Hughston Clinic

Background: Meniscal preservation has been demonstrated to contribute to long-term knee health and has been a successful intervention in isolation and in patients with anterior cruciate ligament reconstruction (ACLR). The long-term results of meniscal repair in the setting of revision ACLR have yet to be documented. Purpose: To report the incidence of meniscal repair failures at the 6-year follow-up in a cohort of patients who underwent concurrent revision ACLR and primary meniscal repair. Study Design: Prospective cohort study; Level of evidence, 2. Methods: All revision ACLRs with concomitant primary meniscal repair cases from a multicenter group between 2006 and 2011 were selected. Six-year follow-up was obtained to determine whether any subsequent surgery had occurred since their initial revision ACLR. If so, operative reports were obtained, whenever possible, to verify pathological condition and treatment. Results: In total, 221 patients from 1234 revision ACLRs underwent concurrent primary meniscal repairs (18% of the cohort). There were 238 repairs performed: 173 medial and 65 lateral. The majority of these repairs (n = 181; 76%) were performed with an all-inside technique. Six-year surgical follow-up was obtained in 77% (171/221) of the cohort, or 189 of 238 (79%) of the repairs (136 medial, 53 lateral). The meniscal repair failure rate, defined as reoperation, was 16% (31/189) at 6 years. Of the 31 failures, 28 were medial (24 all-inside, 4 inside-out; 28/136 = 20.6% failure rate) and 3 were lateral (2 all-inside, 1 inside-out; 3/53 = 5.7% failure rate). Three medial failures were treated in conjunction with a subsequent repeat revision ACLR. Medial tears underwent reoperation for failure at a significantly higher rate than lateral tears (20.6% vs 5.7%; P = .01) and had a significantly shorter survival time compared with lateral tears (P = .02). No difference was found between the failure and nonfailure groups when it came to tear type, tear length, repair technique utilized, suture/implant type, or number of sutures used between the 2 groups. Conclusion: Meniscal repair in the revision ACLR setting has a 16% failure rate at 6 years. Failure rates for medial tears (20.6%) were found to be higher than that for lateral tears (5.7%), which aligns with previous studies in both the revision and primary ACLR setting.

PurposeIntradural spinal arachnoid cysts (SACs) and spinal arachnoid webs (SAWs) are rare extramedullary lesions in the spine. We aimed to assess the relative incidence of the two entities while also better assessing the similarities and differences in imaging appearance and clinical presentation.MethodsA retrospective analysis was performed of the incidence, imaging features, and clinical presentation of SACs and SAWs at a single institution from 2015 to 2021.ResultsThere were 12 cases of SACs and 9 cases of SAWs. The incidence of cysts was .050% and the incidence of webs was .037%. The clinical presentation was similar in the two groups, with the most common signs and symptoms being back pain followed by leg pain. Other signs of myelopathy were common in both groups including absent or diminished reflexes, decreased sensation, and decreased strength. The locations of the cysts were: 1 cervical (8%), 6 thoracic (50%), 5 lumbar (42%). All of the cervical and thoracic cysts caused cord compression. All 9 webs caused focal cord compression (scalpel sign).ConclusionSACs and SAWs are both rare lesions that we believe have a similar incidence, with cysts being only a little more common in our cohort. As they both often present with signs and symptoms of myelopathy, imaging findings are more useful in distinguishing between the two entities. The location of the cyst and the appearance of mass effect on the cord are helpful, as webs cause a focal compression, the scalpel sign, while cysts cause broader and smoother compression.

Madden, Diana MA; Barnert, Elizabeth MD, MPH, MS; Svetaz, Maria Veronica MD, MPH; Huston, Sara MS Author Information

We thank Farkouh and colleagues for reading our publication and commenting on the important link between alcohol use and breast cancer prevalence. We agree that alcohol use among female orthopaedic surgeons warrants additional investigation. However, our study was primarily focused on fluoroscopy, polymethyl methacrylate (PMMA), and protective shielding rather than other risk factors of breast cancer that have been identified in other literature. Although binge drinking may be possible in this population, our one-time survey question asked participants “Approximately, how many alcoholic drinks have you consumed in the past 7 days?” We are not able to extrapolate possible binge drinking or long-term alcohol use from this question. Furthermore, the alcohol question used from the California survey asked “About how many drinks did you have on a typical day when you drank alcohol?” and was from a survey conducted more than 10 years before our survey. We do not know whether a similar pattern of alcohol use would be found had the California residents been asked the same alcohol question a decade later. Our study was not designed to test individual risk factors associated with breast cancer prevalence. Studies, such as Chen et al. (2011), cited by Farkouh and colleagues had repeated measures of alcohol use over years and asked about alcohol use in a typical week are better equipped to answers questions about the link between alcohol use and breast cancer prevalence. We briefly noted a few factors in the study, including the lower body mass index and higher rate of never smoking among orthopaedic surgeons. These factors would also benefit from additional investigation.

BackgroundPhysical therapy (PT) plays an important role in the recovery of function following anatomic total shoulder arthroplasty (aTSA). While several PT protocols have been published for these patients, there is no standardized protocol for aTSA rehabilitation. This lack of standardization may lead to confusion between patients and physicians, possibly resulting in suboptimal outcomes. This study examines how PT protocols provided by academic orthopedic surgery programs vary regarding therapeutic goals and activities following aTSA.MethodsPT protocols for aTSA available online from the Accreditation Council for Graduate Medical Education accredited orthopedic surgery programs were included for review. Each protocol was analyzed to evaluate it for differences in recommendation of length of immobilization, range of motion (ROM) goals, start time for and progression of therapeutic exercises, and timing for return to functional activity.ResultsOf 175 accredited programs, 25 (14.2%) had protocols publicly available, programs (92%) recommended sling immobilization outside of therapy for an average of 4.4±2.0 weeks. Most protocols gave recommendations on starting active forward flexion (24 protocols, range 1–7 weeks), external rotation (22 protocols, range 1–7 weeks), and internal rotation (18 protocols, range 4–7 weeks). Full passive ROM was recommended at 10.8±5.7 weeks, and active ROM was 13.3±3.9 weeks, on average. ROM goals were inconsistent among protocols, with significant variations in recommended ROM and resistance exercise start times. Only 13 protocols (52%) gave recommendations on resuming recreational activities (mean, 17.4±4.4 weeks).ConclusionsPublicly available PT protocols for aTSA rehabilitation are highly variable.Level of evidenceLevel IV.

Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level IV.

Introduction:Orthopaedic surgery is one of the most competitive and least diverse specialties in medicine. Affiliation of an orthopaedics with an allopathic medical school impacts research opportunities and early exposure to clinical orthopaedics. The purpose of this study is to examine the potential effect allopathic medical school affiliation has on orthopaedic surgery resident demographics and academic characteristics.Methods:All 202 Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics programs were divided into 2 groups: Group 1 consisted of residency programs without an affiliated allopathic medical school, and Group 2 consisted of programs with an affiliated allopathic medical school. Affiliations were determined by cross-referencing the ACGME residency program list with the medical school list published by Association of American Medical Colleges (AAMC). Program and resident characteristics were then compiled using AAMC’s Residency Explorer including region, program setting, number of residents, and osteopathic recognition. Resident characteristics included race, gender, experiences (work, volunteer, and research), peer-reviewed publications, and US Medical Licensing Examination Step 1 scores.Results:Of the 202 ACGME-accredited orthopaedics residencies, Group 1 had 61 (30.2%) programs, and Group 2 had 141 (69.8%) programs. Group 2 had larger programs (4.9 vs. 3.2 resident positions/year; p < 0.001) and 1.7 times the number of residency applicants (655.8 vs. 385.5; p < 0.001). Most Group 2 residents were allopathic medical school graduates, 95.5%, compared with 41.6% in Group 1. Group 1 had 57.0% osteopathic medical school graduates, compared with 2.9% in Group 2. There were 6.1% more White residents in Group 1 residencies (p = 0.025), and Group 2 residencies consisted of 3.5% more Black residents in relation to Group 1 (p = 0.03). Academic performance metrics were comparable between the 2 groups (p > 0.05).Conclusion:This study demonstrated that candidates who successfully match into an orthopaedic surgery residency program achieve high academic performance, regardless of whether the program was affiliated with an allopathic medical school. Differences may be influenced by increased representation of minority faculty, greater demand for allopathic residents, or stronger emphasis on promotion of diversity in those residency programs.Availability of Data and Material:Available on reasonable request.Level of Evidence:Level III. See Instructions for Authors for a complete description of levels of evidence.

A survey was developed that was sent to orthopaedic residency program leadership via email through their interaction with the COERG. Additional programs were included to enhance diversity of responding programs. The survey, based on those published from other areas of medicine, included questions about the experiences of the respondents in learning about cost-effective care, as well as how faculty and residents learned about this topic. Seventy one percent (30) of respondents noted that their faculty did not receive formal training in cost-effective care, and education in this area was likely to come from the department, especially review of practice data (12, 44%). Only 19% (8) of respondents agreed with the statement that "the majority of teaching faculty in our program consistently model cost-effective healthcare to residents". Few of the programs (10, 24%) had formal curricula for residents regarding cost-effective care, and the primary mode of education in cost-effective care was through informal discussions with faculty (17, 43%). Few residents (3, 13%) were able to easily find the costs of tests or procedures. There is not consistent education in cost-effective care for orthopaedic surgery program leadership, faculty, or trainees. The results of this survey demonstrate a need for discussion of best practices, including increasing access to cost data at a local level, and engaging with the AOA, CORD, and the American Academy of Orthopaedic Surgeons more broadly in the development of standard education modules for faculty and residents, to improve the current and future delivery of cost-effective musculoskeletal care.