Current Trends in Sex, Race, and Ethnic Diversity in Orthopaedic Surgery Residency

BACKGROUND: The representation of minorities among medical students has increased over the past two decades, but diversity among orthopaedic residents lags behind. This phenomenon has occurred despite a recent focus by the American Academy of Orthopaedic Surgeons on the recruitment of minorities and women. OBJECTIVE: To analyze the impact of recent efforts on diversity in orthopaedic residents in comparison with other surgical specialties from 2006 to 2015. METHODS: Data from the American Association of Medical Colleges on residents in surgical specialty programs in the years 2006 to 2015 were analyzed. Linear regression models were used to estimate trends in diversity among orthopaedic residents and residents in other surgical specialties. A mixed model analysis of variance was used to compare rates of diversification among different specialties over time. RESULTS: Female representation in orthopaedic programs increased from 10.9% to 14.4% between 2006 and 2015. However, the rate of increase was significantly lower compared with other specialties (all P \u3c 0.05) studied, except for urology (P = 0.64). Minority representation in orthopaedics averaged 25.6% over the 10-year period. Residents of Hispanic origin in orthopaedic programs increased (P = 0.0003) but decreased for Native Hawaiian/Pacific Islander (P \u3c 0.0001). During the same period, white representation increased (P = 0.004). No significant changes were found in African Americans or Asian American representation. Diversity decreased among orthopaedic residents over the period studied (P = 0.004). CONCLUSIONS: Recruitment efforts have not reversed the sex, racial, and ethnic disparities in orthopaedic residents. Orthopaedics has the lowest representation of women and minorities among residencies studied. The rate of increase in women lags behind all surgical subspecialties, except for urology

Minimally Invasive Scoliosis Surgery: A Novel Technique in Patients with Neuromuscular Scoliosis

Minimally invasive surgery (MIS) has been described in the treatment of adolescent idiopathic scoliosis (AIS) and adult scoliosis. The advantages of this approach include less blood loss, shorter hospital stay, earlier mobilization, less tissue disruption, and relatively less pain. However, despite these significant benefits, MIS approach has not been reported in neuromuscular scoliosis patients. This is possibly due to concerns with longer surgery time, which is further increased due to more levels fused and instrumented, challenges of pelvic fixation, size and number of incisions, and prolonged anesthesia. We modified the MIS approach utilized in our AIS patients to be implemented in our neuromuscular patients. Our technique allows easy passage of contoured rods, placement of pedicle screws without image guidance, partial/complete facet resection, and all standard reduction maneuvers. Operative time needed to complete this surgery is comparable to the standard procedure and the majority of our patients have been extubated at the end of procedure, spending 1 day in the PICU and 5-6 days in the hospital. We feel that MIS is not only a feasible but also a superior option in patients with neuromuscular scoliosis. Long-term results are unavailable; however, short-term results have shown multiple benefits of this approach and fewer limitations

A dual-team approach benefits standard-volume surgeons, but has minimal impact on outcomes for a high-volume surgeon in AIS patients

© 2020, Scoliosis Research Society. Study design: Retrospective chart review of prospectively collected data. Objective: This study seeks to evaluate the effect of number of surgeons, surgeon experience, and surgeon volume on AIS surgery. Summary of background data: Recent literature suggests that utilizing two surgeons for spine deformity correction surgery can improve perioperative outcomes. However, the surgeon’s experience and surgical volume are likely as important. Methods: AIS patients undergoing PSF from 2009 to 2019 were included. Patient demographics, X-ray and perioperative outcomes were collected and collated based on primary surgeon. Analysis was performed for single versus dual surgeons, surgeon experience (≤ 10 years in practice), and surgical volume (less/greater than 50 cases/year). Median (IQR) values, Wilcoxon Rank Sums test, Kruskal–Wallis test, and Fisher’s exact test were utilized. Results: 519 AIS cases, performed by 4 surgeons were included. Two surgeons were highly experienced, 1 of whom was also high volume. Five cohorts were studied: a single senior high volume (S1) (n = 302), dual-junior surgeons (DJ) (n = 73), dual senior–junior (SJ) (n = 36), dual-senior (DS) (n = 21) and a single senior, standard-volume surgeon alone (S2) (n = 87). Radiographic parameters were similar between the groups (p \u3e 0.05). Preoperative Cobb was significantly higher for DS compared to S1 (p = 0.034) Pre- and post-op kyphosis were similar (p \u3e 0.05). Cobb correction was similar (p \u3e 0.05). Levels fused, fixation points, anesthesia and surgical times were similar (p \u3e 0.05). When the standard-volume surgeon operated with a second surgeon, radiographic parameters were similar (p \u3e 0.05), but anesthesia time, surgical time, and hospital length of stay were significantly shorter (p \u3c 0.05). Additionally, DJ had significantly shorter anesthesia and operative times (p \u3c 0.001) and length of stay (p \u3c 0.001) compared to S2. Conclusion: Standard-volume surgeons have better outcomes with a dual surgeon approach. Junior surgeons benefit operating with an experienced surgeon. A high-volume surgeon, however, does not benefit from a dual surgeon approach. Level of evidence: Level II

CT-Based Anatomical Evaluation of Pre-Vertebral Structures with Respect to Vertebral Body Using a Clock-Face Analogy

STUDY DESIGN: Retrospective Chart and CT Scan ReviewObjective. To define the relationship of the pre-vertebral structures for each level to assist in easier intraoperative visualization. SUMMARY OF BACKGROUND DATA: Vascular and visceral injury from pedicle screw is well-known. This study will define the relationship of the pre-vertebral structures for each level to assist in avoiding potential complications. METHODS: Pre- and post-operative CT scans were reviewed to define the pre-vertebra structures in relation to a clock-face. On reformatted axial slices, a clock-face was superimposed so that the left transverse process (TP) represented 8 o\u27clock and the right TP represented 4 o\u27clock. The positions of the TP on the clock-face did not change with rotation of the vertebra. RESULTS: 108 patients had pre-operative CT scan. 78 had post-operative CT scan. Median age was 15 years, median Cobb angle 50 degrees , levels fused were 12, with 21 fixation points. 6324 axial CT slices were reformatted and analyzed. Trachea was located at 12 o\u27clock at T1, 1 o\u27clock at T2-T4, and between 12 and 1 o\u27clock at T5. Esophagus starts as a midline structure at 12 o\u27clock from T1-T2, moves to 11 o\u27clock from T3-T6, and further to 10 o\u27clock from T7-T9. Aorta starts at 10 o\u27clock at T5-T6, moves left at T7-T8 to 9 o\u27clock, and returns to 10 o\u27clock from T9-T11. It appears at 11\u27clock at T12, and at 12 o\u27clock from L1-L4. In about a third of cases, it is at 1 o\u27clock from L1 to L4, where it bifurcates. CONCLUSIONS: This CT-based anatomical study provides a simple reference frame to help surgeons visualize the vital structures at each level. This three-dimensional visualization is facilitated by fixing the position of TP on the clock-face. Knowledge of this anatomical relationship can help avoid direct injury, and is easier to recall intra-operatively

Underrepresented Minority Applicants Are Competitive for Orthopaedic Surgery Residency Programs, but Enter Residency at Lower Rates.

INTRODUCTION:Orthopaedic surgery residency programs have the lowest representation of ethnic/racial minorities compared with other specialties. This study compared orthopaedic residency enrollment rates and academic metrics of applicants and matriculated residents by race/ethnicity. METHODS:Data on applicants from US medical schools for orthopaedic residency and residents were analyzed from 2005 to 2014 and compared between race/ethnic groups (White, Asian, Black, Hispanic, and Other). RESULTS:Minority applicants comprised 29% of applicants and 25% of enrolled candidates. Sixty-one percent of minority applicants were accepted into an orthopaedic residency versus 73% of White applicants (P \u3c 0.0001). White and Asian applicants and residents had higher USMLE Step 1. White applicants and matriculated candidates had higher Step 2 Clinical Knowledge scores and higher odds of Alpha Omega Alpha membership compared with Black, Hispanic, and Other groups. Publication counts were similar in all applicant groups, although Hispanic residents had significantly more publications. Black applicants had more volunteer experiences. CONCLUSIONS:In orthopaedic surgery residency, minority applicants enrolled at a lower rate than White and Asian applicants. The emphasis on USMLE test scores and Alpha Omega Alpha membership may contribute to the lower enrollment rate of minority applicants. Other factors such as conscious or unconscious bias, which may contribute, were not evaluated in this study

Triggered EMG Potentials in Determining Neuroanatomical Safe Zone for Transpsoas Lumbar Approach: Are They Reliable?

STUDY DESIGN: In vivo analysis in swine model OBJECTIVE.: The purpose of this study is to determine the accuracy of t-EMG and its reliability in LLIF surgery. We also aim to document changes in psoas muscle produced during the approach. SUMMARY OF BACKGROUND DATA: LLIF is preferred over direct anterior approach due to lower complications, blood loss, and shorter recovery time. Threshold-EMGs are utilized for real-time feedback about nerve location, however, neurological deficits are widely reported, and are unique to this approach. Multiple factors have been hypothesized including neuropraxia from retractor and compression from psoas hematoma/ edema. The variable reports of neurological complication even with t-EMGs indicate the need to study them further. METHODS: 8 swines underwent left-sided retroperitoneal approach. Nerve on the surface of psoas was identified and threshold-EMGs were obtained utilizing a ball-tip, and needle probe. 1 EMG and threshold responses required to elicit 20 muV responses were recorded for 2 mm incremental distances up to 10 mm. In the second part, a K-wire was inserted into the mid-lumbar disc space, and a tubular retractor docked and dilated adequately. Post-mortem CT scans were carried out to evaluate changes in psoas muscle. RESULTS: A triggered-EMG stimulus threshold of \u3c 5 mA indicates a higher probability that the probe is close to or on the nerve, but this was not proportional to the distance suggesting limitations for nerve mapping. Negative predictive value of t-EMGs is 76.5% with the ball-tipped probe and 80% with the needle probe for t-EMG \u3e/=10 mA and indicates that even with higher thresholds, the nerve may be much closer than anticipated. Postoperative hematoma was not seen on CT scans. CONCLUSION: Threshold measurements are unreliable in estimating distance from the nerve in an individual subject and higher values do not always correspond to a \u27safe zone . LEVEL OF EVIDENCE: 5

Cadaveric Study of the Safety and Device Functionality of Magnetically Controlled Growing Rods After Exposure to Magnetic Resonance Imaging

© 2017 Scoliosis Research Society Study Design: Cadaveric study. Objective: To establish the safety and efficacy of magnetically controlled growing rods (MCGRs) after magnetic resonance imaging (MRI) exposure. Summary of Background Data: MCGRs are new and promising devices for the treatment of early-onset scoliosis (EOS). A significant percentage of EOS patients have concurrent spinal abnormalities that need to be monitored with MRI. There are major concerns of the MRI compatibility of MCGRs because of the reliance of the lengthening mechanism on strongly ferromagnetic actuators. Methods: Six fresh-frozen adult cadaveric torsos were used. After thawing, MRI was performed four times each: baseline, after implantation of T2–T3 thoracic rib hooks and L5–S1 pedicle screws, and twice after MCGR implantation. Dual MCGRs were implanted in varying configurations and connected at each end with cross connectors, creating a closed circuit to maximize MRI-induced heating. Temperature measurements and tissue biopsies were obtained to evaluate thermal injury. MCGRs were tested for changes to structural integrity and functionality. MRI images obtained before and after MCGR implantation were evaluated. Results: Average temperatures increased incrementally by 1.1°C, 1.3°C, and 0.5°C after each subsequent scan, consistent with control site temperature increases of 1.1°C, 0.8°C, and 0.4°C. Greatest cumulative temperature change of +3.6°C was observed adjacent to the right-sided actuator, which is below the 6°C threshold cited in literature for clinically detectable thermal injury. Histologic analysis revealed no signs of heat-induced injury. All MCGR actuators continued to function properly according to the manufacturer\u27s specifications and maintained structural integrity. Significant imaging artifacts were observed, with the greatest amount when dual MCGRs were implanted in standard/offset configuration. Conclusions: We demonstrate minimal MRI-induced temperature change, no observable thermal tissue injury, preservation of MCGR-lengthening functionality, and no structural damage to MCGRs after multiple MRI scans. Expectedly, the ferromagnetic actuators produced substantial MR imaging artifacts. Level of Evidence: Level V