The double-edged scalpel: Experiences and perceptions of pregnancy and parenthood during Canadian surgical residency training.

INTRODUCTION: Only 34% of Canadian surgeons in 2022 were female. The protracted length of surgical residency training, concerns regarding infertility, and increased rates of obstetrical complications have been shown to contribute to the disproportionate lack of females in surgical specialties. METHODS: A novel online survey was sent to all surgical residents in Canada. Respondents were asked about perceptions of pregnancy and parenthood during surgical training, and parents were asked about parental leave, accommodations they received, and pregnancy complications. Chi squared tests were used to compare opinions of male and female residents. RESULTS: A total of 272/2,419 (11.2%) responses were obtained, with a high response from females (61.8%) and orthopaedic residents (29.0%). There were 56 women reporting 76 pregnancy events during training, 62.5% of which had complications. Notably, 27.3% of men and 86.7% of women 'agreed' or 'strongly agreed' that surgeons have higher pregnancy complication rates than the general population (p<0.001). Men were much less likely to believe that pregnant residents should be offered modified duties (74.2% of men, 90.0% of women, p = 0.003). Women were much more likely to experience significant stigma or bias due to their status as a parent (43% of women, 0% of men, p<0.001). Women reported negative comments from others at a higher rate (58.5% of women, 40.7% of men, p = 0.013). Women believe there is negative stigma attached to being pregnant during training (62.7% of women, 42.7% of men, p = 0.01). The limitations of our study include a small sample size and response bias. CONCLUSION: Challenges and negative perceptions exist around pregnancy and parenthood in surgical residency, which disproportionately affect women trainees.

Anteromedial coronoid fractures: technical description of an extensile surgical approach and outcomes from a small series using this technique.

Background: Varus posteromedial rotatory instability is a difficult clinical problem to diagnose and treat. Fixation of the anteromedial coronoid fracture is often necessary to achieve elbow stability. We describe an extensile surgical approach to the anteromedial coronoid. Methods: A retrospective review was performed of all patients at our institution who had anteromedial coronoid fracture fixed with this approach between 2012 and 2020. Results: Six patients were identified. They all achieved a stable elbow. Four of 6 developed heterotopic ossification and 2/6 required further surgery for this. Only 1 patient had a transient ulnar sensory loss. Conclusion: We describe an approach to the coronoid that allows great visualization of the joint and access to large coronoid fractures. The approach is extensile and does not require extensive dissection or work around the ulnar nerve. Access to fracture and for fixation can be improved by release of the common flexor pronator origin and the medial collateral ligament.

Patient Satisfaction with Pisiform Excision for Pisotriquetral Instability or Arthritis: A Prospective Review.

Background Pisotriquetral pain and instability is an elusive cause of ulnar-sided wrist pain. Initial treatment of chronic pisotriquetral pathology should involve a trial of nonoperative therapy such as neutral wrist splint, anti-inflammatories, and intra-articular steroid injections. The mainstay of surgical management of pisotriquetral pain is pisiform excision. Purpose This prospective study seeks to understand patient satisfaction after pisiform excision in patients with isolated pisotriquetral pathology. Patients and Methods A consecutive series of nine cases of pisiform excision was performed by the senior surgeon. The primary outcome measure was determined a priori to be the Patient-Rated Wrist Evaluation (PRWE) score. Wrist range of motion, grip strength, and QuickDASH (shortened version of Disabilities of the Arm, Shoulder and Hand) scores were also collected preoperatively and at 3 and 12 months postoperatively as secondary outcome measures. Results There was a very rapid improvement in the PRWE by 3 months, which was maintained at 12 months. The QuickDASH score was slower to improve, with a significant improvement by 12 months. There was no change in grip strength or wrist range of motion at any time point. Conclusion Pisiform excision results in a very rapid improvement of symptoms and should be considered in cases of pisotriquetral instability or arthritis that fail conservative management. Level of Evidence Level IV, case series.

Safe Drill Trajectory for Anatomic Repair of Distal Biceps Tendon Through a Single Incision: A Cadaveric Study.

PURPOSE: We sought to determine the safest drill trajectory to avoid injury to the posterior interosseous nerve (PIN) when performing a repair of a distal biceps tendon to an anatomic location through an anterior, single-incision approach using cortical button fixation. METHODS: A standard anterior approach was performed in 10 cadaveric specimens to expose the distal biceps attachment. Three drill holes were made in the radial tuberosity from the center of the anatomic footprint for the distal biceps tendon insertion with the forearm fully supinated. Holes were made in 30° distal, transverse, and 30° proximal directions. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction, leaving adequate bone on the ulnar side to accommodate an 8-mm tunnel for the purpose of docking the biceps tendon into bone. The proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole, and the distance between the PIN and K-wire was measured for each trajectory. RESULTS: The distally directed drill hole placed the trajectory wire closest to the PIN (mean distance, 5.4 mm), contacting the K-wire in 3 cases. The transverse drill trajectory resulted in contact with the PIN in 1 case (mean distance, 7.6 mm). The proximal drill trajectory appeared safest, with no PIN contact (mean distance, 13.3 mm). CONCLUSIONS: In this cadaveric study, the proximal drill trajectory resulted in the widest clearance from the PIN. CLINICAL RELEVANCE: When performing repair of a distal biceps tendon to the anatomic location on the tuberosity, the drill trajectory from the center of the biceps footprint should be radial and proximal to provide the greatest separation between the drill guide and the PIN.

Level of Evidence for the Treatment of Chronic Noninsertional Achilles Tendinopathy.

BACKGROUND: Noninsertional Achilles tendinopathy affects both athletes and sedentary individuals, and its incidence is rising. Conservative management is the mainstay of treatment, but a variety of operative techniques have been described to treat recalcitrant cases. We seek to outline the current available evidence for surgical management of noninsertional Achilles tendinopathy. STUDY DESIGN AND METHODS: A systematic review was performed using the MEDLINE and EMBASE databases, and all articles were reviewed by at least 2 authors. Each article was assigned a level of evidence in accordance with the standards of Journal of Bone and Joint Surgery. The available data were reviewed and a level of evidence was assigned to each intervention of interest, based on the revised classifications of Wright. RESULTS AND CONCLUSION: A total of 46 articles met inclusion and exclusion criteria. There is fair evidence (grade B) in support of open debridement with 1 level II study, 1 level III study, and 8 level IV studies. There is fair evidence (grade B) in support of arthroscopic or minimally invasive surgical techniques. There is poor evidence (grade C) in support of flexor hallucis longus transfer, longitudinal tenotomy, peritenolysis, gastrocnemius recession, and plantaris excision. There is insufficient evidence (grade I) to provide a recommendation about other surgical treatment methods for noninsertional Achilles tendinopathy.Levels of Evidence: Level III: Systematic review.

Effect of orthopaedic resident education on screening for intimate partner violence.

BACKGROUND: Intimate Partner Violence (IPV) is prevalent in women presenting to orthopaedic fracture clinics. Rates of IPV have increased during the COVID-19 global pandemic. Our aim was to determine the effect of educational experiences on IPV knowledge and IPV screening to inform best-practices in resident education. METHODS: Cross-sectional online survey of orthopaedic surgery residency programs in Canada. Demographics, IPV educational experiences, IPV knowledge, and frequency of IPV screening were collected via a modified version of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS). Descriptive statistics and regression modeling identified predictors of IPV knowledge and frequency of IPV screening. RESULTS: Responses were obtained from 105 orthopaedic residents; 84% participated in classroom training, 39% underwent mentorship training, 32% received both classroom training and mentorship, and 10% reported neither. Classroom training had no statistically significant association with IPV knowledge or frequency of IPV screening. Residents who received mentorship were 4.1 times more likely to screen for IPV (95% CI: 1.72-10.05), older residents were more likely to screen for IPV (OR: 8.3, 95% CI: 2.64-29.84), and senior residents were less likely to screen for IPV than junior residents (OR: 0.29, 95% CI: 0.09-0.82). CONCLUSIONS: Classroom training was not associated with any effect on IPV knowledge nor the frequency of IPV screening. Educational efforts should be targeted at increasing mentorship opportunities in order to improve IPV screening practices in Canadian orthopaedic residents.