Daniel N. Bracey

A Cost-effective Junior Resident Training and Assessment Simulator for Orthopaedic Surgical Skills via Fundamentals of Orthopaedic Surgery: Aaos Exhibit Selection

BACKGROUND Psychomotor testing has been recently incorporated into residency training programs not only to objectively assess a surgeons abilities but also to address current patient-safety advocacy and medicolegal trends. The purpose of this study was to develop and test a cost-effective psychomotor training and assessment tool-The Fundamentals of Orthopaedic Surgery (FORS)-for junior-level orthopaedic surgery resident education. METHODS An orthopaedic skills board was made from supplies purchased at a local hardware store with a total cost of less than

An Orthopedic-Hospitalist Comanaged Hip Fracture Service Reduces Inpatient Length of Stay:

350 so as to assess six different psychomotor skills. The six skills included fracture reduction, three-dimensional drill accuracy, simulated fluoroscopy-guided drill accuracy, depth-of-plunge minimization, drill-by-feel accuracy, and suture speed and quality. Medical students, residents, and attending physicians from three orthopaedic surgery residency programs accredited by the Accreditation Council for Graduate Medical Education participated in the study. Twenty-five medical students were retained for longitudinal training and testing for four weeks. Each training session involved an initial examination followed by thirty minutes of board training. The time to perform each task was measured with accuracy measurements for the appropriate tasks. Statistical analysis was done with one-way analysis of variance, with significance set at p < 0.05. RESULTS Forty-seven medical students, twenty-nine attending physicians, and fifty-eight orthopaedic surgery residents participated in the study. Stratification among medical students, junior residents, and senior residents and/or attending physicians was found in all tasks. The twenty-five medical students who were retained for longitudinal training improved significantly above junior resident level in four of the six tasks. CONCLUSIONS The FORS is an effective simulator of basic motor skills that translates across a wide variety of operations and has the potential to advance junior-level participants to senior resident skill level. CLINICAL RELEVANCE The FORS simulator may serve as a valuable tool for resident education.

Angiotensin-(1-7) Attenuates Skeletal Muscle Fibrosis and Stiffening in a Mouse Model of Extremity Sarcoma Radiation Therapy

Introduction: Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States, representing a health-care cost of US

Construct Validity for a Cost-effective Arthroscopic Surgery Simulator for Resident Education.

9 to 20 billion. Hip fracture incidence is projected to increase dramatically. Hospitals must modify clinical models to accommodate this growing burden. Comanagement strategies are reported in the literature, but few have addressed orthopedic-hospitalist models. An orthopedic-hospitalist comanagement (OHC) service was established at our hospital to manage hip fracture patients. We sought to determine whether the OHC (1) improves the efficiency of hip fracture management as measured by inpatient length of stay (LOS) and time to surgery (TTS) and (2) whether our results are comparable to those reported in hip fracture comanagement literature. Methods: A comparative retrospective–prospective cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before (n = 45) and 10 months after implementation (n = 54) of the OHC at a single academic hospital. Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours, 30-day readmission rates, and mortality. Outcomes were compared to comanagement study results published in MEDLINE-indexed journals. Results: Patient cohort demographics and comorbidities were similar. Inpatient LOS was reduced by 1.6 days after implementation of the OHC (P = .01) without an increase in 30-day readmission rates or mortality. Time to surgery was insignificantly reduced from 27.4 to 21.9 hours (P = .27) and surgery within 48 hours increased from 86% to 96% (P = .15). Discussion: The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution. Conclusion: Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly expanding patient population.

Anterior intrapelvic migration of femoral trial head requiring secondary surgical approach for retrieval.

BACKGROUND Radiation-induced fibrosis (RIF) of musculoskeletal tissue is a common complication of radiation therapy for extremity soft-tissue sarcoma, with no standardized strategy for prevention and treatment. Angiotensin-(1-7) (Ang-[1-7]), a well-tolerated endogenous heptapeptide hormone with antitumor and antifibrotic properties, was tested as a radioprotectant for RIF and stiffening of irradiated muscles. METHODS Male CD-1 mice were randomized to one of three treatment groups: control, simulated sarcoma radiation therapy to the gastrocnemius and soleus muscles, or radiation therapy along with continuous Ang-(1-7) delivery initiated three days before radiation therapy. The biologically equivalent dose of radiation (∼100.3 Gy) absorbed by normal musculature during the course of radiation therapy for extremity sarcoma was delivered by means of four dose fractions of 7.3 Gy over two weeks. Fibrosis (n = 5 per group) and mechanical properties (n = 4 to 6 per group) of the muscles were measured at six weeks and four months after radiation therapy, and the intramuscular concentration of the profibrotic cytokines transforming growth factor-beta (TGF-β) and connective tissue growth factor (CTGF) (n = 8 to 10 per group) were measured at six weeks. RESULTS Interstitial (p < 0.01) and perivascular (p < 0.05) fibrosis increased significantly in the muscles treated with radiation therapy alone versus the nonirradiated controls at both six weeks (interstitial, +89%; perivascular, +112%) and four months (interstitial, +154%; perivascular, +88%). The muscles treated with radiation alone also exhibited increased tension (p < 0.01) versus nonirradiated controls at both six weeks (+779%) and four months (+1761%) when placed under 5% strain, and at four months (+1390%; p < 0.001) under 10% strain. At four months, muscle stiffness had increased in the mice treated with radiation therapy alone (+90%; p = 0.002) compared with nonirradiated controls. TGF-β production was also greater in this group at six weeks (+37%; p = 0.06) versus control. Ang-(1-7) administration prevented RIF and stiffening, with no differences observed for any other outcome between those receiving radiation therapy with Ang-(1-7) and the nonirradiated controls. Likewise, Ang-(1-7) mitigated the increase in TGF-β and CTGF concentration from radiation therapy. CONCLUSIONS Ang-(1-7) attenuated RIF, stiffening, and production of profibrotic cytokines that were elevated in mouse skeletal muscles after simulated radiation therapy for extremity sarcoma. CLINICAL RELEVANCE Ang-(1-7) may serve as a potential therapy for the prevention of RIF in patients who require radiation therapy as adjuvant treatment for soft-tissue sarcoma.

Comparison of Transposition Techniques to Reduce Gap Associated With High Ulnar Nerve Lesions

Introduction:Arthroscopy is one of the most challenging surgical skills to assess and teach. Although basic psychomotor arthroscopic skills, such as triangulation and object manipulation, are incorporated into many simulation exercises, they are not always individually taught or objectively evaluated. In addition, arthroscopic instruments, arthroscopy cameras, and the cadaver or joint models necessary for practice are costly. Methods:A low-cost arthroscopic simulator was created to practice triangulation, probing, horizon changes, suture management, and object manipulation. The simulator materials were purchased exclusively from national hardware stores with a total cost averaging

Proving Osteoinductive Potential of a Decellularized Xenograft Bone Substitute

79. The universal serial bus (USB) camera is included in the total cost. Three residency programs accredited by the Accreditation Council for Graduate Medical Education were tested on the simulator. Replica boards were created at each institution. Participants included medical students (20), residents (46), and attending physicians (9). Results:Construct validity—the ability to differentiate between novice, intermediate, and senior level participants—was obtained. On all tasks, junior residents scored at a statistically significant lower rate than senior residents and attending physicians. Conclusions:This cost-effective arthroscopic surgical simulator objectively demonstrated that attending physicians and senior residents performed at a higher level than junior residents and novice medical students. The results of this study demonstrate that this simulator could be an important training tool for resident education.

A Decellularized Porcine Xenograft-Derived Bone Scaffold for Clinical Use as a Bone Graft Substitute: A Critical Evaluation of Processing and Structure

The current report describes a revision total hip arthroplasty in which the trial femoral head disassociated during reduction and migrated into a soft tissue capsule of the true pelvis between the external iliac vein and corona mortise. The authors believe this previously undescribed migration pattern was created by the patients history of recurrent dislocations. To retrieve the trial prosthesis without injuring the adjacent vasculature, a secondary surgical approach was utilized. The described case identifies the risk of pelvic migration in patients with a history of dislocations and reminds us that a secondary surgical approach should be considered to avoid devastating injury to the neighboring vasculature.

A retrospective analysis of the merits and challenges associated with simultaneous bilateral THA using the direct anterior approach.

PURPOSE To determine in a cadaveric model which of 3 anterior transposition techniques allows for maximum gap reduction for high ulnar nerve lesions. METHODS Six fresh-frozen human adult upper extremity cadaveric transhumeral specimens were used. We anchored the ulnar nerve to bone 10 cm proximal and distal to the medial epicondyle along its exact course while keeping the elbow in 30° flexion as the baseline measurement. We then used a thick suture to mimic and measure the exact course of the nerve between the pins in varying elbow positions. The nerve was then transposed first subcutaneously, then intramuscularly, and then submuscularly while taking exact measurements of the distance the nerve had to travel in varying degrees of elbow flexion for each transposition method. We performed comparative analysis to analyze gap reduction with respect to transposition method and elbow position. RESULTS Transposing the ulnar nerve reduced the repair gap required to cross the elbow regardless of transposition technique. When comparing individual techniques, however, the greatest gap reduction was achieved by intramuscular, followed by submuscular and finally subcutaneous transposition. A maximum gap reduction of 25 mm (average, 23 mm) was achieved using intramuscular transposition with the elbow in 90° flexion. Subcutaneous transposition actually increased the repair gap when the elbow was in an extended position. CONCLUSIONS An intramuscular transposition with the elbow in 90° flexion provided the best gap reduction. However, post-neurorrhaphy mobilization may compromise repair site integrity and vascularity if elbow flexion is required to achieve a primary repair, and these factors should be considered carefully when planning treatment. CLINICAL RELEVANCE This study provides guidance on techniques to reduce nerve gap for primary repair of the ulnar nerve at the elbow using transposition and elbow flexion.

Obesity has no effect on outcomes following unicompartmental knee arthroplasty

Background Large bone defects remain a major clinical challenge for orthopaedic surgeons. Tissue engineered bone grafts have garnered increased attention as a solution to this problem. One ideal property of any bone graft is osteoinductivity or the ability to stimulate progenitor cell differentiation into a bone forming lineage. Questions Is the osteoinductive potential of a porcine bone xenograft maintained in vitro after undergoing a novel decellularization and oxidation process? Are porcine bone scaffolds osteoinductive in an in vivo animal model? Methods In Vitro – C2C12 pre-osteoblasts were seeded on the scaffold or a commercial grade demineralized bone matrix (DBM) to study osteogenic differentiation and compare osteoinductive potential. MC3T3-E1 pre-osteoblasts were seeded on the scaffold and compared to a control monolayer to identify early markers of osteogenic differentiation. In Vivo – MC3T3-E1-seeded scaffolds were implanted subcutaneously in mice and assessed for markers of early osteogenic differentiation, new bone formation (micro-computed tomography and histological assessment), and vascular infiltration (histology). Results Osteoinductive potential was demonstrated in in vitro experiments by similar osteogenic marker expression compared to DBM and significantly greater expression than a control monolayer. Osteoinductivity was confirmed with in vivo experiments showing both new bone formation and vascular infiltration. Conclusion Porcine bone maintains osteoinductive properties after decellularization and oxidation. Clinical Relevance This construct could potentially serve as a bone graft substitute maintaining the osteoinductive potential of native bone. The unrestricted supply and controlled donor biology may satisfy a large clinical need for orthopaedic cases requiring bone grafting.