Shepard R. Hurwitz

Mechanical considerations for the syndesmosis screw: a cadaver study

The purpose of this study was to examine the mechanical necessity of using a syndesmosis screw to supplement rigid internal fixation of the fibula and medial malleolus in the treatment of pronation-external rotation fractures. The legs of thirty embalmed and five fresh cadavera were dissected and mounted through the tibia to a frame so that multiple radiographs could be made with a constant relationship between the specimen and the x-ray apparatus. A standardized pronation-external rotation load was applied to the foot, and widening of the syndesmosis was studied on mortise radiographs that were made after each experimental step. On the basis of previous investigations, we developed a model for pronation-external rotation injuries that included disruption of the syndesmosis and interosseous membrane up to the level of the fibular fracture. Accordingly, multiple repaired fibular fractures could be simulated at several levels in the same specimen by incremental proximal division of the interosseous membrane. Specimens were separated into two groups. Group I consisted of thirteen specimens in which the deltoid ligament, syndesmosis, and interosseous membrane were serially sectioned in 1.5-centimeter increments. Group II (ten sections) was subjected to the same protocol, except that the deltoid ligament was kept intact until the final step. The five fresh specimens were sectioned in the same way as those in Group I. In Group I, since the simulated pronation-external rotation injury included a deltoid tear, rigid medial fixation was not possible; accordingly, there was rigid fibular fixation only.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between performance on part I of the American Board of Orthopaedic Surgery Certifying Examination and Scores on USMLE Steps 1 and 2.

Background This study investigated the strength of the relationship between performance on Part I of the American Board of Orthopaedic Surgery (ABOS) Certifying Examination and scores on United States Medical Licensing Examination (USMLE) Steps 1 and 2. Method USMLE Step 1 and Step 2 scores on first attempt were matched with ABOS Part I results for U.S./Canadian graduates taking Part I for the first time between 2002 and 2006. Linear and logistic regression analyses investigated the relationship between ABOS Part I performance and scores on USMLE Step 1 and 2. Results Step 1 and Step 2 individually each explained 29% of the variation in Part I scores; using both scores increased this percentage to 34%. Results of logistic regression analyses showed a similar, moderately strong relationship with Part I pass/fail outcomes: Examinees with low scores on Steps 1 and 2 were at substantially greater risk for failing Part I. Conclusions There is continuing empirical support for use of Step 1 and Step 2 scores in selection of residents to interview for orthopedics residency positions.

Utility of AAOS OITE scores in predicting ABOS Part I outcomes: AAOS exhibit selection.

BACKGROUND Residency programs commonly use performance on the Orthopaedic In-Training Examination (OITE) developed by the American Academy of Orthopaedic Surgeons (AAOS) to identify residents who are lagging behind their peers and at risk for failing Part I of the American Board of Orthopaedic Surgery (ABOS) Certifying Examination. This study was designed to investigate the utility of the OITE score as a predictor of ABOS Part I performance. METHOD Results for 3132 examinees who took Part I of the ABOS examination for the first time from 2002 to 2006 were matched with records from the 1997 to 2006 OITE tests; at least one OITE score was located for 2852 (91%) of the ABOS Part I examinees. After OITE performance was rescaled to place scores from different test years on comparable scales, descriptive statistics and correlations between ABOS and OITE scores were computed, and regression analyses were conducted to predict ABOS results from OITE performance. RESULTS Substantial increases in the mean OITE score were observed as residents progressed through training. Stronger correlations were observed between OITE and ABOS performance during later years in training, reaching a maximum of 0.53 in years 3 and 4. Logistic regression results indicated that residents with an OITE score below the 10th percentile were much more likely to fail Part I compared with those with an OITE score above the 50th percentile. CONCLUSIONS OITE performance was a good predictor of the ABOS score and pass-fail outcome; the OITE can be used effectively for early identification of residents at risk for failing the ABOS Part I examination.

An AOA Critical Issue How to Read the Literature to Change Your Practice: An Evidence-Based Medicine Approach

“... To fix a health care system distorted by spiraling costs... true reform needs to go farther. Certainly any farreaching reform must make greater use of evidence-based medicine...” —“Healing Health Care” The Washington Post, May 15, 2004 What is this “evidence-based medicine” that the editorial staff of The Washington Post feels is a cornerstone of health-care reform, and what, if anything, does it have to do with the current practice of orthopaedic surgery? Does the application of evidence-based medicine offer a way to reduce public expenditure on health care? The short answer is that evidence-based medicine is a process that uses truthful clinical information in addition to the practical experience of the surgeon to make medical decisions1. Also, in theory, the practice guidelines that are generated by scientific clinical studies can reduce the complications and bad surgical outcomes that drive health-care costs higher2. The long answer with regard to how evidence-based medicine works requires some rigorous learning about statistics, probability, clinical research, guided inquiry, systematic reviews, and levels of evidence. Fortunately, the short answer is enough to get started, and orthopaedic surgeons can get up to speed by reading about levels of evidence in peer-reviewed journals. The editors of peer-reviewed clinical journals have adopted a rating system that simplifies the process of rating articles for content3. Levels of evidence have been created to help clinicians to understand that evidence is created by scientific research that answers questions or solves problems. The application of journal articles into practice is the fourth stage of a problem-solving algorithm that starts with (1) formulating answerable questions, (2) gathering evidence, (3) evaluating the evidence, (4) putting evidence into practice, and (5) evaluating the results of putting evidence into practice. Surgeon-scientists have their articles published in journals that rate the …

Orthopaedic surgery milestones.

Peter J. Stern, MD, is Norman S. & Elizabeth C.A. Hill Professor and Chairman of Orthopaedic Surgery at the University of Cincinnati College of Medicine; Stephen Albanese, MD, is Professor and Chair of Orthopedic Surgery and Medical Director of Orthopedic Surgery Clinic at SUNY Upstate Medical University; Mathias Bostrom, MD, is Residency Program Director and Academic Director of Orthopaedics at Hospital for Special Surgery and Professor of Orthopaedic Surgery, Weill Cornell Medical College, Helen Hayes Hospital; Charles S. Day, MD, MBA, is Rabkin Fellow in Medical Education, Associate Professor of Orthopedic Surgery at Harvard Medical School, and Chief/Program Director of Hand and Upper Extremity Surgery at Beth Israel Deaconess Medical Center; Steven L. Frick, MD, is Chairman of Orthopedic Surgery at Nemours Children’s Hospital and Professor of Orthopedic Surgery at the University of Central Florida College of Medicine; William Hopkinson, MD, is Professor, Vice-Chair, and Program Director of Orthopaedic Surgery & Rehabilitation at Loyola University Stritch School of Medicine; Shepard Hurwitz, MD, is Executive Director of the American Board of Orthopaedic Surgery and Professor of Orthopaedics at the University of North Carolina; Keith Kenter, MD, is Director of the Orthopaedic Surgery Residency Program, Associate Professor of Orthopaedic Surgery, and Associate Professor of Physical Medicine and Rehabilitation at the University of Cincinnati College of Medicine; John S. Kirkpatrick, MD, is Professor and Chair of Orthopaedic Surgery and Rehabilitation and Program Director of Orthopaedic Surgery Residency at the University of Florida College of Medicine; J. L. Marsh, MD, is Program Director of Residency Training Program and Professor and Carroll B. Larson Chair of Orthopaedics and Rehabilitation at the University of Iowa; Anand M. Murthi, MD, is Chief of Shoulder and Elbow Surgery and Fellowship Director at MedStar Union Memorial Hospital; Lisa A. Taitsman, MD, MPH, is Associate Professor of Orthopaedics and Sports Medicine at the University of Washington; Brian C. Toolan, MD, is Associate Professor of Surgery and Director of the Residency Program of Orthopaedic Surgery at the University of Chicago Medicine; Kristy Weber, MD, is Virginia & William Percy Professor of Orthopaedic Surgery, Division Chief of Orthopaedic Oncology, and Director of the Sarcoma Center at Johns Hopkins School of Medicine; Rick W. Wright, MD, is Dr Asa C. Dorothy W. Jones Professor of Orthopaedic Surgery, Residency Program Director, and Co-Chief of Sports Medicine at Washington University School of Medicine; Pamela L. Derstine, PhD, MHPE, is Executive Director of the Review Committees for Colon and Rectal Surgery, Neurological Surgery, Orthopaedic Surgery, and Otolaryngology at the Accreditation Council for Graduate Medical Education; and Laura Edgar, EdD, CAE, is Senior Associate Director of Outcome Assessment at the Accreditation Council for Graduate Medical Education.

Current state of fellowship hiring: Is a universal match necessary? Is it possible?

Currently, approximately 90% of the 620 graduating orthopaedic residents in the United States are planning on entering a postgraduate fellowship. Since January 2005, two of the largest fellowship match programs, sports medicine and spine surgery, were dissolved by the National Resident Matching Program (NRMP) because of a gradual decline in participation, leaving approximately 70% of applicants in a nonmatching, decentralized system. This leaves hand, shoulder and elbow surgery, and foot and ankle as the only three orthopaedic subspecialties that remain in some type of match program, creating an extremely complicated hiring environment for all residents. This paper focuses on the current state of fellowship employment and hiring in orthopaedic surgery in the United States, on the likely effects of reinstituting a match, and on how this might be accomplished. For this purpose, we present the results of surveys of fellowship directors and residents that we conducted and we describe how the present market for orthopaedic surgery fellows resembles the market for medical *This report is based on a symposium presented at the Annual Meeting of the American Orthopaedic Association on June 13, 2007, in Asheville, North Carolina.

Retrospective Review of Eighteen Patients Who Underwent Transtibial Amputation for Intractable Pain

Background: Amputations are rarely performed solely for pain relief because of concerns regarding the persistence of pain and disability after the procedure. The purpose of this study was to assess the outcome of below-the-knee amputations performed to relieve intractable foot and ankle pain. Methods: A chart review was conducted to identify all below-the-knee amputations that had been performed for the treatment of chronic foot and ankle pain by three orthopaedic foot and ankle specialists at three institutions. The inclusion criteria included (1) intractable foot or ankle pain as the surgical indication, (2) failure of maximal medical therapy, (3) failure of prior surgical reconstruction, and (4) a minimum follow‐up period of twenty‐four months after below-the-knee amputation. Patients with diabetes mellitus, peripheral vascular occlusive disease, or peripheral neuropathy were excluded. Each participant completed a two-part questionnaire with regard to the levels of disability, function, pain, and recreational activity both before and after the amputation. Results: Twenty patients met the inclusion criteria, and eighteen completed the study. The study group included four women and fourteen men who had an average age of forty‐two years (range, twenty‐six to sixty‐one years) and were followed for an average of forty‐one months (range, twenty‐five to eighty‐five months) after the amputation. When asked whether they would have the below-the-knee amputation done again under similar circumstances, sixteen patients said yes, one was unsure, and one said no. The same distribution was observed when the patients were asked whether they were satisfied with the outcome: sixteen said yes, one was unsure, and one said no. Disability, pain, and recreational status were assessed with a 10-cm visual analog scale. After the amputation, the patients reported a decrease in both pain frequency (with the average score improving from 9.8 to 1.7; p < 0.0001) and pain intensity (with the average score improving from 8.4 to 2.6; p < 0.0001). Ten patients discontinued the use of narcotics, and seven decreased the level and/or dosage. Three patients worked before the amputation, and eight worked after the amputation. The average walking distance increased from 0.3 to 0.8 mile (p = 0.0034). Conclusion: In selected patients, a below-the-knee amputation may be a good salvage procedure for intractable foot and ankle pain that is unresponsive to all medical and local surgical reconstructive techniques.

AOA Symposium: Current State of Fellowship Hiring

Currently, approximately 90% of the 620 graduating orthopaedic residents in the United States are planning on entering a postgraduate fellowship. Since January 2005, two of the largest fellowship match programs, sports medicine and spine surgery, were dissolved by the National Resident Matching Program (NRMP) because of a gradual decline in participation, leaving approximately 70% of applicants in a nonmatching, decentralized system. This leaves hand, shoulder and elbow surgery, and foot and ankle as the only three orthopaedic subspecialties that remain in some type of match program, creating an extremely complicated hiring environment for all residents. This paper focuses on the current state of fellowship employment and hiring in orthopaedic surgery in the United States, on the likely effects of reinstituting a match, and on how this might be accomplished. For this purpose, we present the results of surveys of fellowship directors and residents that we conducted and we describe how the present market for orthopaedic surgery fellows resembles the market for medical *This report is based on a symposium presented at the Annual Meeting of the American Orthopaedic Association on June 13, 2007, in Asheville, North Carolina.

Performance of candidates selecting the subspecialty of spine surgery for the Part II American Board of Orthopaedic Surgery oral certification examination.

The American Board of Orthopaedic Surgery (ABOS) was founded in 1934 to establish standards for the certification of orthopaedic surgeons and educational requirements for postgraduate training in orthopaedic surgery. Educational standards have been well established for residency training, with specific requirements spelled out to successfully complete the five-year accredited orthopaedic residency program. These requirements are clearly noted on the ABOS web site1. Over the past fifteen years, there has been a rapid increase in the number of postgraduate fellowship programs encompassing the multiple subspecialties of orthopaedic surgery. At present, >90% of graduates take a postgraduate fellowship upon completion of their residency training according to ABOS internal documentation obtained from application material. Fellowships in the subspecialties of orthopaedic surgery accredited by the Accreditation Council for Graduate Medical Education (ACGME) are available in the Graduate Medical Education Directory published by the American Medical Association2. There is a wide disparity in the number of accredited or non-accredited fellowships depending on the subspecialty selected. For instance, surgery of the hand and sports medicine have almost 100% of their fellowships accredited by the ACGME with stringent educational, training, and faculty requirements overseen by the Residency Review Committee for Orthopaedic Surgery. Other subspecialties have far fewer accredited programs. These include spine surgery, which has eighteen accredited fellowships of approximately seventy-five available programs. Presently, the ABOS has not mandated educational and training requirements for fellowships as it has previously for resident training. The ABOS recognizes that postgraduate fellowship training has become an accepted path following completion of residency. The board is also aware that non-accredited fellowships are not subject to the same educational and training requirement reviews that accredited fellowships undergo on a regular basis. From 2006 to 2010, there were 359 candidates who sat for the ABOS Part II oral examination as …

Measuring Surgical Skills in Simulation-based Training

Simulation-based surgical skills training addresses several concerns associated with the traditional apprenticeship model, including patient safety, efficient acquisition of complex skills, and cost. The surgical specialties already recognize the advantages of surgical training using simulation, and simulation-based methods are appearing in surgical education and assessment for board certification. The necessity of simulation-based methods in surgical education along with valid, objective, standardized techniques for measuring learned skills using simulators has become apparent. The most commonly used surgical skill measurement techniques in simulation-based training include questionnaires and post-training surveys, objective structured assessment of technical skills and global rating scale of performance scoring systems, structured assessments using video recording, and motion tracking software. The literature shows that the application of many of these techniques varies based on investigator preference and the convenience of the technique. As simulators become more accepted as a teaching tool, techniques to measure skill proficiencies will need to be standardized nationally and internationally.