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Summary:. Demand for gender-affirming facial surgery is growing rapidly. Frontal sinus setback, one of the key procedures used in gender-affirming facial surgery, has a particularly high impact on gender perception. Mixed reality (MR) allows a user to view and virtually overlay three-dimensional imaging on the patient and interact with it in real time. We used the Medivis’s SurgicalAR system in conjunction with the Microsoft HoloLens Lucille2 (Microsoft). Computed tomography imaging was uploaded to SurgicalAR, and a three-dimensional (3D) hologram was projected onto the display of the HoloLens. The hologram was registered and matched to the patient, allowing the surgeon to view bony anatomy and underlying structures in real time on the patient. The surgeon was able to outline the patient’s frontal sinuses using the hologram as guidance. A 3D printed cutting guide was used for comparison. Negligible difference between the mixed reality-based outline and 3D-printed outline was seen. The process of loading the hologram and marking the frontal sinus outline lasted less than 10 minutes. The workflow and usage described here demonstrate significant promise for the use of mixed reality as imaging and surgical guidance technology in gender-affirming facial surgery.

Ultrasound imaging is a vital imaging tool in musculoskeletal medicine, with the number of publications on ultrasound-guided surgery increasing in recent years, especially in minimally invasive procedures of sports, foot and ankle, and hand surgery. However, ultrasound imaging has drawbacks, such as operator dependency and image obscurity. Artificial intelligence (AI) and deep learning (DL), a subset of AI, can address these issues. AI/DL can enhance screening practices for hip dysplasia and osteochondritis dissecans (OCD) of the humeral capitellum, improve diagnostic accuracy for carpal tunnel syndrome (CTS), and provide physicians with better prognostic prediction tools for patients with knee osteoarthritis. Building on these advancements, DL methods, including segmentation, detection, and localization of target tissues and medical instruments, also have the potential to allow physicians and surgeons to perform ultrasound-guided procedures more accurately and efficiently. This review summarizes recent advances in ultrasound-guided procedures for musculoskeletal diseases and provides a comprehensive overview of the utilization of AI/DL in ultrasound for musculoskeletal medicine, particularly focusing on ultrasound-guided surgery.

Background: Surgical scrubbing, gowning, and gloving is challenging for medical trainees to learn in the operating room environment. Currently, there are few reliable or valid tools to evaluate a trainee’s ability to scrub, gown and glove. The objective of this study is to test the reliability and validity of a checklist that evaluates the technique of surgical scrubbing, gowning and gloving (SGG). Methods: This Institutional Review Board-approved study recruited medical students, residents, and fellows from an academic, tertiary care institution. Trainees were stratified based upon prior surgical experience as novices, intermediates, or experts. Participants were instructed to scrub, gown and glove in a staged operating room while being video-recorded. Two blinded raters scored the videos according to the SGG checklist. Reliability was assessed using the intraclass correlation coefficient for total scores and Cohen’s kappa for item completion. The internal consistency and discriminant validity of the SGG checklist were assessed using Cronbach alpha and the Wilcoxon rank sum test, respectively. Results: 56 participants were recruited (18 novices, 19 intermediates, 19 experts). The intraclass correlation coefficient demonstrated excellent inter-rater reliability for the overall checklist (0.990), and the Cohen’s kappa ranged from 0.598 to 1.00. The checklist also had excellent internal consistency (Cronbach’s alpha 0.950). A significant difference in scores was observed between all groups (p < 0.001). Conclusion: This checklist demonstrates a high inter-rater reliability, discriminant validity, and internal consistency. It has the potential to enhance medical education curricula.

Category: Sports Introduction/Purpose: The percentage of the U.S population that is age 65 and older is expected to rise to 19.3% by the year 2030, up from 13% in 2010. Only 39% of seniors get the recommended amount of weekly exercise. This has led to Medicare sponsored fitness plans to increase of the number of older adults being active. For this percentage it is important that they are aware of safety precautions and ways to prevent injuries. One study showed that in elderly men still active in sports 75% of injuries were located in the lower extremity. The purpose of this study is to trend sports related foot and ankle (SFA) injuries in patients 65 and over that presented emergency departments from 2009 to 2018. Methods: Data was obtained from the National Electronic Injury Surveillance System (NEISS). Injury data is obtained daily from the emergency departments of approximately 100 hospitals across the United States and its territories. This serves as a probability sample of over 5000 hospitals across the country. Each case recorded is given a statistical weight based on the study design. CPSC analysis has the ability to make adjustments to more accurately represent the entire United States population. Hospitals are group in five strata mostly based on hospital size and number of ED visits they receive per year. The database was set with query inputs of patients aged 65 and over that presented with sports related injuries of the lower leg, ankle, foot and toes from 2009 - 2018. Results: An approximate total of 216,334 SFA injuries presented to emergency rooms in persons age 65 and over. Contusions/abrasions accounted for 11.7% of total injuries; lacerations (12.4%); fractures (20.9%); sprains and fractures (22.7%). Other types of injuries accounted for 32.3 %. There was an approximate total of 1,654,666 sports related injuries. Upper extremity had the highest percentage at 24.6%. Ages 65-69 accounted for 38.8 %. The trend for the SFA injuries increased 39.9% from 2009 to 2018, while the trend for overall sports injuries rose 83%. The percentage of SFA out of all sports injuries has decreased 23.6% from 14.81% of total sport injuries in 2009 to 11.32% in 2018. Conclusion: As the population ages, more seniors are remaining active and more are participating in sports. Thus, the increase in the number of sport related injuries. This increase however has outpaced the number of foot and ankle specific sport injuries. Over the time span of the study there has been an increase in percentage of hand, wrist and knee injuries. Further research is needed to delineated which specific sports and activities cause the most SFA injuries. This information can then be used to educate this population on injury prevention.

Category: Trauma; Basic Sciences/Biologics Introduction/Purpose: Syndesmotic injuries account for 1-11% of all ankle sprains and are the most predictive factor of chronic ankle dysfunction 6 months after injury. Common surgical techniques include screw fixation (the ‘gold standard’) and dynamic fixation with a suture button device, which may lead to better clinical outcomes than rigid screw. To date, there are no studies comparing the in vivo biomechanics of suture button and rigid screw syndesmotic fixation, and no report of the correlations between biomechanics and patient outcomes. The goal of this study is to characterize the biomechanics of the native ankle syndesmosis, rigid screw fixation, suture button fixation, along with associated patient-reported outcomes. This study will elucidate mechanisms for improved patient-reported outcomes based on the fixation method. Methods: 6 patients (average age:23.6, 4M/1F, 2 suture button, 2 screw fixation and 1 hybrid) consented to participate in this IRB-approved study. After being medically cleared to return to full athletic participation, each participant performed seven movements (two single leg hops (straight and lateral), two alternating single-leg push-offs (front-to-back and side-to-side), vertical jumping, running, and walking within a biplane radiographic system (Figure 1). A validated volumetric model-based tracking system matched patient-specific 3D bone models (obtained from CT) to the synchronized biplane radiographs (Figure 1). Six degree of freedom ankle kinematics were determined for each movement and for the repaired and contralateral ankle of each participant. Patient reported outcomes were also measured using the Foot and Ankle Ability Measure (FAAM) and a Visual Analogue Scale (VAS). Results: The results show that the screw fixation (-0.99 mm) has greater tibiotalar lateral-medial translation of the injured side relative contralateral healthy side compared to the tightrope fixation (-0.73 mm) and hybrid (.05 mm). For the syndesmosis translation, the screw fixation (2.00 mm) also exhibits greater total magnitude of translation compared to the tightrope ((-0.44 mm) and hybrid fixation (1.02 mm). Conclusion: This study shows that the screw fixation exhibits greater translation of the syndemosis and lateral/medial translation of the Talus. This may suggest that this method is inferior to the tight-rope and hybrtid. Future studies will include all the motions and more subjects.

Category: Ankle; Sports; Trauma; Other Introduction/Purpose: Skateboarding has been a part of American culture since its origins in the 1960s. ESPN’s X Games debuted in the 90s and popularity soared. In 1996, there were an estimated 5.8 millions children that participated in the sports with some 750,000 involved weekly. In 1999, there was approximately 51,000 pediatric skateboard related injuries seen in United States emergency rooms. Most injuries happen when the skateboard comes into contact with irregularities in the riding surface. A previous study showed that from 1987-1998, ankle sprains/strains were the most common injury seen in the emergency department (ED). The purpose of this study is to examine the updated trends of skateboard related foot and ankle injuries (SFA) from the years 2009 to 2018. Methods: Data was obtained from the National Electronic Injury Surveillance System (NEISS). Injury data is obtained daily from the emergency departments of approximately 100 hospitals across the United States and its territories. This serves as a probability sample of over 5000 hospitals across the country. Each case recorded is given a statistical weight based on the study design. CPSC analysis has the ability to make adjustments to more accurately represent the entire U.S. population. Hospitals are grouped into five strata mostly based on hospital size and number of ED visits they receive per year. The database was set with query inputs of patients aged 2-17 that presented to the ED with skateboard related lower leg, ankle, or foot (fracture and/or sprain. Time period queried was between January 1, 2009 to December 31, 2018. Results: An estimated total of 107,712 pediatric patients had a SFA injury between 2009-2018. With a mean age of 13.8 years. There was approximately 644,030 total skateboard related injuries. SFA injuries accounted 18.4 % in 2010 and 14.8 % in 2018. There was an estimated total of 4,263,682 foot and ankle sprains and/or fracture, of which 3.4% were SFA in 2010. The annual rate of injury per 100,000 children has decreased 72.1% from 23.3 to 6.5. Skateboard participation was approximately 7.35 millions riders above the age of 6 in the U.S in 2009, this number has declined 12.4% to 6.44 in 2016 with the lowest year being 2011 at 5.83 million. Since 2012 to 2016 this participation figure has ranged from 6.35 – 6.63 million. Conclusion: The decline in the number of participants in the sport has been far outpaced by the decline in injuries being seen in the ED. For the time period of this study, the style and structure of the footwear have not varied significantly. A study showed that shoe height did not change ankle inversion angle. Another possible factor is increase urgent care usage. The number of centers has increased 43.8% from 2013 to 2018. In 2016 these centers saw 4% of all their claims be sprains or strains. Further research is needed to trend data for other points of care.