Is Immediate Postoperative Radiograph Necessary Following Robotic-Assisted Total Knee Arthroplasty?

The necessity of immediate postoperative radiographs following total knee arthroplasty (TKA) has long been debated. With the increasing use of robotic-assisted TKA (RTKA), and thus more precise implant placement, the need for immediate postoperative radiographs to determine implant positioning may be unnecessary. We sought to evaluate implant position on the immediate postoperative radiographs following RTKA to determine their necessity. A retrospective review of 150 RTKAs was performed. The posterior slopes for all TKAs were recorded based on the preoperative three-dimensional template. Additionally, two independent trained researchers (J.G./L.B.) each measured the posterior slope of the postoperative day 0 (POD0) radiograph and postoperative week 2 radiograph. The difference in posterior slope measurement between template and POD0, between template and postoperative week 2, and between POD0 and postoperative week 2 was calculated. Of the 150 TKAs performed, there were no periprosthetic fractures found on the POD0 radiograph. The mean difference between the templated posterior slope and measured posterior slope on POD0 was 0.04 degrees (standard deviation [SD], 1.01; p = 0.615). There was a weak correlation between the two values (rs [95% confidence interval (CI)], 0.38 [0.21, 0.53]). When comparing the template to the postoperative week 2 radiographs, there was a mean difference of 0.02 degrees (SD, 0.48; p = 0.556).  However, a moderate to strong correlation was noted (rs [95% CI], 0.71 [0.61, 0.79]). Comparison of the mean posterior slope from POD0 radiograph to that of postoperative week 2 radiograph showed a mean difference of 0.06 degrees (SD, 1.0; p = 0.427). A weak correlation was found between these two values (rs [95% CI], 0.43 [0.26, 0.56]). Given the accuracy and precision of RTKA, along with the ability to decrease cost and radiation, immediate postoperative radiograph may be unnecessary, when pertaining to the uncomplicated RTKA. However, if there is concern for intraoperative fracture, long stems placed in a revision arthroplasty, or other intraoperative complications, then postoperative radiographs are encouraged.

Publication Rates of Abstracts Presented at American Orthopaedic Society for Sports Medicine Annual Meetings From 2016 to 2019.

Background: Research in the form of poster and podium abstracts is disseminated at subspecialty society meetings. The quality of this research can be defined by exploring the ultimate publication rate of the presented abstracts. Purpose: To investigate (1) the manuscript publication rate of abstracts presented at the American Orthopaedic Society for Sports Medicine (AOSSM) annual meeting; (2) whether abstract format (poster vs podium) influences overall or 2-year publication rates and time to publication; (3) the abstract factors that are associated with increased publication rate; and (4) whether publication quality as measured by journal of publication, level of evidence (LOE), and number of citations differs between posters and podiums. Study Design: Cross-sectional study. Methods: Poster and podium abstracts that were presented at the AOSSM annual meetings between January 1, 2016, and December 31, 2019, were included. The PubMed and GoogleScholar databases were searched by abstract title and authors to determine whether the related manuscript had been published. For published manuscripts, the journal, journal impact factor (IF), time to publication, authors, and LOE were recorded. Results: The manuscripts of 664 abstracts (341 poster, 323 podium presentations) were published during the study period. The overall publication rate was 52.4%. Publication within 2 years of the meeting was found to be higher in podium abstracts (45.8%) compared with poster abstracts (37.8%) (P = .0366). Podium abstracts had a shorter time to publication (P < .001), higher LOE (P = .0166), more citations (P < .0001), and were published in higher IF journals (P = .0028). Poster presentations were more likely to undergo a change in first author between the time of the conference and future publication (P = .0300). The most common journal of publication was the American Journal of Sports Medicine (36.8%). Conclusion: Abstracts presented at the AOSSM annual meeting had a high rate of publication within 2 years. There was no difference in publication rates between podium and poster abstracts, but podium abstracts had a shorter time to publication and more future citations and were published in journals with higher IFs.

A review of chronic pectoralis major tears: what options are available?

Rupture of the pectoralis major muscle typically occurs in the young, active male. Acute management of these injuries is recommended; however, what if the patient presents with a chronic tear of the pectoralis major? Physical exams and magnetic resonance imaging can help identify the injury and guide the physician with a plan for management. Nonoperative management is feasible, but is recommended for elderly, low-demand patients whose functional goals are minimal. Repair of chronic tears should be reserved for younger, healthier patients with high functional demands. Although operative management provides better functional outcomes, operative treatment of chronic pectoralis tears can be challenging. Tendon retraction, poor tendinous substance and quality of tissue, muscle atrophy, scar formation, and altered anatomy make direct repairs complicated, often necessitating auto- or allograft use. We review the various graft options and fixation methods that can be used when treating patients with chronic pectoralis major tears.

Residency Match Rates in Orthopaedic Surgery Based on Sex, Under-Represented in Medicine Status, and Degree Type.

Orthopaedic surgery is well recognized as one of the most competitive and least diverse medical specialties. Despite efforts toward improving diversity, studies have shown that gender and racial/ethnic disparities continue to persist in orthopaedic graduate medical education. Therefore, we sought to identify the match rates of traditionally under-represented groups within orthopaedic surgery-female candidates, racial and ethnic minorities under-represented in medicine (URiM), and osteopathic physicians-compared with their application rates. Methods: A retrospective review of the Electronic Residency Application Service (ERAS) application data from the 2017 to 2021 application cycles was performed, and the total number of applicants, sex, race/ethnicity, and degree type of all students applying for orthopaedic surgery were recorded. A separate database, the Orthopaedic Residency Information Network (ORIN), which is a database self-reported by residency programs to provide information to applicants, was also queried to identify the total number of residents, sex, race/ethnicity, and degree type of all current residents in June 2022, corresponding to those residents who matched in 2017 to 2021. Results: From the ERAS application data, a total of 7,903 applicants applied to orthopaedic surgery during the study period. A total of 1,448 applicants (18%) were female, 1,307 (18%) were URiM, and 1,022 (15%) were from an osteopathic medical school. Based on the ORIN database, 688 of 3,574 residents (19%) were female, 1,131 of 7,374 (19%) were URiM, and 1,022 of US medical school graduates (12%) had a DO degree. The application and match rates were not significantly different for female (p = 0.249) and URiM (0.187) applicants; however, there was a significant difference in the application and match rates (15% vs 12%; p = 0.035) for US medical graduates with a DO degree. Conclusion: In recent years, there has been a significant and necessary push to increase diversity in the field of orthopaedic surgery. From 2017 to 2021, match rates of female and URiM candidates are reflective of their application rates. Osteopathic applicants in orthopaedic surgery have a lower match rate than their allopathic counterparts. Level of Evidence: III.

Risk factors for unexpected admission following arthroscopic and open treatment of shoulder instability: a national database study of 11,230 cases.

BACKGROUND: Shoulder instability procedures have low morbidity; however, complications can arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission and reoperation following arthroscopic and open treatment for shoulder instability. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to find patients who underwent shoulder instability surgery from 2015 to 2019. Independent sample Student t-tests, chi-square, and (where appropriate) Fisher's exact tests were used in univariate analyses to identify demographic, lifestyle, and perioperative variables related to 30-day readmission and reoperation following repair for shoulder instability. Multivariate logistic regression modeling was subsequently performed. RESULTS: Of the 11,230 cases included in our sample, only 0.54% were readmitted, and 0.23% underwent reoperation within the 30-day postoperative period. Multivariate logistic regression modeling confirmed that the following patient variables were associated with statistically significantly increased odds of readmission and reoperation: open repair, congestive heart failure (CHF), and hospital length of stay. CONCLUSIONS: Unplanned 30-day readmission and reoperation after shoulder instability surgery is infrequent. Patients with American Society of Anesthesiologists class II, CHF, longer than average hospital length of stay, or an open procedure have higher odds of readmission than patients without those factors. Patients who have CHF, longer than average hospital length of stay, and open surgery have higher odds of reoperation than others. Arthroscopic procedures should be used to manage shoulder instability, if possible.

Cross-Sectional Analysis of Foot and Ankle Questions on the Orthopaedic In-Training Examination: A Guide for Resident Preparation.

Background: The Orthopaedic In-Training Examination (OITE) is a standardized examination administered annually to orthopaedic surgery residents. The examination is designed to evaluate resident knowledge and academic performance of residency programs. Methods: All OITE foot and ankle questions from 2009 through 2012 and 2017 through 2020 were analyzed. Subtopics, taxonomy, references, and use of imaging modalities were recorded. Results: There were a total of 167 foot and ankle (F&A)-related questions across 8 years of OITE examinations. Trauma remained the most commonly tested subtopic of F&A across both subsets, followed by rehabilitation, tendon disorders, and arthritis. We found an increase in questions related to arthritis (P = .05) and a decrease of questions related to the diabetic foot (P = .02). Taxonomy 3 questions constituted 49.5% of F&A questions from 2009 through 2012 compared with 44.7% of questions from 2017 to 2020 (P = .54). Radiography was the most commonly used imaging modality in both subsets. From 2009 to 2012, 63.6% of questions included a radiograph compared with 76.5% in 2017 through 2020 (P = .13). FAI (Foot & Ankle International), JAAOS (Journal of the American Academy of Orthopaedic Surgeons), and JBJS (The Journal of Bone and Joint Surgery) were the most commonly cited journals, making up more than 50% of total citations. Citations per question increased from 2.20 to 2.42 from 2009-2012 to 2017-2020 (P = .01). The average lag time in the early subset was 8.2 years and 8.9 years in the later subset. Conclusion: This study provides a detailed analysis of the F&A section of the OITE. Use of this analysis can provide residents with a guide on how to better prepare for the OITE examination. Level of Evidence: Level IV, cross-sectional review of Orthopaedic In-Training Examination questions.

Excessively long interfragmentary screws for posterior wall acetabular fractures can predict intra-articular penetration.

BACKGROUND: The fixation of posterior wall acetabular fractures often utilizes interfragmentary screws with varying length. Intricate pelvic anatomy and overhanging greater trochanter make obtaining proper screw trajectory difficult. A large measurement may represent aberrant trajectory and breach of the articular surface. This study aims to identify a preferred maximum screw length that avoids intra-articular penetration. HYPOTHESIS: We hypothesized that a screw measured 40 millimeters or longer has a high likelihood of being intra-articular. PATIENTS AND METHODS: A retrospective review included CT scans of 151 consecutive patients collected at a level-1 trauma center was analyzed by two observers. On axial imaging, a straight line was measured at the largest extraarticular portion of the posterior wall simulating ideal screw placement. Another line was measured tangent to the articular surface simulating longest possible extraarticular screw. Measurements were taken at 2-millimeter increments. RESULTS: The intra-class correlation coefficient between both observers was excellent (0.75-1.00) for most recorded values. The maximum mean length for straight line measured (m=32.18mm, SD=3.74) which was smaller than the mean length for tangent line (m=38.44, SD=4.29). Exploratory multivariate logistic regression analyses demonstrated increased height, age, and acetabular version were associated with larger measurements greater than 40mm (p<0.05). DISCUSSION: This study demonstrates that most acetabular posterior walls cannot accommodate a 40 millimeter lag screw. If the measured drill hole is greater than this length, then careful reconsideration of the screw trajectory is warranted to ensure the screw is not intra-articular. Older and taller patients may be able to accommodate longer screws. LEVEL OF EVIDENCE: III.

9-Phenanthrol modulates postinhibitory rebound and afterhyperpolarizing potentials in an excitatory motor neuron of the medicinal leech.

Postinhibitory rebound (PIR) responses in leech dorsal excitatory motor neurons (cell DE-3) are eliminated by Ca2+ channel blockers but also exhibit a strong dependence on extracellular Na+. These features could be explained by a voltage-gated Ca2+ current acting in concert with a Ca2+-activated nonspecific current (ICAN). In vertebrates, ICAN is associated with TRPM4 channels which are blocked selectively by 9-phenanthrol. Here, we show that 9-phenanthrol selectively inhibits a late phase of PIR and simultaneously enhances afterhyperpolarizing potentials (AHPs). Bath application of NNC 55-0396 or Cd2+ combined with ion substitution experiments indicate that a low-voltage-activated Ca2+ current plays a key role in generating PIR and that Ca2+ influx through low- or high-voltage-activated Ca2+ channels can trigger AHPs via activation of a Ca2+-dependent K+ current. We also demonstrate modulation of rebound responses by other ICAN blockers such as gadolinium and flufenamic acid, as well as the calmodulin antagonist W-7. We discuss how these results provide additional insights into the specific types of ionic currents underlying rebound responses of motor neuron DE-3 in the medicinal leech.