Chondrosarcomas are cartilage-matrix-forming tumors that make up 20-27% of primary malignant bone tumors and are the third most common primary bone malignancy after multiple myelomas and osteosarcomas. Radiographic assessment of this condition includes plain radiography, computed tomography, and magnetic resonance imaging for tumor characterization and delineation of intraosseous and extraosseous involvement. Most chondrosarcomas are refractory to chemotherapy and radiation therapy; therefore, wide en bloc surgical excision offers the best chance for cure. Chondrosarcomas frequently affect the pelvis and upper and lower extremities. In rare instances, the chest wall can be involved, with chondrosarcomas occurring in the ribs, sternum, anterior costosternal junction, and posterior costotransverse junction. In this article, we present a patient with thoracic chondrosarcoma centered at the left T7 costotransverse joint with effacement of the left T7-T8 neuroforamen. We also detail our operative technique of wide en bloc chondrosarcoma excision and review current literature on this topic.

Direct ventral access to the cervicothoracic spine (C7-T4) poses a technical challenge in spine surgery, given the vital neurovascular structures residing anterior to the cervicothoracic junction (CTJ). The transsternal approach is a feasible surgical option that allows for direct anterior exposure of the lower cervical and upper thoracic vertebrae. Here, the authors report a case of an elderly gentleman with upper thoracic (T1-2) vertebral osteomyelitis and epidural abscess who underwent a transsternal full median sternotomy for ventral decompression and fusion of C7-T2. We also detail our operative procedure and review relevant literature on different transsternal approaches to the CTJ.

This article reviews the historical context, indications, techniques, and complications of four posterior fixation techniques to stabilize the subaxial cervical spine. Specifically, posterior wiring, laminar screw fixation, lateral mass fixation, and pedicle screw fixation are among the common methods of operative fixation of the subaxial cervical spine. While wiring and laminar screw fixation are now rarely used, both lateral mass and pedicle screw fixation are technically challenging and present the risk of significant complications if performed incorrectly. With a sound understanding of anatomy and rigorous preoperative evaluation of bony structures, both lateral mass and pedicle screw fixation provide a safe and reliable method for subaxial cervical spine fixation.

Adhesive shoulder capsulitis, or arthrofibrosis, describes a pathological process in which the body forms excessive scar tissue or adhesions across the glenohumeral joint, leading to pain, stiffness and dysfunction. It is a debilitating condition that can occur spontaneously (primary or idiopathic adhesive capsulitis) or following shoulder surgery or trauma (secondary adhesive capsulitis). Here, we review the pathophysiology of adhesive shoulder capsulitis, highlighting its clinical presentation, natural history, risk factors, pathoanatomy and pathogenesis. Both current non-operative and operative treatments for adhesive capsulitis are described, and evidence-based studies are presented in support for or against each corresponding treatment. Finally, the review also provides an update on the gene expression profile of adhesive capsulitis and how this new understanding can help facilitate development of novel pharmacological therapies.

Background

Orthopaedic surgery training programs have lagged behind other surgical specialties in increasing their representation of women and people from under-represented minority (URM) groups. Comparative data between orthopaedic surgery and other specialties are needed to help identify solutions to closing the diversity gap.

Questions/purposes

(1) Which surgical specialties have the greatest representation of women residents and residents from URM groups? (2) How have the proportions of women residents and residents from URM groups changed across the surgical specialties during the past decade?

Methods

This was a retrospective evaluation of a large, longitudinally maintained survey database. Resident data by gender and ethnicity were retrieved from the Accreditation Council for Graduate Medical Education Data Resource Books for the 2011 to 2012 through 2019 to 2020 academic years. The Accreditation Council for Graduate Medical Education database is updated annually; thus, it is the most up-to-date and complete database available for gender and ethnicity data for all surgical residents. Data were obtained and analyzed for seven different surgical specialties: orthopaedic surgery, neurosurgery, ophthalmology, otolaryngology, plastic surgery, general surgery, and urology. No sampling was necessary, and thus descriptive statistics of the data were completed. Because the entire population of residents was included for the period of time in question, no statistical comparisons were made, and the reported differences represent absolute differences between the groups for these periods. Linear regression analyses were performed to estimate the annual growth rates of women residents and residents from URM groups in each specialty.

Results

Among the seven surgical specialties, representation of women residents increased from 28% (4640 of 16,854) of residents in 2012 to 33% (6879 of 20,788) in 2020. Orthopaedic surgery had the lowest representation of women residents every year, with women residents comprising 16% of residents (700 of 4342) in 2020. Among the seven surgical specialties, representation of residents from URM groups increased from 8.1% (1362 of 16,854) in 2012 to 9.7% (2013 of 20,788) in 2020. In 2020, the representation of residents from URM groups in orthopaedic surgery was 7.7% (333 of 4342). In 2020, general surgery had the highest representation of women residents (42%; 3696 of 8809) as well as residents from URM groups (12%; 1065 of 8809). Plastic surgery (1.46% per year) and general surgery (0.95% per year) had larger annual growth rates of women residents than the other specialties did. In each surgical specialty, the annual growth rate of residents from URM groups was insignificant.

Conclusion

During the past decade, there was only a small increase in the representation of women in orthopaedic surgery, while the representation of people from URM groups did not change. In contrast, by 2020, general surgery had become the most diverse among the seven surgical specialties. To increase diversity in our field, we need to evaluate and implement some of the effective interventions that have helped general surgery become the diverse surgical specialty that it is today.

Clinical relevance

General surgery has substantially reduced gender and ethnic disparities that existed in the past, while those in orthopaedic surgery still persist. General surgery residencies have implemented a holistic review of resident applications and longitudinal mentoring programs to successfully address these disparities. Orthopaedic surgery programs should consider placing less emphasis on United States Medical Licensing Examination score thresholds and more weight on applicants' non-academic attributes, and put more efforts into targeted longitudinal mentorship programs, some of which should be led by non-minority faculty.

Letters of recommendation (LORs) are highly influential in the residency selection process. Differences in language and length of LORs by gender have been demonstrated for applicants applying to surgical residencies and fellowships. This had yet to be studied in orthopaedic surgery. Given the gender disparity in the field, we sought to investigate the impact of gender on orthopaedic residency applicant LORs. We hypothesized that differences in length and language would be present for women applicants as compared to men. LORs for 2019 to 2020 applicants who applied to a single academic institution were selected for review. Female and male applicants were matched by medical school attended and United States Medical Licensing Examination Step 1 score. LORs were analyzed using both qualitative and quantitative analyses. Letters were evaluated for their word count, presence of language terms, and frequency of language terms. A similar subgroup language analysis was performed for standardized LORs (SLORs). Six hundred fifty-six applicants met the initial screening criteria-126 women and 530 men. After matching, 71 female applicants were paired with 111 male applicants. Word count was, on average, longer for female applicants. LORs for female applicants were more likely to contain language terms that characterized their ability, achievement, participation in athletics, awards received, fit, leadership, and personality traits. Of these terms, ability and participation in athletics were also found more frequently in LORs written for women. In addition, language characterizing technical skills was found more frequently in LORs of female applicants. Similar codes were found to be statistically significant in the SLOR subgroup analysis. This study highlights that current orthopaedic surgery residency LORs do not appear to be biased by applicant gender. LORs were longer for female applicants and described them more positively. Future female orthopaedic residency applicants should be assured that current female candidates are applying with at least similar if not greater subjective qualifications to their male counterparts based on the findings of this study.

This cohort study uses the Vizient Clinical Data Base to compare the postoperative in-hospital morbidity and mortality of surgical patients with COVID-19 infection with patients without COVID-19 infection.