Identifying Barriers Faced by Applicants without a Home Residency Program when Matching into Plastic Surgery.

Background Applying into plastic surgery (PS) is competitive. Lacking a home residency program (HRP) is another barrier. Our goal is to characterize challenges faced by PS applicants without HRPs and identify solutions. Methods Surveys were designed for current integrated PS residents and applicants in the 2022 Match without HRPs. Surveys were distributed electronically. Only U.S. allopathic graduate responses were included. Results Of 182 individuals surveyed, 74 responded (39%, 33 residents, 41 applicants). Sixty-six percent reported feeling disadvantaged due to lack of an HRP. Seventy-six percent of applicants successfully matched. Of these, 48% felt they required academic time off (research year) versus 10% of unmatched applicants. Ninety-seven percent of matched applicants identified a mentor versus 40% of unmatched applicants ( p < 0.05). Matched applicants identified mentors through research (29%) and cold calling/emailing (25%). Matched versus unmatched applicants utilized the following resources: senior students (74 vs. 10%, p < 0.05) and social media (52 vs. 10%, p < 0.05). Among residents, 16 had PS divisions (48%). Thirty-six percent with divisions felt they had opportunities to explore PS, compared with 12% without divisions. Residents without divisions felt disadvantaged in finding research (94 vs. 65%, p < 0.05), delayed in deciding on PS (50 vs. 28%), and obtaining mentors (44 vs. 35%) and letters of recommendation (31 vs. 24%). Conclusion PS residents and applicants without HRPs reported feeling disadvantaged when matching. The data suggest that access to departments or divisions assists in matching. We identified that external outreach and research were successful strategies to obtain mentorship. To increase awareness for unaffiliated applicants, we should increase networking opportunities during local, regional, and national meetings.

Management of Complex Hand and Wrist Ligament Injuries.

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

Association Between Hospital Monopoly Status, Patient Socioeconomic Disadvantage, and Total Joint Arthroplasty Price Disclosure.

INTRODUCTION: In recent years, healthcare institutions and regulatory bodies have enacted cost transparency mandates for routine interventions such as total hip arthroplasty and total knee arthroplasty. However, disclosure rates remain low. This study examined the effect of financial characteristics of hospitals and the socioeconomic status of patients on price disclosure. METHODS: Hospitals conducting total hip arthroplasty/total knee arthroplasty, their quality ratings, and procedural volumes were identified using the Leapfrog Hospital Survey and linked to procedure-specific prices. Financial performance and the Area Deprivation Index (ADI) were used to correlate disclosure rates with hospital and patient characteristics. Hospital financial, operational, and patient summary statistics were compared by price-disclosure status using two-sample t -tests for continuous variables and Pearson chi-square test for categorical variables. The association between total joint arthroplasty price disclosure and hospital ADI was further evaluated using modified Poisson regression. RESULTS: A total of 1,425 hospitals certified by the Centers for Medicare & Medicaid Services were identified in the United States. 50.5% (n = 721) of hospitals had no published payer-specific price information. Hospitals in an area of higher socioeconomic disadvantage were more likely to disclose prices of total joint arthroplasty (incidence rate ratio = 0.966, 95% CI: 0.937 to 0.995, P = 0.024). Hospitals that were considered monopolies or were for-profit were less likely to disclose prices (IRR = 1.15, 95% CI: 1.030 to 1.280, P = 0.01; IRR = 1.256, 95% CI: 0.986 to 1.526, P = 0.038, respectively). When accounting for both ADI and monopoly status, hospitals with patients who had a higher ADI were more likely to disclose costs for a total joint arthroplasty, whereas for-profit hospitals or hospitals considered monopolies in their HSA were less likely to disclose prices. DISCUSSION: For nonmonopoly hospitals, a higher ADI correlated with a higher likelihood of price disclosure. However, for monopoly hospitals, there was no significant association between ADI and price disclosure. LEVEL OF EVIDENCE: II.

Consequences and Predictors of Prolonged Tissue Expander Duration in Breast Reconstruction.

BACKGROUND: Tissue expanders (TEs) are temporary devices used in breast reconstruction, which are generally removed within 1 year. There is a paucity of data regarding the potential consequences when TEs have longer indwelling times. Thus, we aim to determine whether prolonged TE implantation length is associated with TE-related complications. METHODS: This is a single-center retrospective review of patients who underwent TE placement for breast reconstruction from 2015 to 2021. Complications were compared between patients who had a TE for >1 year and <1 year. Univariate and multivariate regressions were used to evaluate predictors of TE complications. RESULTS: A total of 582 patients underwent TE placement and 12.2% had the expander for >1 year. Adjuvant chemoradiation, body mass index (BMI), overall stage, and diabetes predicted the duration of TE placement (p ≤ 0.006). Rate of return to the operating room was higher in patients who had TEs in place >1 year (22.5 vs 6.1%, p < 0.001). On multivariate regression, prolonged TE duration predicted an infection requiring antibiotics, readmission, and reoperation (p < 0.001). Reasons for longer indwelling times included need for additional chemoradiation (79.4%), TE infections (12.7%), and requesting a break from surgery (6.3%). CONCLUSION: Indwelling TEs for >1 year are associated with higher rates of infection, readmission, and reoperation even when controlling for adjuvant chemoradiation. Patients with diabetes, a higher BMI, advanced cancer stage, and those requiring adjuvant chemoradiation should be advised they may require a TE for a longer time interval prior to final reconstruction.

Variations in Incidence of Trigger Finger and Response to Corticosteroid Injection after Aromatase Inhibitor Therapy for Breast Cancer.

BACKGROUND: Aromatase inhibitors (AIs), such as letrozole and anastrozole, have been demonstrated to have significant musculoskeletal symptoms in patients. The purpose of this study was to evaluate the effect of specific AI medications on the incidence of trigger finger and independent factors affecting treatment outcomes within this population. METHODS: A retrospective chart review was performed at the authors' institution between the years 2014 and 2018 in patients with the diagnosis of breast cancer. This cohort was then sorted based on receiving medication regimens, trigger finger diagnosis, steroid injections, and need for surgical release of trigger finger. RESULTS: A total of 15,144 patients were included for initial review. The overall rate of trigger finger diagnosis was 2.75% in the entire breast cancer population and 4.5% for patients receiving AI therapy. Patients taking letrozole and anastrozole had an increased odds ratio of 2.0 and 1.7, respectively, for developing trigger finger. Patients who switched between letrozole and anastrozole during treatment had a higher rate of failed steroid injection treatment (45.2% versus 23.5%; P = 0.021). Among patients receiving AI treatment diagnosed with trigger finger, diabetes and hemoglobin A1c level greater than 6.5 were associated with significantly increased rates of failed steroid therapy. CONCLUSIONS: Patients receiving AI therapy have an increased incidence of trigger finger. The outcomes of treatment are equivalent between AI and non-AI trigger finger populations. However, steroid therapy is more likely to fail in patients who require switching of regimens because of significant musculoskeletal symptoms. Poorly controlled diabetes was also an independent factor for compromised steroid treatment of trigger finger. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Pyrocarbon hemiarthroplasty of the shoulder: a systematic review and meta-analysis of clinical results.

BACKGROUND: Hemiarthroplasty is often considered in the setting of preserved glenoid cartilage given the high risk of revision associated with total shoulder arthroplasty. Pyrocarbon (PyC) has been used as an implant material that theoretically allows for formation of a neo-membrane that would act like cartilage to reduce glenoid wear. The purpose of this study was to evaluate the clinical outcomes, radiographic outcomes, revision rates, and complication rates in the existing literature on shoulder hemiarthroplasty using PyC. METHODS: The MEDLINE, Embase, and Scopus databases were searched for articles relating to shoulder hemiarthroplasty using the terms "pyrocarbon" or "pyrolytic carbon." Abstracts and articles were screened against predefined inclusion and exclusion criteria, with a minimum of 24 months' follow-up required. Data on patient demographic characteristics, clinical outcome scores, complications, revision rates, and radiographic findings were recorded. Where appropriate, meta-analysis was performed. RESULTS: Twelve studies were selected for final inclusion, with a total of 536 patients. Among the studies reporting preoperative and postoperative range of motion (ROM), an overall improvement in ROM was observed. The mean Constant score was 70.9 points postoperatively, with a mean improvement of 36.2 points (n = 359, 9 studies). Radiographically, 22.8% of patients (n = 536, 8 studies) had evidence of glenoid erosion, 10.4% had changes in implant positioning, and 9.9% had tuberosity thinning. In addition, 1.5% of patients had radiographic subacromial space reduction, whereas 0.7% had an increase in tuberosity thickness. Across all studies, there was an 8.6% complication rate, with the most common cause being glenoid erosion (2.6%, n = 14). There was an overall 7.7% revision rate (n = 41), with 63% of revisions (n = 26) undergoing conversion to reverse or total shoulder arthroplasty. CONCLUSION: PyC hemiarthroplasty shows overall improvements in ROM and patient-reported outcomes for patients. However, there remains concern for glenoid erosion on radiographic evaluation at minimum 2-year follow-up. Although preliminary studies have shown encouraging results, this systematic review emphasizes the need for longer-term follow-up studies with further radiographic evaluation of the severity of glenoid erosion and the association with functional outcomes and failure risk.

Beware the rebound effect: regional anesthesia increases opioid utilization after humerus fracture surgery.

Introduction: Regional anesthesia (RA) is used reduce pain in proximal humerus and humeral shaft fracture surgery. The study hypothesis was that RA would decrease opioid demand in patients undergoing fracture surgery. Materials and methods: Opioid demand was recorded in all patients ages 18 and older undergoing proximal humerus or humeral shaft fracture surgery at a single, Level I trauma center from 7/2013 - 7/2018 (n = 380 patients). Inpatient opioid consumption from 0-24, 24-48, and 48-72 h and outpatient opioid demand from 1-month pre-operative to 90-days post-operative were converted to oxycodone 5-mg equivalents (OE's). Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on opioid utilization. Results: Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.8 estimated OE's without RA vs 8.8 estimated OE's with RA from 0-24 h post-op; 10 vs 13.7 from 24-48 h post-op; and 8.7 vs 11.6 from 48-72 h post-op; all p < 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at all timepoints. Discussion: In proximal humerus and humeral shaft fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics.

Regional anesthesia reduces inpatient and outpatient perioperative opioid demand in periarticular elbow surgery.

HYPOTHESIS: Regional anesthesia (RA) can be used to manage perioperative pain in the treatment of periarticular elbow fracture fixation. However, the opioid-sparing benefit is not well-characterized. The hypothesis of this study was that RA had reduced inpatient opioid consumption and outpatient opioid demand in patients who had undergone periarticular elbow fracture surgery. METHODS: This study retrospectively reviews inpatient opioid consumption and outpatient opioid demand in all patients aged ≥18 years at a single Level I trauma center undergoing fixation of periarticular elbow (distal humerus and proximal forearm) fracture surgery (n=418 patients). In addition to RA vs. no RA, additional patient and operative characteristics were recorded. Unadjusted and adjusted models were constructed to evaluate the impact of RA and other factors on inpatient opioid consumption and outpatient opioid demand. RESULTS: Adjusted models demonstrated decreases in inpatient opioid consumption postoperation in patients with RA (13.7 estimated oxycodone 5-mg equivalents or OEs without RA vs. 10.4 OEs with RA from 0 to 24 hours postoperation, P = .003; 12.3 vs. 9.2 OEs from 24 to 48 hours postoperation, P = .045). Estimated cumulative outpatient opioid demand differed significantly in patients with RA (166.1 vs. 132.1 OEs to 6 weeks, P = .002; and 181 vs. 138.6 OEs to 90 days, P < .001). DISCUSSION: In proximal forearm and distal humerus fracture surgery, RA was associated with decreased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. These results encourage utilization of perioperative RA to reduce opioid use.

Staying Close to Home: The Effects of COVID-19 on the Plastic Surgery Residency Match.

The 2019 novel coronavirus created unique challenges for the integrated plastic surgery match. The goal of this study was to evaluate the trends of the 2020 and 2021 integrated plastic surgery match specifically related to the 2019 novel coronavirus. METHODS: Three separate individual surveys were designed for integrated plastic surgery program directors and applicants from the 2021 to 2020 match. The surveys were distributed to the email addresses of applicants that applied to our institution's integrated residency program. Information of current interns and newly matched applicants from program websites and certified social media accounts were recorded. RESULTS: We received completed surveys from 19 of the 69 program directors for a response rate of 27.5%. The survey for the 2020 and 2021 match applicants was completed by 25 and 68 applicants, respectively, for a response rate of 6.1% and 21.9%. There was a significant difference in the average number of completed virtual subinternships between applicants that did and did not successfully match into plastic surgery (1.48 versus 0.36, P = 0.01). The rate of students matching at their home institution was the highest in 2021 at 26% compared to 2020 (18%) and 2019 (15%). CONCLUSIONS: The results of this study demonstrate that applicants were more likely to match at programs with which they had established previous connections, including home institutions. Applicants also had a higher likelihood to match if they completed a virtual subinternship during the 2021 match. Learning points can be applied to the upcoming application cycle to improve the overall experience.

Impact of Early Weightbearing After Ankle Arthroscopy and Bone Marrow Stimulation for Osteochondral Lesions of the Talus.

BACKGROUND: Osteochondral lesion of the talus (OLT) may be caused by osteochondritis dissecans, osteochondral fractures, avascular necrosis, or focal arthritic changes. For certain focal cartilage defects, bone marrow stimulation (BMS) has been a widely used technique to restore a fibrocartilage substitute overlying the defect. There are various postoperative weightbearing protocols for this procedure, with no single gold standard method. PURPOSE: To retrospectively review the outcomes of patients undergoing ankle arthroscopy with concomitant BMS to determine outcomes based on postoperative weightbearing status. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We retrospectively reviewed the records of patients who underwent ankle arthroscopy with BMS for OLTs between 2015 and 2018. Patients were placed into 2 cohorts based on postoperative immobilization status: the nonweightbearing (NWB) group and the weightbearing-as-tolerated (WBAT) group. Patient characteristics obtained included age, sex, comorbidities, and etiology of talar pathology. Outcomes included the pain visual analog scale (VAS), range of motion (ROM), complications, time to first weightbearing, and the method and length of immobilization. Patients who were lost to follow-up before 30 days were excluded. The chi-square test was used to compare categorical variables between cohorts, and the t test was used for continuous variables. RESULTS: A total of 69 patients met the inclusion criteria for this study, 18 in the WBAT group and 51 in the NWB group. The mean lesion size was 9.48 × 9.21 mm (range, 3-15 mm × 2-20 mm) for the NWB group and 9.36 × 9.72 mm (range, 5-14 mm × 6-20 mm) for the WBAT group (P > .05). The VAS scores improved from 4.40 to 0.67 for the WBAT group and from 6.33 to 2.55 for the NWB group, with the difference in final values reaching statistical significance (P = .0002). Postoperative ROM was not significantly different between the groups. There were 4 repeat operations within the NWB cohort. CONCLUSION: The surgical management of OLTs can be challenging, and the postoperative weightbearing protocol can be an extra obstacle for the patient to navigate. We found no difference in pain, ROM, or complications when allowing immediate, full WBAT.

Regional anesthesia does not decrease inpatient or outpatient opioid demand in femoral shaft fracture surgery.

INTRODUCTION: Regional anesthesia (RA) may be used in femoral shaft fracture surgery to decrease pain and opioid consumption. However, the impact of RA on inpatient and outpatient opioid demand in patients undergoing femoral shaft fracture surgery is largely unknown. The aim of this study was to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand in patients undergoing femoral shaft fracture surgery. METHODS: Inpatient opioid consumption and outpatient opioid demand in all patients undergoing femoral shaft fracture surgery was recorded at a single, Level I trauma center from 7/2013 - 7/2018 (n=436). In addition to RA, baseline and treatment factors including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery were recorded. Unadjusted and adjusted multivariable models were used to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand. RESULTS: Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (6.9 estimated OE's without RA vs 8.8 OE's with RA from 48-72 hours post-op, p<0.05) but no significant differences at other timepoints (10.3 estimated OE's without RA vs 9.2 OE's with RA from 0-24 hours post-op, 8.2 vs 8.8 from 24-48 hours post-op, p>0.05). Estimated cumulative outpatient opioid demand did not differ significantly in patients with RA (82.3 OE's without RA vs 94.8 with RA from discharge to two-weeks, 105.4 vs 116.3 OE's to 6-weeks, and 124.5 vs 137.9 OE's to 90-days, all p>0.05). Late opioid refills were significantly more common in patients with RA (1.57 odds at 2-weeks to 6-weeks, 1.69 odds at 6-weeks to 90-days, p<0.05) DISCUSSION: In femoral shaft fracture surgery, RA was not associated with decreased opioid demand after adjusting for baseline patient and treatment characteristics. These results provide a real-world estimate of the impact of RA on opioid demand in femoral shaft fracture surgery and encourage providers to seek alternative analgesic modalities. LEVEL OF EVIDENCE: Level III, retrospective, therapeutic cohort study.

Legislation Only Limiting Opioid Prescription Length Has Minimal Impact on Prescribing in Orthopaedic Trauma.

This study evaluates the efficacy of North Carolina's Strengthen Opioid Misuse Prevention (STOP) Act in reducing the volume and rate of 90-day perioperative opioid prescribing to patients ages 18 and older after orthopaedic trauma surgery. Patients undergoing fracture surgery from January 2017 to June 2017 (pre-STOP) were compared with patients undergoing fracture surgery from January 2018 to June 2018 (post-STOP). Adjusted analyses demonstrated that patients undergoing surgery after the STOP Act (n = 730) were prescribed significantly lower volume of opioids in the discharge to 2-week time frame and at the first postoperative prescription (7.3 and 5.8 fewer oxycodone, respectively). Otherwise, there were no significant differences between the two cohorts in adjusted volume or rates of 90-day opioid prescribing. The STOP act has had only a minor impact on early post-discharge opioid prescribing in patients undergoing fracture surgery. These findings question the efficacy of this type of legislation in combating opioid overprescribing in orthopaedic trauma. (Journal of Surgical Orthopaedic Advances 30(2):101-107, 2021).

Cystic neutrophilic granulomatous mastitis: The Cleveland Clinic experience with diagnosis and management.

Granulomatous mastitis is an uncommon inflammatory disease that typically presents with painful breast lesions. Recent publications have brought to light a specific subset of granulomatous mastitis patients with a distinct histological pattern of disease termed, "cystic neutrophilic granulomatous mastitis" (CNGM). Although many cases of granulomatous lobular mastitis have been thought to be idiopathic, this rare subset of an uncommon disease has been linked to infections with Corynebacterium species. Herein, a cohort of CNGM patients from a large, tertiary care, North-American, academic medical center is presented. Correlative demographic, clinical, radiographic, pathologic, microbiologic, management, and outcomes data are provided. Collaborative communication between specialists to accurately diagnose and manage these patients is essential to decreasing potential morbidity.