Johnathan A. Bernard

The Incidence and Reporting of Sharps Exposure among Medical Students, Orthopedic Residents, and Faculty at One Institution

OBJECTIVE To compare the incidence of sharps injuries among medical students, orthopedic residents/fellows, and orthopedic faculty at one institution and to determine the rate of reporting exposures. DESIGN Cross-sectional survey. Surveys were completed by 44% (53/120) of medical students, 76% (23/30) of residents/fellows, and 56% (17/30) of full-time faculty. SETTING Academic medical center. PARTICIPANTS Medical students, orthopedic surgery residents/fellows, full-time academic orthopedic surgery faculty. RESULTS Twenty-eight percent of medical students, 83% of residents/fellows, and 100% of faculty had been exposed to a sharps injury at some point in their career; 42% of residents/fellows had experienced a sharps exposure within the past year. The most common single instrument responsible for sharps injuries among all groups was the solid-bore needle; students and residents were significantly more likely than faculty to have a sharps injury from a solid-bore needle than all other devices combined (p = 0.04). Medical students were more likely to ignore the exposure than residents/fellows (p = 0.004) or faculty (p = 0.036). Only 12.5% of medical students followed all the steps of the postexposure protocol. CONCLUSION Sharps exposures occur among orthopedic surgeons and their trainees. Interventions are needed to increase safety among residents and medical students. Further research should evaluate factors suppressing medical student reporting of sharps exposures.

Reliability and Validity of 3 Methods of Assessing Orthopedic Resident Skill in Shoulder Surgery.

OBJECTIVE Traditional measures for evaluating resident surgical technical skills (e.g., case logs) assess operative volume but not level of surgical proficiency. Our goal was to compare the reliability and validity of 3 tools for measuring surgical skill among orthopedic residents when performing 3 open surgical approaches to the shoulder. METHODS A total of 23 residents at different stages of their surgical training were tested for technical skill pertaining to 3 shoulder surgical approaches using the following measures: Objective Structured Assessment of Technical Skills (OSATS) checklists, the Global Rating Scale (GRS), and a final pass/fail assessment determined by 3 upper extremity surgeons. Adverse events were recorded. The Cronbach α coefficient was used to assess reliability of the OSATS checklists and GRS scores. Interrater reliability was calculated with intraclass correlation coefficients. Correlations among OSATS checklist scores, GRS scores, and pass/fail assessment were calculated with Spearman ρ. Validity of OSATS checklists was determined using analysis of variance with postgraduate year (PGY) as a between-subjects factor. Significance was set at p < 0.05 for all tests. RESULTS Criterion validity was shown between the OSATS checklists and GRS for the 3 open shoulder approaches. Checklist scores showed superior interrater reliability compared with GRS and subjective pass/fail measurements. GRS scores were positively correlated across training years. The incidence of adverse events was significantly higher among PGY-1 and PGY-2 residents compared with more experienced residents. CONCLUSION OSATS checklists are a valid and reliable assessment of technical skills across 3 surgical shoulder approaches. However, checklist scores do not measure quality of technique. Documenting adverse events is necessary to assess quality of technique and ultimate pass/fail status. Multiple methods of assessing surgical skill should be considered when evaluating orthopedic resident surgical performance.

Autologous distal clavicle versus autologous coracoid bone grafts for restoration of anterior- inferior glenoid bone loss: a biomechanical comparison

BACKGROUND Treating anterior glenoid bone loss in patients with recurrent shoulder instability is challenging. Coracoid transfer techniques are associated with neurologic complications and neuroanatomic alterations. The purpose of our study was to compare the contact area and pressures of a distal clavicle autograft with a coracoid bone graft for the restoration of anterior glenoid bone loss. We hypothesized that a distal clavicle autograft would be as effective as a coracoid graft. METHODS In 13 fresh-frozen cadaveric shoulder specimens, we harvested the distal 1.0 cm of each clavicle and the coracoid bone resection required for a Latarjet procedure. A compressive load of 440 N was applied across the glenohumeral joint at 30° and 60° of abduction, as well as 60° of abduction with 90° of external rotation. Pressure-sensitive film was used to determine normal glenohumeral contact area and pressures. In each specimen, we created a vertical, 25% anterior bone defect, reconstructed with distal clavicle (articular surface and undersurface) and coracoid bone grafts, and determined the glenohumeral contact area and pressures. We used analysis of variance for group comparisons and a Tukey post hoc test for individual comparisons (with P <.05 indicating a significant difference). RESULTS The articular distal clavicle bone graft provided the lowest mean pressure in all testing positions. The coracoid bone graft provided the greatest contact area in all humeral positions, but the difference was not significant. CONCLUSION An articular distal clavicle bone graft is comparable in glenohumeral contact area and pressures to an optimally placed coracoid bone graft for restoring glenoid bone loss. LEVEL OF EVIDENCE Basic Science Study; Biomechanics.

Diagnostic injections about the shoulder

Injections about the shoulder serve diagnostic as well as therapeutic purposes. Diagnosis of shoulder conditions, such as rotator cuff tears, acromioclavicular joint pathology, subacromial impingement or anterolateral pain syndrome, glenohumeral joint pathology, suprascapular nerve entrapment, and biceps tendon pathologies, is often complicated by concomitant conditions with overlapping symptoms and by inconclusive physical examination and imaging results. Injections of anesthetic agents can often help clinicians locate the source of pain. However, technique and accuracy of needle placement can vary by route. Accuracy is often improved with the use of ultrasonography guidance, although studies differ on the benefits of guided versus unguided injection.

Basic Science Research Trends in Orthopedic Surgery: An Analysis of the Top 100 Cited Articles

BackgroundMuch of current clinical orthopedics traces its origin to basic science investigation of cellular and biochemical pathways, tissue engineering, and biomechanics of bone and joint physiology in animal and cadaveric models.Questions/PurposesWe sought to describe research trends in highly cited basic science studies in orthopedics.MethodsBy searching Web of Science, we identified the 100 most cited basic science orthopedics articles and focused on author position and degree (PhD, MD, or MD/PhD), topic, type of study, country, institution, and citation trends.ResultsThese articles were published from 1970 to 2008 (citation range, 330 to 2111), with the majority from the USA (78). While there was no correlation between years since publication and total citations, more recent articles had higher citation rates. There were 38 unique first authors represented, with Caplan, Harris, Mankin, Noyes, and Warren as primary authors or co-authors of four articles each. Twelve journals published these 100 articles, with the majority in Journal of Bone and Joint Surgery (46) and Clinical Orthopaedics and Related Research (18). Frequent topics included biomechanics (31), healing/regeneration (21), and cellular/molecular biology (13). The Hospital for Special Surgery/Cornell University (10) published the most, followed by the Hospital for Joint Diseases/New York University (6), and University of Pittsburgh (6). No difference was observed in total citations and average citation rate by author degree. Eight articles were contributed from privately owned institutions or industry, with the rest from academic hospitals.ConclusionThis review may aid those seeking insight into landmark studies and future direction of basic science research in orthopedics.

Dorsal radiocarpal dislocation in a patient with Goldenhar syndrome: case report.

BackgroundFracture–dislocations of the carpus are rare, generally occurring after high-energy trauma. Goldenhar syndrome is among a group of genetic abnormalities associated with radial limb defects. We present a case of a dorsal radiocarpal dislocation in a patient with Goldenhar syndrome after a low-energy fall. To our knowledge, there has been no previous report of radiocarpal dislocation in the setting of Goldenhar syndrome.MethodsThis patient with Goldenhar syndrome had a dorsal radiocarpal dislocation in the setting of an absent scaphoid and dysplastic distal radius. A computed tomography scan, recognized as a useful modality to evaluate the wrist and scaphoid, was used to rule out any other osseous trauma or avulsion fractures.ResultsClosed reduction and 6 weeks of immobilization resulted in a successful treatment.ConclusionsThe incidence of radiocarpal dislocations in patients with Goldenhar syndrome and the appropriate long-term treatment for patients with Goldenhar syndrome with radiocarpal dislocations require further investigation.

Floating glenoid after reverse total shoulder arthroplasty: a case report

Reverse total shoulder arthroplasty (RTSA) continues to evolve with new implants and surgical techniques to treat shoulders with rotator cuff deficiencies. However, intraoperative and postoperative complication and revision rates are high. The most frequent complications are scapular notching, dislocation, and glenoid component complications. Stress fractures of the scapular spine and the acromion have been described after RTSA. Few reports in the literature describe the effects of scapular fractures on the outcome of the replacement, but they can be the source of continued pain after RTSA. Fractures of the glenoid are typically intra-articular fractures produced at the time of surgery. We describe a previously unreported fracture of the glenoid neck without baseplate loosening 2 years after RTSA. This case of a unique glenoid neck fracture is important because it may represent a more common cause of pain in RTSA than previously appreciated.