Microbiological Differences Among Age Groups in Patients Diagnosed With Periprosthetic Joint Infection: A Database Analysis of 2,392 Patients.

INTRODUCTION: Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) poses substantial economic and quality-of-life challenges. With the rising incidence of hip and knee arthritis globally, understanding the changing profile of PJIs across different age groups becomes crucial. While various studies have explored risk factors, the influence of age on PJI remains debated, with potential bimodal relationships. This study aims to investigate the causative organisms of PJIs in patients of different age groups undergoing TJA. METHODS: Conducted as a retrospective cohort study at a high-volume PJI referral center, the study adhered to Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data spanned from January 1, 2001, to December 31, 2022, including patients with documented PJI undergoing revision TJA. Patients were categorized into age quintiles, and outcomes analyzed included causative organisms, difficult-to-treat infections, antimicrobial resistance, and Gram stain characteristics. Statistical analyses used descriptive statistics, chi-square tests, and sensitivity analyses for hip and knee patients separately. RESULTS: The study comprised 2,392 patients, with 60.7% undergoing hip arthroplasty and 39.3% undergoing knee arthroplasty. 1,080 women (45.2%) and 1,312 men (54.8%) were included. Older patients were markedly more likely to have gram-negative infections and atypical infections. Patients in the youngest age group had the lowest rates of methicillin-resistant Staphylococcus aureus infection. Results were similar between hip and knee PJIs. CONCLUSIONS: The study reveals age-related variations in the characteristics of PJIs after TJA, emphasizing higher risks of atypical and resistant infections in older patients. These findings underscore the importance of tailored preventive measures and potential considerations for adjunctive or prolonged antibiotic therapies, especially in the elderly population. Recognizing the unique infection patterns in older patients may inform better prevention and treatment strategies, with implications for enhanced patient care and outcomes. Future directions should focus on patient-specific strategies for preventing and treating PJIs, particularly in high-risk populations.

A novel radiological index uses the inner canal diameter and the Citak classification index to predict risk factor for aseptic loosening following hinged total knee arthroplasty.

INTRODUCTION: It remains unclear if distal femoral morphology should be a key consideration when selecting the implant or fixation strategy. A novel radiological index has been proposed to classify patients' distal femoral morphology. This study aims to evaluate the validity of this classification system in a cohort of patients undergoing hinged Total Knee Arthroplasty (TKA), and to determine if distal femoral morphology is a risk factor for aseptic loosening or all cause revision following hinged TKA. MATERIALS AND METHODS: This study was a retrospective analysis of our institutional database. Fifty-nine patients having undergone hinged TKA with adequate radiographs for examination were eligible for inclusion. Radiographic measurements were performed using the Citak radiological index criteria. The proportion of aseptic loosening and all-cause revisions were compared between the different classification groups. RESULTS: The analysis included 41 females (69.5%) and 18 males (30.5%). The mean age of the participants was 71.2 years (SD = 12.6). For inner canal diameter patients were classified as: Type A (31/59, 53%), Type B (19/59, 32%), and Type C (9/59, 15%). For the Index Classification Group, patients were classified as: Group A (26/59, 44%), Group B (20/59, 34%), and Group C (13/59, 22%). There was no significant difference in overall revision rate between the three groups (χ2 = 3.25, P = .197 from a Chi-square test). There was a significantly higher rate of aseptic loosening in Group C compared to Groups A and B, with no significant difference between Groups A and B in terms of aseptic loosening rates (χ2 = 8.72, P = .013 from a Chi-square test). CONCLUSIONS: Distal femoral morphology plays an important role in the risk of aseptic loosening following hinged knee replacement, and should be considered when deciding implant type and fixation in these patients.

The anterior and medial open approaches yield superior outcomes compared to the lateral and posterior open approaches in supracondylar humerus fractures in children: a systematic review and network meta-analysis.

This study aimed to perform a systematic review and network meta-analysis (NMA) to examine which open approach is superior in terms of outcomes and complications in the treatment of pediatric supracondylar humerus fractures. MEDLINE/PubMed, Embase, Web of Science, Clinicaltrials.gov, and Cochrane Library were searched from database inception to December 2022 and screened for relevant studies. Data were collected regarding patient demographics, Flynn's functional and cosmetic outcomes, and complications. Unsatisfactory Flynn's and complications were considered negative events. Comparisons of outcomes from aggregate data from each surgical approach using relative risk (RR) with a 95% confidence interval (95% CI) were performed. The NMA of overall negative events was conducted using a Bayesian hierarchical random-effects model analysis. A total of 26 studies involving 1461 patients were included; 459 (31.4%) patients underwent a closed reduction and percutaneous pinning (CRPP), 84 (5.7%) an anterior approach, 240 (16.4%) a medial, 220 (15%) a lateral, and 458 (31.3%) a posterior. The lateral and posterior approaches demonstrate a higher risk of negative event in the NMA compared to CRPP [RR = 2 (1.03, 3.85); RR = 2.63 (1.96, 3.57), respectively], anterior approach [RR = 3.33 (1.11, 10); RR = 4.35 (1.49, 12.5), respectively], and medial approach [RR = 1.82 (1.16, 2.86); RR = 2.38 (1.23, 4.76), respectively]. The medial approach resulted in a similar negative event rate compared to the anterior [RR = 1.82 (0.58, 5.88)]. The anterior and medial open approaches yield superior functional and cosmetic outcomes with fewer complications compared to the lateral and posterior.

Self-defined former smokers consume the highest opioid quantities following knee and shoulder arthroscopy.

PURPOSE: To identify risk factors associated with increased postoperative opioid consumption and inferior pain outcomes following knee and shoulder arthroscopy. METHODS: Using the data set from the NonOpioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) trial, eight prognostic factors were chosen a priori to evaluate their effect on opioid consumption and patient-reported pain following arthroscopic knee and shoulder surgery. The primary outcome was the number of oral morphine equivalents (OMEs) consumed at 2 and 6 weeks postoperatively. The secondary outcome was patient-reported postoperative pain using the Visual Analogue Scale (VAS) at 2 and 6 weeks postoperatively. A multivariable linear regression was used to analyse these outcomes with eight prognostic factors as independent variables. RESULTS: Tobacco usage was significantly associated with higher opioid usage at 2 (p < 0.001) and 6 weeks (p = 0.02) postoperatively. Former tobacco users had a higher 2-week (p = 0.002) and cumulative OME (p = 0.002) consumption compared to current and nonsmokers. Patients with a higher number of comorbidities (p = 0.006) and those who were employed (p = 0.006) reported higher pain scores at 6 weeks. Patients in the 'not employed/other' category had significantly lower pain scores at 6 weeks postoperatively (p = 0.046). CONCLUSION: Former smoking status was significantly associated with increased post-operative opioid consumption following knee and shoulder arthroscopy at 2 and 6 weeks postoperatively. Increased pain was found to be significantly associated with employment status and an increasing number of comorbidities at 6 weeks postoperatively. These findings can aid clinicians in identifying and mitigating increased opioid utilization as well as worse pain outcomes in high-risk patient populations. LEVEL OF EVIDENCE: Level III, cohort study.

Load Management Among Professional Hockey Goalies: A Retrospective Cohort Study.

BACKGROUND: Load management is a sports science concept describing the execution of well-established training principles to measure athletic workloads and enhance performance. The term 'load management' has become common in sports media to refer to a much wider range of scenarios, including the idea that by limiting regular season workload for athletes, their health and playoff performance will improve. Varying links between load and performance have been demonstrated in baseball and soccer. The purpose of this study was to objectively assess the impact of regular season workload on postseason performance among National Hockey League (NHL) goalies. HYPOTHESIS: NHL goalies with lighter regular season workloads will perform better in postseason appearances. STUDY DESIGN: Retrospective cohort. LEVEL OF EVIDENCE: Level 3. METHODS: NHL goalies with a minimum of 20 regular season games played and 3 playoff game appearances in the same season since 2013-2014 were eligible for inclusion. All regular season and postseason workload and performance metrics were collected from publicly available statistical databases. Workload outcomes included games started, minutes played, and shots faced. Performance outcomes included goals against average, save percentage, goals saved above average, and quality start percentage. Multivariable linear regression was used to determine whether regular season workload predicted postseason performance, when controlling for age and injury status. RESULTS: A total of 51 goalies contributed 111 goalie-seasons to the analysis. The results of the primary model indicated that regular season workload explained only 6.8% of the variance in postseason performance, and that this relationship was not significant (R2 = 0.068; F(5,92) = 1.335; P = 0.26). CONCLUSION: Based on data from 6 full seasons, there is no evidence to support a specific regular season game limit among NHL goalies with the aim of improved performance. CLINICAL RELEVANCE: Individualized workload plans may be more appropriate than a single league-wide standard.

Above-Knee Amputation Following Chronically Infected Total Knee Arthroplasty: Patient-Reported Satisfaction and Functional Outcomes.

INTRODUCTION: Periprosthetic joint infection (PJI) that arises following total knee arthroplasty (TKA) can usually be resolved through surgical and antimicrobial therapy. However, in approximately 5% of cases, an infection that is chronic and persistent will require treatment by above-knee amputation (AKA). This study seeks to provide an enhanced understanding of patient functionality and satisfaction following this devastating complication of one of the most commonly performed surgeries in the world. METHODS: A retrospective chart review of all patients who underwent an AKA as a result of PJI following TKA at our center between January 2000 and November 2023 was performed. Patients completed a post-TKA AKA functionality and satisfaction questionnaire, as well as the 12-Item Short Form Survey (SF-12). Of 27 eligible patients, 14 were contacted by phone for follow-up, 6 were deceased, 6 could not be reached, and 1 declined participation. The mean age at AKA was 62 years old (range, 43 to 85). Patients had an average of 5.5 procedures (range, 3 to 8) between primary TKA and AKA. The average follow-up time post-AKA was 38.5 months (range, 12 to 102). RESULTS: Of the patients, 85.7% were satisfied with their AKA, 85.7% would choose AKA again, and 71.4% would have proceeded with AKA earlier in retrospect. Average SF-12 physical and mental component scores were 37.1 and 50.6, respectively. DISCUSSION: Despite important limitations in functional and ambulatory status, the vast majority of patients who underwent an AKA following an infected TKA are satisfied with their amputation and would choose this treatment modality again if necessary, with many indicating they would do so at an earlier time point. In light of these results, the option of amputation should, when medically indicated, be discussed in a sensitive, but timely manner with patients undergoing treatment for recalcitrant PJI.

When does patient function "Plateau" after total joint arthroplasty? A cohort study.

PURPOSE: With over 100,000 procedures completed per year, hip and knee arthroplasty are two of the most common surgical procedures performed in Canada. There has been literature indicating that patient reported outcome measures (PROM) will start to plateau between six and 12 months. The purpose of this paper was to analyze the trajectory of PROMs following total hip and knee arthroplasty (THA and TKA), as well as assess the impact of any potential confounders on this trajectory. The central research question was: At what point do PROMS plateau among patients that undergo elective THA and TKA? METHODS: This study was a retrospective analysis of data from a prospective database. Patients were eligible if they had undergone an elective, primary THA/TKA with Oxford Scores recorded pre-operatively, and at least at two of the following four time points: six weeks, six months, one year, and two years. RESULTS: Mean pre-operative Oxford scores were 18.0 (7.8) for THA, and 20.1 (7.5) for TKA. For both THA and TKA, there were statistically significant interval improvements in Oxford scores from six weeks [THA: 33.8 (7.9)/TKA: 28.7 (7.8)] to six months [THA: 40.2 (7.3)/TKA: 35.9 (8.3)], and from six months to one year [THA: 41.0 (7.3)/TKA: 37.3 (8.4)], but not from one to two years [THA: 40.0 (8.5)/TKA: 36.4 (9.6)]. CONCLUSIONS: Patients undergoing either primary THA or TKA can expect clinically meaningful improvements in the first six months after surgery. Beyond this time point, there is a plateau in PROMs. These findings are important for both setting patient expectations in pre-operative discussions, and allowing surgeons to have a realistic understanding of their patients' expected post-operative course.

Association Between Periprosthetic Joint Infection and Mortality Following Primary Total Hip Arthroplasty.

BACKGROUND: Periprosthetic joint infection (PJI) remains a dreaded and unpredictable complication after total hip arthroplasty (THA). In addition to causing substantial morbidity, PJI may contribute to long-term mortality risk. Our objective was to determine the long-term mortality risk associated with PJI following THA. METHODS: This population-based, retrospective cohort study included adult patients (≥18 years old) in Ontario, Canada, who underwent their first primary elective THA for arthritis between April 1, 2002, and March 31, 2021. The primary outcome was death within 10 years after the index THA. Mortality was compared between propensity-score-matched groups (PJI within 1 year after surgery versus no PJI within 1 year after surgery) with use of survival analyses. Patients who died within 1 year after surgery were excluded to avoid immortal time bias. RESULTS: A total of 175,432 patients (95,883 [54.7%] women) with a mean age (and standard deviation) of 67 ± 11.4 years underwent primary THA during the study period. Of these, 868 patients (0.49%) underwent surgery for a PJI of the replaced joint within 1 year after the index procedure. After matching, patients with a PJI within the first year had a significantly higher 10-year mortality rate than their counterparts (11.4% [94 of 827 patients] versus 2.2% [18 of 827 patients]; absolute risk difference, 9.19% [95% confidence interval (CI), 6.81% to 11.6%]; hazard ratio, 5.49 [95% CI, 3.32 to 9.09]). CONCLUSIONS: PJI within 1 year after surgery is associated with over a fivefold increased risk of mortality within 10 years. The findings of this study underscore the importance of prioritizing efforts related to the prevention, diagnosis, and treatment of PJIs. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Effect of Depression Interventions in Patients Undergoing Total Joint Arthroplasty Without a Formal Diagnosis of Depression: A Systematic Review.

PURPOSE: Depression is a notable contributor to suboptimal outcomes after total joint arthroplasty (TJA). We conducted a systematic review of comparative studies to review the available evidence of interventions that affected depression scores and/or outcomes for patients undergoing TJA. METHODS: EMBASE, Ovid MEDLINE, PubMed, and Scopus were reviewed systematically from inception until November 15, 2022. Studies that were relevant for this review included comparative studies between patients who received an intervention within 3 months before or after their primary total hip or knee arthroplasty procedure. The interventions included a wide range of modalities, which were grouped into psychotherapy, enhanced perioperative support, and pharmacotherapy. Other interventions included physiotherapy techniques with a psychological focus, art/music-based therapy, occupational therapy support, and educational interventions. Meta-analysis was conducted for psychotherapy and enhanced support. RESULTS: The final systematic review consisted of 28 relevant studies, most of which were randomized controlled trials. A total of 3,702 patients, with a mean age of 66 years, were considered, of whom 59% were female. Most of the studies reported a notable reduction in depressive symptoms and/or scores based on the interventions being analyzed. At 3 months postoperatively, psychotherapy and enhanced support both resulted in markedly better depression and function scores compared with control subjects, with psychotherapy additionally improving pain scores. CONCLUSIONS: Overall, a wide range of interventions aimed at psychological optimization of patients undergoing TJA can improve depressive symptoms, pain, and function, even in the absence of a formal diagnosis of depression. Specifically, cognitive-based psychotherapy and enhanced perioperative support had the best evidence. Routine pharmacotherapy plays a limited role, if any, in the care of TJA. Additional efforts to develop pragmatic, evidence-based, and reproducible interventions are warranted to continue to optimize outcomes in TJA patients.

In-hospital outcomes following primary and revision total hip arthroplasty in nonagenarian patients.

PURPOSE: The primary goal of this study was to assess the risk of postoperative surgical and medical complications and problems among nonagenarian patients operated with hip arthroplasty. METHODS: Data from a specific high-volume arthroplasty clinic, were collected to evaluate postoperative morbidity and complication rates after hip arthroplasty in nonagenarians, compared with a control group of younger, but similar patients. Outcomes evaluated included length of stay, transfusion rate, and postoperative medical and surgical complication rates. RESULTS: A total of 97 nonagenarian patients (mean age 91.4 years) were included, and compared with 89 control group patients (mean age 70.18 years). Nonagenarian patients had significantly longer length of stay (11.44 vs. 7.98 days, p < 0.01), significantly higher risk of needing a transfusion (11.30% vs. 3.40%, p = 0.04), and significantly higher risk of a postoperative medical complication (28.90% vs. 11.20%, p = 0.03). There was no difference in postoperative surgical complication rate (7.20% vs. 2.20%, p = 0.12). CONCLUSION: Nonagenarian patients, when compared to a younger control group, experience significantly longer hospital stays, and risk of non-surgical complications. Arthroplasty in nonagenarian patients carries with it a high risk of complications, and thus careful pre-operative evaluation and the care of these patients at high volume, specialized clinics is important to optimize outcomes. LEVEL OF EVIDENCE: Level III retrospective cohort analysis.

Virtual versus in-person physiotherapy following total knee arthroplasty: a comparative analysis.

PURPOSE: At our centre, we developed and implemented a video-based post-operative physiotherapy program for patients undergoing total knee arthroplasty (TKA). Our aims were to analyse and compare the outcomes of this program to in-person physiotherapy. METHODS: We reviewed the outcomes of 112 patients and captured range-of-motion (ROM) measurements and pain scores (P4 questionnaire). We compared the outcomes to a cohort of 175 patients undergoing in-person therapy. Comparative analysis was performed using a two-tailed Student's t-test. RESULTS: There was no significant difference between the two groups in age, sex, or initial post-operative knee ROM. On discharge from virtual physiotherapy, mean flexion was 122.6° (SD 7.6). There was no significant difference in improvement in knee flexion between the virtual and in-person groups (mean 30.6° vs 34.0°, p = 0.07). There was no significant difference in the proportion of patients achieving ≥ 120° of flexion (85.0% virtual vs 91.3% in-person, p = 0.11) or those achieving an extension deficit of ≤ 5° (96.0% vs 98.3%, p = 0.25). There was no difference in the number of PT visits to discharge (10.5 vs 11.1, p = 0.14) or final pain scores (12.4 vs 11.9, p = 0.61). CONCLUSION: Improvements in knee ROM measures are comparable between virtual and in-person physiotherapy with both groups achieving a good functional range. These findings have implications for the virtual delivery of healthcare, especially among remote populations and patients with mobility limitations.

Impact of the coronavirus disease 2019 pandemic on equity of access to hip and knee replacements: a population-level study.

PURPOSE: The COVID-19 pandemic had innumerable impacts on healthcare delivery. In Canada, this included limitations on inpatient capacity, which resulted in an increased focus on outpatient surgery for non-emergent cases such as joint replacements. The objective of this study was to assess whether the pandemic and the shift towards outpatient surgery had an impact on access to joint replacement for marginalized patients. METHODS: Data from Ontario's administrative healthcare databases were obtained for all patients undergoing an elective hip or knee replacement between January 1, 2018 and August 31, 2021. All surgeries performed before March 15, 2020 were classified as "pre-COVID," while all procedures performed after that date were classified as "post-COVID." The Ontario Marginalization Index domains were used to analyze proportion of marginalized patients undergoing surgery pre- and post-COVID. RESULTS: A total of 102,743 patients were included-42,812 hip replacements and 59,931 knee replacements. There was a significant shift towards outpatient surgery during the post-COVID period (1.1% of all cases pre-COVID to 13.2% post-COVID, p < 0.001). In the post-COVID cohort, there were significantly fewer patients from some marginalized groups, as well as fewer patients with certain co-morbidities, such as congestive heart failure and chronic obstructive pulmonary disease. CONCLUSION: The most important finding of this population-level database study is that, compared to before the COVID-19 pandemic, there has been a change in the profile of patients undergoing hip and knee replacements in Ontario, specifically across a range of indicators. Fewer marginalized patients are undergoing joint replacement surgery since the COVID-19 pandemic. Further monitoring of access to joint replacement surgery is required in order to ensure that surgery is provided to those who are most in need.

Treatment of Concurrent Depression and Its Effect on Outcomes After Total Joint Arthroplasty: A Systematic Review of Comparative Studies.

PURPOSE: There is a growing body of evidence suggesting that patients with a diagnosis of depression suffer worse outcomes after total joint arthroplasty (TJA) procedures. It is unclear whether depression treatment is a modifiable risk factor that can be targeted to improve suboptimal outcomes. We conducted a systematic review to understand the role that various interventions have on outcomes of TJA in patients with diagnosed depression (PDDs). METHODS: PubMed, Ovid MEDLINE, Scopus, and EMBASE were searched systematically from inception until November 2022. Studies of PDDs who underwent TJA that compared any intervention/treatment of depression with a control group and reported pain, functional outcomes, depression scores, and/or revision rates after TJA were relevant for this review. RESULTS: Ten relevant studies were included in the final systematic review, with a total of 33,501 patients included. Two studies reported lower revision rates for patients receiving selective serotonin reuptake inhibitor treatment and psychotherapy. Two studies showed no difference in functional outcomes for patients receiving pharmacologic treatment. One study reported improved functional outcomes for patients receiving cognitive behavioral therapy and another reported improved postoperative functional outcomes for patients receiving alprazolam. CONCLUSION: Interventions targeted at PDDs may improve short-term pain and functional outcomes, and there may be an association between selective serotonin reuptake inhibitor use and implant survival. The current literature is limited and inconclusive, with important gaps in understanding regarding the optimization and treatment of this modifiable risk factor. Surgeons should consider depression treatment as a method to improve outcomes in this cohort.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes.

INTRODUCTION: Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS. METHODS: To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs. RESULTS: Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma. DISCUSSION: There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery.

Background: Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose: This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design: Position statement. Methods: The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results: A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion: A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.

Overcoming the Barriers to Diversity in Orthopaedic Surgery: A Global Perspective.

BACKGROUND: Diversity in orthopaedics continues to lag behind that in other surgical specialties. This pattern exists globally and is not unique to gender or race. This review offers a global perspective on overcoming the barriers to diversity in orthopaedics. METHODS: A literature search of MEDLINE and Embase was conducted and a narrative review was undertaken. Publications that discussed any aspect of diversity or solutions to diversity within orthopaedics or academic orthopaedics were identified. RESULTS: A total of 62 studies were included. Studies showed that diversity in orthopaedic training is limited by structural barriers such as long hours, requirements to relocate during training, training inflexibility, and a lack of exposure to orthopaedics. Implicit bias during the selection process for training, discrimination, and a lack of role models are additional barriers that are experienced by both minority and female surgeons. The global lack of diversity suggests that there are also inherent "cultural barriers" that are unique to orthopaedics; however, these barriers are not uniformly experienced. Perceptions of orthopaedics as promoting an unhealthy work-life balance and the existence of a "boys' club" must be addressed. Strong, committed leaders can embed cultural norms, support trainees, and act as visible role models. Targeted efforts to increase diverse recruitment and to reduce bias in selection processes for medical school and specialty training will increase diversity in the "training pipeline." CONCLUSIONS: Diversity in orthopaedics continues to lag behind that in other specialties. Increasing diversity is important for providing a more inclusive training environment, improving patient care, and reducing health disparities. Structural and cultural barriers need to be addressed to improve diversity in orthopaedics. Promoting a culture supportive of all surgeons is essential to reframing perceptions that may prevent individuals from even considering a career as an orthopaedic surgeon. Changing attitudes require focused efforts from committed leadership in a "top-down" approach that prioritizes diversity. The efforts from national bodies seeking to tackle the lack of diversity, as well as the establishment of organizations committed to diversity, such as the International Orthopaedic Diversity Alliance, provide reasons to be optimistic for the future.

Understanding the Learning Curve of Carpal Tunnel Release With Ultrasound Guidance: A Review.

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy and can be treated through carpal tunnel release (CTR) if nonoperative treatments fail. CTR can be performed through a variety of techniques, including traditional open, mini-open, endoscopic, and CTR with ultrasound guidance (CTR-US). The evidence on endoscopic CTR is mixed, due to a higher potential for nerve injury with endoscopic CTR compared to traditional open CTR. CTR-US offers the potential advantage of allowing the visualization of all key anatomical structures, combined with a very small incision and minimal soft tissue insult. As with any ultrasonographic technique or procedure, the learning curve needs to be considered for any provider considering adopting CTR-US. However, literature on ultrasound use around the wrist, including early evidence on the learning curve of CTR-US specifically, demonstrates this skill can be learned relatively quickly by providers with a wide range of prior experience in ultrasound and CTR. Overall, there is a need for high-quality studies comparing different CTR techniques, particularly CTR-US, as it offers the potential for considerable cost savings.