Trends in Open Versus Endoscopic Carpal Tunnel Release From 2010 to 2021.

BACKGROUND: This study compared trends in use, predictive factors, and reimbursement of endoscopic carpal tunnel release (ECTR) withthose of open carpal tunnel release (OCTR) from 2010 to 2021 using a national administrative database. METHODS: ECTR and OCTR patients were identified in the PearlDiver M151Ortho data set. Numeric and proportional utilization of these procedures was characterized for each year of study. Multivariate analysis was conducted to identify predictive factors for having ECTR performed. The average 90-day reimbursement of ECTR and OCTR was determined. RESULTS: From 2010 through 2021, 441,023 ECTR and 1,767,820 OCTR procedures were identified. The proportional use of ECTR compared with OCTR rose from 2010 (15.7% of procedures) to 2021 (26.1%). Independent predictors of having ECTR performed rather than OCTR included geographic variation (compared with having surgery in the Midwest, Northeast odds ratio [OR], 1.53; West OR, 1.62; and South OR, 1.66), having Medicare or commercial insurance (compared with commercial, Medicare OR, 0.94, and Medicaid OR, 0.69), female sex, and fewer comorbidities. The average 90-day reimbursement for ECTR was $3,114.82, compared with $3,087.62 for OCTR. DISCUSSION: As of 2021, over one-fourth of carpal tunnel releases are done endoscopically. Several factors independently predict whether patients receive ECTR or OCTR.

AOA Critical Issues Symposium: Advancing Diversity, Equity, and Inclusion in Orthopaedic Surgery.

ABSTRACT: In recent years, the medical field has recognized the pivotal role of diversity, equity, and inclusion (DEI) in enhancing patient care and addressing health-care disparities. Orthopaedic surgery has embraced these principles to create a more inclusive and representative workforce. A DEI symposium that was sponsored by the American Orthopaedic Association convened orthopaedic surgeons, researchers, educators, and stakeholders to discuss challenges and strategies for implementing DEI initiatives. The symposium emphasized the importance of equity, and fostered conversations on creating equal opportunities and resources. Speakers covered key topics, including establishing DEI divisions, metrics for success, DEI leadership, and available resources, and promoted excellence and innovation in orthopaedic surgery through a more diverse and inclusive approach.

AOA Critical Issues: Perceptions on the State of Diversity, Equity, and Inclusion in Orthopaedic Surgery: A Survey of the AOA Membership.

BACKGROUND: Orthopaedic surgery continues to trail other specialties in increasing diversity among its physician workforce. Various efforts have been and are currently being made to not only increase diversity, but also promote equity and inclusion in the field. The purpose of this study was to survey members of the American Orthopaedic Association (AOA) to determine how leaders in orthopaedics view diversity, equity, and inclusion (DEI) at the present time and to understand their perspective while moving into the future. METHODS: An anonymous 11-question survey was disseminated online to AOA members in May 2022. These individuals were identified by the AOA membership directory and the email ListServe. The survey included free-response and multiple-choice questions. Demographic information was self-identified, and both qualitative and quantitative data were collected. RESULTS: Of the 1,657 AOA members who were provided the survey, 262 (15.8%) responded. Approximately 29.5% (77) and 45.6% (119) of the surveyed population ranked "retention of underrepresented populations in orthopaedic residency (women, URiM)" as "very important" or "absolutely essential," respectively. The answers to the free-response questions identified multiple core themes that responders were passionate about, namely resident and attending physician recruitment and retention, as well as resident selection. CONCLUSIONS: Leaders in the field of orthopaedic surgery desire for action to be taken in the field of DEI. The findings of this survey denote positive attitudes even though many inequalities still pervade the field of orthopaedics. Through mentorship, objective evaluation, transparency, and continued intentional action, orthopaedic surgery is well-positioned to continue to move forward with DEI.

Three-Dimensional Printing of the Patellofemoral Joints of Patellar Instability Patients.

Three-dimensional (3D) modeling and printing comprise an important tool for orthopaedic surgeons. One area in which 3D modeling has the potential to dramatically improve our understanding of biomechanical kinematics is pathologies of the patellofemoral joint, in particular trochlear dysplasia. We describe a method for creating 3D printed models of the patellofemoral joint, including computed tomography image acquisition, image segmentation, model creation, and 3D printing. The models created can help surgeons understand and plan surgery for recurrent patellar dislocations.

AOA Critical Issues: Gender Justice in Academic Medicine: What It Might Look Like in Orthopaedic Surgery.

ABSTRACT: As the number of women entering medicine has increased, so has the number of women entering orthopaedics; however, many orthopaedic programs struggle to create an equitable space for women, particularly in leadership. Struggles experienced by women include sexual harassment and gender bias, lack of visibility, lack of well-being, disproportionate family care responsibilities, and lack of flexibility in the criteria for promotions. Historically, sexual harassment and bias has been a problem faced by women physicians, and often the harassment continues even when the issue has been reported; many women find that reporting it results in negative consequences for their career and training. Additionally, throughout medical training, women are less exposed to orthopaedics and lack the mentorship that is given to their colleagues who are men. The late exposure and lack of support prevent women from entering and advancing in orthopaedic training. Typical surgery culture can also result in women orthopaedic surgeons avoiding help for mental wellness. Improving well-being culture requires systemic changes. Finally, women in academics perceive decreased equality in promotional considerations and face leadership that already lacks representation of women. This paper presents solutions to assist in developing equitable work environments for all academic clinicians.

Interobserver and Intraobserver Reliability of Classification Systems for Radiographic Complications After Radial Head Arthroplasty.

PURPOSE: Although several classifications are used to assess radiographs following radial head arthroplasty (RHA), including the Popovic classification for radiolucency, the Chanlalit classification for stress shielding (SS), the Brooker classification for heterotopic ossification (HO), and the Broberg-Morrey classification for radiocapitellar arthritis, little is known about the reliability of these classification systems. The purpose of this study was to determine the interobserver and intraobserver reliability of these classifications. METHODS: Six orthopedic surgeons at various levels of training reviewed elbow radiographs of 20 patients who underwent RHA and classified them according to the Popovic, Chanlalit, Brooker, and Broberg-Morrey classifications for radiolucency, SS, HO, and RHA, respectively. Four weeks after initial review, radiographic reviews were repeated. Reliability was measured using the Fleiss kappa and the intraclass correlation coefficient. Agreement was interpreted as none (<0), slight (0.01-0.2), fair (0.21-0.4), moderate (0.41-0.6), substantial (0.61-0.8), and almost perfect (0.81-1) based on agreement among attending surgeons. RESULTS: Among fellowship-trained attending surgeons, interobserver reliability was slight for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), fair for radiocapitellar arthritis (Broberg-Morrey) and HO (Brooker), and substantial for the ordinal interpretation of radiolucency (Popovic). Residents had a higher interobserver reliability than attending physicians when using the Brooker classification. Mean intraobserver reliability was fair for SS (Chanlalit) and the categorical interpretation of radiolucency (Popovic), moderate for HO (Brooker) and radiocapitellar arthritis (Broberg-Morrey), and almost perfect for the ordinal interpretation of radiolucency (Popovic). Trainees had higher intraobserver reliability than attending surgeons using the SS (Chanlalit) classification. CONCLUSIONS: The number of Popovic zones is reliable for communication between physicians, but caution should be taken with the Brooker, Chanlalit, Broberg-Morrey, and categorical interpretation of the Popovic classifications. All the classifications had better intraobserver than interobserver reliability. CLINICAL RELEVANCE: Reliability of classification systems for radiographic complications after RHA is less than substantial except the number of zones of radiolucency; therefore, caution is required when drawing conclusions based on these classifications.

AOA Critical Issues Symposium: Deficit Recovery for the Orthopaedic Service Line.

ABSTRACT: The COVID-19 pandemic and the mandated cessation of surgical procedures for a substantial portion of the 2020 year placed tremendous strain, both clinically and financially, on the health-care system in the United States. As a surgical specialty that accounts for nearly a quarter of all hospital net income, the revenue recovery of orthopaedic service lines (OSLs) is of particular importance to the financial recovery of their broader health-care institutions. In this American Orthopaedic Association (AOA) symposium report, the OSL leaders from 4 major academic medical institutions explain and reflect on their approaches to address their revenue deficits. Cost-reduction strategies, such as tightening budgets, adopting remote-work models, and limiting costs of human capital, were vital to stabilizing departmental finances at the onset of the pandemic, while strategies that focused on expanding surgical volume, such as those that improve efficiency in clinical and surgical settings, were important in growing revenue once elective procedures resumed. Institutional policy, payer administrative procedures, and the overall context of an ongoing public health crisis all placed limitations on recovery efforts, but engaging relevant stakeholders and working with available resources helped OSLs overcome these limitations. Due to clear strategic actions that were taken to address their deficits, each OSL represented in this AOA symposium saw substantial improvement in its year-end financial performance compared with its financial status at the end of the period of mandatory cessation of elective surgical cases.

Recruitment of the Next Generation of Diverse Hand Surgeons.

Hand surgery encompasses a diaspora of pathology and patients, but the surgeons treating this population are not commensurately diverse. A physician population that reflects the population it treats consistently leads to improved patient outcomes. Despite increasing diversity amongst surgeons entering into pipeline specialties such as General Surgery, Plastic Surgery, and Orthopaedic Surgery, the overall makeup of practicing hand surgeons remains largely homogenous. This article outlines organizations, such as the Perry Initiative, which have increased recruitment of women and underrepresented minorities into pipeline programs. Techniques of minimizing bias and increasing opportunities for underrepresented groups are also discussed.

Anatomic Radial Head Arthroplasty: The Importance of Implant Angle.

PURPOSE: Multifragmentary radial head and neck fractures not amenable to open reduction and internal fixation are usually treated with radial head arthroplasty (RHA). Although the optimal implant design is still subject to debate, anatomic designs are common. We hypothesized that positioning of the implant leading to increased radial stem angle (RSA) (angle of the RHA stem with respect to the proximal radius shaft, RSA) in anatomic RHA designs will contribute to failures. The aim of this study was to characterize the risk of RHA failure with respect to the stem angle in anatomic RHA design. METHODS: A retrospective review of patients who underwent anatomic RHA for acute fractures between 2006 and 2019 at 2 academic centers was conducted. Initial postoperative elbow radiographs were reviewed to measure RSA on the anterior-posterior and lateral views. Radiolucency, stress shielding, and radiocapitellar arthritis were also evaluated. Implant failure was defined as prosthesis removal or revision. RESULTS: Implant failure was associated with significantly larger lateral RSA than that in intact implants. Increasing stem shaft angle on a lateral radiograph was associated with decreased implant survival. Radiolucency, stress shielding, and radiocapitellar arthritis were similar between the 2 groups. CONCLUSIONS: Anatomic radial head implants are commonly used; however, the importance of prosthesis positioning, specifically that of the stem within the proximal radius, remains understudied. Higher RSA is associated with the risk of implant failure and need for revision. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Interpretation of regulatory factors for 3D printing at hospitals and medical centers, or at the point of care.

3D printing is revolutionizing the medical device landscape through its ability to rapidly create patient-specific anatomic models, surgical instruments, and implants. Recent advances in 3D printing technology have allowed for the creation of point-of-care (PoC) 3D printing centers. These PoC centers blur the line between healthcare provider, medical center, and device manufacturer, creating regulatory ambiguity. The United States Food & Drug Administration (FDA) currently regulates 3D printed devices through existing medical device regulations. However, the FDA is increasingly interested in developing guidelines and regulations specifically for PoC 3D printing due to its rapid adoption across the healthcare institutions. In this article, we review the regulatory framework that governs medical devices, discuss how PoC 3D printing falls within this framework, and describe a novel conceptual framework that the FDA has proposed. Finally, through analysis of the aforementioned regulations and discussions with industry medical 3D printing regulatory experts, we provide recommendations for PoC medical 3D printing best practices so that institutions are best positioned to utilize this revolutionary technology safely and effectively.

Patient outcomes and costs after isolated flexor tendon repairs of the hand.

BACKGROUND: Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries. PURPOSE: We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care. STUDY DESIGN: A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued. METHODS: A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs. RESULTS: The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation. CONCLUSION: Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

The Perry Initiative's Impact on Gender Diversity Within Orthopedic Education.

PURPOSE OF REVIEW: Orthopedic surgery lags behind the other surgical specialties in terms of reaching gender equality, and women remain underrepresented in the field. The reason for this disparity is multifaceted, with lack of exposure and mentorship frequently cited as two key reasons women fail to choose orthopedic surgery as a specialty. Recognizing these gender differences, The Perry Initiative was founded to increase young women's exposure to the field, provide mentorship opportunities, and recruit women into orthopedic surgery and related engineering fields. The purpose of this article is to describe the measurable impact of The Perry Initiative on increasing the number of women matriculating into orthopedic residencies. RECENT FINDINGS: Though roughly half of medical school graduates today are women, only 16% of active orthopedic surgery residents are women. To date, The Perry Initiative has reached over 12,000 women in high school and medical school, and of the program participants who are eligible to match into any residency program, 20% matched into orthopedic surgery residencies. This indicates that the women who participated in Perry Initiative outreach programs are entering orthopedic surgery at a rate that is higher than the current rate of women entering orthopedic surgery. The model behind The Perry Initiative's outreach efforts can be scaled and expanded, ideally reaching more women and making progress towards closing the gender gap within orthopedic surgery and achieving greater gender diversity.

Composite Vascularized Autograft Elbow Transplant: A Case Report.

CASE: A 37-year-old man presented with an absent right elbow joint secondary to trauma, subsequent ankylosis, total elbow arthroplasty (TEA), and TEA explantation after infection. The patient also had a contralateral complete brachial plexus injury, but an intact elbow joint. Given that the patient had a functional right hand/wrist, composite vascularized autograft elbow transplant was performed from left to right upper extremity. Four years postoperatively, the patient could independently complete activities of daily living. CONCLUSION: This case is the first to report composite vascularized autograft elbow transplant. Although indications are limited, this case illuminates novel uses of standard techniques for a difficult problem.

An accessible method for screening aerosol filtration identifies poor-performing commercial masks and respirators.

BACKGROUND: The COVID-19 pandemic has presented an acute shortage of regulation-tested masks. Many of the alternatives available to hospitals have not been certified, leaving uncertainty about their ability to properly protect healthcare workers from SARS-CoV-2 transmission. OBJECTIVE: For situations where regulatory methods are not accessible, we present experimental methods to evaluate mask filtration and breathability quickly via cost-effective approaches (e.g., ~$2000 USD) that could be replicated in communities of need without extensive infrastructure. We demonstrate the need for screening by evaluating an existing diverse inventory of masks/respirators from a local hospital. METHODS: Two experimental approaches are presented to examine both aerosol filtration and flow impedance (i.e., breathability). For one of the approaches ("quick assessment"), screening for appropriate filtration could be performed under 10 min per mask, on average. Mask fit tests were conducted in tandem but are not the focus of this study. RESULTS: Tests conducted of 47 nonregulation masks reveal variable performance. A number of commercially available masks in hospital inventories perform similarly to N95 masks for aerosol filtration of 0.2 µm and above, but there is a range of masks with relatively lower filtration efficiencies (e.g., <90%) and a subset with poorer filtration (e.g., <70%). All masks functioned acceptably for breathability, and impedance was not correlated with filtration efficiency. SIGNIFICANCE: With simplified tests, organizations with mask/respirator shortages and uncertain inventories can make informed decisions about use and procurement.

Improving Sexual, Racial, and Ethnic Diversity in Orthopedics: An Imperative.

Orthopedics is the least diverse medical specialty. From residents to faculty, the representation of women and underrepresented minorities lags behind that of all other specialties. The crux of the disparity stems from the pipeline, as medical students who are female and are underrepresented minorities are simply not applying to orthopedic surgery. Grassroots efforts providing early exposure to orthopedics have led to a considerable proportion of alumnae pursuing science majors and eventually medical school. Institutions with a stated commitment to diversity have successfully produced residency classes with greater diversity. The culture should be one that combats biases, dispels misconceptions about orthopedics, and prioritizes recruiting/retaining diverse providers. [Orthopedics. 2020;43(3):e134-e140.].

The Use of Photogrammetry for Interactive, Three-Dimensional Modeling of an Open Reduction and Internal Fixation of the Elbow.

We present our step-by-step guide to acquire and combine intraoperative photographs into three-dimensional models of surgical anatomy. We then apply our technique to model six steps in an open reduction and internal fixation of the elbow. Our protocol can be done with equipment and software retailing for under $500.

Reporters of TCR signaling identify arthritogenic T cells in murine and human autoimmune arthritis.

How pathogenic cluster of differentiation 4 (CD4) T cells in rheumatoid arthritis (RA) develop remains poorly understood. We used Nur77-a marker of T cell antigen receptor (TCR) signaling-to identify antigen-activated CD4 T cells in the SKG mouse model of autoimmune arthritis and in patients with RA. Using a fluorescent reporter of Nur77 expression in SKG mice, we found that higher levels of Nur77-eGFP in SKG CD4 T cells marked their autoreactivity, arthritogenic potential, and ability to more readily differentiate into interleukin-17 (IL-17)-producing cells. The T cells with increased autoreactivity, nonetheless had diminished ex vivo inducible TCR signaling, perhaps reflective of adaptive inhibitory mechanisms induced by chronic autoantigen exposure in vivo. The enhanced autoreactivity was associated with up-regulation of IL-6 cytokine signaling machinery, which might be attributable, in part, to a reduced amount of expression of suppressor of cytokine signaling 3 (SOCS3)-a key negative regulator of IL-6 signaling. As a result, the more autoreactive GFPhi CD4 T cells from SKGNur mice were hyperresponsive to IL-6 receptor signaling. Consistent with findings from SKGNur mice, SOCS3 expression was similarly down-regulated in RA synovium. This suggests that despite impaired TCR signaling, autoreactive T cells exposed to chronic antigen stimulation exhibit heightened sensitivity to IL-6, which contributes to the arthritogenicity in SKG mice, and perhaps in patients with RA.

Open Surgical Release of Posttraumatic Elbow Contracture in Children and Adolescents.

BACKGROUND: Posttraumatic elbow contractures in children and adolescents are challenging to manage, and studies investigating surgical treatment are limited by the rarity of this condition. Small case series have shown variable gains in immediate and long-term elbow arc of motion after open surgical release. We reviewed our experience with open surgical release of posttraumatic elbow contracture in patients <21 years old at 2 institutions. METHODS: A retrospective chart review identified patients who underwent posttraumatic open elbow contracture release by 2 surgeons at 2 institutions between 2006 and 2013. Nontraumatic contractures and arthroscopic releases were excluded. Twenty-six patients were included in this study. Mean age at the time of injury was 12 years (5 to 19 y) and at the time of surgery was 14 years (7 to 20 y). Capsulotomy, osteoplasty, removal of hardware, ulnar nerve release or transposition, and ligament reconstruction were performed through medial and lateral approaches as indicated by the pathology. Ten patients had ligament repair or stabilization, and 16 patients used a continuous passive motion (CPM) postoperatively. Outcomes included active range of motion and complications. RESULTS: Mean time from injury to surgical release was 29 months. Mean postoperative follow-up was 42 months. Elbow active flexion-extension and forearm rotation arcs both increased significantly by a mean of 49 and 70 degrees, respectively, at final follow-up. A mean 85% of intraoperative flexion-extension arc was maintained at final follow-up. Ligament repair or reconstruction and the use of a postoperative CPM did not significantly change these outcomes. Outcomes were not significantly different if our contracture release was performed within a year from injury. Patients who had surgery before our contracture release had decreased restoration of forearm rotation after release. Complications included 2 recurrent contractures (1 used a CPM and 1 did not), and 2 postoperative ulnar neuropathies (1 used a CPM and 1 did not). CONCLUSIONS: Open contracture release for posttraumatic elbow contracture in an adolescent population can significantly improve active range of motion. LEVEL OF EVIDENCE: Level 3-therapeutic.