Orrin I. Franko

Smartphone App Use Among Medical Providers in ACGME Training Programs

The past decade has witnessed the advent of the smartphone, a device armed with computing power, mobility and downloadable “apps,” that has become commonplace within the medical field as both a personal and professional tool. The popularity of medically-related apps suggests that physicians use mobile technology to assist with clinical decision making, yet usage patterns have never been quantified. A digital survey examining smartphone and associated app usage was administered via email to all ACGME training programs. Data regarding respondent specialty, level of training, use of smartphones, use of smartphone apps, desired apps, and commonly used apps were collected and analyzed. Greater than 85% of respondents used a smartphone, of which the iPhone was the most popular (56%). Over half of the respondents reported using apps in their clinical practice; the most commonly used app types were drug guides (79%), medical calculators (18%), coding and billing apps (4%) and pregnancy wheels (4%). The most frequently requested app types were textbook/reference materials (average response: 55%), classification/treatment algorithms (46%) and general medical knowledge (43%). The clinical use of smartphones and apps will likely continue to increase, and we have demonstrated an absence of high-quality and popular apps despite a strong desire among physicians and trainees. This information should be used to guide the development of future healthcare delivery systems; expanded app functionality is almost certain but reliability and ease of use will likely remain major factors in determining the successful integration of apps into clinical practice.

iPad Apps for Orthopedic Surgeons

The development and distribution of mobile applications, or apps, designed for medical professionals and patients is quickly expanding, and within this group are apps designed specifically for orthopedic use. Currently, the most popular mobile apps are sponsored by private companies and focus on delivering device-specific information. If this trend toward the use of privately funded educational materials continues, regulations may need to be established to ensure that the information provided is accurate, honest, and supported by peer-reviewed literature. It will likely be the responsibility of the orthopedic community to ensure that the development and use of these apps has appropriate oversight and validation as they are incorporated into clinical practice and training.

QUANTIFICATION OF PARTIAL OR COMPLETE A4 PULLEY RELEASE WITH FDP REPAIR IN CADAVERIC TENDONS

PURPOSE Repair of a lacerated flexor digitorum profundus (FDP) tendon underneath or just distal to the A4 pulley can be technically challenging, and success can be confounded by tendon triggering and scarring to the pulley. The purpose of this study was to quantify the effect of partial and complete A4 pulley release in the context of a lacerated and repaired FDP tendon just distal to the A4 pulley. METHODS Tendon biomechanics were tested in 6 cadaveric hands secured to a rigid frame, permitting measurement of tendon excursion, tendon force, and finger range of motion. After control testing, each finger had laceration and repair of the FDP tendon at the distal margin of the A4 pulley using a 6-strand core suture technique and epitendinous repair. Testing was then repeated after the following interventions: (1) intact A4 pulley, (2) release of the distal half of the A4 pulley, (3) complete release of the A4 pulley, and (4) continued proximal release of the sheath to the distal edge of A2 (release of C2, A3, and C1 pulleys). Release of the pulleys was performed by incision; no tissue was removed from the specimens. RESULTS From full extension to full flexion, average FDP tendon excursion for all intact digits was 37.9 ± 1.5 mm, and tendon repair resulted in average tendon shortening of 1.6 ± 0.4 mm. Flexion lag increased from <1 mm to >4 mm with venting of the A4 pulley, complete A4 release, and proximal sheath release, respectively. Compared to the intact state, repair of the tendon with an intact A4 pulley, release of half the A4 pulley, complete A4 release, and proximal sheath release resulted in percentage increases in work of flexion of 11.5 ± 3.1%, 0.83 ± 2.8%, 2.6 ± 2.4%, and 3.25 ± 2.2%, respectively. CONCLUSIONS After FDP laceration and repair in the region of the A4 pulley, work of flexion did not increase by more than 3% from control conditions after partial or complete A4 pulley release, and work of flexion was significantly less than that achieved by performing a repair and leaving the A4 pulley intact.

MOMENT ARMS OF THE HUMAN DIGITAL FLEXORS

For the extrinsic hand flexors (flexor digitorum profundus, FDP; flexor digitorum superficialis, FDS; flexor pollicis longus, FPL), moment arm corresponds to the tendons distance from the center of the metacarpalphalangeal (MP), proximal interphalangeal (PIP), or distal interphalangeal (DIP) joint. The clinical value of establishing accurate moment arms has been highlighted for biomechanical modeling, the development of robotic hands, designing rehabilitation protocols, and repairing flexor tendon pulleys (Brand et al., 1975; An et al., 1983; Thompson and Giurintano, 1989; Deshpande et al., 2010; Wu et al., 2010). In this study, we define the moment arms for all of the extrinsic flexor tendons of the hand across all digital joints for all digits in cadaveric hands.

Mobile Device Trends in Orthopedic Surgery: Rapid Change and Future Implications.

Mobile devices are increasingly becoming integral communication and clinical tools. Monitoring the prevalence and utilization characteristics of surgeons and trainees is critical to understanding how these new technologies can be best used in practice. The authors conducted a prospective Internet-based survey over 7 time points from August 2010 to August 2014 at all nationwide American Council for Graduate Medical Education-accredited orthopedic programs. The survey questionnaire was designed to evaluate the use of devices and mobile applications (apps) among trainees and physicians in the clinical setting. Results were analyzed and summarized for orthopedic surgeons and trainees. During the 48-month period, there were 7 time points with 467, 622, 329, 223, 237, 111, and 134 responses. Mobile device use in the clinical setting increased across all fields and levels of training during the study period. Orthopedic trainees increased their use of Smartphone apps in the clinical setting from 60% to 84%, whereas attending use increased from 41% to 61%. During this time frame, use of Apple/Android platforms increased from 45%/13% to 85%/15%, respectively. At all time points, 70% of orthopedic surgeons believed their institution/hospital should support mobile device use. As measured over a 48-month period, mobile devices have become an ubiquitous tool in the clinical setting among orthopedic surgeons and trainees. The authors expect these trends to continue and encourage providers and trainees to be aware of the limitations and risks inherent with new technology.

Functional Consequence of Distal Brachioradialis Tendon Release: A Biomechanical Study

PURPOSE Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, this common procedure has the potential to decrease elbow flexion strength. To determine the potential morbidity associated with brachioradialis release, we measured the change in elbow torque as a function of incremental release of the brachioradialis insertion footprint. METHODS In 5 upper extremity cadaveric specimens, we systematically released the brachioradialis tendon from the radius and measured the resultant effect on brachioradialis elbow flexion torque. We defined release distance as the distance between the release point and the tip of the radial styloid. RESULTS Brachioradialis elbow flexion torque dropped to 95%, 90%, and 86% of its original value at release distances of 27, 46, and 52 mm, respectively. Importantly, brachioradialis torque remained above 80% of its original value at release distances up to 7 cm. CONCLUSIONS Our data demonstrate that release of the brachioradialis tendon from its insertion has minor effects on its ability to transmit force to the distal radius. CLINICAL RELEVANCE These data imply that release of the distal brachioradialis tendon during distal radius open reduction internal fixation can be performed without meaningful functional consequences to elbow flexion torque. Even at large release distances, overall elbow flexion torque loss after brachioradialis release would be expected to be less than 5% because of the much larger contributions of the biceps and brachialis. Use of the brachioradialis as a tendon transfer donor should not be limited by concerns of elbow flexion loss, and the tendon could be considered as an autograft donor.

Twitter as a Communication Tool for Orthopedic Surgery

Twitter is a social networking Web site that has changed the way information is communicated. This study involved identifying, categorizing, and reviewing orthopedic Twitter profiles. A total of 412 profiles were identified. Of those, 176 (50.3%) were surgeons; 89 (50.5%) were based in the United States and 77 (43.8%) were not (10 unclassified). Most surgeons were young; 66% of surgeons were board certified within the past 10 years. Only a small percentage of orthopedic surgeons and practices currently use Twitter, but the use of social networking for orthopedic communication is likely to play an increasing role in future clinical practice.

Mobile Software Applications for Hand Surgeons

E I c r In B ri ef AS SMARTPHONES AND tablet computers gain increasing popularity among physicians and trainees, recent articles have focused on mobile pplications (apps) for particular specialties. Most ecently, authors Barr and Yao discussed the uses, caabilities, and regulations of smartphones as they apply o hand surgeons. In their article, the authors eluciated many of the useful features of smartphones, inluding the utility of apps, software developed specifially for mobile devices. They noted that no study had pecifically examined apps designed for the hand sureon. This article describes many of the currently availble apps that would be most useful to practicing hand urgeons. Many of the presented apps are available or both iPhone and Android devices, although ost are available exclusively for the iPhone and Pad. Many are free, others require purchase, and ll are available through the iTunes App Store or ndroid Market (Table 1). I encourage readers who re interested in these apps or others to seek addiional reviews from app review websites such as ww.TopOrthoApps.com, which reviews only orhopedic apps.

Reply To Letter to the Editor: Smartphone Apps for Orthopaedic Surgeons

I appreciate and agree with the comments shared by Rohman and Boddice regarding the expanding library of useful orthopaedic applications. In fact, since the initial publication of “Smartphone apps for Orthopaedic Surgeons” in July 2011 [3], much has changed in the realm of available orthopaedic apps. A followup study specifically examining iPad apps [4] and another review of orthopaedic apps [1] were published. I and others are continuing to examine the role that mobile technology will play in the lives of orthopaedic surgeons and patients. Rohman and Boddice identified an important concept: that the world of apps is in a state of constant change. With this in mind I launched www.TopOrthoApps.com in December 2011 to serve as a continuously updated resource of orthopaedic mobile apps. The site currently includes more than 200 apps for iPhone, iPad, and Android devices, a substantial increase from the 74 apps identified for my original article just 18 months ago. The website includes a listing of peer-reviewed apps and current literature on the topic of orthopaedic applications. In addition, the recent release of the “Top Ortho” app from the iTunes App Store (https://itunes.apple.com/us/app/toportho/id553738826?mt=8) now allows users to read reviews and download apps directly from their mobile devices. I also appreciate the authors’ mention of many newer apps and general surgical and anatomy apps that were not included in the initial review. To expand on their list, it is worth mentioning new educational resource apps such as AAOS eBooks, a plethora of online journals (Spine, Journal of Hand Surgery, JBJS Image Quiz, Journal of Orthopaedic Trauma, etc), TraumaLine, and EBSS.Live from AO. There also exist new reference and decision-management apps, such as OrthoRef, Septic Hip, SLIC, and eSplint. Newer apps have been released that focus on patient information and education, including the “Decide” series (SpineDecide, HandDecide, FootDecide, KneeDecide, etc) and DrawMD Orthopedics. Some publications [5, 7, 8, 11–13, 15] have started validating particular apps, which to this point have focused mostly on goniometer-based devices for angular measurements (ie, simple gait or function analysis measures). Finally, the number of nonEnglish apps has been increasing and currently includes apps such as OmbroCotov, OrtoClas, and TumorOsseo (Portuguese). With the prevalence and use of clinical apps on the rise, concerns have increased regarding app validation [6, 10], the risk of decreased hand hygiene [2, 14], confidentiality [9], and physician distraction [16]. Ultimately it is the responsibility of the physician to make decisions based on appropriate medical information and to ensure the safety of his or her patients. I encourage all providers to consider how apps influence their own practice and to remain diligent about ensuring patient safety and care.

Open Access and Online Journals in Orthopaedics: What Does the Future Hold?

An orthopaedic surgeon has just completed a clinical outcomes research project in his area of expertise and wishes to publish a report in a widely read journal so that he can share his findings with the orthopaedic community. After the manuscript was rejected by two widely read subscription-based orthopaedic journals, the author submits the work to a so-called “peer-reviewed open access” orthopaedic journal that he finds online. Within two months, he receives a congratulatory acceptance letter stating that the manuscript has been accepted without revision and will be published both online and in print with open access. He is required to pay a