Association of an Early Interest in Orthopedic Surgery with Match Rate into Orthopedic Surgery.

OBJECTIVES: Orthopedic surgery residency is considered one of the most competitive specialties in which to match. Studies examining the factors associated with a successful match have neglected whether participation in an orthopedic interest group (OIG) improves the chances of orthopedic residency match. The goal of this study was to test the hypothesis that participation in the OIG would improve matching into an orthopedic surgery residency. METHODS: We performed a retrospective cohort study between May 2017 and 2019 at one state-funded medical school. All of the applicants in orthopedic surgery from 2004 to 2019 were identified and contacted for OIG membership status. The Office of Student Affairs provided academic performance data (US Medical Licensing Examination scores and third-year clinical clerkship grades), Alpha Omega Alpha and Gold Humanism Honor Society status, and demographics (race and sex) of applicants. RESULTS: Between 2004 and 2019, 67 students (56 OIG and 11 non-OIG) applied for orthopedic surgery residency match. The match rate for the OIG was 86% compared with 64% for the non-OIG group, resulting in an adjusted odds ratio (adjusted for academic performance) of 10.23 (95% confidence interval 1.14-92.3, P = 0.038). CONCLUSIONS: OIG membership was associated with a significantly higher rate of orthopedic surgery residency matches. The higher rate of match associated with OIG membership may be the result of opportunities to diversify a residency application. Future studies are needed to further evaluate the potential association between OIG involvement and orthopedic surgery match.

Morphologic analysis of the sublime tubercle: considerations in the approach to ulnar collateral ligament reconstruction.

Background: Given the increased incidence of ulnar collateral ligament (UCL) injuries and the projected increase in reconstruction procedures, a robust understanding of the morphologic location of the sublime tubercle is paramount to anatomic reconstruction. There is limited research evaluating the morphology of the sublime tubercle of the proximal ulna in an anterior-to-posterior plane. Methods: Twenty-five computed tomography (CT) scans of intact proximal elbow joints for patients were selected using a de-identified database. Cases with history of fracture or surgical intervention to the elbow joint were excluded. These CT scans were then imported into the Mimics Innovation Suite 24.0 software to analyze the sublime tubercle angle from the midpoint of the trochlear notch. All left elbow angle and clock-face values were converted to right elbow values for analysis. Results: The average sublime tubercle angle from the midpoint of the trochlear notch was 282.53 degrees. The angle was converted to a clock face descriptor which located the sublime tubercle at 9.42. Our findings demonstrate that, in the non-throwing population, the morphology of the sublime tubercle can be expected to have a consistent medial location between 9 and 10 o'clock or 2 and 3 o'clock on the contralateral elbow. Conclusions: In relation to the proximal ulnar landmarks, the sublime tubercle, in the non-throwing population, has a consistent relative location.

Viscoelastic and failure properties of two configurations of triple-folded hamstring tendons used for anterior cruciate ligament (ACL) reconstruction.

BACKGROUND: Hamstring autografts are commonly used for anterior cruciate ligament (ACL) reconstruction. Different folding techniques exist in tripling the semitendinosus. Few anatomical studies exist in evaluating their viscoelastic properties. The purpose of this study was to characterize and compare the viscoelastic and failure properties of two hamstring graft configurations, the "Z" construct and "2" construct. METHODS: Ten matched pairs of fresh-frozen cadaveric semitendinosus hamstring grafts were used to create the "2" configuration or "Z" configuration. The biomechanical testing consisted of four phases: preconditioning, where graft dimensions (mm) were measured; stress relaxation, where load, displacement and time data were collected and equilibrium relaxation (%) was calculated; dynamic creep, where the total construct elongation was calculated; and ramp-to-failure, where maximum failure load was recorded. RESULTS: The "2" configuration demonstrated recorded forces (N) significantly greater at each time point when compared to the "Z" configuration during stress relaxation (p = 0.003). The "2" configuration exhibited significantly less construct elongation (mm) during dynamic creep at 10 cycles (p = 0.008) and 2000 cycles (p = 0.0001). The maximum measured load at failure was significantly greater in the "2" configuration constructs than "Z" configuration (p = 0.013). Moreover, the axial loads at 2, 3 and 4 mm of displacement were, on average, greater in the "2" configuration than "Z" configuration (p = 0.152; p = 0.080; p = 0.012), respectively. CONCLUSION: The results of this study provide support for folding techniques for tripled grafts to provide higher viscoelastic and failure properties for techniques with less suture interfaces. Future studies can potentially evaluate the clinical significance of these findings.

The effect of residency training on arthroscopic knot tying and knot stability: which knot is best tied by Orthopaedic surgery residents?

BACKGROUND: The aim of this study is to evaluate which of three arthroscopic knots are most reliably taught to and executed by residents at varying levels of training. METHODS: Three arthroscopic knots, the Samsung Medical Center (SMC), the Weston, and the surgeon's knot, were taught to 16 orthopaedic surgery residents. Each knot was tied in triplicate at two sessions 1 week apart. The knots were then biomechanically tested for strength. Corresponding knots tied by a sports medicine fellow served as the respective controls. RESULTS: Comparing all knots regardless of year of training, the SMC knot failed at significantly higher loads (237.2 ± 66.6 N) than the surgeon's knot (203.7 ± 45.3 N, p = 0.049) and the Weston knot (193.5 ± 56.1 N, p = 0.013). No significant differences in knot strength were found when comparing knots tied by residents at different levels of training and when comparing residents to the sports medicine fellow. There was no difference in conditioning elongation between surgeon's (p = 0.343), Weston (p = 0.486), or SMC knots (p = 0.200) tied by post-graduate year one and five residents. CONCLUSIONS: We report the first study that evaluates the loop strength of an arthroscopically tied knot performed by orthopaedic surgery residents in various levels of training. In our cohort, the SMC knot required a higher load to failure, when compared to the Surgeon's and Weston knot, after a simple arthroscopic knot tying curriculum. Based on these findings, he SMC knot should be considered as a part of future orthopaedic surgery resident arthroscopic training programs.

Surface Electromyography of the Forearm Musculature During the Windmill Softball Pitch.

BACKGROUND: Previous studies investigating the windmill softball pitch have focused primarily on shoulder musculature and function, collecting limited data on elbow and forearm musculature. Little information is available in the literature regarding the forearm. This study documents forearm muscle electromyographic (EMG) activity that has not been previously published. PURPOSE: Elbow and upper extremity overuse injuries are on the rise in fast-pitch softball pitchers. This study attempts to describe forearm muscle activity in softball pitchers during the windmill softball pitch. Overuse injuries can be prevented if a better understanding of mechanics is defined. STUDY DESIGN: Descriptive laboratory study. METHODS: Surface EMG and high-speed videography was used to study forearm muscle activation patterns during the windmill softball pitch on 10 female collegiate-level pitchers. Maximum voluntary isometric contraction of each muscle was used as a normalizing value. Each subject was tested during a single laboratory session per pitcher. Data included peak muscle activation, average muscle activation, and time to peak activation for 6 pitch types: fastball, changeup, riseball, curveball, screwball, and dropball. RESULTS: During the first 4 phases, muscle activity (seen as signal strength on the EMG recordings) was limited and static in nature. The greatest activation occurred in phases 5 and 6, with increased signal strength, evidence of stretch-shortening cycle, and different muscle characteristics with each pitch style. These 2 phases of the windmill pitch are where the arm is placed in the 6 o'clock position and then at release of the ball. The flexor carpi ulnaris signal strength was significantly greater than the other forearm flexors. Timing of phases 1 through 5 was successively shorter for each pitch. There was a secondary pattern of activation in the flexor carpi ulnaris in phase 4 for all pitches except the fastball and riseball. CONCLUSION: During the 6 pitches, the greatest muscular activity was in phases 5 and 6. Flexor carpi ulnaris activity was greatest among the muscles tested. The riseball had the highest peak activity, but the curveball and dropball had the highest average signal strength. This muscle activity correlates with increasing distraction in the elbow, suggesting that flexor muscles act to counterdistract the elbow as they do for the baseball pitch. CLINICAL RELEVANCE: Windmill pitchers are unique among overhead athletes as they throw, on average, more pitches per overhead athlete. Understanding the mechanics and physiology of the elbow in windmill pitchers is crucial to prevention and treatment of these increasingly common elbow injuries. This study establishes baseline data that will be useful to further prevent windmill pitch elbow injury.

FLS skill acquisition: a comparison of blocked vs interleaved practice.

INTRODUCTION: Fundamentals of Laparoscopic Surgery (FLS) certification is required for general surgery. The recommended practice for learning FLS is to practice tasks one at a time until proficient (blocked practice). Learning theory suggests that interleaved practice, a method in which tasks are rotated rather than learned one at a time, may result in superior learning. METHOD: Residents were randomized into 1 of 2 groups: blocked practice or interleaved practice. We compared the performance of residents across groups over 20 trials of each of 4 FLS tasks (peg transfer, pattern cut, extracorporeal suture, and intracorporeal suture). Four weeks later, participants returned to the laboratory and completed 2 additional trials of each of the 4 tasks. RESULTS: Performance on each of the tasks improved with increased practice. The interleaved group showed significantly better performance on the peg transfer task; trends favoring the interleaved group resulted for the other tasks. Standardized mean differences in favor of the interleaved group were substantial both at the end of practice and at follow-up (with the exception of the pattern cut). CONCLUSION: Interleaved practice appears to have advantages over blocked practice in developing and retaining FLS skills. We encourage others to experiment with the method to confirm our findings.

Regeneration of a discoid meniscus after arthroscopic saucerization.

We report the case of a 5-year-old girl who presented to the clinic with recurrent knee pain after meniscal repair and saucerization at age 3. The finding of a regenerated discoid meniscus was confirmed arthroscopically and radiographically. To our knowledge, this is the first report in the literature to confirm regeneration of a discoid meniscus after saucerization. The case has significant implications for management of pediatric discoid meniscus tears and patient counseling, and is encouraging in terms of the potential for repair and regeneration of meniscal tissue, particularly in the very young pediatric population.

Objective preoperative measurement of anterior glenoid bone loss: a pilot study of a computer-based method using unilateral 3-dimensional computed tomography.

PURPOSE: The purpose of this study was to evaluate the reproducibility of unilateral computed tomography (CT) measurement of glenoid surface area, based on the typically circular geometry of the inferior glenoid. METHODS: This study used 3-dimensional shoulder CT scans before reconstruction for anterior instability. The en face CT views of the normal and abnormal glenoids were randomized and evaluated by 3 independent observers (2 experienced shoulder surgeons and 1 medical student). ImageJ (National Institutes of Health, Bethesda, MD) was used to overlay a perfect circle that was fit to the glenoid. The anterior aspect of the circle was then adjusted to match the true anatomic contour of the anterior glenoid. This adjusted region was used to determine the percentage of the perfect circle occupied by the glenoid, which we defined as the anatomic glenoid index (AGI). RESULTS: For the 23 normal shoulders, the AGI reflected a nearly perfect fit of the circle, with very high consistency and reliability among the 3 observers. Overall, mean AGI for the normal shoulders was 100.5%, with an SD of 2.2%. For the 12 shoulders that underwent Bankart repair, the overall AGI was 92.1% ± 5.2%, and 9 of 12 patients had an AGI below the threshold of 96.1%. For the 11 shoulders that underwent Latarjet reconstruction, the overall AGI was 89.6% ± 4.7%. CONCLUSIONS: This study confirms that the normal inferior glenoid surface is a nearly perfect circle with remarkably low variability. This observation allows for determination of a tight reference range that can be applied to clinical analysis of unilateral CT reconstructions of symptomatic shoulders. This pilot study evaluates a simple and reliable method for determination of the AGI, creating an anatomic preoperative description of bone loss. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Diagnosis of an ulnar collateral ligament tear using musculoskeletal ultrasound in a collegiate baseball pitcher: a case report.

OBJECTIVE: To demonstrate a comparative diagnostic approach between magnetic resonance imaging (MRI) and musculoskeletal ultrasound for detecting UCL trauma of the elbow in a collegiate baseball pitcher. BACKGROUND: A 19 year-old male baseball pitcher with no previous history of an elbow injury presented with left medial elbow pain after experiencing a popping sensation during a bull pen throwing session. Patient initially demonstrated palpable tenderness directly over the UCL and a positive milking maneuver. Minimal swelling and no observable discoloration were noted upon examination. Diagnostic ultrasound was utilized to assess the elbow anatomical structures. The differential diagnosis included medial epicondylitis, flexor pronator muscle strain, ulnar collateral ligament tear TREATMENT: Initial treatment was conservative while preparing for a ligament reconstruction. Goals included pain control, restoration of range of motion, and reduction of inflammation. UNIQUENESS: Accurate diagnosis of UCL disruption was made using dynamic diagnostic musculoskeletal ultrasound despite a negative MRI. The ability to accurately identify the injury contributed to the timeliness of the appropriate surgical intervention and the facilitation of a timely and successful rehabilitation program. CONCLUSIONS: Dynamic musculoskeletal ultrasound may offer an effective option for diagnosing UCL tears of the elbow. Diagnostic musculoskeletal ultrasound is an affordable, accessible, and portable option that provides a clinician with real-time information and accurate observations in the hands of a skilled operator. Diagnostic musculoskeletal ultrasound may play an increased role as a diagnostic tool in the sports medicine community.

Diagnostic ultrasound in sports medicine: current concepts and advances.

Diagnostic ultrasound is a valuable imaging tool that is slowly gaining in popularity among sports medicine clinicians. Commonly referred to as "musculoskeletal ultrasound," its valuable role in assisting with sports medicine diagnoses has been to date underused for a variety of reasons. Effective clinical usage for sports medicine diagnoses includes commonly seen conditions such as rotator cuff disease, ulnar collateral ligament of the elbow injury, and internal derangement of the knee, among many others. Limitation of clinical usage has been deterred by the cost of the unit, perception of time associated with assessment procedures, and the lack of formal training associated with diagnostic implementation. However, when properly used, musculoskeletal ultrasound can increase the accuracy of diagnosis and treatment, improve time to treatment intervention, and improve patient satisfaction. The purpose of this paper is to review the fundamentals of musculoskeletal ultrasound and present its specific diagnostic uses.

Negotiating contractual relationships.

Team coverage can be the most rewarding and the most challenging aspect of a physician's career; however, evaluate the realistic risks and benefits of covering a team. Understand what the team is looking for. Prior physicians may have been dismissed for a specific action, may have left on their own, or may have been asked to pay for the privilege of serving. Tell the team what you have to offer and what you need to make the relationship work, and be prepared to walk away from the deal if the risks are too high. Understanding the implications of working without a contract and the elements of an appropriate contract is paramount to a successful relationship.