Fractures in Patients With Diabetes Mellitus: Findings From a 20-year Registry at a Single Level 1 Trauma Center.

INTRODUCTION: Diabetes mellitus (DM) is a risk factor of infection. Although DM has been associated with worse functional outcomes after acetabular fracture, literature regarding the effect of DM on surgical site infection and other early complications is lacking. METHODS: A 20-year registry from a level 1 trauma center was queried to identify 134 patients with DM and 345 nondiabetic patients with acetabular fractures. RESULTS: The diabetic patient population was older (57.2 versus 43.2; P < 0.001) and had higher average body mass index (33.6 versus 29.5; P < 0.001). Eighty-three patients with DM and 270 nondiabetics were treated surgically (62% versus 78%; P < 0.001). Diabetic patients who were younger (54.6 versus 61.4; P = 0.01) with fewer comorbidities (1.7 versus 2.2; P = 0.04) were more frequently managed surgically. On univariate analysis, patients with DM more commonly developed any early infection (28.4% versus 21%; P = 0.049) but were no more likely to develop surgical site infection, or other postoperative complications. Older patient age, length of stay, baseline pulmonary disease, and concurrent abdominal injury were independent predictors of postoperative infection other than surgical site infection. Diabetics that developed infection had more comorbidities (2.4 versus 1.5; P < 0.001) and higher Injury Severity Score (24.1 versus 15.8; P = 0.003), and were more frequently insulin-dependent (72.7% versus 41%; P = 0.01). DISCUSSION: Independent of management strategy, diabetic patients were more likely to develop an infection after acetabular fracture. Insulin dependence was associated with postoperative infection on univariate analysis. Optimal selection of surgical candidates among patients with DM may limit postoperative infections.

Optimizing calibration of modern skeletal maturity systems.

Purpose: Greulich and Pyle is the most used system to estimate skeletal maturity but has significant drawbacks, prompting the development of newer skeletal maturity systems, such as the modified Fels skeletal maturity systems based on knee radiographs. To create a new skeletal maturity system, an outcome variable, termed a "skeletal maturity standard," must be selected for calibration of the system. Peak height velocity and 90% of final height are both considered reasonable skeletal maturity standards for skeletal maturity system development. We sought to answer two questions: (1) Does a skeletal maturity system developed using 90% of final height estimate skeletal age as well as it would if it was instead developed using peak height velocity? (2) Does a skeletal maturity system developed using 90% of final height perform as well in lower extremity length prediction as it would if it was instead developed using peak height velocity? Methods: The modified Fels knee skeletal maturity system was recalibrated based on 90% of final height and peak height velocity skeletal maturity standards. These models were applied to 133 serially obtained, peripubertal antero-posterior knee radiographs collected from 38 subjects. Each model was used to estimate the skeletal age of each radiograph. Skeletal age estimates were also used to predict each patient's ultimate femoral and tibial length using the White-Menelaus method. Results: The skeletal maturity system calibrated with 90% of final height produced more accurate skeletal age estimates than the same skeletal maturity system calibrated with peak height velocity (p < 0.05). The 90% of final height and peak height velocity models made similar femoral and tibial length predictions (p > 0.05). Conclusion: Using the 90% of final height skeletal maturity standard allows for simpler skeletal maturity system development than peak height velocity with potentially more accuracy.

The Addition of Hand-specific Skeletal Maturity Parameters Does Not Improve Skeletal Maturity Estimation Accuracy of the Modified Fels Wrist System.

BACKGROUND: The Modified Fels Wrist system is potentially the most accurate clinically accessible skeletal maturity system utilizing hand or wrist radiographs. During development, parameters distal to the metacarpals were excluded. We attempted to further optimize the Modified Fels wrist system through the inclusion of hand parameters distal to the metacarpals. METHODS: Forty-three new anteroposterior (AP) hand radiographic parameters were identified from the Fels and Greulich and Pyle (GP) skeletal maturity systems. Twelve parameters were eliminated from further evaluation for poor correlation with skeletal maturity, poor reliability, and lack of relevance in the peripubertal years. In addition to the 8 previously described Modified Fels Wrist parameters, 31 hand radiographic parameters were evaluated on serial peripubertal AP hand radiographs to identify the ones most important for accurately estimating skeletal age. This process produced a "Modified Fels hand-wrist" model; its performance was compared with (1) GP only; (2) Sanders Hand (SH) only; (3) age, sex, and GP; (4) age, sex, and SH; and (5) Modified Fels Wrist system. RESULTS: Three hundred seventy-two radiographs from 42 girls and 38 boys were included. Of the 39 radiographic parameters that underwent full evaluation, 9 remained in the combined Modified Fels Hand-Wrist system in addition to chronological age and sex. Four parameters are wrist specific, and the remaining 5 are hand specific. The Hand-Wrist system outperformed both GP and SH in estimating skeletal maturity ( P <0.001). When compared with the Modified Fels Wrist system, the Modified Fels Hand-Wrist system performed similarly regarding skeletal maturity estimation (0.36±0.32 vs. 0.34±0.26, P =0.59) but had an increased (worse) rate of outlier predictions >1 year discrepant from true skeletal maturity (4.9% vs. 1.9%, P =0.01). CONCLUSIONS: The addition of hand parameters to the existing Modified Fels Wrist system did not improve skeletal maturity estimation accuracy and worsened the rate of outlier estimations. When an AP hand-wrist radiograph is available, the existing Modified Fels wrist system is best for skeletal maturity estimation. LEVEL OF EVIDENCE: Level III.

The Modified Fels and Abbreviated Modified Fels Knee Skeletal-Maturity Systems in the Prediction of Leg-Length Discrepancy.

BACKGROUND: The Modified Fels (mFels) and Abbreviated Modified Fels (abFels) knee systems have been recently developed as options for grading skeletal maturity without the need for a separate hand radiograph. We sought to determine the interobserver reliability of these systems and to compare their prediction accuracy with that of the Greulich and Pyle (G-P) atlas in a cohort managed with epiphysiodesis for leg-length discrepancy (LLD). METHODS: Three reviewers scored 20 knee radiographs using the mFels system, which includes 5 qualitative and 2 quantitative measures as well as a quantitative output. Short leg length (SL), long leg length (LL), and LLD prediction errors at maturity using the White-Menelaus (W-M) method and G-P, mFels, or abFels skeletal age were compared in a cohort of 60 patients managed with epiphysiodesis for LLD. RESULTS: Intraclass correlation coefficients for the 2 quantitative variables and the quantitative output of the mFels system using 20 knee radiographs ranged from 0.55 to 0.98, and kappa coefficients for the 5 qualitative variables ranged from 0.56 to 1, indicating a reliability range from moderate to excellent. In the epiphysiodesis cohort, G-P skeletal age was on average 0.25 year older than mFels and abFels skeletal ages, most notably in females. The majority of average prediction errors between G-P, mFels, and abFels were <0.5 cm, with the greatest error being for the SL prediction in females, which approached 1 cm. Skeletal-age estimates with the mFels and abFels systems were statistically comparable. CONCLUSIONS: The mFels skeletal-age system is a reproducible method of determining skeletal age. Prediction errors in mFels and abFels skeletal ages were clinically comparable with those in G-P skeletal ages in this epiphysiodesis cohort. Further work is warranted to optimize and validate the accuracy of mFels and abFels skeletal ages to predict LLD and the impact of epiphysiodesis, particularly in females. Both the mFels and abFels systems are promising means of estimating skeletal age, avoiding additional radiation and health-care expenditure. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

The Reliability of the Modified Fels Knee Skeletal Maturity System.

BACKGROUND: The recently described Modified Fels knee skeletal maturity system (mFels) has proven utility in prediction of ultimate lower extremity length in modern pediatric patients. mFels users evaluate chronological age, sex, and 7 anteroposterior knee radiographic parameters to produce a skeletal age estimate. We developed a free mobile application to minimize the learning curve of mFels radiographic parameter evaluation. We sought to identify the reliability of mFels for new users. METHODS: Five pediatric orthopaedic surgeons, 5 orthopaedic surgery residents, 3 pediatric orthopaedic nurse practitioners, and 5 medical students completely naïve to mFels each evaluated a set of 20 pediatric anteroposterior knee radiographs with the assistance of the (What's the Skeletal Maturity?) mobile application. They were not provided any guidance beyond the instructions and examples embedded in the app. The results of their radiographic evaluations and skeletal age estimates were compared with those of the mFels app developers. RESULTS: Averaging across participant groups, inter-rater reliability for each mFels parameter ranged from 0.73 to 0.91. Inter-rater reliability of skeletal age estimates was 0.98. Regardless of group, steady proficiency was reached by the seventh radiograph measured. CONCLUSIONS: mFels is a reliable means of skeletal maturity evaluation. No special instruction is necessary for first time users at any level to utilize the (What's the Skeletal Maturity?) mobile application, and proficiency in skeletal age estimation is obtained by the seventh radiograph. LEVEL OF EVIDENCE: Level II.

Correlations Between Eight Comprehensive Skeletal Maturity Systems in a Modern Peripubertal Pediatric Population.

BACKGROUND: Several skeletal maturity systems allow for accurate skeletal age assessment from a wide variety of joints. However, discrepancies in estimates have been noted when applying systems concurrently. The aims of our study were to (1) compare the agreement among 8 different skeletal maturity systems in modern pediatric patients and (2) compare these discrepancy trends qbetween modern and historic children. METHODS: We performed a retrospective (January 2000 to May 2022) query of our picture archiving and communication systems and included peripubertal patients who had at least two radiographs of different anatomic regions obtained ≤3 months apart for 8 systems: (1) proximal humerus ossification system (PHOS), (2) olecranon apophysis ossification staging system (OAOSS), (3) lateral elbow system, (4) modified Fels wrist system, (5) Sanders Hand Classification, (6) optimized oxford hip system, (7) modified Fels knee system, and (8) calcaneal apophysis ossification staging system (CAOSS). Any abnormal (ie, evidence of fracture or congenital deformity) or low-quality radiographs were excluded. These were compared with a cohort from a historic longitudinal study. SEM skeletal age, representing the variance of skeletal age estimates, was calculated for each system and used to compare system precision. RESULTS: A total of 700 radiographs from 350 modern patients and 954 radiographs from 66 historic patients were evaluated. In the modern cohort, the greatest variance was seen in PHOS (SEM: 0.28 y), Sanders Hand (0.26 y), and CAOSS (0.25 y). The modified Fels knee system demonstrated the smallest variance (0.20 y). For historic children, the PHOS, OAOSS, and CAOSS were the least precise (0.20 y for all). All other systems performed similarly in historic children with lower SEMs (range: 0.18 to 0.19 y). The lateral elbow system was more precise than the OAOSS in both cohorts. CONCLUSIONS: The precision of skeletal maturity systems varies across anatomic regions. Staged, single-parameter systems (eg, PHOS, Sanders Hand, OAOSS, and CAOSS) may correlate less with other systems than those with more parameters. LEVEL OF EVIDENCE: Level III-retrospective study.

Postmobilization Plain Radiography After Lateral Compression Type 1 Pelvic Ring Injury Does Not Affect Treatment.

INTRODUCTION: The purpose of this study was to describe the practice of postmobilization radiography after lateral compression type 1 pelvis ring injury. We hypothesized that postmobilization radiographs would be more frequent over time and would not influence treatment. METHODS: Displacement of pelvis ring injury on initial and final plain radiographs was measured. Frequency of postmobilization radiography was determined, and the impact on treatment and final radiographical outcome were assessed. RESULTS: Of the 156 patients reviewed, 98 (62.8%) were women and mean age was 60.1 years. Thirty-three of 156 patients (21.2%) had a postmobilization radiograph. Over 5 years, radiographs increased to 67% of presenting patients. None of the patients who received postmobilization plain radiographs (n = 33) had any change in clinical plan afterward; all continued with nonsurgical care. Initial fracture characteristics and alignment were no different for patients with postmobilization radiographs. Final alignment was unchanged in nearly 70%. Overall, 74% of all nonsurgical patients experienced no change in alignment, with similar rates among the patients with postmobilization radiographs. DISCUSSION: Patients with an lateral compression type 1 fracture demonstrated no changes in care after receiving postmobilization radiographs. However, the frequency of postmobilization radiographs increased over time, denoting opportunities to reduce costs and to improve efficiency and safety.

Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries.

BACKGROUND: Pediatric femoral shaft nonunion after use of a plate or intramedullary nail (IMN) is uncommon in the United States. In low and middle-income countries, as defined by The World Bank, these complications may occur with greater frequency. We assessed the rates of union and painless weight-bearing after IMN fixation of pediatric femoral shaft nonunion in lower-resource settings. METHODS: We queried the SIGN (Surgical Implant Generation Network) Fracture Care International online database to identify all pediatric femoral shaft nonunions that had occurred since 2003 and had ≥3 months of follow-up after their treatment; our query identified 85 fractures in 83 patients. We defined nonunion as failure of initial instrumentation >90 days following its placement, lack of radiographic progression on radiographs made >3 months apart, or the absence of signs of radiographic healing >6 months after initial instrumentation. We evaluated the most recent follow-up radiograph to determine a Radiographic Union Scale in Tibial fractures (RUST) score. We also recorded rates of painless full weight-bearing as assessed by the treating surgeon. RESULTS: Fifty-seven patients with pediatric femoral shaft nonunions (including 42 male and 15 female patients from 18 countries) were included. The average age (and standard deviation) at the time of revision surgery was 13.8 ± 3.0 years (range, 6 to 17 years). The median duration of follow-up was 67 weeks (range, 13 weeks to 7.7 years). The initial instrumentation that went on to implant failure included plate constructs (56%), non-SIGN IMNs (40%), and SIGN IMNs (4%). At the time of the latest follow-up, 52 patients (91%) had a RUST score of ≥10 and 51 (89%) had painless full weight-bearing. No patient had radiographic evidence of femoral head osteonecrosis at the time of complete fracture-healing or the latest follow-up. CONCLUSIONS: Pediatric femoral shaft nonunion can occur after both plate and IMN fixation in low and middle-income countries. IMN fixation is an effective and safe treatment for these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Applicability of Shoulder, Olecranon, and Wrist-based Skeletal Maturity Estimation Systems to the Modern Pediatric Population.

BACKGROUND: The proximal humerus ossification system (PHOS), olecranon apophyseal ossification system (OAOS), and modified Fels wrist skeletal maturity system (mFWS) were recently developed or updated using a historical, mostly White, pediatric population. These upper extremity skeletal maturity systems have demonstrated skeletal age estimation performance superior or equivalent to Greulich and Pyle in historical patients. Their applicability to modern pediatric populations has not yet been evaluated. METHODS: We reviewed anteroposterior shoulder, lateral elbow, and anteroposterior hand and wrist x-rays of 4 pediatric cohorts: White males, Black males, White females, and Black females. Peripubertal x-rays were evaluated: males 9 to17 years and females 7 to 15 years. Five nonpathologic radiographs for each age and joint were randomly selected from each group. Skeletal age estimates made by each of the 3 skeletal maturity systems were plotted against the chronological age associated with each radiograph and compared between cohorts, and with the historical patients. RESULTS: Five hundred forty modern radiographs were evaluated (180 shoulders, 180 elbows, and 180 wrists). All radiographic parameters had inter- and intra-rater reliability coefficients at or above 0.79, indicating very good reliability. For PHOS, White males had delayed skeletal age compared with Black males (Δ-0.12 y, P =0.02) and historical males (Δ-0.17 y, P <0.001). Black females were skeletally advanced compared with historical females (Δ0.11 y, P =0.01). For OAOS, White males (Δ-0.31 y, P <0.001) and Black males (Δ-0.24 y, P <0.001) had delayed skeletal age compared with historical males. For mFWS, White males (Δ0.29 y, P =0.024), Black males (Δ0.58 y, P <0.001), and Black females (Δ0.44 y, P <0.001) had advanced skeletal age compared with historical counterparts of the same sex. All other comparisons were not significant ( P >0.05). CONCLUSIONS: The PHOS, OAOS, and mFWS have mild discrepancies in skeletal age estimates when applied to modern pediatric populations depending on the race and sex of the patient. LEVEL OF EVIDENCE: Level III - retrospective chart review.

Value Challenge: A Bottoms-Up Approach to Minimizing Cost and Waste in Orthopaedic Surgery.

Astronomical increases in medical expenses and waste produce widespread financial and environmental impacts. Minor changes to minimize costs within orthopaedics, the most used surgical subspecialty, could result in substantial savings. However, few orthopaedic surgeons are educated or experienced to implement cost containment strategies. This study aims to investigate cost containment opportunities and provide a framework for educating and incorporating residents into cost-saving initiatives. Methods: Orthopaedic surgical residents from an academic program with a Level I trauma center were queried during 2019 to 2022 regarding suggestions for cost containment opportunities. Based on feasibility and the estimated impact, 7 responses were selected to undergo cost-saving analyses. Results: The proposed initiatives fell into 2 categories: minimizing waste and optimizing patient care. Eliminating nonessential physical therapy/occupational therapy consults led to the greatest estimated savings ($8.6M charges/year), followed by conserving reusable drill bits ($2.2M/year) and reducing computed tomography scans on lower extremity injuries ($446K/year). Conclusion: Current medical training provides limited formal education on cost-effective care. Efforts to mitigate the growing financial and environmental costs of health care should include encouraging and incorporating resident feedback into cost reduction strategies. This tactic will likely have a positive impact on the behavior of such resident surgeons as they enter practice and have more awareness of costs and value. Level of Evidence: V (cost-minimization study).

Evaluating patient recall following operative orthopaedic trauma.

INTRODUCTION: Orthopedic trauma patients may have poor recall of their injuries and treatment. This may lead to poor adherence to instructions. The purposes of this project were to quantify recall about injury and treatment information, and to assess adherence to postoperative instructions and satisfaction with care. METHODS: A prospective cohort of 110 consecutive adult orthopaedic trauma patients treated for acute injury at a Level 1 trauma center were included. All had undergone surgical treatment of fractures of the pelvis or lower extremity. A brief survey to assess patient recall about injury and treatment knowledge, adherence to weightbearing and DVT recommendations and to evaluate patient satisfaction was administered during the first post-hospital clinic visit. RESULTS: Patients correctly answered 64% of recall-oriented questions. 82% and 83% of patients, respectively, reported adherence to their weightbearing restrictions and their DVT prophylaxis regimen, while 66% of patients reported adherence to both. Forty-two percent of non-adherent patients could not remember their weightbearing restrictions, while 78% of non-adherent patients could not remember their DVT prophylaxis regimen. Average patient satisfaction was 4.3 (range 1-5), with 15% of patients indicating neutral sentiment or dissatisfaction with their care. CONCLUSION: Orthopaedic trauma patients have poor recall, which likely reduces postoperative adherence and may impair patient satisfaction. A postoperative educational protocol focused on improving patient recall may be useful. LEVEL OF EVIDENCE: Level 4, prognostic.

Applicability of the Modified Fels and Optimized Oxford Skeletal Maturity Estimation Systems to the Modern Pediatric Population.

BACKGROUND: The recently developed modified Fels knee and optimized Oxford hip skeletal maturity systems (SMS) have demonstrated impressive performance compared with the Greulich and Pyle skeletal age atlas when applied to the same historical, mostly white, pediatric population. We sought to determine whether these 2 systems require modification before being used in modern children. METHODS: We collected knee and hip radiographs between January 2015 and September 2020 from our electronic medical record from 4 groups of children: (1) white males, (2) black males, (3) white females, and (4) black females. Males between 9 and 17 years and females between 7 and 15 years were included. After reliability analyses, 5 nonpathologic radiographs for each age and joint were randomly selected from each group and evaluated with the appropriate SMS. The mean discrepancy between each group's chronological age at the time of radiograph and estimated skeletal age was compared between our modern cohort and the historical Bolton-Brush children. After normality testing, paired t tests or Wilcoxon signed-rank tests were performed, as appropriate. A Bonferroni correction was applied to address multiple testing. RESULTS: Three hundred sixty modern radiographs were evaluated (180 knees and 180 hips). All 7 modified Fels knee parameters and all 5 optimized Oxford hip parameters had inter and intrarater reliability coefficients ≥0.7, indicating good to very good reliability. For the modified Fels knee SMS, white males (Δ0.74 y, P <0.001), black males (Δ0.69 y, P <0.001), and black females (Δ0.4 y, P =0.04) had advanced skeletal age compared with their historical counterparts of the same sex. No differences were found between historical and modern patients for the optimized Oxford hip SMS. No differences were found for either SMS comparing modern patients along racial lines ( P >0.05 for all). CONCLUSIONS: Discrepancies in skeletal age estimates made by the modified Fels knee SMS exist between modern pediatric white males, black males, and black females and their historic counterparts. No differences were found when using optimized Oxford hip SMS. Future studies should evaluate how these translate to clinical decision-making. LEVEL OF EVIDENCE: Level III; retrospective chart review.

Anterior and superior plate positions in diaphyseal clavicle fractures produce similar patient outcomes.

PURPOSE: While diaphyseal clavicle fractures can be treated with plate fixation on either the superior or anteroinferior aspect of the clavicle, the optimal plate position remains controversial. The purpose of this study was to determine if anteroinferior vs. superior plating for clavicle fracture fixation leads to better patient outcomes. METHODS: A retrospective review of patients who sustained clavicle fractures (OTA/AO 15.2) treated with superior or anteroinferior plating at a tertiary Level I trauma center from 2015 to 2021 was performed. The clinical outcomes of clavicle fractures were compared between groups treated with an anterior versus a superior approach via Mann-Whitney U and Chi-squared tests as appropriate to evaluate for differences in outcomes between the two plate positions. RESULTS: A total of 315 diaphyseal clavicle fractures were identified. One hundred and forty patients were excluded due to inadequate follow-up. Of the remaining 175 patients, 25 were treated with an anteroinferior approach (14%) and 150 were treated with a superior approach (86%). There were no differences in age, BMI, tobacco use, or substance use between the two groups (p > 0.05 for all). On univariate analysis, there was no difference in rate of union (p = 0.60), nerve injury (p = 0.60), infection (p = 1.0), implant-related irritation (p = 0.42), implant removal (p = 0.26), or revision (p = 1.0) based on approach. Contoured plates had an association with risk of nerve injury (p = 0.04). CONCLUSION: There are no differences in union, nerve injury, infection, symptomatic implant, or revision rate between anteroinferior and superior clavicle approaches. Plate positioning during diaphyseal clavicle fracture fixation can reasonably be dictated based on surgeon preference and ideal reduction quality.

Which Application Factors Are Associated With Outstanding Performance in Orthopaedic Surgery Residency?

BACKGROUND: Identifying ideal candidates for orthopaedic surgery residency is difficult. Data available for applicant selection are evolving; preclinical grades and the Alpha Omega Alpha (AOA) honors society are being phased out at some medical schools. Similarly, three-digit United States Medical Licensing Examination (USMLE) Step 1 scores have been eliminated. There is renewed interest in improving resident selection to provide a diverse, comprehensive educational opportunity that produces orthopaedic surgeons who are prepared for practice. QUESTIONS/PURPOSES: We sought to identify whether (1) academic achievements, (2) letters of recommendation, (3) research activity, and (4) miscellaneous factors available on Electronic Residency Application Service (ERAS) applications were associated with outstanding residency performance. METHODS: Ten faculty members (22% of all full-time faculty) with extensive educational involvement for at least 7 years, whose expertise covered all subspecialty departments at an urban, academic orthopaedic surgery residency program, were given an anonymous survey on the performance of the four most recent classes of residency graduates (24 residents). This survey was developed due to the lack of a validated residency outcomes tool or objective metrics for residency performance. The evaluated criteria were decided upon after discussion by a relatively large group of academic orthopaedic surgeons considering the factors most important for graduating orthopaedic residents. The faculty were selected based on their long-term knowledge of the residency, along with their diversity of specialty and backgrounds; there were no nonresponders. Faculty graded each resident on a scale from 1 to 10 (higher is better) on six criteria: surgical technical skills, research productivity, clinical knowledge, professionalism, personality, and fellowship match. The mean of the faculty ratings made by all faculty for all six criteria was calculated, producing the overall residency performance score. Factors available on each resident's ERAS application were then correlated with their overall residency performance score. Categorical ERAS factors, including AOA status, five or more honors in core clerkships, at least three exceptional letters of recommendation, collegiate athletics participation, expertise with a musical instrument, and research (6-year) track residents, were correlated with overall residency performance score via point biserial analysis. Continuous ERAS factors including USMLE Step 1 and Step 2 scores, number of publications before residency, number of research years before residency, medical school ranking, and number of volunteer experiences were correlated with overall residency performance score via Pearson correlation. USMLE Step 1 three-digit scores were evaluated despite their recent elimination because of their historic importance as a screening tool for residency interviews and for comparison to USMLE Step 2, which retains a three-digit score. Application factors with a p < 0.2 on univariate analysis (five or more honors in core clerkships, at least three exceptional letters of recommendation, research track residents) were included in a stepwise linear regression model with "overall residency performance score" as the outcome variable. All p values < 0.05 were considered significant. RESULTS: The mean overall residency performance score was 7.9 ± 1.2. Applicants with at least five honors grades in core clerkships had overall residency performance scores 1.2 points greater than those of their peers (95% confidence interval (CI) 0.3 to 2.0; p = 0.01, Cohen ƒ 2 = 0.2, representing a small effect size). ERAS applications including at least three exceptional letters of recommendation were associated with a 0.9-point increase in residency performance (95% CI 0.02 to 1.7; p = 0.046, Cohen ƒ 2 = 0.1, representing a small effect size). Participation in the residency research (6-year) track was associated with a 1-point improvement in residency performance (95% CI 0.1 to 1.9; p = 0.03, Cohen ƒ 2 = 0.2, again, representing a small effect size). Together, these three factors accounted for 53% of the variance in overall residency performance score observed in this study. CONCLUSION: Past clinical excellence, measured by core clerkship grades and exceptional letters of recommendation, is associated with slightly improved overall orthopaedic residency performance scores. Applicants meeting both criteria who also complete a research track residency may perform substantially better in residency than their counterparts, as these three factors accounted for half of all the variance observed in the current study. Although minimum requirements are necessary, traditionally used screening factors (such as USMLE scores, AOA status, medical school rank, and number of publications) may be of less utility in identifying successful future residents than previously thought. LEVEL OF EVIDENCE: Level III, therapeutic study.

Biologics, Stem Cells, Growth Factors, Platelet-Rich Plasma, Hemarthrosis, and Scaffolds May Enhance Anterior Cruciate Ligament Surgical Treatment.

Biologics including mesenchymal stem cells (MSCs), growth factors, and platelet-rich plasma may enhance anterior cruciate ligament (ACL) reconstruction and even ACL primary repair. In addition, hemarthrosis after acute ACL injury represents a source of biologic factors. MSCs can differentiate into both fibroblasts and osteoblasts, potentially providing a transition between the ligament or graft and bone. MSCs also produce cytokines and growth factors necessary for cartilage, bone, ligament, and tendon regeneration. MSC sources including bone marrow, synovium, adipose tissue, ACL-remnant, patellar tendon, and umbilical cord. Also, scaffolds may represent a tool for ACL tissue engineering. A scaffold should be porous, which allows cell growth and flow of nutrients and waste, should be biocompatible, and might have mechanical properties that match the native ACL. Scaffolds have the potential to deliver bioactive molecules or stem cells. Synthetic and biologically derived scaffolds are widely available. ACL reconstruction with improved outcome, ACL repair, and ACL tissue engineering are promising goals. LEVEL OF EVIDENCE: Level V, expert opinion.

Factors influencing participation in psychosocial programming among orthopaedic trauma patients with PTSD.

INTRODUCTION: Post Traumatic Stress Disorder (PTSD) commonly occurs following acute trauma. Post-injury outcomes are negatively impacted by PTSD. Trauma Recovery Services (TRS) programming was developed at our institution in 2013 to provide psychosocial programming that increases patient satisfaction with care and ability to return to work and decreases PTSD symptoms. We sought to identify factors that influence patients' decision to participate in programming. METHODS: Over a 3-year period at a single, urban level 1 trauma center, 172 patients over the age of 18 screened positive for PTSD on the validated PTSD checklist for DSM-5 (PCL-5) screening tool. Demographic, socioeconomic, injury, and medical comorbidity information was collected. Variables were initially compared in a univariate manner via Chi-squared, Fisher exact, t-test, or Mann-Whitney U, as appropriate. Variables that had a p-value <0.2 on univariate analysis were entered into a backward stepwise logistic regression model to identify independent predictors of participation in TRS programming. RESULTS: Mean age was 37.8 years. 70.1% of patients were male. The most common mechanisms of injury were gunshot wound (33.7%), motor vehicle crash (19.0%), and burn. 33.5% of patients participated in TRS programming. Nine predictors had p<.2 on univariate analysis and were entered into the stepwise regression model. Four predictors remained in the final model. Patients with private insurance (RR=2.2, p=.038), high school diploma or greater (RR=1.53, p=.002; Table 1), and PCL-5 score greater than 50 were more likely to participate in TRS programming (RR=1.42, p=.046). Patients who live 20 or more minutes away by car from TRS were less likely to participate in programming (RR=0.47, p=.065). DISCUSSION: Patients with more severe PTSD, higher levels of education, and private insurance were more likely to participate in TRS programming. Participation in TRS and similar psychosocial programs may be improved by minimizing the participant's potential commute to the program location.

The Systematic Isolation of Key Parameters for Estimating Skeletal Maturity on Lateral Elbow Radiographs.

BACKGROUND: Skeletal maturity estimation is central in the management of scoliosis and lower-limb deformity. Utilizing demographic characteristics and modern computing, we sought to create a reliable, rapid, and accurate method for measuring skeletal maturity on an elbow radiograph. METHODS: Utilizing the Bolton-Brush Collection, 4 parameters from the modified Sauvegrain method and 7 novel parameters were screened. Ten parameters were evaluated on serial peripubertal elbow radiographs, using Greulich and Pyle (GP) skeletal age from corresponding hand radiographs as a comparison. Stepwise linear regression and generalized estimating equations were used to identify radiographic and demographic parameters for estimating skeletal maturity based on 90% of final height. The elbow system was compared with GP only; olecranon apophysis only; age, sex, and GP; age, sex, and olecranon apophysis; age, sex, and elbow system with anteroposterior and lateral parameters; age, sex, and elbow system with anteroposterior parameters; and age, sex, and elbow system with lateral parameters. RESULTS: In this study, 367 radiographs from 77 patients (40 girls and 37 boys) were included. Following stepwise linear regression, 4 radiographic parameters were included in the anteroposterior and lateral elbow system; 3 were included in the anteroposterior elbow system; and 4 were included in the lateral elbow system. The lateral elbow system predicted skeletal maturity with a mean discrepancy of 0.41 year and produced similar mean discrepancies to GP with age and sex (0.42; p = 0.93), and it trended toward better performance than the olecranon apophysis system with age and sex (0.43; p = 0.06). The lateral elbow system had the lowest percent of outlier predictions >1 year discrepant from the skeletal maturity reference (4.6%), although it was only significantly better than the GP-only group (29.4%) and the olecranon apophysis-only group (21.0%) (p < 0.001 for both). CONCLUSIONS: We systematically developed a lateral elbow system that performed equivalently to GP using 4 simple parameters and trended toward outperforming the olecranon apophysis systems in skeletal maturity estimation. Future clinical validation will be necessary to understand the utility of this system. CLINICAL RELEVANCE: The lateral elbow system may be a more accurate prediction of skeletal maturity compared with the previously described olecranon apophysis system and can be used to guide the management of many pediatric orthopaedic conditions.

The Utility of the Modified Fels Knee Skeletal Maturity System in Limb Length Prediction.

BACKGROUND: Predicting ultimate lower extremity length is important in the treatment of lower limb length discrepancy (LLD), congenital limb deficiency, and other etiologies. Utilizing skeletal age over chronological age improves the prediction of ultimate lower extremity length. The recently described modified Fels knee skeletal maturity system allows for skeletal age estimation via imaging always available in LLD patients. We sought to compare the accuracy of the modified Fels knee skeletal maturity system versus chronological age in ultimate limb length prediction of a modern adolescent clinical population. METHODS: The medical records of all patients treated at our institution over a 20-year period with unilateral lower extremity pathology and available lower extremity imaging before and after reaching skeletal maturity were reviewed. Skeletal maturity was defined radiographically by closed distal femoral, proximal tibial, and proximal fibular physes. The femoral, tibial, and lower extremity length was measured in all radiographs. The modified Fels knee skeletal maturity system was applied to all radiographs obtained before maturity to estimate skeletal age. The accuracy of 3 widely utilized lower extremity length prediction systems was compared when utilizing estimated Fels skeletal age versus chronological age inputs. RESULTS: A total of 245 radiographs (109 before maturity) from 43 patients were eligible for inclusion. On cross-sectional analysis, linear modeling using Fels skeletal ages was uniformly associated with higher (improved) R2 values than chronological age-based models. On longitudinal analysis, skeletal age mixed-effects models had significantly lower (improved) Akaike information criterion and Bayesian information criterion values than chronological age models in all cases. Cohen d values were also significantly different (P<0.05) for the skeletal age models compared with chronological age models in all cases. CONCLUSIONS: In the treatment of LLD, the modified Fels knee skeletal maturity system can be readily applied to available imaging to improve the prediction of ultimate femoral, tibial, and lower extremity length. This skeletal maturity system may have significant utility in the estimation of ultimate LLD and determination of appropriate timing of epiphysiodesis. LEVEL OF EVIDENCE: Level III.

Estimating Skeletal Maturity Using Wrist Radiographs During Preadolescence: The Epiphyseal:Metaphyseal Ratio.

BACKGROUND: Although skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances, such as scoliosis, limb length discrepancy, or endocrinopathies. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents using wrist radiographs is lacking. METHODS: Serial anteroposterior wrist radiographs taken at historical growth study visits leading up to the chronological age (CA) associated with 90% of the final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 102 children. Epiphyseal and metaphyseal widths of 5 physes were evaluated: distal radius, distal ulna, first metacarpal, third metacarpal, and fifth metacarpal. Ulnar styloid height and radial styloid height were also measured, for a total of 7 epiphyseal:metaphyseal radiographic parameters. Greulich and Pyle (GP) bone age was also measured. A combination of stepwise linear regression and generalized estimating equation analyses was used to produce a skeletal maturity estimation model incorporating demographics (CA and sex) and the epiphyseal:metaphyseal ratios significantly correlated with skeletal maturity. RESULTS: A total of 273 left anteroposterior hand-wrist radiographs from 56 girls (163 radiographs, range 4 to 13 y) and 46 boys (112 radiographs, range 3.8 to 15 y) were included. The demographics+ratios model had better prediction accuracy than GP only and GP with demographics (0.44, 0.87, and 0.47 y mean discrepancy from actual skeletal age, P <0.05 for both comparisons). There was no significant difference in the rate of outlier skeletal age estimates, defined as an estimate >1 year off from the true skeletal age, between the demographics+ratios model and the demographics+GP model (5.9% vs. 8.4%, P =0.12). CONCLUSIONS: When combined with CA and sex data, measurement of the epiphyseal:metaphyseal ratios of the left first and third metacarpals allows for improved skeletal maturity estimation compared with the GP technique. CLINICAL RELEVANCE: Our modified wrist skeletal maturity system offers a relatively quick and reproducible method for estimating skeletal maturity extending into the juvenile age range. This study is a level III retrospective study of longitudinal human growth data obtained from the Bolton Brush Collection in Cleveland, Ohio.

Treating trauma more effectively: A review of psychosocial programming.

IMPORTANCE: Traumatic events are the leading cause of life-altering disability in adults of working age. The management of patients with traumatic injury has substantially improved due to development of sophisticated trauma centers increasing survival after injury. Unlike the adoption of the trauma system framework, the same has not occurred with specialized trauma recovery services to include mental and social health needs. This literature review will discuss unique issues facing trauma survivors, some current recovery programs available, outcomes and benefits of these programs, and barriers that impair widespread incorporation. OBSERVATIONS: Studies have shown that patients with traumatic injury experience reduction in quality of life and concurrent threats to mental health, including post-traumatic stress disorder (PTSD), alcohol use disorder, and recreational substance abuse. Patients with traumatic injury also have high recidivism rates, low pain management satisfaction, and poor engagement in care following injury. Screening efforts for PTSD, mental illness, and alcohol and substance abuse are more widely available interventions. Early coordinated efforts included dedicated multidisciplinary recovery teams. Recently, more methodical and organized programs, such as the Trauma Survivors Network, trauma collaborative care, Trauma Recovery Services, and Center of Trauma Survivorship, have been implemented. CONCLUSIONS AND RELEVANCE: The enrollment of patients with traumatic injury in novel programs to enhance recovery has led to heightened self-efficacy, better coping mechanisms, and increased use of mental health services. Additionally, trauma recovery services have been shown to reduce recidivism and have generated cost savings for hospital systems. While positive outcomes have been demonstrated, they are not consistently predictable. Barriers for widespread implementation include limitations of time, funding, and institutional support. This article describes models of successful programs initiated within some trauma centers, which may be duplicated to serve future trauma survivors.