Abstract

Purpose: Currently, approximately 90% of the 620 graduating orthopaedic residents are planning on entering a post-graduate fellowship. Since January of 2005, two of the largest orthopaedic fellowship match programs, Sports Medicine and Spine Surgery, were dissolved by the NRMP due to gradual decline and reduced participation leaving approximately 70% of applicants in a non-match, decentralized system.

Method: An on-line survey was designed by orthopaedic leadership of the AOA with the help of two Harvard business school “match” economists. The survey was administered to PGY-4 orthopaedic residents participating in the AOA Resident Leadership Forum (RLF) of 2007. This data was used as the cornerstone of the RLF for 2007, where the residents deliberated the results of the survey and formulated a brief recommendation list. The survey responses were then tabulated electronically and subjected to market analysis.

Results: Sixty-five out of 112 (58%) RLF Residents answered the on-line survey, while 93 (83%) answered audience response questions at the RLF. Thirty percent of residents (19/64) did not have enough time and exposure in their residency to decide which subspecialty to enter. They felt the ideal interview period should be held from January through March of the PGY-4 year. Over 50% of residents felt pressure to accept early offers, had to accept an offer before finishing interviewing or accepted their first offer. Sixty-eight percent (43/64) had to respond to an offer in less than one week. Seventy-six percent (31/47) felt they were given inadequate time to accept or reject offers. Thirty-six percent (17/47) asked for more time to think about an offer. Over 50% (33/65) accepted their first offer and 8% (5/47) had an offer withdrawn because they did not give a response within a designated time frame (exploded offer). Residents cancelled a mean of 2.7 interviews per resident (range 0–9). Eighty-percent (50/64) thought a match would be better than the current system, if most programs would adhere to it. Approximately 47% (41/88) of the residents favored a more centralized process involving all orthopedic surgery fellows, while 35% (31/88) favored a subspecialty based system.

Conclusion: The RLF deliberations can be summarized as follows:

The current fellowship hiring process is decentralized, poorly functioning, unraveled and generally unfair. It creates anxiety for residents, residency directors, and fellowship directors alike. Residents are facing exploding offers, limited exposure to fellowship programs and, ultimately, an unraveling hiring market.

Purpose: While several studies have reported improved pain control with use of femoral nerve blocks (FNB) following ACL reconstruction, there are few studies that have evaluated the effect of continuous perineural infusion on quadriceps activation and recovery of range of motion after ACL reconstruction. The purpose of this prospective randomized placebo-controlled clinical trial was to determine if the use of continuous infusion of levobupivacaine for pain control following ACL reconstruction had an adverse effect on postoperative quadriceps activation and recovery of ROM.

Method: Two-hundred-seventy patients underwent ACL reconstruction and were randomly assigned to one of three FNB groups (placebo bolus and infusion, active bolus with placebo infusion, or active bolus and continuous infusion). The patients’ ability to perform a SLR was assessed daily for the first four post-operative days. Range of motion of the knee was measured with a goniometer 1, 4, 8 and 12 weeks after surgery. Range of motion complications requiring arthroscopic debridement, manipulation under anesthesia, or application of a drop-out cast were recorded.

Results: There were no significant differences between groups in their ability to perform a SLR on postoperative day 1 through 4. There were also no differences between active and passive ROM values between groups at each follow-up period. There were 7 (3.2%) early ROM complications, but no detectable differences between groups.

Conclusion: Continuous perineural infusion of levobupivacaine (0.25% at 5mL/hr for 50 hours) following ACL reconstruction does not appear to negatively influence quadriceps activation as evidenced by the inability to perform a SLR or adversely affect recovery of range of motion in the early postoperative period after ACL reconstruction. Continuous perineural infusion can provide effective pain relief without adversely affecting post-operative recovery following ACL reconstruction.