Orthopaedic education in the era of surgical simulation: Still at the crawling stage.

Surgical skills education is in the process of a crucial transformation from a master-apprenticeship model to simulation-based training. Orthopaedic surgery is one of the surgical specialties where simulation-based skills training needs to be integrated into the curriculum efficiently and urgently. The reason for this strong and pressing need is that orthopaedic surgery covers broad human anatomy and pathologies and requires learning enormously diverse surgical procedures including basic and advanced skills. Although the need for a simulation-based curriculum in orthopaedic surgery is clear, several obstacles need to be overcome for a smooth transformation. The main issues to be addressed can be summarized as defining the skills and procedures so that simulation-based training will be most effective; choosing the right time period during the course of orthopaedic training for exposure to simulators; the right amount of such exposure; using objective, valid and reliable metrics to measure the impact of simulation-based training on the development and progress of surgical skills; and standardization of the simulation-based curriculum nationwide and internationally. In the new era of surgical education, successful integration of simulation-based surgical skills training into the orthopaedic curriculum will depend on efficacious solutions to these obstacles in moving forward.

Occupational hazards for pregnant or lactating women in the orthopaedic operating room.

Pregnant or lactating staff working in the orthopaedic operating room may be at risk of occupational exposure to several hazards, including blood-borne pathogens, anesthetic gases, methylmethacrylate, physical stress, and radiation. Because the use of proper personal protective equipment is mandatory, the risk of contamination with blood-borne pathogens such as hepatitis B, hepatitis C, and HIV is low. Moreover, effective postexposure prophylactic regimens are available for hepatitis B and HIV. In the 1960s, concerns were raised about occupational exposure to harmful chemicals in the operating room such as anesthetic gases and methylmethacrylate. Guidelines on safe levels of exposure to these chemicals and the use of personal protective equipment have helped to minimize the risks to pregnant or lactating staff. Short periods of moderate physical activity are beneficial for pregnant women, but prolonged strenuous activity can lead to increased pregnancy complications. The risk of prenatal radiation exposure during orthopaedic procedures is of concern, as well. However, proper lead protection and contamination control can minimize the risk of occupational exposure to radiation.

Aggregate Interview Method of ranking orthopedic applicants predicts future performance.

This article evaluates and describes a process of ranking orthopedic applicants using what the authors term the Aggregate Interview Method. The authors hypothesized that higher-ranking applicants using this method at their institution would perform better than those ranked lower using multiple measures of resident performance. A retrospective review of 115 orthopedic residents was performed at the authors' institution. Residents were grouped into 3 categories by matching rank numbers: 1-5, 6-14, and 15 or higher. Each rank group was compared with resident performance as measured by faculty evaluations, the Orthopaedic In-Training Examination (OITE), and American Board of Orthopaedic Surgery (ABOS) test results. Residents ranked 1-5 scored significantly better on patient care, behavior, and overall competence by faculty evaluation (P<.05). Residents ranked 1-5 scored higher on the OITE compared with those ranked 6-14 during postgraduate years 2 and 3 (P⩽.5). Graduates who had been ranked 1-5 had a 100% pass rate on the ABOS part 1 examination on the first attempt. The most favorably ranked residents performed at or above the level of other residents in the program; they did not score inferiorly on any measure. These results support the authors' method of ranking residents. The rigorous Aggregate Interview Method for ranking applicants consistently identified orthopedic resident candidates who scored highly on the Accreditation Council for Graduate Medical Education resident core competencies as measured by faculty evaluations, performed above the national average on the OITE, and passed the ABOS part 1 examination at rates exceeding the national average.

Treatment of blocked elbow flexion in congenital radioulnar synostosis with radial head excision: a case series.

BACKGROUND: Congenital radioulnar synostosis (CRUS) causes a spectrum of presentations, most commonly a restriction of forearm rotation. Because most of these children are not treated operatively, many are not followed clinically after the diagnosis has been made. This report describes that a subset of the Cleary and Omer type IV synostoses (anterior dislocation of the radial head) can present with a progressive block to elbow flexion that worsens with growth. The location of this synostosis allows the physis of the radial head to grow untethered. The enlarged radial head can impinge upon the capitellum, blocking elbow flexion and snapping on the annular ligament. We propose excision of the radial head as a method of treating the anteriorly dislocated radial head in type IV synostoses. METHODS: We evaluated 4 patients with Cleary and Omer type IV synostoses who presented with an anteriorly dislocated radial head impinging on elbow flexion with snapping of the annular ligament. Each patient was treated with excision of the radial head. RESULTS: In 4 patients excision of the radial head was performed through a lateral Kocher approach. At follow-up, all patients showed relief from their pain and mechanical symptoms, with return of baseline range of motion. One complication which occurred was transient radial nerve neuropraxia. CONCLUSIONS: Although surgery is rarely needed for CRUS, excision of the radial head may be indicated if progressive loss of elbow flexion occurs secondary to impingement of the anteriorly dislocated radial head with the distal humerus in patients with type IV synostosis. We report that excision of the radial head can successfully treat this condition. Patients with type IV CRUS should be educated about the potential for loss of elbow flexion and/or followed until skeletal maturity to evaluate for this potential condition. LEVEL OF EVIDENCE: Case series consistent with level IV evidence; therapeutic study.

Objective structured assessment of technical skill in upper extremity surgery.

PURPOSE: Objective assessment of technical skills in hand surgery has been lacking. This article reports on an Objective Structured Assessment of Technical Skills format of a multiple bench-station evaluation of orthopedic surgery residents' technical skills for 3 common upper extremity surgeries. METHODS: Twenty-seven residents (6 postgraduate year [PGY] 2, 8 PGY 3, 8 PGY 4, and 5 PGY 5) participated in the examination. Each resident performed surgery on a cadaveric specimen at 3 stations, trigger finger release (TFR), open carpal tunnel release, and distal radius fracture fixation. A board-certified hand surgeon evaluated trainee performance at each station, using a procedure-specific detailed checklist, a validated global rating scale, and pass/fail assessment. A resident post-testing evaluation was collected. RESULTS: Construct validity with correlation between year in training and detailed checklist scores was demonstrated for TFR and carpal tunnel release; between year in training and global rating scores for TFR and distal radius fracture fixation; and between year in training and pass/fail assessment for TFR. Criterion validity was demonstrated by the correlation between global rating scale scores, detailed checklist scores, and pass/fail assessment for TFR, carpal tunnel release, and distal radius fracture fixation. Time to complete the surgery was not correlated with surgical performance. Residents rated the multiple-station Objective Structured Assessment of Technical Skills format as highly educational. CONCLUSIONS: This study reports that a surgeon's ability to release a trigger finger does not correlate specifically to his or her ability to perform a carpal tunnel release or to perform plate fixation of a radius fracture. The results of this study would indicate that, for 3 different surgical simulations representing procedures of varying complexity, assessments by a single assessment tool is not adequate. To completely understand a resident's abilities, assessment by checklist (understanding the steps of the surgery), global rating scales (assessment of basic surgical skills in light of lesser or greater complexity surgeries), and pass/fail assessment (examination of adverse events) are all necessary components. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Wrist centralization using the dorsal rotation flap in radial longitudinal deficiency.

Although the role of wrist centralization has been controversial, the surgeon must knowledgeably make surgical decisions for patients with radial longitudinal deficiency, understanding the advantages and disadvantages of centralization techniques. The goals of surgical intervention for correction of radial longitudinal deficiency are to correct the radial deviation deformity of the wrist by centralizing the carpus on the distal end of the ulna, concomitant with balancing the soft tissue structures at the wrist maintaining finger and wrist motion. Wrist centralization is indicated in children with complete absence of the radius with elbow range of motion of greater than 90 degrees, and stable medical condition. This article presents the technique of wrist centralization surgery using a dorsal rotation flap. The wrist capsule is released from the radial side of the ulna, and the carpus is relocated over the distal end of the ulna, with a longitudinal pin placed through the ulna, across the carpus, and between or down the middle ray metacarpal. If the ulna has greater than 30 degrees angulation, a concomitant ulnar osteotomy is performed. Complications can include recurrence, pin problems, stiff digits, and diminished long-term ulnar growth. Long-term splint wear may be necessary to decrease the risk of recurrence. At the present time, an optimal single surgical technique for intervention for this complex congenital deformity has not yet been described.

Do men outperform women during orthopaedic residency training?

BACKGROUND: Orthopaedic surgery residency has one of the lowest percentages of women (13.1%) of all primary surgical specialties. There are many possible reasons for this, including bias during the selection process. QUESTIONS/PURPOSES: We therefore asked whether performance during residency might adversely bias the selection of future female orthopaedic residents by researching whether males and females perform equally in orthopaedic surgery residency. METHODS: Ninety-seven residents enrolled in our residency between 1999 and 2009; six males and one female left the program, leaving 90 residents (73 males, 17 females) as the study cohort. Resident performance was compared for OITE scores, ABOS results, faculty evaluations, and in a resident graduate survey. RESULTS: Males and females had similar faculty evaluations in all ACGME competency areas. Males and females had similar mean OITE scores for Years 2-5 of residency, although males had higher mean scores at Years 3 through 5. Males and females had similar mean ABOS Part 1 scores and ABOS Part 1 pass rates; however, fewer males than females took more than one attempt to pass. Males and females had similar Part 2 pass rates or attempts. For the 45 resident graduates surveyed, females pursued fellowships equally to males, worked slightly less hours in practice, and reported higher satisfaction with their career choice. CONCLUSIONS: For the 90 residents at one residency program, we observed no differences between males' and females' performance. Although females pursue orthopaedic residency less frequently than males, performance during residency should not bias their future selection.

Grip lock injury in male gymnasts.

BACKGROUND: Grip lock is a high bar injury in male gymnastics and occurs while the gymnast is rotating around the high bar. Its mechanism and treatment have been poorly documented. STUDY DESIGN: Case reports. RESULTS: One gymnast sustained an extensor tendon injury and ulnar styloid fracture and was treated nonoperatively. The second gymnast sustained open fracture of the radius and ulna with extensor tendon ruptures and was surgically treated. Both gymnasts healed and were able to return to collegiate gymnastics despite residual finger extensor lag. CONCLUSIONS: Grip lock is a physically and psychologically devastating injury on the men's high bar that can cause forearm fractures and extensor tendon injuries at the wrist (Zone 8), which may result in residual extensor tendon lag. Injuries may be prevented with proper grip fit, appropriate maintenance of grips, and limited duration of use, as well as education of athletes, athletic trainers, and coaches.

Extensor retinaculum impingement in the athlete: a new diagnosis.

BACKGROUND: Athletes with repetitive weightbearing hyperextension activities are predisposed to wrist pain. PURPOSE: To describe extensor retinaculum impingement of the extensor tendons as a new diagnosis for wrist pain for the athlete performing repetitive wrist hyperextension, to present cadaveric dissections to further understand the anatomical basis for extensor retinaculum impingement, and to report treatment outcomes of extensor retinaculum impingement. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective chart review was performed for athletes treated from 1987 to 2006 for wrist pain due to extensor retinaculum impingement. Eight wrists in 7 athletes were reviewed with a mean presenting age of 19.6 years. The hallmark symptom was dorsal wrist pain, and signs were extensor tendon synovitis and tenderness at the distal border of the extensor retinaculum, provoked by wrist hyperextension. Ten cadaveric wrists were dissected and examined to evaluate anatomical factors that may contribute to extensor retinaculum impingement. RESULTS: Two athletes (2 wrists) were treated with corticosteroid injections. Five patients (6 wrists) were treated operatively, with pathologic findings of thickening of the distal border of the extensor retinaculum and concomitant extensor tendon synovial thickening or, in 1 patient, tendon rupture. Partial distal resection of the extensor retinaculum was performed to eliminate impingement. All patients had complete relief of pain and full return to sport. CONCLUSION: Competitive sports that require repetitive wrist extension with an axial load predispose the athlete to extensor retinaculum impingement. Athletes with dorsal wrist pain and tenosynovial thickening worsened with wrist hyperextension should be considered for the diagnosis of extensor retinaculum impingement. When nonoperative management fails, surgical resection of the distal impinging border of the extensor retinaculum can eliminate pain and can still allow athletes to return to sport without diminishing the opportunity for significant athletic accomplishments.

Dorsal rotation flap for centralization in radial longitudinal deficiency.

PURPOSE: The purpose of this report is to present the results of a dorsal rotation flap for centralization in the treatment of radial longitudinal deficiency. METHODS: All patients surgically treated for radial longitudinal deficiency with a centralization procedure and use of the dorsal rotation flap between 1996 and 2006 were retrospectively reviewed. RESULTS: Twenty-one limbs in 15 patients treated with centralization using the dorsal rotation flap were reviewed, with photographs of the scar available for review for 15 limbs in 10 patients. There were no primary wound-healing problems, no hypertrophic scarring, and no color mismatch. In the 15 limbs with available photographs, all scars were rated as good. Use of this incision allowed good surgical access to the necessary structures on the radial and ulnar side of the wrist to allow for centralization. CONCLUSIONS: The dorsal rotation flap allows rotation of the skin in a radial direction while the hand and carpus are rotated in an ulnar direction; the redundant skin on the ulnar side of the wrist is rotated to compensate for the shortage of skin on the radial side of the wrist. This report describes use of the dorsal rotation flap with no complications attributable to the surgical approach.

Wrist deformities after fracture.

Wrist deformities can occur after fracture because of malunion of the fracture or injury to the growth plate leading to imbalance of growth. Prevention of malunion is paramount by early recognition with proper reduction and casting or fixation with casting. If a mal-union occurs, an osteotomy may be necessary if anticipated growth will not correct the deformity. Injury of the growth plate may lead to wrist deformity in two ways: angular growth or growth arrest. Angular growth deformities are corrected most commonly by osteotomy. Growth arrest of the radius or the ulna leads to an ulnar-positive or an ulnar-negative variance at the wrist. If the ulnar variance is symptomatic, treatment is centered on achieving a level joint. Options for joint leveling procedures include epiphysiodesis or physeal stapling of the longer bone, lengthening osteotomy of the shorter bone, or shortening osteotomy of the longer bone.