Orthopaedic Surgery Training in North Carolina: The Impact of The Flexner Report and The Sherman Antitrust Act - L. Andrew Koman, MD; Kerry A. Danelson, PhD; Alexander Jinnah, MD; Anirudh K. Gowd, MD; and David Popoli, MD

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The current medical schools and orthopaedic residency programs in the state of North Carolina have evolved based upon geopolitical, economic events, historical reports and regulations. The American Medical Association Committee on Medical Education, the Flexner Report and the Sherman Antitrust Act and their recommendations were codified by state regulatory agencies and state law. These important pressures created the programs as they are known today. The result was the forced closure of most early medical institutions in the state of North Carolina in the early 1900s. Industrial resource consolidation by monopolies was the motivation for the Sherman Antitrust act. Enforced by Theodore Roosevelt, this legislation disbanded major monopolies and encouraged philanthropy. This manuscript details the evolution of modern medical education and highlights the impact of historical social, economic and political events on the development of Duke, Wake Forest, University of North Carolina and Charlotte/ Atrium Health orthopedic programs in North Carolina. (Journal of Surgical Orthopaedic Advances 31(3):139–143, 2022)

Key words: medical history, tobacco, industry, orthopaedic training in North Carolina

An Innovative Seven-year Physician Scientist Residency Training Program That Addresses the Shortage of Academic Surgeons - L. Andrew Koman, MD; Kerry A. Danelson, PhD; Alexander Jinnah, MD, PhD; Johannes F. Plate, MD, PhD; Sandeep Mannava, MD, PhD; Daniel N. Bracey, MD, PhD; Alejandro Marquez- Lara MD, PhD; T. David Luo, MD, PhD; Sam Rosas, MD, PhD; Austin V. Stone MD, PhD; David Popoli, MD; Kaitlin Henry; Riyaz H. Jinnah, MD; Beth P. Smith, PhD; Gary G. Poehling, MD; and Thomas L. Smith, PhD

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Due to the declining number of scientifically trained physicians and increasing demand for high-quality literature, our institution pioneered a seven-year Physician Scientist Training Program (PSTP) to provide research-oriented residents the knowledge and skills for a successful academic career. The present study sought to identify orthopaedic surgeons with MD/PhD degrees, residency programs with dedicated research tracks, and to assess the effectiveness of the novel seven-year program in training prospective academic orthopaedic surgeons. Surgeons with MD/PhD degrees account for 2.3% of all 3,408 orthopaedic faculty positions in U.S. residency programs. During the last 23 years, our PSTP residents produced 752 peer-reviewed publications and received $349,354 from 23 resident-authored extramural grants. Eleven of our seven-year alumni practice orthopaedic surgery in an academic setting. The seven-year PSTP successfully develops clinically trained surgeon scientists with refined skills in basic science and clinical experimental design, grant proposals, scientific presentations, and manuscript preparation. (Journal of Surgical Orthopaedic Advances 31(3):144–149, 2022)

Key words: resident education, basic science, academic faculty

Resident Education and Wellness: A Strategy for Future Pandemics - Samuel L. Posey, MD; Josef E. Jolissaint, MD; Aaron M. Brandt, MD; Rachel B. Seymour, PhD; Stephen H. Sims, MD; Joseph R. Hsu MD; Joshua C. Patt, MD; and Brian P. Scannell, MD

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The Coronavirus Disease 2019 (COVID-19) pandemic presented a novel challenge to modern healthcare systems and medical training. Resource allocation and risk mitigation dramatically affected resident training. The objective of this article is to develop new strategies to maintain a healthy, competent residency program while combating the unique challenges to resident education and wellness. In 2020, our institution implemented a revolving 3-Team system. While the “Inpatient-Team” delivered direct care, the “Back-up Team” and “Quarantine-Team” managed the telemedicine virtual clinic and educationwellness strategy, respectively. Our 3-Team system allowed delivery of safe, high-quality patient care while optimizing resident education, research, and wellness. The efficient use of technology led to both improved virtual education outside of the hospital and intentional wellness opportunities despite social distancing restrictions. Utilization of virtual platforms for patient care, education, research, and wellness grew out of necessity in this pandemic, yet represent an opportunity for lasting improvement. (Journal of Surgical Orthopaedic Advances 31(3):150–154, 2022)

Key words: education, wellness, mentorship, risk management, strategy, pandemic, COVID, mental health, tieredteam research, and surgical training

Distal Radius Fractures and Bone Health: A Survey of Hand Surgeons - Natalie Huntington Vaughn, MD; Kerry A. Danelson, PhD; Kaitlin Henry;  Anne F. Lake, DNP, ONP-C, CCD; and Benjamin R. Graves, MD

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Following low-energy distal radius fractures (DRF) patients rarely receive a bone health evaluation. The purpose of this survey was to investigate the attitudes and practices of American Society for Surgery of the Hand (ASSH) members regarding osteoporosis and low-energy DRF. An electronic survey was sent to 4,125 members of the ASSH. Physicians were asked about referral patterns, comfort level with labs and imaging related to bone health, and barriers. There were 475 responses (response rate 11.5%). Most respondents always (33.1%) or often (32.8%) talk about osteoporosis risk after low-energy DRF. Most respondents (87.6%) do not routinely order metabolic labs. Less than half knew of an available Fracture Liaison Service. Barriers to discussion included not enough time (32.6%), not comfortable with the topic (12.6%), and not within practice scope (33.3%). Respondents reported variable comfort levels discussing and implementing osteoporosis care in the setting of lowenergy DRF. (Journal of Surgical Orthopaedic Advances 31(3):155–160, 2022)

Key words: osteoporosis, distal radius fractures, bone health

Promoting Bone Formation and Healing in Segmental Defects Through Ectopic Induced Membrane - John A. Ruder, MD; Katherine Li, MD; Paul E. Matuszewski, MD; J. Stewart Buck, MD; Didier Dréau, PhD; Chandra Williams, DVM; Bailey V. Fearing, PhD; Rachel B. Seymour, PhD; and Joseph R. Hsu, MD

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We aimed to determine whether addition of an in vivo ectopic induced membrane (EM) to the Masquelet Technique enhanced angiogenesis and bone formation in a segmental defect. After generating and stabilizing a diaphyseal femur defect, 10 rats received a polymethylmethacrylate (PMMA) spacer within the defect (control); 10 received another PMMA spacer implanted subcutaneously (EM). We removed the spacers and added autograft; the excised EM was added to their autograft (EM group). Post-mortem x-rays assessed bone formation and bridging. Osteogenesis in the proximal defect was significantly more uniform (p < 0.01), and there was greater amount of bone remodeling distally in the EM group (p < 0.05). There was no difference in bone formation (p = 0.19) but greater degrees of bridging in the EM group (2.20 vs. 1.20, p = 0.09). The EM resulted in more homogeneous proximal osteogenesis and increased bone remodeling distally. These findings could lead to more consistent and predictable bone healing. (Journal of Surgical Orthopaedic Advances 31(3):161–165, 2022)

Key words: Masquelet Technique, in vivo ectopic induced membrane, bone formation, segmental defect

Management of Tibial and Femoral Non-unions and Stress Fractures with Severe Ipsilateral Knee Arthritis with Long Stemmed Modular Total Knee Arthroplasty - James Aitken, DO; Emily Sparks; and John Shields, MD

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Management of patients with non-unions or stress fractures of the tibia or distal femur with debilitating ipsilateral knee arthritis can be difficult to manage. In these examples of care, we present three illustrations of using long stemmed modular total knee components to successfully manage both tibial and femoral non-unions and stress fractures as well as ipsilateral arthritis with resultant deformity. The average improvement in our knee outcome scores for these three patients via preoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) and one-year post-operative KOOS, JR is 44.37. After treatment with a long stemmed modular total knee prosthesis all three examples of care went on to union and the arthritic deformity was corrected. (Journal of Surgical Orthopaedic Advances 31(3):166–168, 2022)

Key words: total joint, arthroplasty, revision total knee, adult reconstruction, stress fracture, non-union

Orthopaedic Implant Coatings: Recent Approaches and Clinical Translation - Bailey V. Fearing, PhD; K. Eddie Afetse, BS, BA; Rachel B. Seymour, PhD; Joseph C. Wenke, PhD; and Joseph R. Hsu, MD

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Despite improved surgical techniques and prophylactic procedures, orthopaedic implant-associated infections remain high with complications that can lead to devastating outcomes for the patient. Implant coatings and associated surface modification techniques represent a promising means to prevent infections. Various approaches have emerged to address the challenges associated with implant infections, such as antibacterial resistance, biofilm prevention, and appropriate efficacy kinetics. Methods including antibiotic and antimicrobial peptide surface tethering, use of osteo-conductive and -inductive materials, and altering hydrophobicity and hydrophilicity of the implant surface, have all demonstrated efficacy toward diminished infection risk. Though many of these techniques have shown great potential in in vitro and in vivo studies, clinical translation remains limited with very few commercially available implant coatings globally. This review summarizes recent advancements in orthopaedic implant coatings, pre-clinical studies, and clinical translation, as well as potential future marketed products. (Journal of Surgical Orthopaedic Advances 31(3):169–176, 2022)

Key words: orthopaedic trauma, implant, infection, musculoskeletal, coating

Pitching Biomechanics Normative Values and Kinetic Differences by Competition Level - Kristen F. Nicholson, PhD; Joseph A. Mylott, MS; Brian R. Waterman, MD; and Garrett S. Bullock, PT, DPT, DPhil

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Pitching kinematic and kinetic assessments require normative values to make valuable comparisons to athletic peers. The purpose of this research note was to report normative values of pitching kinematics and kinetics and to compare kinetics by competition level. A retrospective review was performed on three-dimensional baseball pitching biomechanical evaluations. Kinematics and kinetics were calculated. Pitchers were portioned into competition level groups. Kinetic group differences were assessed through analyses of variance with significance level p < 0.05. One-hundred and twenty pitchers were included. Elbow varus torque was greater in higher competition levels. Shoulder distraction force was greater in higher competition levels. All levels demonstrated similar maximum vertical push off ground reaction force (p = 0.960) and maximum vertical landing ground reaction force (p = 0.135). Higher competition level pitchers demonstrated improved pitching kinematic efficiency compared to lower-level pitchers. However, college and professional pitchers exhibited greater arm stress, which may be attributed to increased pitching velocity. These pitching biomechanical data can be used as normative comparisons when examining pitching mechanics at multiple competition levels throughout an athlete’s baseball career. (Journal of Surgical Orthopaedic Advances 31(3):177–180, 2022)

Key words: kinematics, ground reaction force, youth, high school, college, professional

Treatment Order and Risk of Surgical Site Infection in Patients Undergoing Concurrent Operative Fixation of Closed and Open Fractures - Olivia Rice, MD; Alicia Williams, MPH; Louis Lewandowski, MD; Tamar Roomian, MS, MPH; Joseph R. Hsu, MD; and EMIT

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This study aimed to characterize postoperative infection rate among patients undergoing definitive fixation of both open and closed fractures during the same surgery. Outcomes between patients with open fractures (OF) treated first were compared to those with closed fractures (CF) treated first. We identified 303 adult patients with multiple (≥ 2) pelvis and extremity fractures who presented to our Level 1 Trauma hospital in 2017. Forty patients with at least one open and one closed fracture treated with operative fixation during the same surgery were included in analysis. Eight surgical site infections (SSI) developed in seven patients. There was no significant difference between treatment order groups (OF = 4 patients (5 fractures), CF = 3 patients (3 fractures); p > 0.99). This is the first study comparing different chronologies of operative fixation in coexisting open and closed fractures. Our study shows that the choice of treatment order does not influence SSI risk. (Journal of Surgical Orthopaedic Advances 31(3):181–186, 2022)

Key words: treatment order, infection, fracture

A Randomized Trial of Preoperative Practice in a Simulated Operative Environment: 3D Printed Pilon Model Improves Resident Performance - Kevin D. Phelps, MD; Olivia M. Rice, MD; John A. Ruder, MD; Rachel B. Seymour, PhD; Joshua C. Patt, MD, MPH; Madhav A. Karunakar, MD; and Stephen H. Sims, MD

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This study assessed the effect of preoperative planning using a 3D-printed periarticular fracture model on operative performance. A complex pilon fracture was 3D-printed, and a preoperative plan was developed. Orthopaedic surgery residents (n = 20) were randomized into two groups. Group 1 performed routine preoperative planning, while Group 2 was also practiced using a 3D-printed construct before performing fixation of the 3D-printed model. Resident performance was assessed using a video motion capture system and evaluated by blinded reviewers. Three residents (3D group) completed fixation within the allotted 45 minutes. The 3D group had less hand distance traveled for step 1 (89 m vs. 162 m, p = 0.04). The 3D group had better performance on three of the four components and more acceptable reductions (6 vs. 0, p = 0.009). Average global rating scale was higher in the 3D group (3.0 vs. 1.7, p = 0.0095). Use of 3D-printed models for preoperative planning improved resident performance. (Journal of Surgical Orthopaedic Advances 31(3):187–192, 2022)

Key words: resident education, 3D-printed fracture model, preoperative planning, fracture fixation, simulated operative environment, simulation-based training

Prevalence of Depressive Symptoms in Adolescent Athletes - Ashley Long, PhD, LAT, ATC, CBIS; Allison Bickett, PhD; and David Price, MD

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The objective of this study is to measure the prevalence and demographic predictors of depressive symptoms in a diverse group of adolescent athletes. Retrospective chart review of demographic and Patient Health Questionnaire-Adolescent (PHQ-A) data obtained during a mass pre-participation physical exam (PPE) was examined. Independent variables included race and sex. A total of 16.9% (n = 115) of students had clinically meaningful depressive symptoms, while 2.5% (n = 23) reported having thoughts that they would be better off dead or of hurting themselves. Of those who had moderate to severe levels of depressive symptoms, 25.8% (n = 31) were Black females, significantly more than any other race-sex group. A majority of our sample did not have depressive symptoms but a plan for those in severe mental distress must be in place. Prevalence of adolescent depressive symptoms, mental health emergency preparedness and culturally sensitive interventions deserve further investigation. (Journal of Surgical Orthopaedic Advances 31(3):193–198, 2022)

Key words: depression, athlete, mental health

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