Virtual Reality and Augmented Reality-Translating Surgical Training into Surgical Technique.

PURPOSE OF REVIEW: As immersive learning outside of the operating room is increasingly recognized as a valuable method of surgical training, virtual reality (VR) and augmented reality (AR) are increasingly utilized in orthopedic surgical training. This article reviews the evolving nature of these training tools and provides examples of their use and efficacy. The practical and ethical implications of incorporating this technology and its impact on both orthopedic surgeons and their patients are also discussed. RECENT FINDINGS: Head-mounted displays (HMDs) represent a possible adjunct to surgical accuracy and education. While the hardware is advanced, there is still much work to be done in developing software that allows for seamless, reliable, useful integration into clinical practice and training. Surgical training is changing: AR and VR will become mainstays of future training efforts. More evidence is needed to determine which training technology translates to improved clinical performance. Volatility within the HMD industry will likely delay advances in surgical training.

Physiologic widening of the medial clear space: What's normal?

BACKGROUND: Literature has validated the use of stress radiographs for evaluation of ankle stability. However, to our knowledge no study has reported the amount of physiological widening that occurs with manual external rotation stress test in uninjured ankles. The purpose of this study was to assess the amount of medial clear space widening that occurs with a manual external rotation stress test in uninjured ankles. METHODS: A cohort of adult patients undergoing operative fixation of unstable ankle fractures were prospectively enrolled to have their contralateral ankle undergo manual external rotation stress examination. Fluoroscopic images of the unaffected ankle were performed in the OR. A non-stressed mortise view and manual external rotation stress view were obtained with a standardized marker to correct for magnification differences. The images were de-identified, presented in a randomized order and reviewers who were blinded. Each reviewer measured the medial clear space. RESULTS: Thirty fluoroscopic images on fifteen patients were obtained. The mean medial clear space on the non-stressed mortise view was 3.1 mm (SD-0.69; Range 1.9 to 4.2, 95% CI [2.75, 3.45]) versus a mean of 3.2 mm (SD-0.71; Range 2.0 to 4.7, 95% CI [2.94, 3.66]) in the stressed mortise view group. Inter-rater reliability was excellent between all observers for medial clear space (ICC-0.88; CI [0.78, 0.94]). CONCLUSIONS: Our results support the previous literature and allow us to advocate for ankle fractures with >5 mm medial clear space after external rotational stress to be considered unstable. Additionally, ankles with a medial clear space between 4 and 5 mm, instability should be considered only if lateral shift is > 2 mm on stress examination. Our data shows that no physiologically healthy ankles widened beyond these established cut-offs before or after the manual external rotation stress.

Plantar Medial Avulsion Fragment Associated With Tongue-Type Calcaneus Fractures.

BACKGROUND: The plantar fascia attaches to the tuberosity of the calcaneus, which produces a distinct plantar medial avulsion (PMA) fracture fragment in certain calcaneal fractures. We hypothesized that tongue-type fractures, as described by the Essex-Lopresti classification, were more likely to be associated with this PMA fracture than joint depression fractures. METHODS: A retrospective chart review was performed at 2 distinct Level I trauma centers to identify patients sustaining calcaneal fractures. Radiographs were then reviewed to determine the Essex-Lopresti classification, OTA classification, and presence of a PMA fracture. RESULTS: The review yielded 271 total patients with 121 (44.6%) tongue-type (TT), 110 (40.6%) joint depression (JD), and 40 (14.8%) fractures not classifiable by the Essex-Lopresti classification. In the TT group, 73.6% of the patients had the PMA fracture whereas only 8.2% of JD and 15.0% of nonclassifiable fractures demonstrated a PMA fragment ( P < .001). CONCLUSION: Plantar medial avulsion fractures occurred in 38.4% of the calcaneal fractures reviewed with a significantly greater proportion occurring in TT (73.6%) as opposed to JD (8.2%). Given the plantar fascia attachment to the PMA fragment, there may be clinical significance to identifying this fracture and changing treatment management; however, this requires further investigation. LEVEL OF EVIDENCE: Level III, comparative study.

Dealing with the loss of a resident: An analysis of burnout rates in a reduced complement training program.

BACKGROUND: Residents in all fields of medicine experience high levels of burnout and less job-related satisfaction due to the stress experienced during training. Reduced complement residency classes often experience increased workloads due to the need to compensate for the fewer number of classmates. OBJECTIVE: The goal of this study was to examine whether residency classes of reduced size experience higher levels of burnout. METHODS: The Maslach Burnout Inventory Survey was distributed to all orthopaedic residents at our institution for four consecutive years. Emotional exhaustion≥27 and depersonalization≥10 correlate with high levels of burnout. At our institution, two residents were lost during their second year of training. Group 1 (n = 56) consisted of residents with reduced-size classes, while group 2 (n = 60) consisted of residents with full complement classes. RESULTS: Mean emotional exhaustion (29 vs. 30) and depersonalization (17 vs. 17) scores were comparable between reduced and full complement classes. The Maslach data from our study showed no statistical difference in burnout levels between classes of full complement and reduced complement. CONCLUSIONS: When compared to a previous study on burnout conducted in large orthopaedic residency programs, our entire residency program did demonstrate similar levels of emotional exhaustion and depersonalization.

Concomitant Proximal and Distal Tibiofibular Joint Dislocation Associated With a Tibial Shaft Fracture.

An association exists between tibial shaft fractures and ankle injuries. In addition, although uncommon, an association between tibial shaft fractures and proximal tibiofibular dislocations has also been established. A review of the previous literature resulted in one case report of a complete proximal and distal tibiofibular joint dislocation without fracture of the tibia or fibula. Here, we discuss a case of a complete proximal and distal tibiofibular syndesmotic complex dislocation associated with a tibial shaft fracture. To the best of our knowledge, this is the first report of this injury pattern associated with a tibial shaft fracture.

Safe Zone Quantification of the Third Sacral Segment in Normal and Dysmorphic Sacra.

OBJECTIVE: To quantify the osseous anatomy of the dysmorphic third sacral segment and assess its ability to accommodate internal fixation. DESIGN: Retrospective chart review of a trauma database. SETTING: University Level 1 Trauma Center. PATIENTS: Fifty-nine patients over the age of 18 with computed tomography scans of the pelvis separated into 2 groups: a group with normal pelvic anatomy and a group with sacral dysmorphism. MAIN OUTCOME MEASUREMENTS: The sacral osseous area was measured on computed tomography scans in the axial, coronal, and sagittal planes in normal and dysmorphic pelves. These measurements were used to determine the possibility of accommodating a transiliac transsacral screw in the third sacral segment. RESULTS: In the normal group, the S3 coronal transverse width averaged 7.71 mm and the S3 axial transverse width averaged 7.12 mm. The mean S3 cross-sectional area of the normal group was 55.8 mm. The dysmorphic group was found to have a mean S3 coronal transverse width of 9.49 mm, an average S3 axial transverse width of 9.14 mm, and an S3 cross-sectional area of 77.9 mm. CONCLUSIONS: The third sacral segment of dysmorphic sacra has a larger osseous pathway available to safely accommodate a transiliac transsacral screw when compared with normal sacra. The S3 segment of dysmorphic sacra can serve as an additional site for screw placement when treating unstable posterior pelvic ring fractures.

The Correlation Between the OTA/AO Classification System and Compartment Syndrome in Both Bone Forearm Fractures.

OBJECTIVE: To evaluate the efficacy of using the Orthopaedic Trauma Association (OTA/AO) classification for both bone forearm fractures in predicting compartment syndrome. DESIGN: Retrospective cohort. SETTING: Level 1 Academic Trauma Center. PATIENTS/PARTICIPANTS: One hundred fifty-one patients 18 years of age and older, with both bone forearm fractures diagnosed from 2001 to 2016 were categorized based on the OTA/AO classification. Patients with both bone fractures caused by gunshot wounds were excluded. MAIN OUTCOME MEASUREMENTS: The endpoint for our study was whether forearm fasciotomies were performed based on the presence of compartment syndrome. RESULTS: Of a total of 151 both bone forearm fractures, 15% underwent fasciotomy. Six of 80 (7.5%) grouped 22-A3, 8 of 44 (18%) grouped 22-B3, and 9 of 27 (33%) grouped 22-C underwent fasciotomies for compartment syndrome (P = 0.004). The relative risks of developing compartment syndrome for group 22-B3 versus 22-A3 was 2.42 (P = 0.08), 22-C versus 22-B3 was 1.83 (P = 0.15), and 22-C versus 22-A3 was 4.44 (P = 0.002). CONCLUSIONS: There is a significant correlation between the OTA/AO classification and the need for fasciotomies, with group C fractures representing the highest risk. Clinicians can use this information to have a higher index of suspicion for compartment syndrome based on OTA/AO classification to help minimize the risk of a missed diagnosis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The role of computed tomography scans in diaphyseal femur fractures following gunshot injuries: A survey of orthopaedic traumatologists.

The objective of this study was to analyze if the addition of CT changed the management of femoral shaft fractures caused by gunshot wounds when compared to those managed with plain radiography alone. METHODS: A multiple-choice, single-answer electronic survey was created to compare utility of advanced imaging when treating femur fractures resulting from gunshot injury. A total of ten femoral shaft fracture cause by gunshot injuries were selected for an online survey to be administered to orthopeaedic traumatologists. The survey compared the use the of fixation device and surgical planning before and after the CT scan. RESULTS: A total of 99 surveys were initiated, of which 82 were completed. For proximal shaft fractures, 37% of experts reported that a CT scan should be ordered based on the radiograph alone, prior to reviewing the CT. After reviewing the CT, 5% of experts reported that they would have performed a "major" change, and 10% reported that they would have performed a "minor" change. 4% of surveyors would have changed their decision regarding ordering a CT. For distal femoral shaft fractures, 42% of experts selected that a CT scan would have been ordered prior to reviewing the CT. After reviewing the CT, 2% would have performed a "major" change, and 8% would have performed a "minor" change in management. 5% of surveyors would have changed their decision regarding ordering a CT. CONCLUSION: Our study demonstrated that CT scans are relatively unlikely to cause major changes in fracture management of gunshot-induced fractures of femoral shaft.

The Antibiotic Nail in the Treatment of Long Bone Infection: Technique and Results.

Antibiotic cement nails provide a useful and relatively simple technique to treat intramedullary osteomyelitis of the long bones. These devices provide stability as well as local, targeted antibiotics, which are both critical aspects of osteomyelitis management. Additionally, the use of a threaded core is a critical component of successful cement nail assembly. With adherence to the simple principles outlined in this review, surgeons can expect reliably good results using these drug-delivery implants.

Evaluation of Intra-articular Fracture Extension After Gunshot Wounds to the Lower Extremity: Plain Radiographs Versus Computer Tomography.

OBJECTIVE: This study was to compare the use of computer tomography with plain radiographs for the evaluation of intra-articular extension of long bone fractures in the lower extremity after low-energy gunshot wounds. DESIGN: Retrospective chart and radiographic review. SETTING: Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Data were collected from a single institution from 2000 to 2014. Inclusion criteria consisted of patients greater than 17 years of age, low-velocity gunshot injuries causing fracture of the femur or tibia, plain radiographs with adequate films, and computed tomography (CT) imaging of the fracture. This consisted of 133 patients with 140 fractures. INTERVENTION: Intra-articular fracture extension was evaluated on initial plain radiographs and CTs. MAIN OUTCOME MEASURES: Comparison of "gold standard" CT with all reviewers' evaluation of plain radiographs. RESULTS: There were 140 total fractures; 108 were femoral fractures and 32 were tibial fractures. By comparing plain radiographs with the gold standard CT, the reviewers demonstrated correct diagnosis in 85% of intra-articular fractures and 96% of non-intra-articular fractures. In addition, the reviewers accurately diagnosed 70.8% of intra-articular extensions in the diaphysis and 70.5% in the metaphysis. The sensitivity and specificity for plain radiographs were 85.3% and 96.0%, respectively, for all locations. Metaphyseal and diaphyseal fractures demonstrated the poorest sensitivity at 80.7% and 82.1%, respectively. CONCLUSIONS: Low-energy gunshot wounds with fractures in the diaphyseal of the distal femur and all metaphyseal fractures warrant CT evaluation to better examine for intra-articular fracture extension. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Role of Computed Tomography in Surgical Planning for Trimalleolar Fracture. A Survey of OTA Members.

OBJECTIVE: Does the additional information provided by computed tomography (CT) alter surgeons' treatment plans for trimalleolar ankle fracture? DESIGN: Prospective. SETTING: Electronic survey. PATIENTS/PARTICIPANTS: Members of the OTA. INTERVENTION: Compare management of trimalleolar ankle fracture before and after CT. MAIN OUTCOME MEASUREMENTS: Compare types of fixation used, indication for fixation, and approach need for fixation before and after CT. RESULTS: Overall, OTA members' operative technique changed in 430 of the 1710 (25.1%) cases after review of the CT images. Of the 430 observations in which the operative technique was altered, the surgeon had initially stated that they would not have requested a CT in 51.2% incidences. When analyzing if CT affected whether or not operative fixation was indicated, a total of 16.3% responses changed. Surgeons were significantly more likely to change from no fixation to fixation (11.5%) than vice versa (4.8%) after reviewing CT imaging. A total of 17.8% of responses changed operative approach after reviewing the CT; 11.7% changed to open reduction internal fixation, whereas 6.1% changed away from open reduction internal fixation. CONCLUSION: A consensus on the ideal treatment of trimalleolar fractures remains elusive, evidenced by a high variation in treatment preference, both before and after CT review. Our results demonstrate with the additional information delineated on CT, a surgeons' operative plan, technique, and approach often change. With greater than 25% of respondents changing their treatment strategy after seeing CT imaging, radiographs alone limited surgeon understanding of fracture pattern. Because of difficulty understanding the posterior fracture fragment, we recommend preoperative CT on all trimalleolar fractures. LEVEL OF EVIDENCE: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Multiple Giant Cell Tumors of Tendon Sheath Found within a Single Digit of a 9-Year-Old.

Giant cell tumor of tendon sheath is one of the most common soft tissue tumors of the hand. These tumors typically occur in the third or fourth decade of life and present as solitary nodules on a single digit. Currently, the greatest reported number of lesions found within a single digit is five. Although uncommon, giant cell tumor of tendon sheath does occur in the pediatric population. Herein we present a report of a rare case of GCTTS in a child in which seven lesions were identified within a single digit-the greatest number of lesions within a single digit reported to date.

Strangulation of Radial Nerve Within Nondisplaced Fracture Component of Humeral Shaft Fracture.

Rates of radial nerve injury, which is commonly associated with humeral shaft fractures, range from 8% to 12%. This neurapraxia typically recovers with nonoperative management. In some conservatively treated cases, the radial nerve is lacerated or entrapped. Patients with a lacerated or entrapped nerve may have better outcomes with early operative management. We report on a rare case of the radial nerve entrapped within a nondisplaced segment of a closed humeral shaft fracture and describe the clinical outcome of early operative management.

Steinmann pin augmentation versus locking plate constructs.

BACKGROUND: Aggressive bone neoplasms, such as giant cell tumors, often affect the proximal tibia warranting bony resection via curettage leaving behind massive defects that require extensive reconstruction. Reconstruction is usually accomplished with poly(methyl methacrylate) (PMMA) packing supplemented with an internal fixation construct. The purpose of this study is to compare Steinmann pin augmentation to locking plate constructs to determine which offers the stiffer reconstruction option. MATERIALS AND METHODS: Large defects were created below the lateral condyle of fresh frozen tibias. The defects extended for an average of 35 mm beneath the lateral plateau in the frontal plane, and from the anterior to posterior cortex in the sagittal plane. Distally the defect extended for an average of 35 mm to the metadiaphyseal junction. In the Pin group, the tibias were reconstructed with three 4-mm diameter Steinmann pins placed in the medullary canal and PMMA packing. In the Plate group, the tibias were reconstructed with a 6-hole 3.5-mm LCP Proximal locking plate fixed to the proximal-lateral tibia utilizing seven 3.5-mm screws and PMMA packing. The tibias were tested for stiffness on a MTS machine by applying up to 400 N to the tibial plateau in force control at 5 N/s. Fatigue properties were tested by applying a haversine loading waveform between 200 N and 1,200 N at 3 Hz simulating walking upstairs/downstairs. RESULTS: Locking plate constructs (801.8 ± 78 N/mm) had greater (p = 0.041) stiffness than tibial constructs fixed with Steinmann pins (646.5 ± 206.3 N/mm). CONCLUSIONS: Permanent deformation was similar between the Pin and Plate group; however, two tibia from the Pin group exhibited displacements >5 mm which we considered failure. LEVEL OF EVIDENCE: n/a.

From amputation to limb salvage reconstruction: evolution and role of the endoprosthesis in musculoskeletal oncology.

In 1943, Austin Moore developed the first endoprosthesis fashioned from Vitallium, providing the first alternative to traditional amputation as primary treatment of bone tumors. The success of the Vitallium endoprosthesis has since then led to the development of new materials and designs further advancing limb salvage and reconstructive surgery. Combined with the advent of chemotherapy use and imaging advances, conservative treatment of musculoskeletal tumors has expanded greatly. As the implantable options increased with the development of the Lewis expandable adjustable prosthesis and the noninvasive Phenix Growing prosthesis, receiving the diagnosis of a bone tumor no longer equates to automatic limb loss. Our review details the history and development of endoprostheses throughout orthopedic oncology in the treatment of musculoskeletal tumors.

An innovative approach to concave-convex allograft junctions: a biomechanical study.

Allograft bone is often used in oncologic and trauma limb salvage procedures. In this study, we hypothesize that a concave-convex allograft junction with plate fixation would improve multiple aspects of the reconstruction process, allowing for a larger contact surface area between the allograft junction and increased uniformity in pressure distribution at the junction. Thirty large femoral artificial polyresin femurs were randomly separated into 2 groups: allograft junctions fixed with flat locking plates and allograft junctions fixed with prebent locking plates. Each group was then randomly subdivided into 3 sets: concave-convex allograft junctions, matched transverse-cut allograft junction, and non-matched transverse-cut allograft junctions. All but 1 reconstructions of concave-convex allograft junctions, compared with non-matched or matched transverse-cut allograft junctions fixed with flat or pre-bent locking plates showed statistically significantly greater mean contact surface area and greater mean percent contact surface area (P<.05). Concave-convex allograft junctions demonstrated increased mean contact surface area, mean percent contact surface area, and a more uniform pressure distribution. We believe our approach to allograft junctions using concave-convex reamers may improve multiple aspects of the reconstruction process, allowing for increased contact surface area between the allograft junction, increased uniformity in pressure distributions at the allograft junction, and decreased length of time taken for intraoperative preparation.

Epithelioid sarcoma: an unusual presentation in the distal phalanx of the toe.

Epithelioid sarcoma is rare soft tissue sarcoma first described by Enzinger in 1970. The classic variant often occurs in the deep or superficial soft tissue of the distal upper extremities of individuals between the ages of 10 and 35. Due to the tumor's benign clinical presentation, infrequent occurrence, and histological similarities with other disease processes, diagnosing epithelioid sarcoma in its early stages has become extremely difficult. We report a rare case of epithelioid sarcoma of the toe with bone metastasis, as well as the clinical, pathological, and radiological difficulties in correctly diagnosing epithelioid sarcoma.

Financial debt of orthopedic residents.

Many orthopedic residents accrue considerable debt by residency graduation. These debts for graduating medical students continue to increase due to the yearly increase of medical school tuition. The purpose of this study was to examine the causes of financial debt, as well the effects of debt on orthopedic residents.Orthopedic residents from postgraduate years 1 to 5 (N=27) completed an anonymous, optional financial survey. The survey asked questions regarding the characteristics of the residents' debt and their concern caused by their debt. All residents from our institute (N=27) voluntarily participated in the survey. The residents consisted of 4 (15%) women and 23 (85%) men, with 14 (56%) single residents and 12 (44%) married residents. No statistically significant difference existed in total debt >$100,000 between single and married residents or men and women. Forty-eight percent (n=13) of the residents had medical educational debt >$100,000, whereas 45% (n=12) had total debt >$200,000. Residents with total debt >$100,000 were concerned about their debt, whereas 1 of 4 residents with <$100,000 of total debt reported concern (P<.001).Debts affect orthopedic residents financially and may cause stress and hinder their medical training. Appropriate measures should be taken to help residents properly manage their debt and to provide supplemental assistance with their financial struggles.

Infected total femoral replacements: evaluation of limb loss risk factors.

A complication of total femoral replacement (TFR) is periprosthetic infection. Studies have shown that infected endoprostheses have a significant amputation rate, as high as 36.7%. This study examined possible risk factors that may attribute to unsalvageable TFRs following periprosthetic infections, including age, sex, primary vs secondary TFRs, number of irrigation and debridements, recent history of periprosthetic infection, early vs late infection, use of antibiotic cement, and the number of postoperative antibiotics. In a retrospective chart review, 10 patients who had periprosthetic infections of their TFRs were identified from our orthopedic surgical database between 2000 and 2010. Seven of 10 TFRs were unsalvageable due to infection. The 2 greatest risk factors that influenced unsalvageable TFR were age older than 50 years and recipients of secondary TFRs. All 6 patients older than 50 years had unsalvageable TFRs, whereas 1 of 4 patients younger than 50 years had an unsalvageable TFR (P<.05). Similarly, all 6 patients who received secondary TFRs had unsalvageable TFRs, whereas 1 of 4 patients who received a TFR as the primary method of treatment had an unsalvageable TFR (P<.05). No other risk factors showed statistical significance or could be identified as possible risk factors. Surgeons should educate patients who fall into high-risk categories about the benefits of early intervention, such as amputation, that could prevent additional surgeries and decrease the lengths of hospitalizations.