Does arthroscopic or open washout in native knee septic arthritis result in superior post-operative function? A systematic review and meta-analysis of randomised controlled trials and observational studies.

AIMS: Septic arthritis (SA) of the native knee joint is associated with significant morbidity. This review compared post-operative functional outcomes (patient-reported outcome measures (PROMs) and range of movement (ROM)) following arthroscopic washout (AW) and open washout (OW) amongst adult patients with SA of the native knee. The need for further operative intervention was also considered. METHODS: Electronic databases of PubMed, MEDLINE, Embase, Cochrane, Web of Science and Scopus were searched between 16 February 2023 and 18 March 2023. Randomised controlled trials (RCTs) and comparative observational analytic studies comparing function (reflected in PROMs or ROM) at latest follow-up following AW and OW were included. A narrative summary was provided concerning post-operative PROMs. Pooled estimates for mean ROM and re-operation rates were conducted using the random-effects model. The risk of bias was assessed using the Cochrane risk-of-bias assessment tool-2 for RCTs and the Risk of Bias in Non-Randomized Studies of Interventions tool for observational analytic studies. RESULTS: Of 2580 retrieved citations, 7 articles (1 RCT and 6 cohort studies) met the inclusion criteria. Of these, five had some concerns/moderate risk of bias, and two had serious risk. There was a slight tendency for superior mean PROMs following AW compared with OW, but due to small effect sizes, this was unlikely clinically relevant. Additionally, the use of four different PROMs scales made direct comparisons impossible. AW was associated with superior ROM (mean difference 20.18° (95% CI 14.35, 26.02; p < 0.00001)), whilst there was a tendency for lower re-operation requirements following AW (OR 0.64, 95% CI 0.26, 1.57, p = 0.44). CONCLUSIONS: AW was associated with equivalent to superior post-operative function and lower requirement for further intervention compared with OW. Results need to be interpreted cautiously, taking into consideration the methodological and clinical heterogeneity of the included studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO 2022, CRD42022364062.

A retrospective single-institution review of the impact of COVID-19 on severity of biliary disease.

BACKGROUND: The COVID-19 pandemic possessed far-reaching health implications beyond the public health impact that have yet to be fully elucidated. We hypothesized that the COVID-19 pandemic led to an increase in biliary disease complexity and incidence of emergency cholecystectomy. METHODS: We reviewed our institutional experience with cholecystectomy from February 2019-February 2021, n = 912. Pre COVID-19 pandemic patients were compared to patients after the onset of the pandemic. Baseline characteristics were compared between groups. A Cochran-Armitage test for trend assessed the temporal impact of COVID-19 on emergency presentation and gallbladder disease complexity. RESULTS: We identified 442 patients pre-pandemic and 470 patients during the pandemic. No significant differences were noted in demographics. COVID-19 significantly impacted emergency presentation (43.2% vs. 56.8%, p= <0.01), cholecystitis (53.2% vs 61.8%; p=<0.01), and gangrenous cholecystitis (2.8% vs 6.1%; p=<0.01). Both groups had similar clinical outcomes. CONCLUSIONS: The COVID-19 pandemic affected an increased incidence of emergency presentation and complexity of gallbladder disease but did not significantly impact clinical outcomes. These findings may have broader implications for other diseases possibly affected by COVID-19.

Comparing pinning in situ and capital realignment procedures for severe, stable slipped capital femoral epiphysis: a systematic review.

In severe, stable slipped capital femoral epiphysis, it is unclear whether pinning in situ (PIS) or capital realignment procedures (CRPs) are superior. Our primary aim was to compare patient-reported outcome measures (PROMs) following each strategy. Secondary aims were to compare rates of femoral head avascular necrosis (AVN) and complications. MEDLINE, Embase and Cochrane databases were searched according to an agreed strategy. Narrative review articles, case reports, letters to the editor and articles not written in English were excluded. The risk of bias was assessed using the Newcastle-Ottawa Scale. Of the 132 citations identified, 127 were excluded following de-duplication and application of the exclusion criteria. Three observational studies comparing PIS with CRP and two case series considering CRP alone were identified. One article was considered fair quality, and four articles were considered poor. In total, 198 hips from five studies were included (66 PIS, 132 CRP). PIS was associated with moderate-good functional outcomes, and CRP with good-high outcomes. Two comparative studies reported significantly better PROMs following CRP. AVN was reported in 1.5% following PIS and 10.6% following CRP. Regarding other complications, chondrolysis occurred in 3.0% following PIS and 2.4% following CRP. Femoroacetabular impingement rates were markedly higher following PIS (60.6% versus 2.3%). Reoperation rates were also greater following PIS (34.5% versus 13.3%). PIS tends to be associated with favourable AVN rates, but CRP with favourable PROMs and complication rates. However, comparisons were drawn from heterogeneous studies lacking long-term follow-up. Further high-quality research is required.

Leadership Development Among Junior Surgery Residents: Communication and Perception.

INTRODUCTION: Leadership is necessary for effective health care teams, particularly for surgeons. Trainees similarly must acquire foundational leadership skills to maximize effectiveness. However, surgical leadership is rarely formally assessed, particularly for junior trainees. We aimed to establish themes of communication, perception and engagement styles, as well as strengths and weaknesses among junior surgical residents at a single institution. METHODS: The Data Dome Inc. (datadome.com) DISC personality assessment was administered in 2018-2021 to junior residents at an academic general surgery training program at a single institution. Resident demographics were recorded, and themes from deidentified reports were analyzed by year (PGY-1 and PGY-2) using JMP 16 Pro Text Explorer. RESULTS: PGY-1 communication was most frequently described as "accomplished best by well-defined avenues" with "duties and responsibilities of others who will be involved explained" in "friendly terms." PGY-2 communication involved "deal [ing] with people," "strong feelings about a particular problem," and being "good at giving verbal and nonverbal feedback." In ideal environments, PGY-1s self-perceived as "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-1s were perceived by others as "poor listener [s]," "self-promoter [s]," "detached," and "insensitive." In ideal environments, PGY-2s were also "good listener [s]," "good-natured," and "team player [s]." However, under stress, PGY-2 external perception was "overly confident," "poor listener [s]," and "self-promoter [s]." CONCLUSIONS: Clear expectations, friendly work environments, and opportunities to succeed are key to effectively train junior surgical residents. In environments where time is often a limited resource, surgical simulation, stress training, and standardized teaching methods from attending surgeons are needed to develop competent trainees.

Does Chair of Surgery Gender Influence Divisional or Residency Program Director Gender Diversity?

BACKGROUND: Workplace diversity is beneficial and results in new ideas and improved performance. Within surgery leadership, the gender gap is improving, but still present. Given the increasing number of women surgery department chairs, we aimed to examine the association of surgery chair gender with division and residency program director gender. We hypothesized that surgery departments with female leadership would have an increase in gender diversity compared to departments led by male chairs. MATERIALS AND METHODS: A list of all surgery departments were compiled from the Society of Surgical Chairs website. Gender of department chair, division director and residency program director were examined and compared. Chair position term length was determined based on online public announcements, publicly available curriculum vitae, and institutional profile biographies. RESULTS: Of 178 department chairs included, 10.7% were female, and 89.3% were male. There was no difference in female residency program director leadership between female versus male led programs (42.1 versus 26.1%, P= 0.147). Of the programs with female department chairs, only 29.4% had any female division directors compared to 54.6% led by male chairs (P= 0.055). When examining departments with ≥5 division directors, there was no difference in the average number of female division directors within departments led by female versus male chairs. There was a significant difference in length of surgery chairship, with female chairs holding the position for fewer years than male chairs (median time 5.3 (IQR = 3.4-5.8) versus 7.0 (IQR=4.3-12.3) years, P= 0.032). CONCLUSIONS: Female department chair leadership was not associated with increased diversity in divisional leadership compared to departments of surgery led by males.

Improving Identification of Cognitive Impairment in Fragility Fracture Patients: Impact of Educational Guidelines on Current Practice.

INTRODUCTION: Cognitive impairment can hinder a fracture patient's capacity to consent to surgery and negatively impact their postoperative recovery and rehabilitation. National guidelines recommend screening for cognitive impairment upon admission, and the Abbreviated Mental Test Score (AMTS) is a commonly used tool for this. This project aimed to assess current practice regarding documentation of AMTS among frail fracture patients upon admission and to improve AMTS documentation following a simple intervention. METHODS: Baseline data were obtained by inpatient chart review throughout November to December 2018 in a district general hospital with emergency fracture services. All patients admitted with a fragility hip fracture and patients over 65 years with any fracture were included. National guidelines and baseline results were then distributed among junior doctors. Following an intervention, further data were collected throughout January to February 2019. RESULTS: Preintervention, 40 suitable patients (mean age: 82 years) were identified; 9 (22.0%) of whom had an AMTS recorded upon admission. Among the hip fracture subgroup (n = 25), 7 (26.9%) had an AMTS recorded. Postintervention, 39 patients (mean age: 80 years) were identified; 15 (38.5%) of whom had an AMTS recorded. Among the hip fracture subgroup (n = 30), 11 (36.7%) had an AMTS recorded. Statistical analysis demonstrated a significant improvement in AMTS documentation both among the overall cohort (P = .001) and hip fracture patients (P = .019). No significant association was found between AMTS documentation and patient age (P = .566), grade of admitting doctor (P = .058), or prior cognitive/mental health disorder (P = .256). DISCUSSION: A small yet significant improvement in AMTS documentation among elderly/hip fracture patients was observed following distribution of educational material. Further work should explore the effect of cognitive impairment on outcomes related to orthopedic injuries beyond hip fractures.