus quadrupled semitendinosus autograft (ST), at a minimum follow-up of 1-year postoperatively. METHODS: Patients who underwent ACL reconstruction with ST/G or ST hamstring autografts were retrospectively identified. Isometric hamstring strength was tested with a hand-held dynamometer at 30, 60, and 90° of knee flexion. Anterior knee laxity was assessed using a KT-1000 arthrometer. Functional outcomes were collected using the single-leg hop test and single-leg squat test. Side-to-side differences were determined and compared between the ST/G and ST groups. Patient-reported outcomes were collected on all patients. RESULTS: Eighty-four patients who underwent ST/G (n = 34) or ST (n = 50) autograft ACL reconstruction were recruited to participate in this study. There was no difference in knee laxity between the groups. Side-to-side hamstring strength deficits increased with increased flexion angles. At 90° of flexion, the ST/G group had a significantly greater flexion strength deficit compared with the ST group (37.8 ± 15.1% vs 24.7 ± 12.5%, P < .001). Aside from a significant difference in the KOOS pain Score (P .045), no other significant differences in functional or patient reported outcomes between the groups were identified. CONCLUSIONS: Patients who underwent ACL reconstruction with ST/G compared with ST autograft have a significantly greater isometric flexion strength deficit at 90° of flexion. Future investigations are required to determine the clinical relevance of this difference and whether specialized therapy protocols can mitigate this deficit. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Pectoralis Major Injuries in the National Football League.

BACKGROUND: Pectoralis major (PM) injuries are rare, primarily occurring in males during athletic activity. In the current literature, these injuries have not been well described in National Football League (NFL) athletes. HYPOTHESIS: The incidence of PM injuries will be low in NFL athletes, with athletes missing significantly more time after injuries requiring operative management. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 4. METHODS: All documented PM injuries were retrospectively analyzed using the NFL Injury Surveillance System over a 15-season period. The data were analyzed by season, session, position, activity, and contact type at the time of injury. Additionally, the incidence, treatment, and days missed as a result of injury were assessed. RESULTS: Over 15 consecutive seasons, there were a total of 211 PM injuries. Of these injuries, 132 were classified as strains and 79 as ruptures. The incidence of strains was 0.41 per 10,000 athlete-exposures, compared with 0.25 per 10,0000 athlete-exposures for ruptures (P < 0.01). Players with PM ruptures treated operatively missed significantly more days than players treated nonoperatively (146.7 ± 55.0 vs 77.2 ± 72.9; P < 0.01). CONCLUSION: NFL athletes miss significantly more time after operative compared with nonoperative management of PM ruptures. CLINICAL RELEVANCE: PM injuries are rare, with the current literature lacking description of these injuries in NFL athletes. The paucity of data limits physicians from providing adequate counseling and expectations for athletes with this injury. This research represents the largest study assessing PM injuries in NFL athletes.

The negative impact of anterior cruciate ligament reconstruction in professional male footballers.

BACKGROUND: Soccer is one of the most common international sports in which ACL injuries occur, with previous studies reporting high return-to-play rates following ACL reconstruction (ACLR). Return-to-play analysis fails to take into consideration how effective a player remains once returning to competition. The aims of this study are to provide a large-scale international analysis of return-to-play and player performance statistics among professional soccer athletes following ACLR. METHODS: Using publicly available sources, professional soccer athletes who have undergone ACLR between the 1996 and 2015 seasons were identified. Player metrics including statistical performance, recovery time, and return-to-play rates were analyzed both before and after reconstruction. Furthermore, player performance statistics during each of three consecutive seasons post-ACLR were compared. RESULTS: A total of 176 athletes who underwent ACLR were included in this study. The return-to-play rate was 93.2% (164 athletes). Cumulative post-surgical statistical analysis of ACLR players demonstrated fewer games/season, minutes/season, minutes/game, goals/season, and more fouls/season following ACLR (p < 0.04). Analysis of player performance statistics suggests that athletes do not return to their baseline number of games/season and minutes/game until two and three seasons post-ACLR, respectively. At three seasons post-ACLR, athletes are still starting fewer games/season and scoring fewer goals/90 min (p < 0.04). CONCLUSION: Return-to-play rate is high following ACLR; however, athletes exhibit poorer statistical performance, especially in the first few seasons upon return. Our data shows that athletes continue to start fewer games/season and score fewer goals/90 min at three seasons post-ACLR.

Early diagnosis of septic arthritis in immunocompromised patients.

OBJECTIVES: Septic arthritis results in rapid joint destruction if not properly diagnosed and treated. A work up for septic arthritis includes a peripheral white blood cell count, inflammatory markers, and a joint aspiration. In the general population, the interpretation of these labs has been well-defined by prior studies. To this point, no study has determined how immunosuppressive states affect this work up. METHODS: Patients with immunosuppressive conditions who received a joint aspiration for a painful joint were retrospectively identified. Laboratory results from their work up were gathered and analyzed. RESULTS: 216 patients were included in the study, 21 of whom were diagnosed with septic arthritis. The average aspiration WBC count was 74,190 with 88% PMNs. 81% had a positive gram stain. DISCUSSION: Laboratory values for immunosuppressed patients with septic arthritis were similar to those associated with septic arthritis in historical general population controls.

Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures.

BACKGROUND: Simulation-based education has been integrated into many orthopaedic residency programs to augment traditional teaching models. Here we describe the development and implementation of a combined didactic and simulation-based course for teaching medical students and interns how to properly perform a closed reduction and percutaneous pinning of a pediatric supracondylar humeral fracture. METHODS: Subjects included in the study were either orthopaedic surgery interns or subinterns at our institution. Subjects all completed a combined didactic and simulation-based course on pediatric supracondylar humeral fractures. The first part of this course was an electronic (e)-learning module that the subjects could complete at home in approximately 40 minutes. The second part of the course was a 20-minute simulation-based skills learning session completed in the simulation center. Subject knowledge of closed reduction and percutaneous pinning of supracondylar humeral fractures was tested using a 30-question, multiple-choice, written test. Surgical skills were tested in the operating room or in a simulated operating room. Subject pre-intervention and post-intervention scores were compared to determine if and how much they had improved. RESULTS: A total of 21 subjects were tested. These subjects significantly improved their scores on both the written, multiple-choice test and skills test after completing the combined didactic and simulation module. Prior to the module, intern and subintern multiple-choice test scores were significantly worse than postgraduate year (PGY)-2 to PGY-5 resident scores (p < 0.01); after completion of the module, there was no significant difference in the multiple-choice test scores. After completing the module, there was no significant difference in skills test scores between interns and PGY-2 to PGY-5 residents. Both tests were validated using the scores obtained from PGY-2 to PGY-5 residents. CONCLUSIONS: Our combined didactic and simulation course significantly improved intern and subintern understanding of supracondylar humeral fractures and their ability to perform a closed reduction and percutaneous pinning of these fractures.

Recombinant human bone morphogenetic protein-2 versus iliac crest bone graft in anterior cervical discectomy and fusion: Dysphagia and dysphonia rates in the early postoperative period with review of the literature.

Recombinant human bone morphogenetic protein-2 (rhBMP-2) is a growth factor utilized to stimulate bone development in several clinical scenarios. Although the U.S. Food and Drug Administration approved this therapeutic modality for only two applications, it is frequently used off-label in anterior cervical discectomy and fusion (ACDF) procedures as an alternative to iliac crest bone graft (ICBG), the prior standard of care. This usage has been a source of controversy in the medical community due to evidence of increased rates of postoperative edema and dysphagia. This retrospective cohort study investigates two groups of 200 patients having undergone ACDF, one using rhBMP-2 and the other using ICBG, to evaluate the incidence of complications in the early postoperative period. A significant reduction in average length of stay was found in the rhBMP-2 cohort (1.40days) compared to the ICBG cohort (1.85days) as well as a significantly increased rate of dysphagia (25.5% in rhBMP-2 vs. 15% in ICBG; p=0.01). An increased rate of dysphonia was observed among patients undergoing revision surgery (25.0%) compared to primary surgery (1.6%), but stratification by number of levels, gender, and smoking status yielded no differences in complication rates. Our evaluation of two large cohorts along with review of the literature on the topic sheds light on potential benefits and risks of rhBMP-2 in ACDF procedures. Further investigation is warranted to determine if clinical gains outweigh the potential harms of rhBMP-2 use in this setting.