Publications

OBJECTIVE: Although the number of female medical school graduates has dramatically increased over the last decades, Orthopaedic surgery continues to struggle in attracting women and under-represented minorities to the field. Potential barriers include limited exposure during medical school and the scarcity of female mentors. We hypothesized that a structured, low-cost, workshop for medical students allowing exposure to orthopaedic surgery would increase students' interest in the field. Our primary outcome was the perceived satisfaction with the program and the number of students who subsequently expressed an interest in pursuing a career in orthopaedic surgery. Our secondary outcome was the number of student participants who subsequently matched in orthopaedic surgery.

DESIGN: Combining female faculty from surrounding hospitals, we developed a free half-day program including skills workshops and panel discussions for women medical students in the region. Participants were asked to complete an anonymous survey grading their satisfaction with the utility of the information presented, the comfort level in interacting with faculty and how the experience may have impacted their potential interest in orthopaedic surgery. Eligible participants were contacted by email to determine their ultimate career choices and match results. Furthermore, participants were followed over time to determine how many chose and matched into an orthopaedic surgery residency.

SETTING: The workshop took place in Boston at the Harvard Medical School affiliated hospitals.

PARTICIPANTS: Student participants were invited from all New England allopathic and osteopathic medical schools. Faculty participants included staff, residents and fellows from the Harvard Combined Orthopaedic Residency Program.

RESULTS: Over 3 years, 155 female medical students participated in the program and 97% found it useful. Among 59 students who have since become eligible for the match, 22 matched into an orthopaedic surgery residency. Eight of 36 (22%) match eligible first and second year participants matched in orthopaedic surgery while 14 of 23 (61%) match eligible third and fourth year student attendees successfully matched in orthopaedic surgery programs.

CONCLUSIONS: Taking advantage of local resources, we demonstrated that outreach is effective in enhancing students' interest in the field. We encourage as many programs as possible to consider similar initiatives.

BACKGROUND:  This study examines the effect of prior abdominal surgery on flap, donor-site, and overall complications in women undergoing deep inferior epigastric artery perforator (DIEP) flap breast reconstruction and assesses whether preoperative computed tomography angiography (CTA) affects outcomes.

METHODS:  All DIEP flaps performed at our institution between 2004 and 2015 were identified retrospectively. Patients were stratified based on a history of prior abdominal surgery and whether or not they underwent a preoperative CTA. A subgroup analysis was performed to compare operative times and incidence of complications using adjusted odds ratios (ORs).

RESULTS:  Over a 12-year period, 425 patients (640 flaps) had prior abdominal surgery, and 393 patients (547 flaps) had no prior abdominal surgery. Of the patients with previous abdominal surgery, 67 (15.7%) underwent preoperative CTA and 333 (78.4%) did not. Patients with prior abdominal surgery were more likely to have donor-site wound complications (OR: 1.82, 95% confidence interval [CI]: 1.15-2.87, p = 0.01), fat necrosis ≥2cm of the transferred flap (OR: 1.39, 95% CI: 1.0-1.94, p = 0.05), and were more likely to have bilateral DIEP flap reconstruction (OR: 1.61, 95% CI: 1.22-2.12, p < 0.001). Preoperative CTA did not reduce the risk of complications and did not affect operative times.

CONCLUSION:  DIEP flap reconstruction can be safely performed in women with prior abdominal surgery. However, these patients should be counseled that they are at an increased risk for donor-site wound breakdown and fat necrosis of the reconstructed breast. Preoperative CTA does not reduce complication rate, overall operative time, or time needed to dissect perforators in women with abdominal scars.

PURPOSE: The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale.

METHODS: We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008-2018). Preoperative and postoperative range of motion, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed.

RESULTS: We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry's translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen.

CONCLUSIONS: The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

As the number of total joint arthroplasties continues to rise, periprosthetic joint infection (PJI), a significant and devastating complication of total joint arthroplasty, may also increase. In PJI, bacterial biofilms are formed by causative pathogens surrounded by extracellular matrix with relatively dormant cells that can persist, resulting in a barrier against the host immune system and antibiotics. These biofilms not only contribute to the pathogenesis of PJI but also result in diagnostic challenges, antibiotic resistance, and PJI treatment failure. This review discusses the development of biofilms and key features associated with biofilm pathogenicity in PJI, current PJI diagnostic methods and their limitations, and current treatment options. Additionally, this article explores novel approaches to treat PJI, including targeting persister bacteria, immunotherapy, antimicrobial peptides, nanoparticles, and bacteriophage therapy. Biofilm eradication can also be achieved through enzymatic therapy, photodynamic therapy, and ultrasound. Finally, this review discusses novel techniques to prevent PJI, including improved irrigation solutions, smart implants with antimicrobial properties, inhibition of quorum sensing, and vaccines, which may revolutionize PJI management in the future by eradicating a devastating problem.

PURPOSE: To determine the rate of and risk factors for complications in solid organ transplant (SOT) patients who have had surgery of the upper extremity.

METHODS: All SOT recipients who had an upper extremity procedure performed by 1 of 6 surgeons at our institution were identified from 2006 to 2018. Demographic data, transplant date and type, upper extremity surgery procedure and date, antirejection medications, American Society of Anesthesiologists Physical Status Classification System (ASA) score, and complications were recorded. Complications were defined as any surgical complication within 1 year and any medical complication within the first 30 days after surgery. Complications were categorized according to the Clavien-Dindo classification system.

RESULTS: Fifty-one upper extremity procedures in 32 SOT patients were included. Of the 51 procedures, 21 were complicated, for an overall complication rate of 41%. Surgical complications occurred equally before and after 30 days with infection being the most common. Only 1 of the procedures resulting in surgical site infection had an implant (temporary K-wire fixation). The majority of complications were grade II, and there were no grade IV or V complications. Age, ASA score, type or number of SOT, and immunosuppressive regimens were similar between complicated and noncomplicated procedures. Procedures involving male patients were more likely to be complicated than those involving female patients.

CONCLUSIONS: Complications after upper extremity operations are common in SOT patients, and surgical complications often occur after 30 days. Surgeons should counsel this population that they carry a higher complication risk than the general population and may require longer-term monitoring after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Post-traumatic elbow stiffness is a major cause of functional impairment after elbow trauma. A stiff elbow limits patients' ability to position their hand in space for optimal use of their upper extremities, and as such, is a frequent indication for reoperation. This article reviews current concepts on the pathogenesis of post-traumatic elbow stiffness. Current nonoperative treatment options include therapy, bracing, and manipulation under anesthesia, while operative treatment options include arthroscopic and open arthrolysis. The pros and cons of various treatment options are discussed, with a focus on the evidence supporting their use, the expected functional gains, and associated complications. Future directions in post-traumatic elbow stiffness are highlighted.

STUDY DESIGN: Narrative review.

OBJECTIVES: Postoperative surgical site infections (SSIs) are among the most common acute complications in spine surgery and have a devastating impact on outcomes. They can lead to increased morbidity and mortality as well as greater economic burden. Hence, preventive strategies to reduce the rate of SSIs after spine surgery have become vitally important. The purpose of this article was to summarize and critically analyze the available evidence related to current strategies in the prevention of SSIs after spine surgery.

METHODS: A literature search utilizing Medline database was performed. Relevant studies from all the evidence levels have been included. Recommendations to decrease the risk of SSIs have been provided based on the results from studies with the highest level of evidence.

RESULTS: SSI prevention occurs at each phase of care including the preoperative, intraoperative, and postoperative periods. Meticulous patient selection, tight glycemic control in diabetics, smoking cessation, and screening/eradication of Staphylococcus aureus are some of the main preoperative patient-related preventive strategies. Currently used intraoperative measures include alcohol-based skin preparation, topical vancomycin powder, and betadine irrigation of the surgical site before closure. Postoperative infection prophylaxis can be performed by administration of silver-impregnated or vacuum dressings, extended intravenous antibiotics, and supplemental oxygen therapy.

CONCLUSIONS: Although preventive strategies are already in use alone or in combination, further high-level research is required to prove their efficacy in reducing the rate of SSIs in spine surgery before evidence-based standard infection prophylaxis guidelines can be built.

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PURPOSE: Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery.

METHODS: We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention.

RESULTS: Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years.

CONCLUSIONS: In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.