What Effects Have Resident Work-hour Changes Had on Education,Quality of Life,and Safety? A Systematic Review

Background

More than 15 years ago, the Institute of Medicine (IOM) identified medical error as a problem worthy of greater attention; in the wake of the IOM report, numerous changes were made to regulations to limit residents’ duty hours. However, the effect of resident work-hour changes remains controversial within the field of orthopaedics.

Questions/purposes

We performed a systematic review to determine whether work-hour restrictions have measurably influenced quality-of-life measures, operative and technical skill development, resident surgical education, patient care outcomes (including mortality, morbidity, adverse events, sentinel events, complications), and surgeon and resident attitudes (such as perceived effect on learning and training experiences, personal benefit, direct clinical experience, clinical preparedness).

Methods

We performed a systematic review of PubMed, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Google Scholar using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Inclusion criteria were any English language peer-reviewed articles that analyzed the effect(s) of orthopaedic surgery resident work-hour restrictions on patient safety, resident education, resident/surgeon quality of life, resident technical operative skill development, and resident surgeon attitudes toward work-hour restrictions. Eleven studies met study inclusion criteria. One study was a prospective analysis, whereas 10 studies were of level IV evidence (review of surgical case logs) or survey results.

Results

Within our identified studies, there was some support for improved resident quality of life, improved resident sleep and less fatigue, a perceived negative impact on surgical operative and technical skill, and conflicting evidence on the topic of resident education, patient outcomes, and variable attitudes toward the work-hour changes.

Conclusions

There is a paucity of high-level or clear evidence evaluating the effect of the changes to resident work hours. Future research in this area should focus on objective measures that include patient safety as a primary outcome.     

Robinow syndrome: Report of two cases and review of the literature

We report two patients with Robinow syndrome, review the published literature and stress the importance and limitations of radiographic examination in the diagnosis of this disorder, which shows extreme clinical and radiographic variability. The radiographic differential diagnosis of Robinow syndrome is discussed.     

The Incidence of Posterior and Combined AP Shoulder Instability Treatment with Surgical Stabilization Is Higher in an Active Military Population than in the General Population: Findings from the US Naval Academy

BackgroundAnterior instability has consistently been shown to be the most common type of glenohumeral instability. Recent studies have demonstrated a higher percentage of posterior and combined (anterior and posterior) instability than had previously been reported; however, this work has not been replicated recently in a particularly young military population, which may be representative of an especially athletic or high-demand group.Question/purposeWhat proportion of arthroscopic shoulder stabilization procedures are performed to address isolated anterior instability, isolated posterior instability, and combined instability in a young, military population?MethodsBetween August 2009 and January 2020, two sports medicine fellowship–trained surgeons performed arthroscopic shoulder surgery on 543 patients at a single institution. During that time, the indication to be treated with arthroscopic stabilization surgery was symptomatic glenohumeral instability, as diagnosed by the operative surgeon, that restricted patients from carrying out their military duties. Of those, 82% (443 of 543) could be evaluated in this retrospective study, while 18% (100 of 543) were excluded due to either incomplete data or because the procedure performed was not to address instability. No patient underwent an open stabilization procedure during this period. Of the 443 patients investigated, the mean age was 22 ± 4 years, and 88% (392 of 443 patients) were men. Instability type was characterized as isolated anterior, isolated posterior, or combined (anterior and posterior) according to the physician’s diagnosis as listed in the patient’s clinical records and operative reports after the particular capsulolabral pathology was identified and addressed.ResultsIsolated anterior instability occurred in 47% of patients (210 of 443). Isolated posterior instability happened in 18% of patients (80 of 443), while combined anteroposterior instability occurred in 35% of patients (153 of 443).ConclusionShoulder instability is common in the military population. Although anterior instability occurred most frequently, these findings demonstrate higher proportions of posterior and combined instability than have been previously reported. Surgeons should have a heightened suspicion for posterior and combined anteroposterior labral pathology when performing arthroscopic stabilization procedures to ensure that these instability patterns are recognized and treated appropriately. The current investigation examines a unique cohort of young and active individuals who are at particularly high risk for instability and whose findings may represent a good surrogate for other active populations that a surgeon may encounter.Level of Evidence Level III; therapeutic study.     

Interventional radiology‐operated percutaneous cholecystoscopy with ultrasonic lithotripsy and stone basket retrieval: A treatment for symptomatic cholelithiasis in non‐operative candidates

Interventional radiology‐operated percutaneous endoscopy has seen a recent resurgence with potential to return to the scope of Interventional Radiology practice. Endoscopy adds a new dimension to the Interventional Radiology armamentarium by offering a unique opportunity to diagnose and treat conditions under direct visualization with improved maneuverability. Cholecystoscopy (gallbladder endoscopy), as a method for percutaneous removal of gallstones, is an effective treatment option in patients with symptomatic cholelithiasis who are poor candidates for surgical cholecystectomy. This article presents a case of Interventional Radiology‐operated cholecystoscopy using ultrasonic lithotripsy and stone basket retrieval with an emphasis on the equipment, technique, and peri‐procedural management essential to the procedure, as well as a review of the literature.     

输血传播西尼罗病毒

西尼罗病毒(WNV)属黄病毒科黄热病毒属。黄热病毒属的其它成员包括登革热病毒、扁虱热传播性脑炎、黄热病,日本脑炎和圣·路易斯大脑炎病毒。1937年Smithburn及其同事首先从白尼罗河源头乌干达北部的西尼罗河地区一例37岁妇女的血液中分离出WNV,按照当时的情况,新分离的虫媒病毒的命名以获得该病毒的地理名称命名。耶例妇女参与了昏睡病监视项目,并且在抽血的当天有38.1℃的发热,分离出的病毒在恒河猴大脑内和鼻内接种以后导致发热和脑炎(但是当给予静脉注射时只有发烧)以及诱导了免疫。非洲绿猴脑内接种该病毒没有使其患上脑炎,仅有发热,感染该病毒后做鼠生物实验,发现3只恒河猴中有2只血液中含有该病毒达9天。     

Anatomic Osteochondral Glenoid Reconstruction for Recurrent Glenohumeral Instability With Glenoid Deficiency Using a Distal Tibia Allograft

The treatment of glenoid bone loss in the setting of recurrent shoulder instability remains a challenge. This is because of the nonanatomic nature and resultant incongruous joint resulting from most bony augmentation procedures. We present a novel technique for the management of glenoid bone deficiency by using a fresh osteochondral distal tibial allograft. We have found that the distal tibia has excellent articular conformity to unmatched humeral heads, fits nearly anatomically on the distal two thirds of the glenoid, is composed of dense weight-bearing cortical and metaphyseal distal tibia bone, and provides for a cartilaginous surface for which the humeral head to articulate. This article describes the technique, initial results, and postoperative findings with the use of a distal tibia allograft (the lateral portion of the distal tibia) for the treatment of glenoid bone deficiency (mean loss of 30%) in a series of 3 patients.