United States

Background: Achilles tendon rupture is a common orthopedic injury presenting to the clinic and emergency room. Patients with comorbidities are not ideal surgical candidates and often must be treated with cast or boot immobilization. The risk of complications includes pressure sores, skin infections, and joint stiffness. Recently, 3D-printed (3DP) casting has become popular due to customizability and inexpensiveness. This study performs a systematic review on the clinical application of 3D-printed (3DP) for conservative management of injuries.

Methods: The search phrase “(3d printed cast) AND ((fracture) OR (injury) OR (tendon))” was entered into PubMed, yielding 50 results published between 2015 and 2024. 15 articles were included in this review.

Results: 3 studies showed proof-of-concept in a non-clinical setting for 3DP casting using biomechanical and materials testing in both UE and LE models. 5 clinical studies without a control group reported overall patient satisfaction and good to excellent clinical healing of UE fractures with 3DP but also reported incidents of cast breakage. 7 studies in a clinical setting showed that 3DP casting is superior to conventional fiberglass in patient satisfaction and non-inferior in clinical efficacy.

Discussion: Based on the current literature, this study proposes a novel 3D-printed cast that provides immobilization at the maximum plantar flexion required for Achilles tendon healing and eliminates the need for constant cast changes in a non-surgical treatment plan. The proposed device will act to maintain stability and reapproximation for healing at the injury site, whilst providing easy access for hygiene and wound care, thus mitigating the risk of infections and promoting optimal healing. Future direction will establish proof-of-concept using finite element analysis for customization of stress distribution and biomechanical testing for load-bearing analysis. By extending its usage to acute Achilles tendon injuries, 3DP casting has the potential to enhance outcomes for non-surgical candidates.

AMA Research Challenge 2024 

Systematic Review and Novel Proposal of 3D-Printed Casting for Non-Surgical Treatment of Acute Achilles Tendon Rupture

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Background
Females and underrepresented in medicine (URiM) individuals currently comprise 50.5% and 23.8% of all medical student matriculates in the United States, respectively. However, orthopaedics remains the least diverse specialty with 18.3% female and 17.3% URiM residents. There has been an increasing amount of effort to increase diversity, equity, and inclusion (DEI) and remedy these representation gaps, however there remains a gap in the literature regarding the effectiveness of DEI initiatives at the medical student level and their impact on the future diversity of the orthopedic workforce. Thus, the purpose of this systematic review was to analyze the progress and current state of DEI efforts within orthopaedics at the medical student level.
Methods
A systematic review of the English literature was performed according to PRISMA guidelines using the following databases: PubMed, Web of Science, Embase, Scopus, Crochane from inception to October 20, 2023 using a combination of search terms. Eligible full text articles reported on various domains of DEI at the medical student level in the United States such as demographics, initiatives, and perspectives.
Results
A total of 3184 studies were screened and subsequently, 26 full-text articles met inclusion criteria. Eight articles discussed trends in diversity demographics within interest, application, and match with orthopaedics (30.8%), 10 articles discussed initiatives detailing methods and results of how to increase DEI in orthopaedics (38.4%), and 8 articles discussed perspectives on where to focus future outreach endeavors (30.8%).
Conclusion
Efforts to enhance female and URiM representation amongst orthopeadic residency programs at the medical student level have greatly improved over the past 15 years. Evidence shows a strong correlation between both the presence of underrepresented populations in faculty and resident positions as well as the implementation of outreach programs in influencing medical students' application into orthopeadic residency. A large majority of initiatives created for medical students stemmed from outside organizations as opposed to individual residency programs. Future studies should quantify the impact of local initiatives and national organizations on medical students and aim to better understand additional barriers into entrance of residency programs.

The Current State of DEI in Orthopaedics at the Medical Student Level; a Systematic Review

Background: Anterior Cruciate ligament reconstruction (ACLR) is one of the most common surgeries performed in orthopedics. The optimal timepoint for ACLR is not consistently defined. Our study aimed to address this gap by comparing patient-reported outcomes (PROs) in acute versus chronic ACLR groups using 60 days as a marker for chronicity. 



Methods: This historical cohort study was based on prospectively collected PROs following ACLR. Inclusion criteria were based on complete pre-operative and 2-year follow-up. Patients were categorized as acute with an injury to surgery interval of less than 60 days, those over 60 days were considered chronic. Descriptive analysis was conducted using Fisher’s exact tests and Chi-square analysis. A mixed linear model regression analysis was conducted to examine the effect of time on outcome variables using Restricted Maximum Likelihood (REML) across two groups (acute and chronic). The dependent variables were: IKDC Score, EuroQol Score, PROMIS Global Mental and Physical Health Scores, KOOS Score, and VAS Pain Score with time as the primary fixed effect. Data was analyzed using Python version 3.8 with pandas and statsmodels packages. 



Results: 97 out of 1235 patients from the institutional database met the inclusion criteria, with 54 chronic, 43 acute, 62 males, 35 females, and a median age at the time of surgery of 28 [21, 40]. The median BMI was 25.2 [23, 28.2], 26.6 [23.3, 30.1] for chronic cases and 24.2 [22.6, 26.8] for acute cases (p < 0.011). ACL grafts included 25 autografts and 72 allografts. Autograft was used more frequently in acute cases (p < 0.011), while chronic cases had an increased use of allografts (p < 0.011). Overall median PROs improved: from 50.6 to 86.2 (IKDC), 0.7 to 0.8 (EuroQol), 56 to 59 (PROMIS Global Mental Health), 50.8 to 57.7 (PROMIS Global Physical Health), 66 to 92 (KOOS), and 3 to 1 (VAS Pain). Linear mixed model analysis revealed a significant positive effect of time on IKDC (p < 0.001), and a random effects analysis demonstrated a group variance of 2.355, indicating variability in IKDC scores between acute and chronic groups. 



Conclusion: Using a 60-day cut-off for defining acute versus chronic ACLR showed greater improvement in median PROs. The IKDC score is a valuable predictor to compare acute versus chronic ACL injuries using 60 days as a cutoff for chronicity. Using this marker may aid in optimizing future surgical timing and recommendations that will improve individual patient recovery.

The Effect on Patient-Reported Outcomes in Acute vs. Chronic ACL Reconstruction

The Impact of Concomitant Pathologies on Patient Outcomes in Acute vs. Chronic ACL Reconstruction

Authors: Blake Padgett BS, Jonathan Brutti BS, Camila Torres-Caiaffa BA, Alexandra Moutafis BS, David Vasserman BS, Mendel Shloush BS, Jose Lima BS, Carlos Simon BS, Carlos Bermudez BS, Carolina Carrandi BS, Anshul Saxena BDS PhD, Matthias R. Schurhoff MD, Luis A. Vargas MD PhD, Gautam P. Yagnik MD, John E. Hechtman MD, John E. Zvijac MD, John W. Uribe MD

Background: ACL reconstruction (ACLR), a prevalent orthopedic procedure, often involves concomitant meniscal and chondral damage. Current literature lacks consistent differentiation between acute and chronic ACLR regarding short-term outcomes and their relationship with concomitant pathologies. This study compares the impact of surgical timing and the presence of meniscal and chondral pathologies on patient-reported outcomes (PROs).

Methods: This study used a historical cohort with prospectively collected PROs following ACLR. Inclusion criteria required complete pre-operative and 2-year follow-up data. Patients were categorized as acute if the injury-to-surgery interval was less than 60 days, and chronic if over 60 days. Dependent variables included IKDC, EuroQol, PROMIS Global Mental and Physical Health, KOOS, and VAS Pain scores, with time as the primary fixed effect. Intraoperative data included the location of chondral lesions and detailed meniscal injuries. A mixed linear model regression analysis examined the effect of time on outcome variables using REML across two groups (acute and chronic). Data was analyzed using Python 3.8 with pandas and statsmodels packages.

Results: Of 1235 patients, 97 met the inclusion criteria (54 chronic, 43 acute). Of these, 73 (75.3%) had an ACL tear with concomitant pathology (72.1% acute, 77.8% chronic). Medial meniscal tears were found in 45.4%, lateral tears in 60.8% with partial tears most frequently associated with the posterior horn (73.9% medial, 47.5% lateral). Medial chondral lesions were found in 22.7%, lateral in 18.6%, and patellofemoral in 41.2%. Among acute patients, 53.5% had meniscal injuries, 25.6% had chondromalacia, and 20.1% had both. Among chronic patients, 31.5% had meniscal injuries, 5.6% had chondromalacia, and 44.4% had both. Acute injuries had more meniscal tears (p < 0.048), while chronic injuries had significantly more combined meniscal and chondral pathology (p < 0.027). Chondral lesions showed no significant difference between timing of intervention. Overall, partial meniscectomies were performed in 55.6% (20.6% acute, 35% chronic) and meniscal repairs in 46.4% (23.7% acute, 22.7% chronic). Linear mixed model analysis showed a significant positive effect of time on IKDC scores (p < 0.001). Random effects analysis indicated a group variance of 2.355, highlighting variability in IKDC scores between acute and chronic groups.

Conclusion: Combined chondral lesions and meniscus pathologies were more prevalent in chronic ACL reconstruction. Acute intervention showed greater improvement in median PROs compared to delayed reconstruction. Earlier treatment plans may reduce the occurrence of combined meniscal injury and cartilage damage in ACLR and may improve patient outcomes.

The Impact of Concomitant Pathologies on Patient Outcomes in Acute vs. Chronic ACL Reconstructions

Abstract Title: TKA Femoral Flexion Angle Distribution and Range of Motion

Background: Femoral implant flexion angle (FF) is an underutilized metric with wide reported ranges. Increased understanding of current FF use may establish specific sagittal alignment targets. 

Methods: Demographics, knee ROM, and implant alignment parameters were collected for patients undergoing TKA with a CT-based robotic knee replacement system. The range and distribution of FF angles was determined. “High-FF” and “Low-FF” groups were divided at the FF mean. ROM measurements were taken in four windows: Preoperative, Early postoperative (7- 42 days), Middle postoperative (43-135 days), and Late postoperative (>136 days). ROM was compared between groups. 

Results: 976 patients of age 66.3±8.74 years, BMI 32.9±10.9, and 56.6% female. Average FF was 4.04°±2.10° flexion [0°-9°]. The Low-FF group [0.0°-4.0°] had 528 patients. The High-FF group [4.5°-9.0°] had 448 patients. There were no differences in preoperative knee parameters: varus/valgus alignment, flexion/extension ROM (p>0.2). High-FF patients were often female (Low-FF 53.0%; High-FF 62.5%; p=0.006) and more frequently cemented implants (Low-FF 14.4%; High-FF 20.4%; p=0.020). High-FF patients had smaller femoral implants (Size 4 or lower: Low-FF 52.2%; High-FF 68.7%; p<0.001), smaller tibial implants (Size 4 or lower: Low- FF 50.1%; High-FF 63.9%; p<0.001), and lower tibial slope (Low-FF 3.2°; High-FF 3.0°; p<0.001). There were no differences in patient size (p>0.1) or femur-tibia size mismatch frequency (p=0.539). 193 patients had measurements in all four windows. Repeated measures found no ROM differences between groups at any timepoint. 

Conclusion: The observed femoral implant flexion angles assumed a normal distribution ranging from 0° to 9° flexion, centered at 4° flexion. Patients receiving a femoral flexion angle above 4° were more often female, cemented, had lower tibial slope angle, and smaller femur and tibia implant sizes. Patients with larger femoral flexion angles showed no difference in flexion or extension range of motion at any timepoint when compared to patients with smaller femoral flexion angles.

TKA Femoral Flexion Angle Distribution and Range of Motion

Background:
Approximately 400,000 ACL reconstructions are performed each year in the United States. Effective ACL injury prevention programs may be paramount in reducing this significant injury burden. 
Objective: To determine the effectiveness of ACL injury prevention programs and generate updated guidelines that can be implemented to protect athletes from these injuries.

Methods:
Embase, PubMed, and Ovid (MEDLINE) were searched in accordance with PRISMA guidelines. Included studies focused on ACL injury prevention as opposed to treatment and provided data on ACL injury rates after intervention implementation. Using random-effects models, the pooled risk ratio (RR) was generated for all data. Sub-analyses were completed for female-only, high school vs. collegiate/professional, handball, soccer, and balance board data.

Results:
A total of 18 articles were identified (9 randomized control trials, 9 prospective cohort studies). The 25,166 studied athletes played handball, soccer, basketball, or volleyball (mean age = 19.3, SD = 3.6 years; >85% female). All interventions were studied for a minimum of one season (mean = 1.3, SD = 0.59). Athletes who participated in an ACL injury prevention program were significantly less likely to sustain an ACL rupture with a pooled RR of 0.46 (95% CI, 0.36-0.57; P < 0.01; I2 = 49%). When analyzed by age, there was a significant risk reduction in ACL rupture for collegiate/professional athletes over age 18 (RR = 0.50; 95% CI, 0.38-0.64; P < 0.01; I2 = 66%) but no significant change for players under age 18 (RR = 0.35; 95% CI, 0.22-0.55; P = 0.47; I2 = 0%). Of the 12 studies including female players, the pooled RR was 0.57 and not statistically significant (95% CI, 0.43-0.74; P = 0.13; I2 = 32%). There was no significant RR for athletes playing soccer (RR = 0.30; 95% CI, 0.19-0.46; P = 0.06; I2 = 47%) or handball (RR = 0.66; 95% CI, 0.46-0.96; P = 0.38; I2 = 5%). Players who participated in programs including balance boards exhibited a significantly lower risk of ACL rupture (RR = 0.49; 95% CI, 0.35-0.67; P < 0.01; I2 = 74%).

Conclusion:
Athletes who did not partake in an ACL injury prevention program were nearly twice as likely to sustain an ACL rupture compared to those who did, with particular ACL injury risk reduction in collegiate/professional athletes and those who used balance boards. This study provides strong support for using neuromuscular training programs to significantly reduce the risk of ACL rupture among athletes.

Training to Stay in the Game: A Systematic Review and Meta-Analysis of ACL Injury Prevention Programs

Gonzalo F. Del Rio Montesinos 
Abstract Title : Unveiling the Risks: A Deep Dive into Vertebral Artery Injuries Post Cervical Disc Arthroplasty 
Background
Cervical Disc Arthroplasty (CDA) treats cervical disc degeneration and spinal compression, offering a high success rate and improved neck disability index. During CDA, the vertebral artery (VA), a major blood vessel branching from the subclavian artery, is at risk. This courses the transverse foramen of C2-C6 vertebrae, exits at C2, and enters the skull via the foramen magnum. Injuries are often due to anatomical variations, though rare, can cause severe complications. The objective of this narrative review is to analyze variables such as Normal Anatomy, FDA-approved Devices, increase CDA, the prevalence of VAI in the anterior approach, case reports regarding the injury, preventative measures, and treatment were considered. 

Methods
The articles chosen were from June 30th, 2000, to June 30th, 2024, and sourced from PubMed, Science Direct, and Web of Science. The keywords were cervical, cervical disc, vertebral artery, vertebral artery injury, disc arthroplasty, and degenerative disc. 

Results 
Extensive literature exists regarding the anatomic variations such as a 7.6% occurrence among 250 individuals. The anterior approach of CDA has a 0.4% occurrence of VAI. Pre-operative MRI and post-operative advanced imaging techniques such as MRI must be implemented with more frequency to determine artery course and health outcomes. Physician experience has significant effects upon possible injuries. Surgeons with < 300 procedure experience had a 0.33% possibility of injuring the artery and those with > 300 had 0.06%. CDA has been implemented in Europe since the 1960s however it wasn’t until 2007 where the FDA approved the first CDA device for the USA. Among 11 FDA-approved devices, eight reported blood loss, two Vascular Intra op, and one cerebrovascular bleeding, however no device indicated to have a VAI as a complication. Two case reports were found regarding VAI following CDA. In VAI, a stent has 97% success rate, however one must consider long term re-stenting and symptom reappearance. Two case reports regarding VAI following CDA indicated the lack of literature of the injury and the possible complication when approaching the procedure. In the years 2007-2013 there has been a nonlinear 190% increase in the use of CDA, exponentially replacing anterior cervical fusion and one must consider that this continuous implementation will bring about increased case reports regarding complications. 

Conclusion
VAI must be considered when approaching a CDA due the higher prevalence of these procedures being implemented. Anatomic variations, Physician Experience, preventative and treatment management are factors to consider in VAI.

Unveiling the Risks: A Deep Dive into Vertebral Artery Injuries Post Cervical Disc Arthroplasty

Background: Revision total joint arthroplasty (TJA) becomes necessary when a primary TJA fails, leading to worse patient outcomes, higher complication rates, and increased economic burdens on the healthcare system. With the global aging population, the demand for revision TJA’s are projected to rise significantly by 2030 which highlights the need for effective machine learning (ML) models to improve outcomes in revision TJA. Although prior systematic reviews have evaluated the utility of ML in predicting outcomes for primary TJA, there is a notable gap in assessing ML’s potential in the context of revision TJA . This study aims to systematically review the application of ML for predicting outcomes following revision total hip arthroplasty (THA) and revision total knee arthroplasty (TKA).

Methods: A comprehensive literature search was conducted to May 2024 in Ovid MEDLINE, Ovid Embase, and Web of Science. Studies were imported into Covidence for screening. The exclusion criteria were: (1) other systematic reviews; (2) animal models; (3) studies not utilizing artificial intelligence; (4) studies not involving revision arthroplasty; (5) case reports; (6) technical notes; (7) editorial notes; (8) studies on joints other than the hip and knee; and (9) studies without full-text availability. The search strategy yielded 1289 articles, of which 19 were assessed as eligible for this review.

Results: Search criteria yielded 19 relevant studies. Topics of study included patient complications (n = 12), readmissions (n = 2), discharge dispositions (n = 2), patient-reported outcome measures (n = 0), inpatient status and length of stay (LOS) (n = 4), and patient function (n = 1). Studies involved revision TKA (n = 8), revision THA (n = 7), or a combination (n = 5). Studies were of solely revision arthroplasty (n = 16) or included primary and revision arthroplasty (n = 4). Of reported AUC, greater than 71% of predictive outcomes for at least one model had an area under the receiver operating characteristic curve (AUC) in the excellent or outstanding range (AUC > 0.8). Additionally, 14 studies were internally validated and only 3 studies were externally validated.

Discussion/Conclusion: Machine learning algorithms are being increasingly used to predict patient outcomes after revision THA and TKA. Machine learning has shown utility in clinical settings in the context of risk stratification and prediction of complications, patient reported outcome scores, and readmissions. While machine learning algorithms have been received with considerable interest, they should be critically assessed and externally validated prior to clinical adoption.


Using Machine Learning to Enhance Predictive Outcomes in Revision Total Joint Arthroplasty: A Systematic Review

Background
Otolaryngologists utilize drug-induced sleep endoscopy (DISE) to evaluate the anatomic location and pattern of upper airway collapse in patients with obstructive sleep apnea (OSA). The cardiovascular consequences of OSA are due to intermittent hypoxia and negative intrathoracic pressure swings, leading to sympathetic activation. It is challenging, however, to assess these physiologic pressure swings during natural sleep; therefore, we applied objective measures of airflow and respiratory effort during DISE to measure pharyngeal pressure changes. We hypothesized greater retroepiglottic pressure changes during respiratory events from DISE to correlate with reduced nocturnal blood pressure “dipping” during 24-hour ambulatory blood pressure monitoring (ABPM), thereby enhancing surgical management of OSA by linking intraoperative findings to cardiovascular outcomes.

Methods
Patients with untreated OSA prospectively underwent ABPM and DISE with pharyngeal manometry. Retroepiglottic pressure (cm H2O) was calculated as the mean pressure differential for each obstructed breath between the start of inspiration and the nadir of negative pressure during inspiration. ABPM recorded blood pressure every 30 minutes while awake and hourly while asleep. Pearson’s correlation evaluated associations between retroepiglottic pressure changes and ABPM values. 

Results
Twenty patients were included for analysis. Patients, on average, were middle-aged (48.7±16.3 years), overweight (body-mass index [BMI] 29.5±3.46 kg/m2), male (65%), White (60%), with moderate-severe OSA at baseline (AHI 40.0±21.2 events/hour), normotensive (24-hour systolic & diastolic pressure 121±13.5 and 72.3±8.24 mmHg), and taking anti-hypertensive medications (45%). Correlational analysis showed greater retroepiglottic pressure swings were correlated with higher nocturnal, diurnal, and 24-hour ABPM values: 24-hour mean arterial pressure (MAP) (r=0.48, p=0.03), 24-hour systolic blood pressure (SBP) (r=0.46, p=0.04), 
higher 24-hour diastolic blood pressure (DBP) (r=0.39, p=0.09).

Conclusion
In this study, a relationship between nocturnal blood pressure and retroepiglottic pressure swings during DISE was identified. These findings underscore the importance of intraoperative physiologic assessments in predicting cardiovascular risk in patients with OSA and highlight Otolaryngologists’ role in managing these risks. Future directions involve expanding the sample size and comparing these pharyngeal pressures against conventional polysomnographic OSA measures of cardiovascular risk.

Association Between Retroepiglottic Pressure During Drug-Induced Sleep Endoscopy & Nocturnal Blood Pressure: A Pilot Study

Subglottic stenosis (SGS) is a narrowing of the airway distal to the vocal cords. It is a common post-intubation complication treated by otolaryngologists. The narrowing is typically due to a band of fibrotic scar tissue, with few cases reporting calcification of this band in the post-cricoid region. To date, there have been fewer than 5 reports of calcified SGS, each treated with a unique surgical approach. In this case report, we describe our technique for the removal of a calcified subglottic stenotic band at the level of the cricoid in a 46 year-old female. We also review the current literature to compare outcomes and complications of the various surgical techniques implemented for this unique pathology. The technique utilized in this report adds to the previous literature and offers a viable treatment alternative for calcified SGS.

Diagnosis and Surgical Management of a Patient with Calcified Subglottic Stenosis

Introduction: The objective is to develop a proof-of-concept smartphone-based eye-tracking algorithm to assess non-pathologic optokinetic (OKN) nystagmus in healthy participants. Current videonystagmography (VNG) is typically restricted to in-office use, and advances in ambulatory or portable vestibular diagnostic devices would yield immense public health benefits.

Methods: Healthy participants (n=39) without a history of dizziness or vertigo were recruited for this prospective comparison study. A smartphone attached to a custom head stabilization device illuminated by a white LED circuit was used to record nystagmus induced with a 30 frames/sec OKN stimulus over a 30-second period. A centroid tracking algorithm ("VertiScope") was created and optimized to detect slow-phase velocity (SPV) of horizontal nystagmus in a diverse subject cohort in a variety of lighting conditions. A cohort of subjects measured in ideal lighting conditions (n=16) underwent standard VNG for comparison of nystagmus recordings with our novel VertiScope algorithm. 

Results: Non-pathologic nystagmus was measured across multiple lighting conditions, with high signal-to-noise ratios (SNR) and mean SPV of 22.53+/-5.16 deg/sec. Nystagmus SPV was not significantly different between the device and standard VNG system (t= -0.5, p=0.6). Lighting conditions produced SNRs of 49.28 (dark), 48.90 (backlit), 51.33 (side-lit), 55.65 (outdoor lighting), and 58.42 (ideal). VertiScope SPV was not significantly different when compared against quantitative facial metrics for all participants. 

Conclusions: Here, we demonstrate the feasibility of a novel oculography device and in the detection of non-pathologic nystagmus in healthy subjects. Future applications of this device include: obtaining real-time measurements of nystagmus during an acute vertigo attack in patients with vestibular disorders; testing patients unable or unwilling to present to a specialized vestibular laboratory; efficiently repeating testing overtime; and improving accessibility of vestibular testing.

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