The Effects of Radial Longitudinal Deficiency on Long-Term Use of the Thumb in Pediatric Patients Following Index Pollicization.

PURPOSE: To assess the effect of radial longitudinal deficiency on the function of pollicized digits as determined by the Thumb Grasp and Pinch (T-GAP) assessment. METHODS: We retrospectively evaluated 25 hands with thumb hypoplasia that underwent index finger pollicization. Patients were followed for an average of 10.4 years. Hands were divided by severity into two groups: no or mild radial longitudinal deficiency (RLD) (Group 1 = 16) and moderate to severe RLD (Group 2 = 9). We collected demographic information and completed physical examination measures, including hand strength, elbow, wrist, and hand range of motion, the Kapandji opposition score, active grasp span, and T-GAP total score. RESULTS: Patients with moderate to severe forms of RLD had stiffer long fingers, lower Kapandji opposition scores, and limited active and passive range of motion for elbow flexion, wrist ulnar deviation, and pollicized thumb interphalangeal flexion. They had shorter forearms, decreased active grasp span, and fewer thumb creases at the interphalangeal thumb joint. In addition, the T-GAP total score was significantly lower when comparing the two groups. Children with mild dysplasia were able to achieve 32% of age-matched normal grasp strength. Patients with more severe radial dysplasia averaged 17% less grasp strength compared with children with mild dysplasia. Patients with moderate to severe RLD also had lower T-GAP total scores and strength measurements if they had limited wrist ulnar deviation. CONCLUSIONS: Individuals with moderate to severe RLD have unique anatomical factors that affect outcomes after pollicization. These individuals use their thumbs for fewer activities, have weaker grasp, and retain more primitive grasp patterns compared with those who have milder forms of RLD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Syndromic Involvement of Patients Presenting With Congenital Upper Limb Anomalies: An Analysis of 4,317 Cases.

PURPOSE: This study investigated the patterns of syndromic involvement for patients with congenital upper limb anomalies (CULAs). We hypothesize that patients with CULAs will present with predictable syndromic patterns. METHODS: This retrospective study queried the multicenter Congenital Upper Limb Differences (CoULD) Registry. Of the 4,317 patients enrolled, 578 (13%) reported one or more syndromes. Syndromes were confirmed to be recognized by the Online Mendelian Inheritance in Man. Demographics were reviewed and compared with the full CoULD registry group. Syndromes reported by five or more patients were examined to determine the type of CULA according to Oberg/Manske/Tonkin classifications. RESULTS: Of the 578 children with one or more reported syndromes, 517 had Online Mendelian Inheritance in Man recognized syndromes (cohort A), In cohort A, 58 syndromes were each represented by a single patient within the registry. Forty-eight syndromes in cohort A were reported by two or more patients, which accounted for 461 of the total patients with reported syndromes. However, VACTERL and Poland syndromes were the most commonly reported syndromes. Patients with CULAs and syndromes frequently exhibited bilateral involvement (61%), compared with the entire CoULD group (47%) and other orthopedic (50%) and medical conditions (61%) compared with the entire CoULD group (24% and 27%, respectively). Additionally, they exhibited a lower frequency of family history of a congenital orthopedic condition (21%) or a family member with the same CULA (9%) compared with the entire CoULD group (26% and 14%, respectively). CONCLUSIONS: Associated syndromes were recorded in 578 patients (13%) in the CoULD registry as follows: 58 syndromes represented by a single patient, 48 by 2 or more patients, and 23 syndromes by 5 or more patients. Rare syndromes that are only represented by a single patient are more likely to be unknown by a pediatric hand surgeon, and consultation with a geneticist is advised. TYPE OF STUDY/LEVEL OF EVIDENCE: Differential Diagnosis/Symptom Prevalence Study IV.

Congenital Upper-Limb Differences: A 6-Year Literature Review.

➤ The Oberg-Manske-Tonkin (OMT) classification of congenital hand and upper-limb anomalies continues to be refined as our understanding of the genetic and embryonic etiology of limb anomalies improves.➤ We have conducted an evaluation of graft and graftless techniques for syndactyly reconstruction; strengths and drawbacks exist for each technique.➤ Treatment for radial longitudinal deficiency remains controversial; however, radialization has shown promise in early follow-up for severe deformities.➤ Recent emphasis on psychosocial aspects of care has demonstrated that children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability.

Do Nails and Nubbins Matter? A Comparison of Symbrachydactyly and Transverse Deficiency Phenotypes.

PURPOSE: Transverse deficiency (TD) and symbrachydactyly may be difficult to distinguish due to shared phenotypes and a lack of pathognomonic features. The 2020 Oberg-Manske-Tonkin classification update modified these anomalies to include "with ectodermal elements" for symbrachydactyly and "without ectodermal elements" for TD as a defining differentiating characteristic. The purpose of this investigation was to characterize ectodermal elements and the level of deficiency and to examine whether ectodermal elements versus the level of deficiency was a greater determining factor for Congenital Upper Limb Differences (CoULD) surgeons making the diagnosis. METHODS: This was a retrospective review of 254 extremities from the CoULD registry with a diagnosis of symbrachydactyly or TD by pediatric hand surgeons. Ectodermal elements and the level of deficiency were characterized. A review of the registry radiographs and photographs was used to classify the diagnosis and compare it with the diagnosis given by the pediatric hand surgeons. The presence/absence of nubbins versus the level of deficiency as the determining factor to differentiate the pediatric hand surgeons' diagnosis of symbrachydactyly (with nubbins) versus TD (without nubbins) was analyzed. RESULTS: Based on radiographs and photographs of the 254 extremities, 66% had nubbins on the distal end of the limb; of the limbs with nubbins, nails were present on 51%. The level of deficiency was amelia/humeral (n = 9), <1/3 transverse forearm (n = 23), 1/3 to 2/3 transverse forearm (n = 27), 2/3 to full forearm TD (n = 38), and metacarpal/phalangeal (n = 103). The presence of nubbins was associated with a four times higher likelihood of a pediatric hand surgeon's diagnosis of symbrachydactyly. However, a distal deficiency is associated with a 20-times higher likelihood of a diagnosis of symbrachydactyly than a proximal deficiency. CONCLUSIONS: Although both the level of deficiency and ectodermal elements are important, the level of deficiency was a greater determining factor for a diagnosis of symbrachydactyly versus TD. Our results suggest that the level of deficiency and nubbins should both be described to help provide greater clarity in the diagnosis of symbrachydactyly versus TD. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Complications in the 2-Year Postoperative Period Following Pediatric Syndactyly Release.

PURPOSE: Syndactyly surgical release is one of the most common congenital hand surgeries performed by pediatric hand surgeons. The purpose of our study was to evaluate the complications associated with syndactyly release and determine factors that correlate with higher complication rates within the 2-year postoperative period. METHODS: A retrospective chart review was completed for patients who underwent syndactyly release at a single pediatric center between 2005 and 2018. Patients were included if they had a diagnosis of syndactyly and underwent surgical release, and excluded for a diagnosis of cleft hand, incomplete surgical documentation, surgery performed at an outside institution, or follow-up care that did not extend beyond the first postoperative visit. Complications were classified using the Clavien-Dindo (CD) system. RESULTS: Fifty-nine patients met the inclusion criteria, which included 143 webs released in 85 surgeries. A total of 27 complications occurred for the 85 surgeries performed. The severity of complications was CD grade I or II in 23% of surgeries, most commonly unplanned cast changes, and CD grade III in 8% of surgeries. No CD grade IV or V complications occurred. The CD grade III complications included 6 reoperations. The complication rate was higher when performing >1 syndactyly release per surgery. It also was higher for patients undergoing >1 surgical event. Rates of complication per surgery were similar between patients with multiple surgeries compared with those with a single surgery. Concomitant diagnoses and complexity of syndactyly was not associated with a higher complication rate. CONCLUSIONS: Syndactyly release was associated with a complication rate of 31% per surgical event with 44% of these complications related to unplanned cast changes and 8% of complications that required admission or reoperation. Risk factors for complications following syndactyly release include >1web operated on per surgery and undergoing >1 surgical event. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognosis IV.

American Board of Orthopaedic Surgery's Initiatives Toward Competency-Based Education.

The American Board of Orthopaedic Surgery (ABOS) is the national organization charged with defining education standards for graduate medical education in orthopaedic surgery. The purpose of this article is to describe initiatives taken by the ABOS to develop assessments of competency of residents to document their progress toward the independent practice of orthopaedic surgery and provide feedback for improved performance during training. These initiatives are called the ABOS Knowledge, Skills, and Behavior Program. Web-based assessment tools have been developed and validated to measure competence. These assessments guide resident progress through residency education and better define the competency level by the end of training. The background and rationale for these initiatives and how they serve as steps toward competency-based education in orthopaedic residency education in the United States will be reviewed with a vision of a hybrid of time and competency-based orthopaedic residency education that will remain 5 years in length, with residents assessed using standardized tools.

A 15-Year Report on the Uneven Distribution of Women in Orthopaedic Surgery Residency Training Programs in the United States.

This study was undertaken to update reports from 2004 to 2005 through 2008 to 2009, and 2009 to 2010 through 2013 to 2014, including 5 additional years of GME Track data. Our hypothesis is there have been no significant changes during the past 5 years in the distribution of Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics residency programs that train female residents, compared with the previous 10 years. METHODS: Data for ACGME-accredited orthopaedics residency training programs in the United States were analyzed for 5 consecutive academic years (2014-2015 through 2018-2019). Programs were classified as having no women, 1 woman, 2 women, or greater than 2 women in training. Programs were analyzed for percentage of female residents and classified as having above the national average (>20%), similar to the national average (between 10 and 20%), or below the national average (<10%). RESULTS: Analysis of the original 5 years (2004-2009) compared with the most recent data (2014-2019) demonstrated a statistically significant improvement in the number of programs training women (p < 0.001). From 2004 to 2009 to 2014 to 2019, the absolute number and percent of female trainees have increased (p < 0.001). Similar analysis of the middle 5 years (2009-2014) compared with the most recent 5 years (2014-2019) did not demonstrate a statistically significant change (p = 0.12). From 2014 to 2019, residency programs in the United States continue to train women at unequal rates: 37 programs had no female trainees, while 53 programs had >20% female trainees during at least one of these 5 years. CONCLUSIONS: Female medical students continue to pursue orthopaedics at rates lagging behind all other surgical specialties. Not all residency programs train women at equal rates. If the rate of training of female residents over the past 15 years were projected over time, we would not achieve 30% women within orthopaedics residency training programs until approximately 2060. LEVEL OF EVIDENCE: III.

Trend and Economic Implications of Implant Selection in the Treatment of Intertrochanteric Hip Fractures: A Review of the American Board of Orthopaedic Surgery Database From 2007 to 2017.

INTRODUCTION: Intertrochanteric (IT) fractures are estimated to burden the healthcare system six billion dollars annually. Previous studies have documented a trend of early-career orthopaedic surgeons favoring intramedullary nails (IMNs) for these fractures, despite multiple randomized controlled trials demonstrating no evidence for improved patient outcomes when compared with sliding hip screws (SHSs). The purpose of this study was to report the trend of implant utilization for IT fracture fixation from 2007 to 2017. METHODS: The American Board of Orthopaedic Surgery (ABOS) Part II (oral) database was used to identify IT fractures (International Classification of Diseases, 9th revision, code 820.21 or 820.31, and 10th revision, code S72.14) over a 10-year period (2007 to 2017). The cases were categorized by IMN or SHS fixation by surgeon-reported Current Procedural Terminology codes. Utilization of the devices was analyzed according to year, and the implants were compared for outcomes, complications, and cost. RESULTS: As of 2017, 92.4% of IT fractures were being fixed through IMN, representing a 49.1% increase in the number of IMN devices used during the course of this study. SHS had significantly lower medical complication rate (21.3%) and readmittance rate (4.0%) compared with the IMN (medical complication: 26.9%; P < 0.01) (readmittance rate: 5.4%; P = 0.02). SHS also had significantly lower rates of anemia (5.2%) and patient expiration (4.8%) compared with IMN (anemia: 10.2%; P < 0.01) (patient expiration: 6.1%; P = 0.01). Overall surgical complication rates, reoperative rates, and anesthetic complications did not differ between constructs. A cost differential of $671,812 was found from the 2007-projected distribution, which rose to $3,911,211.00 across the entire 11-year duration of the study for the population. DISCUSSION: Early-career orthopaedic surgeons continue to use a more expensive implant for IT fractures despite limited evidence for improved outcomes. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Study.

Cost Comparison of Botulinum Toxin Injections Versus Surgical Treatment in Pediatric Patients With Cerebral Palsy: A Markov Model.

PURPOSE: The purpose of this study was to compare the cost-effectiveness of surgical release to botulinum toxin injections in the treatment of upper-extremity (UE) cerebral palsy (CP). METHODS: A Markov transition-state model was developed to assess the direct and indirect costs as well as accumulated quality-adjusted life-years associated with surgery (surgery group) and continuous botulinum toxin injections (botulinum group) for the treatment of UE CP in children aged 7 to 12 years. Direct medical costs were obtained from institutional billing departments. The number of parental missed workdays associated with each treatment was estimated and previously published regressions were used to calculate indirect costs associated with missed work. Total costs, cost-effectiveness, and incremental cost-effectiveness ratios were calculated. Incremental cost-effectiveness ratios and willingness to pay thresholds were used to make decisions regarding society's willingness to pay for the incremental cost of each treatment given the incremental benefit. RESULTS: The surgery group demonstrated lower direct, indirect, and total costs compared with the botulinum group. Direct costs were $29,250.50 for the surgery group and $50,596.00 for the botulinum group. Indirect costs were $9,467.46 for the surgery group and $44,428.60 for the botulinum group. Total costs were $38,717.96 for the surgery group and $95,024.60 for the botulinum group, a difference of $56,306.64. The incremental cost-effectiveness ratio was -$42,019.88, indicating that surgery is a less costly and more effective treatment and that botulinum injections fall outside the societal willingness to pay threshold. Excluding indirect costs associated with parental missed work during home occupational therapy did not have a significant impact on the model. CONCLUSIONS: Surgery is associated with lower direct, indirect, and total costs, as well as a greater number of accumulated quality-adjusted life-years. Surgery provides a greater benefit at a lower cost, which suggests that botulinum injections should be used sparingly in this population. Treatment with surgery could represent savings of $5.6 to $11.3 billion annually in the United States. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic/Decision Analysis II.

A Comparative Analysis of 150 Thumb Polydactyly Cases from the CoULD Registry Using the Wassel-Flatt, Rotterdam, and Chung Classifications.

PURPOSE: Three commonly used classifications for thumb polydactyly are the Wassel-Flatt, Rotterdam, and Chung. The ideal classification system would have high validity and reliability and be descriptive of the thumb anomaly. The purposes of this investigation were to (1) compare the inter- and intrarater reliability of these 3 classifications when applied to a large sample of patients enrolled in the Congenital Upper Limb Differences (CoULD) Registry and (2) determine the prevalence of radial polydactyly types when using the various classifications in a North American population. METHODS: Inter- and intrarater reliability were determined using 150 cases of radial polydactyly presented in a Web-based format to 7 raters in 3 rounds, a preliminary training round and 2 observation rounds. Raters classified each case according to the Wassel-Flatt, Rotterdam, and Chung classifications. Inter- and intrarater reliability were evaluated with the intraclass correlation coefficient (ICC) calculated using 2-way random measures with perfect agreement. RESULTS: For Wassel-Flatt, both the interrater (ICC, 0.93) and the intrarater reliability (ICC, 0.91) were excellent. The Rotterdam classification had excellent reliability for both interrater reliability (ICC, 0.98) and intrarater reliability (ICC, 0.94), when considering type alone. Interrater analysis of the additional subtypes demonstrated a wide range of reliabilities. The Chung classification had good interrater (ICC, 0.88) and intrarater reliability (ICC, 0.77). Within the Wassel-Flatt classification, the most frequent unclassifiable thumb was a type IV hypoplastic thumb as classified by the Rotterdam classification. CONCLUSIONS: The Wassel-Flatt and Rotterdam classifications for radial polydactyly have excellent inter- and intrarater reliability. Despite its simplicity, the Chung classification was less reliable in comparison. The Chung and Rotterdam classification systems capture the hypoplastic subtypes that are unclassifiable in the Wassel-Flatt system. Addition of the hypoplastic subtype to the Wassel-Flatt classification (eg, Wassel-Flatt type IVh) would maintain the highest reliability and classify over 90% of thumbs deemed unclassifiable in the Wassel-Flatt system. CLINICAL RELEVANCE: The Wassel-Flatt and Rotterdam classifications have excellent inter-and intrarater reliability for the hand surgeon treating thumb polydactyly. Addition of a hypoplastic subtype to the Wassel-Flatt (Type 4h) allows classification of most previously unclassifiable thumbs.

Use of the Behavior Assessment Tool in 18 Pilot Residency Programs.

BACKGROUND: The purpose of this study was to determine the feasibility and evaluate the effectiveness of the American Board of Orthopaedic Surgery Behavior Tool (ABOSBT) for measuring professionalism. METHODS: Through collaboration between the American Board of Orthopaedic Surgery and American Orthopaedic Association's Council of Residency Directors, 18 residency programs piloted the use of the ABOSBT. Residents requested assessments from faculty at the end of their clinical rotations, and a 360° request was performed near the end of the academic year. Program Directors (PDs) rated individual resident professionalism (based on historical observation) at the outset of the study, for comparison to the ABOSBT results. RESULTS: Nine thousand eight hundred ninety-two evaluations were completed using the ABOSBT for 449 different residents by 1,012 evaluators. 97.6% of all evaluations were scored level 4 or 5 (high levels of professional behavior) across all of the 5 domains. In total, 2.4% of all evaluations scored level 3 or below reflecting poorer performance. Of 431 residents, the ABOSBT identified 26 of 32 residents who were low performers (2 or more < level 3 scores in a domain) and who also scored "below expectations" by the PD at the start of the pilot project (81% sensitivity and 57% specificity), including 13 of these residents scoring poorly in all 5 domains. Evaluators found the ABOSBT was easy to use (96%) and that it was an effective tool to assess resident professional behavior (81%). CONCLUSIONS: The ABOSBT was able to identify 2.4% low score evaluations (

Posterior Elbow Capsulotomy and Triceps Lengthening for Elbow Extension Contracture in Children with Arthrogryposis Multiplex Congenita.

Posterior elbow capsulotomy plus triceps lengthening facilitates passive elbow flexion in children with arthrogryposis multiplex congenita, allowing independent function for activities of daily living, such as feeding and self-care of the face and hair. DESCRIPTION: The posterior aspect of the distal end of the humerus and the olecranon are identified by palpation and exposed via a curvilinear incision over the posterior aspect of the elbow. Identifying the osseous landmarks can be challenging in some patients. The ulnar nerve is identified and protected. The triceps tendon is isolated, and z-lengthening is performed. Next, the posterior elbow capsule is incised proximal to the tip of the olecranon to expose the joint surface, and the arthrotomy is continued incrementally along the medial and lateral capsule until elbow flexion increases by ≥40°, or past 90° (maximum, 120°), with contact between the lengthened ends of the triceps tendon for repair. The triceps tendon is then repaired in the elongated position. After the wound is closed, the elbow is placed in flexion and immobilized in a cast. ALTERNATIVES: Alternative treatments include passive stretching exercises to increase elbow flexion. RATIONALE: Elbow extension contractures result in substantial limitations in the activities of daily living for children with arthrogryposis multiplex congenita. Those who fail to attain at least 90° of elbow flexion with passive stretching in the first year of life benefit from posterior elbow release and triceps lengthening. In addition, children with <30° of passive elbow flexion are at risk of developing valgus instability of the elbow from passive flexion exercises because the axis of rotation of the elbow is difficult to detect. Once passive elbow flexion is attained, such children may be candidates for tendon transfers allowing active elbow flexion.

The American Board of Orthopaedic Surgery Response to COVID-19.

The COVID-19 pandemic has disrupted every aspect of society in a way never previously experienced by our nation's orthopaedic surgeons. In response to the challenges the American Board of Orthopaedic Surgery has taken steps to adapt our Board Certification and Continuous Certification processes. These changes were made to provide flexibility for as many Candidates and Diplomates as possible to participate while maintaining our high standards. The American Board of Orthopaedic Surgery is first and foremost committed to the safety and well-being of our patients, physicians, and families while striving to remain responsive to the changing circumstances affecting our Candidates and Diplomates.

Women in Orthopaedics: How Understanding Implicit Bias Can Help Your Practice.

Women comprise approximately 50% of medical students; however, only 14% of current orthopaedic residents are women. There are many factors that contribute to the reluctance of female medical students to enter the field including limited exposure to musculoskeletal medicine during medical school, negative perception of the field, lack of female mentors, barriers to promotion, and acceptance by senior faculty. Diversity in orthopaedics is critical to provide culturally competent care. Two pipeline programs, the Perry Initiative and Nth Dimensions, have successful track records in increasing female and underrepresented minorities in orthopaedic surgery residency training. Recognizing and combating implicit bias in orthopaedics will improve recruitment, retention, promotion, and compensation of female orthopaedic surgeons. The purpose of this chapter is to provide an overview of the current status of women in orthopaedics, describe ways to improve diversity in the field, and make surgeons aware of how implicit bias can contribute to discrepancies seen in orthopaedic surgery, including pay scale inequities and women in leadership positions.

What Proportion of Orthopaedic Surgery Residency Programs Have Accessible Parental Leave Policies, and How Generous are They?

BACKGROUND: Parental leave during graduate medical education is a component of wellness in the workplace. Although every graduate medical education program is required by the Accreditation Council for Graduate Medical Education (ACGME) to have a leave policy, individual programs can create their own policies. The ACGME stipulates that "the sponsoring institution must provide a written policy on resident vacation and other leaves of absence (with or without pay) to include parental and sick leave to all applicants." To our knowledge, a review of parental leave policies of all orthopaedic surgery residency programs has not been performed. QUESTION/PURPOSES: (1) What proportion of orthopaedic surgery residency programs have accessible parental (maternity, paternity, and adoption) leave policies? (2) If a policy exists, what financial support is provided and what allotment of time is allowed? METHODS: All ACGME-accredited orthopaedic surgery residency programs in 2017 and 2018 were identified. One hundred sixty-six ACGME-accredited allopathic orthopaedic surgery residency programs were identified and reviewed by two observers. Reviewers determined if a program had written parental leave policy, including maternity, paternity, or adoption leave. Ten percent of programs were contacted to verify reviewer findings. The search was sequentially conducted starting with the orthopaedic surgery residency program's website. If the information was not found, the graduate medical education (GME) website was searched. If the information was not found on either website, the program was contacted directly via email and phone. Parental leave policies were classified as to whether they provided dedicated parental leave pay, provided sick leave pay, or deferred to unpaid Family Medical Leave Act (FMLA) policies. The number of weeks of maternity, paternity, and adoption leave allowed was collected. RESULTS: Our results showed that 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated policy on their program website. Overall, 81% (134 of 166) had policy information on the institution's GME website; 7% (12 of 166) of programs required direct communication with program coordinators to obtain policy information. Further, 9% (15 of 166) of programs were deemed to not have an available written policy as mandated by the ACGME. A total of 21% of programs (35 of 166) offered designated parental leave pay, 29% (48 of 166) compensated through sick leave pay, and 50% (83 of166) deferred to federal law (FMLA) requiring up to 12 weeks of unpaid leave. CONCLUSIONS: Although 91% of programs meet the ACGME requirement of written parental leave policies, current parental leave policies in orthopaedic surgery are not easily accessible for prospective residents, and they do not provide clear compensation and length of leave information. Only 3% (5 of 166) of orthopaedic surgery residency programs had a clearly stated leave policy accessible on the program's website. Substantial improvements would be gained if every orthopaedic residency program clearly outlined the parental leave policy on their residency program website, including compensation and length of leave, particularly in light of the 2019 American Board of Orthopaedic Surgery changes allowing time away to be averaged over the 5 years of training. CLINICAL RELEVANCE: Parental leave policies are increasingly relevant to today's trainees []. Applicants to orthopaedic surgery today value work/life balance including protected parental leave [].

Perceptions of the Recommended Resident Experience with Common Orthopaedic Procedures: A Survey of Program Directors and Early Practice Surgeons.

BACKGROUND: U.S. orthopaedic residency training is anchored by the Accreditation Council for Graduate Medical Education (ACGME) requirements, which include minimum numbers for 15 categories of procedures. The face validity of these recommendations and expectations for exposure to other common procedures has not been rigorously investigated. The main goals of this investigation were to understand the perceptions of program directors and early practice surgeons regarding the number of cases needed in residency training and to report which of the most commonly performed procedures residents should be able to perform independently upon graduation. METHODS: We sent surveys to 157 current program directors of ACMGE-approved orthopaedic surgery residency programs and to all examinees sitting for the American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination in 2017, requesting that they estimate the minimum number of exposures for the 22 adult and 24 pediatric procedures that are most commonly performed during residency and the first 2 years in practice. Where applicable, we compared these with the ACGME "Minimum Numbers" and the average ACGME resident experience data from 2010 to 2012 for resident graduates. For each of the 46 procedures, participants were asked if every orthopaedic resident should be able to independently perform the procedure upon graduation. We compared the percent for independence between the early practice surgeons and the program directors. RESULTS: For the majority of adult and pediatric procedures, the early practitioners reported significantly higher numbers of cases needing to be performed during residency than the program directors. ACGME Minimum Numbers were always lower than the case numbers that were recommended by the early practice surgeons and the program directors. Overall we found good-to-excellent agreement for independence at graduation between program directors and early practitioners for adult cases (intraclass correlation coefficient [ICC], 0.98; 95% confidence interval [CI], 0.82 to 0.99) and moderate-to-good agreement for pediatric cases (ICC, 0.96; 95% CI, 0.74, 0.99). CONCLUSIONS: The program directors frequently perceived the need for resident operative case exposure to common orthopaedic procedures to be lower than that estimated by the early practice surgeons. Both program directors and early practice surgeons generally agreed on which common cases residents should be able to perform independently by graduation.

Resident Surgical Skills Web-Based Evaluation: A Comparison of 2 Assessment Tools.

BACKGROUND: Evaluation of surgical skill competency is necessary as graduate medical education moves toward a competency-based curriculum. This study by the American Board of Orthopaedic Surgery (ABOS) and the Council of Orthopaedic Residency Directors (CORD) compares 2 web-based evaluation tools that assess the level of autonomy that is demonstrated by residents during surgical procedures in the operating room as measured by faculty. METHODS: Two hundred and ninety-four residents from 16 orthopaedic surgery residency programs were evaluated by 370 faculty using 2 web-based evaluation tools in a crossover design in which residents requested faculty review of their surgical skills before starting a case. One thousand, one hundred and fifty Ottawa Surgical Competency Operating Room Evaluation (O-Score) assessments, which included a 9-question evaluation of 8 steps of the surgical procedure, were compared with 1,186 P-score evaluations, which included a single-question summative evaluation. Twenty-five different surgical procedures were evaluated. RESULTS: There were no significant differences in rates of resident requests or faculty completion of the 2 scores. The most common surgical procedures that were assessed were total knee arthroplasty (n = 254, 11%), carpal tunnel release (n = 191, 8%), open reduction and internal fixation (ORIF) of stable hip fractures (n = 170, 7%), ORIF of simple ankle fractures (n = 169, 7%), and total hip arthroplasty (n = 166, 7%). Both instruments disclosed significant differences in competency among entry, intermediate, and advanced-level residents. The findings support the construct validity of the evaluation method. The survey results indicated that >70% of the faculty were confident that use of either the P-score or the O-score allowed them to distinguish a resident who can perform the surgery independently from one who needs additional training. CONCLUSIONS: This research has led to the modification of the O-score and the P-score into a combined OP-score instrument. The ABOS envisions that the OP-score instrument can be used with an expanded number of surgical procedures as a required element of residency training in the near future. CLINICAL RELEVANCE: This study allows the profession of orthopaedic surgery education to take a leadership role in the measurement of competence for surgical skills for orthopaedic surgeons in residency training, an important clinically relevant topic to the practice of orthopaedic surgery.

Did a Minimum Case Requirement Improve Resident Surgical Volume for Closed Wrist and Forearm Fracture Treatment in Orthopedic Surgery?

OBJECTIVE: The purpose of this study is to determine whether the 2013 implementation of ACGME minimum case requirements was associated with increased documented case volume of closed manipulation of forearm and wrist fractures (CMFWF) for graduating orthopedic surgery residents. DESIGN: We reviewed ACGME case log data for CMFWF among graduating orthopedic surgery residents from 2007 to 2016. Annual national mean, and median number of CMFWF performed by residents in the 10th, 30th, 50th, and 90th case volume percentile were evaluated. Preminimum (2007-2010) data was compared to postminimum (2013-2016) values to assess the impact of ACGME minimum requirements on resident case volume. SETTING: Review of publically available ACMGE Orthopedic Surgery Residency Program case log data. PARTICIPANTS: ACGME case log data for orthopedic surgery residents graduating between 2007 and 2016. RESULTS: National mean number of CMFWF increased significantly pre- to postminimum requirement (30.0 ± 2.84 to 45.0 ± 3.36, p < 0.001). Between 2010 and 2016 there was a 1100%, 300%, 83%, and 9% increase in the median number of CMFWF within the 10th, 30th, 50th, and 90th percentiles, respectively. CONCLUSIONS: ACGME's 2013 case minimum requirement corresponded to an increase in case counts for CMFWF; the greatest increase occurred in residents below the 50th percentile of case volume. Implementation of case minimum requirements may allow for more accurate depiction of resident experience and program strengths with regards to procedural exposure. However, the current case log system measures only case quantity, which may inaccurately depict mastery of given procedures. Future work should focus not only on improving case counts in underperforming residents and training sites, but also on refining metrics that ensure accurate assessment of resident skill for essential orthopedic procedures prior to graduation.

Outcomes After Surgical Treatment of Spastic Upper Extremity Conditions.

Surgical interventions for the spastic upper extremity aim to correct the common deformities of elbow flexion, forearm pronation, wrist flexion and ulnar deviation, and thumb-in-palm deformity. One goal is achieving optimal function and improved limb positioning. Aesthetics of the limb have a profound impact on self-esteem and satisfaction. Surgical deformity correction has not reliably been shown to improve sensory function such as stereognosis. Validated outcome measures are used to present outcomes after surgical treatment of the spastic upper extremity as it relates to motor function and limb positioning, sensory function, and self-esteem.

A New, Direct Measure of Thumb Use in Children After Index Pollicization for Congenital Thumb Hypoplasia.

PURPOSE: After index pollicization for congenital thumb hypoplasia, time-based hand dexterity tests do not indicate whether the new thumb is being used by a child. The Thumb Grasp and Pinch assessment (T-GAP) is a new outcome measure that classifies grasp and pinch styles to quantify use of the new thumb. The goal of this study was to establish concurrent validity and construct validity in the T-GAP. METHODS: Data from children treated with index finger pollicization for congenital thumb hypoplasia were retrospectively reviewed. Measures of strength, range of motion, and scores on the Box and Blocks Test (BBT), 9-Hole Peg Test (NHPT), Functional Dexterity Test (FDT), and Task 7 (Heavy Objects) from the Jebsen-Taylor Test (JTT7) were recorded. Patients also completed the T-GAP consisting of 9 age-appropriate tasks, during which grasp patterns were classified. Spearman correlation coefficients were calculated comparing the T-GAP score with scores on the BBT, NHPT, FDT, and JTT7. RESULTS: We evaluated 21 thumbs in 21 children an average of 71.7 months after pollicization surgery (range, 9-175 months). The T-GAP score was significantly correlated with BBT, NHPT, FDT, and JTT7 (R = 0.69, -0.60,-0.59, and -0.60, respectively). The T-GAP score was significantly correlated with tripod pinch, key pinch, and grip strength (R = 0.77, 0.75, and 0.71, respectively) and with opposition and grasp span (R = 0.50 and 0.52, respectively). The T-GAP was the only functional measure correlated with parent and patient satisfaction with thumb function. CONCLUSIONS: Concurrent validity was supported by significant correlations between T-GAP score for all 4 dexterity measures. Construct validity was supported by significant correlations between strength and range of motion of the thumb and T-GAP score. CLINICAL RELEVANCE: This evaluation may help surgeons and therapists better understand results after pollicization and determine whether the new thumb is being incorporated into daily activities.