This study aimed to assess the views and leadership competencies of incoming medical students and determine whether leadership traits predicted patient-centeredness in these students. Incoming medical students at one institution from 2017-2020 (N=428) completed a Leadership Needs Assessment assessing self-reported ability and the importance of competency in teamwork, selfless service, integrity, critical thinking, and emotional intelligence. Participants in the entering class of 2020 (n=92) also completed the Johns Hopkins University Patient-Centeredness Assessment to evaluate patient-centered attitudes. This cohort repeated both surveys at the completion of the first year to assess for changes in the perceived importance of leadership qualities, self-reported competencies, and patient-centeredness. Participants self-reported the highest competency (mean, SD) in integrity (7.92, 1.19) and the lowest in critical thinking (6.59, 1.12). Leadership Development Opportunity (difference between leadership expectation and self-reported ability) was largest in teamwork (2.31, 1.11) and smallest in integrity (0.97, 1.18). Post-first-year assessments were compared in the 2020 cohort, and statistically significant increases (mean, p-value) were found in critical thinking (0.31, p<0.01), emotional intelligence (0.18, p<0.03), and patient-centeredness (0.92, p<0.05). Patient-centeredness was positively predicted by integrity and negatively predicted by critical thinking. Incoming medical students highly value leadership and enter medical school with a robust self-reported ability level. Our data suggest that integrity may increase patient-centeredness and that incoming medical students perceive teamwork as the greatest area for leadership competency development. Further research is needed to determine the best curricula to develop leadership competencies and increase patient-centeredness.

IntroductionAnterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed procedures in orthopedics. We hypothesize that predictive modeling of the outcomes after ACLR can improve the quality of information available for treatment discussions. In this study, we describe a model that provides detailed outcome predictions based on patient demographics, graft choice, and reconstructive technique.MethodsA Markov decision model of the natural history after ACLR was constructed. Patients were divided into four therapeutic categories – 1. Single-bundle, autologous hamstring reconstruction; 2. Single-bundle, autologous patellar tendon reconstruction; 3. Single-bundle, allograft reconstruction; and 4. Double-bundle reconstruction. The model was run for both anatomic and trans-tibial drilling techniques. The primary outcomes were graft failure requiring revision surgery and IKDC overall grade. Outcome probabilities and utilities were derived from the highest-level evidence available in the literature. Utilities range from 0 (failure) to 1 (normal knee).Results45 studies (Level I-III), 24 of which were level I, were used to build the model. Monte Carlo micro-simulation on a population of 200,000 – the estimated yearly incidence of ACL rupture – was performed. The mean utilities were 0.88 for double-bundle reconstruction, 0.78 for single-bundle autologous hamstring reconstruction, 0.76 for allograft reconstruction and 0.75 for single-bundle autologous patellar tendon reconstruction. Utility scores for single-bundle hamstring autograft using anatomic and trans-tibial drilling techniques were 0.8 and 0.76, respectively. Utility scores for single-bundle bone-patellar tendon-bone autograft using anatomic and trans-tibial drilling techniques were 0.82 and 0.72, respectively. Re-rupture rates were higher in patients < 20 years, those returning to IKDC Level I/II activity, and those with a contact mechanism of injury. The probability of attaining an excellent (IKDC grade A) outcome was 66.1% for double-bundle reconstruction, 43.5% for single-bundle autologous hamstring reconstruction, 38.1% for single-bundle, autologous patellar tendon reconstruction, and 37.7% for single-bundle allograft reconstruction.ConclusionWe present a disease model of the natural history of ACLR using varying graft choices to aid in both individual and population-based decision-making. This model is based on the highest quality available literature, and it can be used to assist patients and surgeons in choosing between various surgical options. IntroductionAnterior cruciate ligament reconstruction (ACLR) is one of the most commonly performed procedures in orthopedics. We hypothesize that predictive modeling of the outcomes after ACLR can improve the quality of information available for treatment discussions. In this study, we describe a model that provides detailed outcome predictions based on patient demographics, graft choice, and reconstructive technique.

Introduction Recurrent instability following a first-time anterior shoulder dislocation (FTASD) is very common and approaches 100% in some reports. Arthroscopic stabilization can decrease the rate of recurrent instability and improve outcomes, but the decision for surgery remains complex. Multiple patient and provider specific factors exist that affect this treatment algorithm. In this paper, we examine the interaction of these complex factors and provide threshold values at which either surgery or non-operative treatment is preferred. Methods A Markov Monte Carlo decision model comparing non-operative versus surgical treatment for a FTASD was constructed using TreeAge Pro (Williamstown, MA, 2007). Four health states were incorporated into the model: initial dislocation, stable shoulder, recurrent instability and revision stabilization. Input parameters included patient-specific variables (age, gender, activity level, time lost from work or sport, and coping with instability) and physician-specific variables such as success of surgery as well as outcome probabilities and effectiveness. Values were derived from the literature or estimated by expert opinion where necessary. The primary outcome, treatment-related quality of life years, was calculated based upon the Western Ontario Shoulder Instability index (WOSI). Specific factors examined were age, gender, time lost from work or sport, surgical success rate, activity level and ability to cope with instability. Multivariate sensitivity analyses were performed to identify key variables that influenced the preferred treatment strategy. Results Surgery for a FTASD was preferred for all men age 15-35 and for women age 30 and younger. For high-risk patients such as overhead athletes, surgery was preferred for all men age 15-35 and women age 33 and younger. Non-operative management was preferred when the relative risk of dislocation after surgery rises above 0.7 and 0.5, for men and women, respectively. Non-operative management was preferred for men with an unstable shoulder when they were comfortable with a 14 point drop in WOSI score or when the WOSI benefit of surgery lasted 2.1 years or less. For women these values were 8 WOSI points and 3.6 years. Time lost from work or sport strongly effected the decision for surgery. This relationship is displayed in Figure 1, a two-way sensitivity analysis of time lost from work or sport against age at first dislocation. Conclusion Surgery for a first time anterior shoulder dislocation resulted in improved outcomes (WOSI) for all men and women under age 30 and was therefore the preferred treatment. Beyond age 30, patient and provider specific factors exerted strong influences on the decision for surgery. Our study clarified the relationship among these factors and indicated threshold values at which surgery resulted in improved outcomes. These thresholds could potentially be useful for guiding clinical decision-making, designing future studies, or benchmarking.

To define the rotator interval (RI) from both open and arthroscopic approaches, compare their dimensions, and compare arthroscopic and open techniques of suture passage for closure of the RI. Twelve fresh cadaveric shoulders were randomized between arthroscopic and open RI closure methods. For the open group, the optimal site of suture placement was first marked arthroscopically on both the superior and middle glenohumeral ligaments (SGHL and MGHL). Sutures were then placed in open fashion. Two coordinate planes were oriented along the SGHL and MGHL and their respective origins centered on the optimal arthroscopic sites previously marked. Distance of the suture from the origin and its location in one of four superimposed quadrants defined by the coordinate planes were noted. For the arthroscopic group, these steps were reversed. The length of the superior border of the SGHL and that of the superior edge of the subscapularis between the SGHL and MGHL were measured both arthroscopically and open. The subscapularis measurements were performed in neutral, maximal internal, and maximal external rotation. The maximum opening of the capsule from outside and the maximum arthroscopic distance from the lateral insertion of the SGHL to the inferior opening of the capsule along the MGHL were determined. Sutures placed arthroscopically through the SGHL always captured the coracohumeral ligament (CHL) in the superolateral quadrant and averaged 15.0 mm (SD=10.8 mm) from the marked optimal location. Sutures placed open through the SGHL never engaged the CHL and exited in the superomedial quadrant with a mean distance from the optimal location of 8.3 mm (SD=5.4 mm). Arthroscopic MGHL sutures exited 5.5 mm (SD=4.0 mm) and open MGHL sutures exited 6.4 mm (SD=7.2 mm) from the optimal locations in multiple quadrants. The arthroscopic inferior border of the RI extended more inferiorly than the superior border of the subscapularis in all specimens. Five of 12 specimens had an additional foramen between the MGHL and anterior band of the IGHL (aIGHL) that, from an open approach, was similar in appearance to the interval between the SGHL and MGHL. The RI capsule tends to decrease in medial to lateral width with internal rotation. Arthroscopically placed sutures in the SGHL always capture the CHL, which may cause more loss of external rotation in arthroscopic RI closures than in similar open procedures. There was less variation between MGHL sutures placed arthroscopically and open. The inferior border of the RI capsular defect does not correspond to the classically described superior border of the subscapularis tendon and actually extends more inferiorly. The presence of two intervals (between the SGHL and the MGHL and between the MGHL and the aIGHL) in several specimens points to the existence of anatomic variability that may drastically affect surgical outcomes should the inappropriate interval be closed. RI closure surgery performed from an open approach is not equivalent to that performed arthroscopically and more study of the two techniques is warranted.

Syndesmosis ankle sprains, though potentially disabling, often appear benign initially. These sprains are characterized by a rotational mechanism of injury, long recovery, and, frequently, heterotopic ossification. Diagnosis and grading are based on physical exam findings and imaging studies. Treatment ranges from aggressive functional rehabilitation to surgical stabilization. Long-term results can be good if the ankle mortise is anatomically reduced and a synostosis between the tibia and fibula does not form.