JAAOS, Volume 25, No. 6

Survival Guide for the Orthopaedic Surgery Match

The process of matching into an orthopaedic surgery residency program can be daunting for medical students. Rumors, innuendo, urban myths, and electronic misinformation can accentuate the angst experienced by students both domestically and internationally. This article dispels myths and presents an up-to-date, evidence-based (where possible), and experience-laden road map to assist medical students interested in pursuing a career in orthopaedic surgery. Our framework takes into account the program selection, test scores, letters of recommendation, visiting rotations, interviews, and communication. We hope that this survival guide will serve as a reference point assisting medical students in achieving successful matches into orthopaedic surgery residency programs.

      Resident Selection Beyond the United States Medical Licensing Examination

      The resident application process has matured over the decades to become an efficient system. An unforeseen consequence of this efficiency is the massive number of applications that each orthopaedic surgery residency program must sort through to arrive at a manageable rank list. The most widely used filter in today’s application cycle is an applicant’s performance on the United States Medical Licensing Examination Step 1. Although no evidence exists to prove that this examination is predictive of any of the potentially defining characteristics of a successful resident, orthopaedic surgery programs historically have had few alternative options. A growing body of literature suggests that a more focused investigation of an applicant’s inherent personality traits, as evidenced by his or her past accomplishments, as well as a structured use of questionnaires as part of the application process may improve the ability of orthopaedic surgery residency programs to predict who will be a successful resident.

          A Perspective on the Effect of the 80-Hour Work Week: Has It Changed the Graduating Orthopaedic Resident?

          Orthopaedic residency education has changed substantially in recent decades because of the imposition of the 80-hour work week, a decrease in quality and quantity of general surgical education, regulations mandating closer trainee supervision, and an expansion of orthopaedic subspecialty rotations. These factors pose a challenge in efforts to prepare competent, confident, cautious, caring, and communicative orthopaedic residents within the traditional 5-year program. Evidence suggests that contemporary graduates are more intelligent, better balanced in life and work, and more in touch with humanistic aspects of medicine than were earlier graduates. Yet insufficient competence and confidence in surgical skills after residency and a lack of “ownership” of patient care have become an increasing concern of educators and trainees. The concept of 10,000 hours of deliberate practice to achieve mastery of a technical skill applies to orthopaedic residency education. A different approach to graduate medical education must address the critical minimum training time required to achieve the necessary skills to support independent medical and surgical practice.

              Maximizing Surgical Skills During Fellowship Training

              Orthopaedic surgery fellowship provides an opportunity to further develop skills in a particular subspecialty. However, the condensed time frame, complex skill acquisition, and clinical demands require efficient and effective learning techniques to achieve mastery. As with any advanced task, success during fellowship training can be achieved with active participation and a goal-directed approach. Skill acquisition can be successfully achieved by following a framework that includes preparation, execution, and reflection for every surgical case.

                  The Humeral Implant in Shoulder Arthroplasty

                  Humeral hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse total shoulder arthroplasty all rely on a prosthetic articular surface fixed to the proximal humerus. Humeral implant designs have changed considerably as a result of improved understanding of proximal humeral anatomy and prosthetic biomechanics. Fixed, monoblock implants have been superseded by modular implants with variable inclination, offset, version, and stem length. Press-fit designs now commonly have surface coatings that allow bony ingrowth. Metaphyseal fixation is often favored over diaphyseal fixation. Both cemented and noncemented fixation continue to be used, and each of these techniques has advantages and disadvantages. Although aseptic loosening rarely requires revision, complications, such as osteolysis, stress shielding, radiolucent lines, and proximal humeral bone loss, can occur. Humeral periprosthetic fractures continue to be a disabling complication and are difficult to manage. Innovations such as short-stemmed implants, stemless implants, and platform stems are currently under clinical investigation.

                      • Subspecialty:
                      • Shoulder

                    Denervation of the Wrist Joint for the Management of Chronic Pain

                    Wrist denervation for the management of chronic wrist pain is a safe and effective procedure that can delay or eliminate the need for more invasive and kinematically compromising salvage procedures. Wrist denervation has become increasingly popular since it was first described in 1959, and the technique has evolved from more extensive denervations to limited single-incision approaches. Many physicians have performed this procedure as a palliative approach to managing chronic wrist pain and as an adjunct to other procedures.

                        • Subspecialty:
                        • Wrist

                      Cost-minimization Analysis of the Management of Acute Achilles Tendon Rupture

                      Background: Outcomes of nonsurgical management of acute Achilles tendon rupture have been demonstrated to be noninferior to those of surgical management. We performed a cost-minimization analysis of surgical and nonsurgical management of acute Achilles tendon rupture.

                      Methods: We used a claims database to identify patients who underwent surgical (n = 1,979) and nonsurgical (n = 3,065) management of acute Achilles tendon rupture and compared overall costs of treatment (surgical procedure, follow-up care, physical therapy, and management of complications). Complication rates were also calculated. Patients were followed for 1 year after injury.

                      Results: Average treatment costs in the year after initial diagnosis were higher for patients who underwent initial surgical treatment than for patients who underwent nonsurgical treatment ($4,292 for surgical treatment versus $2,432 for nonsurgical treatment; P < 0.001). However, surgical treatment required fewer office visits (4.52 versus 10.98; P < 0.001) and less spending on physical therapy ($595 versus $928; P < 0.001). Rates of rerupture requiring subsequent treatment (2.1% versus 2.4%; P = 0.34) and additional costs ($2,950 versus $2,515; P = 0.34) were not significantly different regardless whether initial treatment was surgical or nonsurgical. In both cohorts, management of complications contributed to approximately 5% of the total cost.

                      Conclusion: From the payer’s perspective, the overall costs of nonsurgical management of acute Achilles tendon rupture were significantly lower than the overall costs of surgical management.

                      Level of Evidence: III, Economic Decision Analysis

                          • Subspecialty:
                          • Leg

                        Feasibility of and Rationale for the Collection of Orthopaedic Trauma Surgery Quality of Care Metrics

                        Introduction: Reproducible metrics are needed to evaluate the delivery of orthopaedic trauma care, national care, norms, and outliers. The American College of Surgeons (ACS) is uniquely positioned to collect and evaluate the data needed to evaluate orthopaedic trauma care via the Committee on Trauma and the Trauma Quality Improvement Project.

                        Methods: We evaluated the first quality metrics the ACS has collected for orthopaedic trauma surgery to determine whether these metrics can be appropriately collected with accuracy and completeness. The metrics include the time to administration of the first dose of antibiotics for open fractures, the time to surgical irrigation and débridement of open tibial fractures, and the percentage of patients who undergo stabilization of femoral fractures at trauma centers nationwide. These metrics were analyzed to evaluate for variances in the delivery of orthopaedic care across the country.

                        Results: The data showed wide variances for all metrics, and many centers had incomplete ability to collect the orthopaedic trauma care metrics. There was a large variability in the results of the metrics collected among different trauma center levels, as well as among centers of a particular level.

                        Discussion: The ACS has successfully begun tracking orthopaedic trauma care performance measures, which will help inform reevaluation of the goals and continued work on data collection and improvement of patient care. Future areas of research may link these performance measures with patient outcomes, such as long-term tracking, to assess nonunion and function. This information can provide insight into center performance and its effect on patient outcomes.

                        Conclusions: The ACS was able to successfully collect and evaluate the data for three metrics used to assess the quality of orthopaedic trauma care. However, additional research is needed to determine whether these metrics are suitable for evaluating orthopaedic trauma care and cutoff values for each metric.

                            • Subspecialty:
                            • Trauma

                          A Cross-sectional Analysis of Minimum USMLE Step 1 and 2 Criteria Used by Orthopaedic Surgery Residency Programs in Screening Residency Applications

                          Introduction: The purpose of this study was to analyze how program directors (PDs) of orthopaedic surgery residency programs use United States Medical Licensing Examination (USMLE) Step 1 and 2 scores in screening residency applicants.

                          Methods: A survey was sent to each allopathic orthopaedic surgery residency PD. PDs were asked if they currently use minimum Step 1 and/or 2 scores in screening residency applicants and if these criteria have changed in recent years.

                          Results: Responses were received from 113 of 151 PDs (75%). One program did not have the requested information and five declined participation, leaving 107 responses analyzed. Eighty-nine programs used a minimum USMLE Step 1 score (83%). Eighty-three programs (78%) required a Step 1 score ≥210, 80 (75%) required a score ≥220, 57 (53%) required a score ≥230, and 22 (21%) required a score ≥240. Multiple PDs mentioned the high volume of applications as a reason for using a minimum score and for increasing the minimum score in recent years.

                          Discussion: A large proportion of orthopaedic surgery residency PDs use a USMLE Step 1 minimum score when screening applications in an effort to reduce the number of applications to be reviewed.

                              • Subspecialty:
                              • General Orthopaedics

                            Assessment of Malpractice Claims Associated With Acute Compartment Syndrome

                            Background: Because acute compartment syndrome is one of the few limb-threatening and life-threatening orthopaedic conditions and is difficult to diagnose, it is a frequent source of litigation. Understanding the factors that lead to plaintiff verdicts and higher indemnity payments may improve patient care by identifying common pitfalls.

                            Methods: The VerdictSearch legal claims database was queried for the term “compartment syndrome.” After 46 cases were excluded for missing information or irrelevancy, 139 cases were reviewed. The effects of plaintiff demographics, mechanism of injury, and complications were assessed.

                            Results: Of 139 cases, 37 (27%) were settled, 69 (50%) resulted in a defendant ruling, and 33 (24%) resulted in a plaintiff ruling. Juries were more likely to rule in favor of juvenile plaintiffs than adult patients (P = 0.002) and female plaintiffs than male plaintiffs (P = 0.008), but indemnity payments were not affected by the age or sex of the plaintiff. Plaintiffs who experienced acute compartment syndrome as a complication of surgery were more likely to win their suit and receive higher awards (P < 0.05), compared with those in whom the condition developed as a result of trauma. Amputation or delay in diagnosis or treatment did not affect plaintiff verdicts or awards.

                            Conclusion: Defendants were more likely to lose a lawsuit concerning the management of acute compartment syndrome if the patient was a woman or child or if acute compartment syndrome developed as a complication of a surgical procedure.

                                • Subspecialty:
                                • Trauma

                              The Effect of Absorbable Calcium Sulfate on Wear Rates in Ultra-high–Molecular-weight Polyethylene: Potential Implications for Its Use in Treating Arthroplasty Infections

                              Introduction: Patients, hospitals, and healthcare systems incur substantial burdens when infections result in total joint revisions. One potential solution to mitigate some of these burdens may be to transition from a two-stage infection treatment to a single-stage procedure. Off-label use of an absorbable calcium sulfate antibiotic carrier has been implemented in single-stage and two-stage procedures globally, with the goal of moving toward more single-stage revisions in the United States. Adverse effects of calcium sulfate on the joint space during articulation are currently unknown.

                              Methods: This study aims to determine the impact of calcium sulfate beads on wear of polyethylene during and following exposure. Two phases of in vitro pin-on-disk testing were conducted. The first phase exposed polyethylene pins to calcium sulfate for 500,000 cycles of a 2-million cycle test. The second phase examined the wear of pins that were created from retrieved components exposed to calcium sulfate in vivo.

                              Results: No clinically significant difference was observed between the wear rates of the calcium sulfate–exposed polyethylene pins and the control polyethylene pins.

                              Discussion: Preliminary results suggest that a substantial increase in the wear rate of polyethylene is not expected with the addition of calcium sulfate beads during treatment of infection.

                                  The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015: What's New?

                                  The Centers for Medicare and Medicaid Services (CMS) released its Final Rule on the Medicare Access and CHIP [Children's Health Insurance Program] Reauthorization Act (MACRA) in November 2016. The Rule finalizes the details of the merit-based incentive payment system (MIPS) and the alternative payment model (APM), which will now collectively be referred to as the Quality Payment Program (QPP). This article offers the orthopaedic community a summary of the alterations in healthcare policy that will affect practices nationwide.