Does a Career in Orthopaedic Surgery Affect a Woman's Fertility?

BACKGROUND: Orthopaedic surgery lags behind other specialties in the recruitment of women. Concerns about fertility, pregnancy, and childbearing may be a deterrent to women when considering orthopaedic surgery as a specialty. METHODS: An anonymous 168-item survey was distributed to the members of Ruth Jackson Orthopedic Society and the Women in Orthopaedics, an online group exclusive to female orthopaedic surgeons. Respondents were queried regarding family planning, contraceptive length of use, fertility, perinatal work habits, age and stage at each pregnancy, pregnancy complications, and miscarriages. RESULTS: Eight hundred one surveys were collected. Seven hundred fifty (94%) expressed interest in having children of their own, with 60% having at least one child at the time of the survey. The average maternal age at birth of the first child was 33.6 ± 3.6 years. Voluntary childlessness was reported by 6% (49/801) of survey respondents. Eighteen percent of this group stated that their choice as an orthopaedic surgeon served as a barrier to having children. Among those with children, childbearing was intentionally delayed by 53% because of their career choice (425/801). Fifty-two percent did not conceive their first child until the end of their training. Complications during pregnancy were reported among 24%. A total of 853 children were conceived by this cohort with assisted reproductive technology being used 106 times. Miscarriages were reported by 38% (304/801). Of those who miscarried, only 28% informed their employer and 8% took time off during or immediately after their miscarriage. CONCLUSION: Most respondents desire to have children but two-thirds delay doing so because of their career choice and its demands. Having a family is an important part of life for many orthopaedic surgeons, and our study provides an updated description of the fertility and pregnancy characteristics of female orthopaedic surgeons to help guide present and future surgeons in their family planning.

Pedicle Screw Safety: How Much Anterior Breach Is Safe?: A Cadaveric and CT-Based Study.

MINI: The objective of this study was to determine the safety limits of anterior/anterolateral pedicle screw breaches. Through clinical and cadaveric study, it appears that less than 4 mm of breach has a significantly lower likelihood of impingement on vital structures (P < 0.001). STUDY DESIGN: Clinical retrospective chart review and basic science study. OBJECTIVES: To determine the safety limits of an anterior/anterorolateral misplaced pedicle screw on computed tomography (CT) scan in spinal deformity. SUMMARY OF BACKGROUND DATA: Although the limits of medial breaches (<4 mm) are known, the safe limits for anterior/anterolateral breaches in spine deformity are not yet defined. METHODS: The present study had two parts. In part I, postoperative CT scans of 165 patients operated on for spine deformity were reviewed for screw misplacement (2800 screws). The amount of anterior/anterolateral breach was measured. Protrusions were also evaluated for proximity to vital structures. All scans were reviewed by musculoskeletal radiologist. In part II, eight cadavers were instrumented with 6 × 30 and 6 × 40 mm bilaterally from T1-S1. Screws were randomly inserted under navigation guidance either "IN" or "OUT-anterior/lateral." CT scan was performed, followed by gross dissection to determine screw position. RESULTS: Part I: 116(4.2%) screws were misplaced anterior/anterolaterally. Thirty-one (26.7%) were adjacent to vital structures. Fisher exact test showed 4 mm or less breach has significantly lower likelihood of impingement (P < 0.001). Screws adjacent/impinging the aorta protruded an average 5.7 ±â€Š0.6 mm, whereas screws not involving the aorta breached an average 3.9 ±â€Š0.2 mm, (P < 0.001). Part II: 285 screws were inserted. On CT scan, 125 were misplaced anterior/anterolaterally. On gross dissection, 89 were visibly misplaced; 23 were covered entirely by soft tissue but were palpable; and 13 were contained in bone. All 23 screws did not endanger any structures and protruded less than 4 mm on CT scan. CONCLUSION: Anterior/anterolateral breaches of 4 mm or less on CT poses no significant risk of impingement and therefore can be considered safe. LEVEL OF EVIDENCE: 3.

Low-Dose Radiation 3D Intraoperative Imaging: How Low Can We Go? An O-Arm, CT Scan, Cadaveric Study.

MINI: The objective of this study was to evaluate the accuracy and reliability of pedicle screw placement using O-Arm at dosages below the manufactured recommended dose. O-Arm at reduced dose showed a 90% accuracy when compared with computed tomography; however, about 30% medial breaches were misclassified. STUDY DESIGN: Cadaveric study. OBJECTIVE: The objective was to evaluate O-Arm's ability at low-dose (LD) settings to assess intraoperative screw placement. SUMMARY OF BACKGROUND DATA: Accurate placement of pedicle screws is crucial because of proximity to vital structures. Malposition of screws may result in significant morbidity and potential mortality. O-arm provides real-time, intraoperative imaging of patient's anatomy and provides higher accuracy in scoliosis surgeries, avoiding risk to vital structures. We hypothesize using LD or ultra-low doses (ULDs) to obtain intraoperative images allow for accurate assessment of screw placement, both minimizing radiation exposure and preventing screw misplacement. METHODS: Eight cadavers were instrumented with pedicle screws bilaterally from T1 to S1. Screws were randomly placed using O-arm navigation into three positions: contained within the bone, OUT-anterior/lateral, and OUT-medial. O-arm images were obtained at three dosage settings: LD (kVp120/mAs125-lowest manufacturer recommended), very-low dose (VLD) (kVp120/mAs63), and ULD (kVp120/mAs39). Computed tomography (CT) scan was performed using institution's LD protocol (kVp100/mAs50) and gross dissection to identify screw positions. RESULTS: LD, VLD, ULD, and CT for identifying "IN" screws relative to gross dissection had, a mean (standard deviation) sensitivity of 84.2% (±5.7), specificity of 76.1% (±9.3), and accuracy of 79.9% (±3.1) from all three observers. Across the three observers, the interobserver agreement was 0.67 (0.61-0.72) for LD, 0.74 (0.69-0.79) for VLD, 0.61 (0.56-0.66) for ULD, and 0.79 (0.74-0.84) for CT. Effective doses of radiation (mSV) for LD O-arm scan was 2.16, VLD 1.08, ULD 0.68, and our LD CT protocol was 1.05. CONCLUSION: Accuracy of pedicle screw placement is similar for O-arm at all doses and CT compared to gross dissection. Interobserver reliability was substantial for VLD and CT. Approximately 30% of medial screw breaches are, however, misclassified. ULD and VLDs can be used for intraoperative navigation and evaluation purposes within these limitations. LEVEL OF EVIDENCE: N/A.

Ultrasound elastography in children: establishing the normal range of muscle elasticity.

BACKGROUND: Ultrasound elastography allows assessment of tissue elasticity. To the best of our knowledge, the elastography appearance of muscles in normal children has not been described. OBJECTIVE: To determine the US elasticity of muscles in children at rest and following exercise. MATERIALS AND METHODS: Cine elastography of biceps brachii and rectus femoris muscles was obtained at rest and after exercise in 42 healthy children (23 males, 19 females; mean: 11.2 ± 4.4 years, range: 2-18 years). Elastography scores were assigned to each clip based on a five-point color scale. Mean elastography scores and standard deviations were calculated and resting and postexercise elastography scores were compared. RESULTS: Resting muscle elasticity was lower in the biceps brachii than in the rectus femoris (P = 0.008), and higher in the dominant than in the nondominant biceps brachii (P < 0.032). Rectus femoris elasticity was higher in males than females (P = 0.051). Postexercise muscle elasticity significantly increased in both the dominant and nondominant biceps brachii (P < 0.001) and in the rectus femoris (P < 0.001). There was no significant gender-related difference in postexercise muscle elasticity. Biceps brachii elasticity decreased and rectus femoris elasticity increased with increasing body mass index. Younger subjects had a greater change in muscle elasticity with exercise. CONCLUSION: Resting muscle elasticity in children is significantly lower in the biceps brachii than in the rectus femoris and in the nondominant biceps brachii than in the dominant biceps brachii. Elasticity significantly increases immediately postexercise in both muscle groups; resting differences between biceps brachii and rectus femoris elasticity, and dominant and nondominant biceps brachii elasticity, do not persist after exercise. The change in muscle elasticity with exercise is higher in younger children.