Cannada, Lisa K.

Background: In recent years, there has been an increased push for diversity in orthopaedics at the residency level. There has also been a noticeable shift away from foot and ankle fellowship, with many fellowship positions open throughout the country annually. With the increase in osteopathic and female orthopaedic applications to orthopaedic surgery residency, we hypothesized that this would be reflected in the foot and ankle fellowship applications in the last decade. Methods: The San Franscisco Match data from 2012 to 2023 were analyzed for degree type and from 2013 to 2023 for gender. There were 1082 applicants for adult foot and ankle fellowships from 2012 to 2023, 74 osteopathic applicants (11.4%), and 573 allopathic applicants (88.6%). There were 126 female applicants (21.3%) and 465 male applicants (78.7%). The 435 international graduates were excluded from this analysis. The degree type, gender, number of applicants, and number of applicants matched into orthopaedic foot and ankle fellowship was reviewed. Results: The number of osteopathic applicants and female applications did not change significantly over the study period. There was a statistically significant decrease in the number of allopathic applicants ( P = .003) and a significant decrease in the number of male applicants to foot and ankle fellowship ( P = .00004). The match rate for allopathic, osteopathic, and male applicants all statistically increased over the study periods, whereas the female applicant match rate remained stable. Programs tended to rank their matched allopathic residents higher, whereas osteopathic applicants’ position in the fellowship program rank list remained steady. Female and male applicants matched at programs higher on their rank lists, whereas programs match applicants lower on theirs. Conclusion: More orthopaedic foot and ankle surgeons are needed nationwide. Understanding recent trends in applicant demographics and match outcomes may help inform strategies to increase interest and participation in this subspecialty. Level of Evidence: IV, cross-sectional study.

Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. Setting: Fourteen level-1 trauma centers across the United States. Patients: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. Intervention: Delay definitive fixation and flap coverage in tibial type III fractures. Main Outcome Measurements: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). Conclusion: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives:To determine the radial nerve palsy (RNP) rate and predictors of injury after humeral nonunion repair in a large multicenter sample.Design:Consecutive retrospective cohort review.Setting:Eighteen academic orthopedic trauma centers.Patients/Participants:Three hundred seventy-nine adult patients who underwent humeral shaft nonunion repair. Exclusion criteria were pathologic fracture and complete motor RNP before nonunion surgery.Intervention:Humeral shaft nonunion repair and assessment of postoperative radial nerve function.Main Outcome:Measurements: Demographics, nonunion characteristics, preoperative and postoperative radial nerve function and recovery.Results:Twenty-six (6.9%) of 379 patients (151 M, 228 F, ages 18–93 years) had worse radial nerve function after nonunion repair. This did not differ by surgical approach. Only location in the middle third of the humerus correlated with RNP (P= 0.02). A total of 15.8% of patients with iatrogenic nerve injury followed for a minimum of 12 months did not resolve. For those who recovered, resolution averaged 5.4 months. On average, partial/complete palsies resolved at 2.6 and 6.5 months, respectively. Sixty-one percent (20/33) of patients who presented with nerve injury before their nonunion surgery resolved.Conclusion:In a large series of patients treated operatively for humeral shaft nonunion, the RNP rate was 6.9%. Among patients with postoperative iatrogenic RNP, the rate of persistent RNP was 15.8%. This finding is more generalizable than previous reports. Midshaft fractures were associated with palsy, while surgical approach was not.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Calcaneus fractures have serious potential complications. Tongue type calcaneus fractures, in particular, are at risk for secondary soft tissue breakdown due in part to the tension placed on the soft tissue by the forces of the Achilles tendon on the superior fragment of the posterior calcaneal tuberosity. The current literature is limited regarding outcomes in pure tongue type calcaneus fractures. The purpose of this study is to report injury details, treatment, and complications in this group of fractures. Methods: The study is a retrospective study of patients between 2007 and 2015 with tongue type calcaneus fractures. Demographic data and comorbidities were collected for each patient. Clinical data including details of the injury, time to surgery, length of hospital stay, wound complications, additional surgical procedures, and follow-up data were evaluated. Results: There were 25 patients with 26 fractures included in this study, including 7 open fractures. Wound complications occurred in 7 (27%) patients, and fixation failure occurred in 4 (21%) patients. Patients with open fractures reached full healing in less time (2.8±0.4 mo) compared with patients with closed fractures (4±1.3 mo). The difference in time to full healing was not statistically significant (P>0.05) when comparing smokers and nonsmokers. Conclusions: The literature is limited regarding outcomes of pure tongue type calcaneus fractures. We found these fractures had similar or even higher rates of wound complications compared with other studies investigating intra-articular calcaneus fractures. This is one of the first studies to report on the complication rates associated specifically with these fractures. Level of Evidence: Level IV.

Abstract: The observation of decreased resident autonomy, ultimately influencing the readiness of a new graduate to practice, has been supported with a number of recent surveys. This perceived lack of autonomy is felt to be due, in part, to many reasons, including duty-hour regulations, increased supervision requirements, patient safety measures, concern for complication rates, and other performance measures. Pressure on faculty members to have increased clinical productivity may not allow for more resident autonomy. Increased clinical exposure to improve resident independence may come from several suggested areas. First, restructuring the residency program to allow for more clinical time may be one way to improve education. Second, increased use of surgical simulation will allow for more experience to develop technical skills within a controlled environment. Surgical simulators can be used to acquire new skills and also as a means of assessing competence. Third, competency-based education (CBE) has been offered as a way to improve resident education. At its core, CBE offers criterion-based assessments for residents and faculty that allow for more frequent feedback.