Citations

Gross anatomy courses often utilize teaching assistants (TAs) to serve a multifaceted purpose. Qualitative analysis of interviews with gross anatomy TAs reveals seven distinct roles: formal teaching during course lectures, informal teaching during dissection, prosecting a demonstration cadaver, orchestrating regular review sessions, coordinating formative feedback about academic progress and professionalism, tutoring struggling students outside of class time, and supporting students in crisis should the need arise. Analysis also finds that TAs did not anticipate the full scope of their duties prior to undertaking them, and felt particularly unprepared to address issues of student mental health. We report our findings and propose a model for proactively training TAs for their inherently complex role. This work was supported by the Mayo Clinic Department of Anatomy. Grant Funding Source Student/Postdoctoral Travel Award Student Award

Early medical education courses provide opportunities for promoting leadership in future physicians. Our research sought to integrate explicit activities of teamwork and leadership into the first‐year gross anatomy course and assess student leaders through self reflection and team evaluation. Fifty first‐year medical students were assigned to three‐ or four‐member dissection teams with group leaders designated on a rotating basis. Teamwork was emphasized through daily group quizzes, oral patient presentations relating clinical diagnoses to anatomy, and extensive embryology presentations. Group leaders were responsible for leading the dissections after attending daily orientation sessions on the teaching cadaver. Team and self evaluations of group leaders were gathered with weekly electronic surveys. Preliminary results suggest that team leaders rate themselves lower than their teammates do with respect to altruism, accountability and responsibility. One explanation for this discrepancy is decreased self‐awareness of student leaders regarding their own performance. Further research may demonstrate whether increased communication between leaders and team members can improve leaders' awareness of their capabilities. Research support came from the Mayo Clinic Department of Anatomy. Grant Funding Source N/A

Recent curricular redesign at Mayo Medical School integrated radiology into first‐year gross and developmental anatomy. The resulting six‐week (120 contact hours) Human Structure block teaches gross anatomy through dissection, radiologic imaging, and correlation with embryology. To further promote holistic physician‐development, refinement of the Human Structure course has been driven by the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME): patient care, medical knowledge, practice‐based learning, interpersonal skills, professionalism, and systems‐based practice. We report here more than 20 educational interventions built into the Human Structure block that may serve as a model for incorporating the ACGME core competencies into early medical education. The block emphasizes clinically oriented anatomy, invites self‐ and peer‐evaluation, provides daily formative feedback through an audience response system, and employs team‐based learning. The course curriculum includes didactic briefing sessions and roles for students as teachers, leaders, and collaborators. Third‐year medical students serve as teaching assistants, enhancing their own knowledge of anatomy, bettering their skills as medical educators, and facilitating group communication and critiques. This work was supported by the Mayo Clinic Department of Anatomy. Grant Funding Source None

Background: With the expanding use of reverse shoulder arthroplasty (RSA) to treat various shoulder conditions, there has been a rise in the number of RSAs performed, especially in physically active patients. Limited information regarding sports after RSA is available to properly counsel patients on postoperative expectations. Purpose: To assess the rate of return to sports as well as the ability to return to the same level of preoperative intensity, frequency, and duration of sport after primary RSA. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of patients who underwent primary RSA at our institution between 2014 and 2016. Shoulder motion, Subjective Shoulder Value score, American Shoulder and Elbow Surgeons score, pre- and postoperative sports activities, and barriers to return to sport were assessed in 109 patients after RSA (93 patients with unilateral RSA and 16 patients with bilateral RSA). The mean age at the time of surgery was 70 years (range, 34-86 years), with a mean follow-up of 3.9 years (range, 2-12 years). Results: The mean rate of return to sports was 70.1% (range, 0%-100%). There was no difference in return to sports between those with uni- and bilateral RSA ( P = .64). Fishing, swimming, elliptical/treadmill, and hunting were the most common sports after RSA with return rates of 91%, 73%, 86%, and 82% respectively. A majority of patients returned to the same level of preoperative intensity, frequency, and duration for all sports except for climbing and swimming. There was a lower mean rate of return for high-demand sports (62.9%) compared with low- and medium-demand sports (76.7%) ( P = .005). The most common reasons for inability to return to sports included limited motion, fear of injury, and weakness. Conclusion: Patients who had undergone primary uni- or bilateral RSA reported a 70.1% rate of return to sports with maintenance of the same level of intensity, duration, and frequency of preoperative sport participation. Rates of return to high-demand sports were lower than low- and medium-demand sports. Patients also had difficulty returning to overhead sports.

Background: Charge and reimbursement trends for arthroscopic partial meniscectomies among orthopaedic surgeons, anesthesiologists, and hospital/surgery centers have not been formally analyzed, even though meniscectomies are the most commonly performed orthopaedic surgery. Purpose: To analyze Medicare charge and reimbursement trends for surgeons, anesthesiologists, and hospital/surgery centers for outpatient arthroscopic partial meniscectomies performed in the United States. Study Design: Economic and decision analysis; Level of evidence, 4. Methods: We analyzed trends in surgeon, anesthesiologist, and hospital charges and reimbursements for outpatient isolated arthroscopic partial meniscectomies from 2005 to 2014. Current Procedural Terminology codes were used to capture charge and reimbursement information using the nationally representative 5% Medicare sample. National and regional trends for charge, reimbursement, and Charlson Comorbidity Index (CCI) were evaluated using linear regression analysis. Results: A total of 31,717 patients were analyzed in this study. Charges across all groups increased significantly ( P < .001) during the 10-year study period, with an increase of 18.4% ($2754-$3262) for surgeons, 85.5% ($802-$1480) for anesthesiologists, and 116.8% ($2743-$5947) for hospitals. Surgeon reimbursements declined by 15.5% ($504-$426; P = .072) during this period. Anesthesiologist and hospital reimbursements increased significantly during by 36.5% ($133-$182; P < .001) and 28.9% ($1540-$1984; P < .001) during the 10-year study period, respectively. The annual incidence of partial meniscectomies per 10,000 database patients decreased significantly from 18.3 to 15.6 over the course of the study (14.8% decrease; P = .009), while the CCI did not change significantly ( P = .798). Conclusion: Hospital and anesthesiologist Medicare reimbursements for outpatient arthroscopic partial meniscectomies increased significantly, while surgeon reimbursements decreased. In 2005, hospitals were reimbursed 205% more ($1540 vs $504) than surgeons, and by 2014, they were reimbursed 365% more ($1984 vs $426), indicating that the gap between hospital and surgeon reimbursement is rising. Improved understanding of charge and reimbursement trends represents an opportunity for key stakeholders to improve financial alignment across the field of orthopaedics.

Purpose To evaluate the effect of the Nonoperative Instability Severity Index Score (NISIS) criteria on an established US‐geographic population‐based cohort of patients with anterior shoulder instability. Methods An established geographically based medical record system was used to identify patients <40 years of age with anterior shoulder instability between 1994 and 2016. Medical records were reviewed to obtain patient demographics and instability characteristics. Patient‐specific risk factors were individually incorporated into the 10‐point NISIS criteria: age (>15 years), bone loss, type of instability (dislocation vs subluxation), type of sport (collision vs noncollision), male sex, and dominant arm involvement. High risk was considered a score of ≥7 points and low risk as <7 points. Failure was defined as either progression to surgery or recurrent instability diagnosed by a consulting physician at any point after initial consultation. Results The study population consisted of 405 patients with a mean follow‐up time of 9.6 ± 5.9 years. Failure was defined as recurrent instability or progression to surgery, and the overall failure rate was 52.8% (214/405). The rate of recurrent instability after initial consultation was 34.6% (140/405), and the rate of conversion to surgery was 37.8% (153/405). A total of 264 (65.2%) patients were considered low risk (NISIS < 7), and 141 (34.8%) patients were considered high risk (NISIS ≥ 7). Patients in the high‐risk group were more likely to fail nonoperative management than those in the low‐risk group (60.3% vs 48.9%; P = .028). Conclusions The NISIS has been proposed as a potentially useful tool in clinical decision‐making regarding the appropriate use of nonoperative treatment in scholastic athletes. When applied to an established US‐geographic population‐based cohort consisting of competitive and recreational athletes under the age of 40 with longer‐term follow‐up, the NISIS high‐risk cutoff was able to predict overall failure with 60.3% accuracy. Level of Evidence III, retrospective observation trial

Objective: To report the injury characteristics, radiographic findings, and long-term outcomes of nonoperative management for posterior shoulder instability (PSI). Design: A retrospective review of 143 patients with PSI using a large geographic database. Setting: Single county between January 1994 and July 2012. Patients: A clinical history and diagnosis of PSI, one confirmatory imaging study to support the diagnosis, and a minimum of 5 years follow-up were required for inclusion. Patients with seizure disorders, anterior-only instability, multidirectional instability, and superior labrum from anterior to posterior diagnosis were excluded. Interventions: Patients with PSI were managed nonoperatively or operatively. Main Outcome Measures: Pain, recurrent instability, and progression into glenohumeral osteoarthritis at long-term follow-up. Results: One hundred fifteen patients were identified. Thirty-seven (32%) underwent nonoperative management. Twenty (54%) patients were diagnosed with posterior subluxation, 3 (8%) with a single dislocation, and 7 (19%) with multiple dislocations. Symptomatic progression of glenohumeral arthritis was observed in 8% (3) of patients. Pain improved in 46% (17) of patients and worsened in 19% (7). Recurrent instability and progression to osteoarthritis occurred in 15% (3/20) of patients with a traumatic instability event compared with 0% of atraumatic patients after nonoperative management ( P = 0.234). Pain at follow-up was more common in nonoperative than operative patients ( P = 0.017). Conclusions: Nonoperative management is a viable option for many patients with posterior shoulder instability; however, many may continue to have posterior shoulder pain.

Purpose To define the success rate of initial nonoperative treatment for traumatic anterior shoulder instability in a defined U.S. geographic population, describe factors that predict conversion to surgery after initial nonoperative management, and describe the long‐term outcomes of nonoperative treatment after the index traumatic anterior instability event. Methods The Rochester Epidemiology Project database was used to identify patients aged 14 to 39 years treated for anterior shoulder instability between 1994 and 2016. Patient demographic characteristics, comorbidities, injury characteristics, and imaging were evaluated. Patients treated nonoperatively for the first 6 months after the index instability event were analyzed to determine long‐term outcomes (recurrence rate, pain at last follow‐up, radiographic outcomes), the success rate of continued nonoperative treatment (no conversion to surgery), and factors associated with conversion to surgery (patient and injury characteristics). Survivorship free of surgery was reported with a Kaplan‐Meier survival curve, and Cox proportional hazards models were used to evaluate association of variables with conversion to surgery. Results A total of 379 patients met the study criteria, with an average follow‐up period of 10.2 years (range, 0.53‐25.00 years). The average age was 23.9 years, the mean body mass index was 26.2, and 100% of instability events were due to trauma. Of the shoulders, 79 (20.1%) ultimately failed initial nonoperative treatment and progressed to surgery. At final follow‐up, the rate of recurrent instability was 52.3% in the group treated definitively without surgery, and the recurrence rate decreased from 92.4% to 10.1% in patients who underwent conversion to surgical treatment. Factors associated with conversion to surgery included 2 or more subluxations prior to the first evaluation (hazard ratio [HR], 1.82; P = .002), 2 or more dislocations prior to the first evaluation (HR, 1.76; P = .006), and recurrent instability at follow‐up (HR, 4.21; P < .001). Conclusions Most patients younger than 40 years with shoulder instability who were initially treated nonoperatively for 6 months were definitively treated without surgery. Ultimately, 35% of these patients experienced recurrent dislocations after 6 months of conservative treatment and 20% underwent surgical treatment. In most patients who underwent conversion to surgical treatment, surgery was performed within 12.5 years of their first instability event. Patients who experienced multiple instability events before or after consultation were more likely to undergo conversion to surgery after initial nonoperative management. Level of Evidence Level III, retrospective database review.

Purpose To evaluate both the potential causes and resultant outcomes in patients in whom subchondral insufficiency fracture of the knee (SIFK) develops after arthroscopy. Methods We performed a retrospective review of all patients with a magnetic resonance imaging diagnosis of SIFK after arthroscopic meniscectomy and chondroplasty over a 12‐year period. Results A total of 28 patients were included, with a mean age of 61 years and mean follow‐up period of 5.7 years. SIFK showed a predilection for the medial compartment (n = 25, 89%), specifically the medial femoral condyle (n = 21, 75%). In 7 patients (25%), SIFK developed in both the femoral condyle and tibial plateau in the ipsilateral compartment. Fifteen patients (54%) went on to conversion to arthroplasty at a mean of 0.72 years. The rate of survival free of conversion to arthroplasty was 57%, 45%, and 40% at 1 year, 2 years, and 5 years, respectively. Furthermore, 63% of patients with a meniscal tear and SIFK in the same compartment went on to arthroplasty ( P = .04). There was an increased risk of conversion to arthroplasty if SIFK was present in both the femur and tibia in the same compartment ( P = .04). A higher Kellgren‐Lawrence grade at the time of the SIFK diagnosis increased the likelihood of eventual arthroplasty ( P = .03). The presence of SIFK in both the femur and tibia in the ipsilateral compartment, an increased Kellgren‐Lawrence grade, and a meniscal tear or prior meniscectomy in the same compartment as SIFK were associated with an increased risk of eventual arthroplasty. Conclusions Post‐arthroscopic SIFK most commonly occurs in the medial compartment, particularly in patients who underwent a prior meniscectomy. The presence of meniscal root and radial tears in these patients is notable (75%). Ultimately, there is a high rate of progression of arthrosis (33%) and eventual conversion to arthroplasty. Level of Evidence Level IV, case series.

Purpose To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD). Methods A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non‐randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return‐to‐sport rates, patient‐reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded. Results Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non‐randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from –4° to 6° of flexion and –0.4° to 14° of extension, with prono‐supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations. Conclusions Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid‐term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects. Level of Evidence Level IV, systematic review of studies, all Level IV evidence.