Variations in subpectoral biceps tenodesis locations do not impact clinical outcomes.

Background: Biceps tenodesis is a common treatment for pathologies involving the long head of the biceps brachii. Given variations in surgical approach, focus has been placed on the location of the tenodesis to maintain appropriate length-tension relationship. The purpose of this study is to assess for variations in the tunnel placement in subpectoral biceps tenodesis procedures and correlation of tunnel position with patient-reported outcomes. Methods: This is a retrospective case series of outcomes as a function of tunnel location with open subpectoralis biceps tenodesis. The location of the biceps tenodesis tunnel was measured on postoperative Grashey radiographs. Correlation between the tenodesis tunnel and postoperative American Shoulder and Elbow Surgeons (ASES) score and Visual Analog Scale (VAS) was assessed. Results: 31 patients were included in the study with an average follow-up of 17 months. The overall tunnel position from the superior edge of the greater tuberosity ranged from 4.20 cm to 12.61 cm, with an average of 7.46 cm. Final ASES score and VAS were 84.5 and 1.2, respectively. There was only weak correlation between both ASES score and tunnel position (r = -0.12) and VAS and tunnel position (r = -0.23). Discussion: Subpectoralis biceps tenodesis continues to be a viable treatment option for biceps and superior labral pathology. There remains no consensus on tenodesis location, and this study found no significant difference between tunnel location and patient-reported outcomes. Therefore, it is likely that a range of tenodesis locations exists in which favorable clinical results are achieved, explaining the numerous recommendations on tunnel placement.

Suspensory fixation for bone transfer procedures in shoulder instability is superior to screws in an angled construct: a biomechanical analysis.

Background: The Latarjet procedure is a common bony augmentation procedure for anterior shoulder instability. Historically, screw fixation is used to secure the coracoid graft to the anterior glenoid surface; however, malpositioning of the graft leads to oblique screw insertion that contributes to complications. Suture buttons (SBs) are a more recent fixation technique that have not been studied alongside standard screw fixation in the context of biomechanical models of angulated fixation. This study aims to compare the biomechanical strength of single and double, screw and SB fixation at various levels of angulation. Methods: Testing was performed using polyurethane models from Sawbones. The graft piece was secured with screw fixation (Arthrex, Naples, FL, USA) or suspensory button (ABS Tightrope, Arthrex, Naples, FL, USA). Single or double constructs of screws and SBs were affixed at 0°, 15°, and 30° angles to the face of the glenoid component. An aluminum testing jig held the samples securely while a materials testing system applied loads. Five constructs were used for each condition and assessed load to failure testing. Results: For single fixation constructs, suspensory buttons were 60% stronger than screws at 0° (P < .001), and 52% stronger at 15° (P = .004); however, at 30°, both were comparable (P = .180). Interestingly, single suspensory button at 15° was equivalent to a single screw at 0° (P = .310). For double fixation, suspensory buttons (DT) were 32% stronger than screws at 0° (P < .001) and 35% stronger than screws at 15° (P < .001). Both double fixation methods were comparable at 30° (P = .061). Suspensory buttons at 15° and 30° were equivalent to double screws at 0 (P = .280) and 15° (P = .772), respectively. Conclusion: These measurements indicate that the suspensory button has a significantly higher load to failure capacity over the screw fixation technique, perpendicularly and with up to 15° of angulation. These analyses also indicate that the suspensory button fixation offers superior strength even when positioned more obliquely than the screw fixation. Therefore, suspensory button fixation may confer more strength while offering greater margin for error when positioning the graft.

Cardiovascular disease in retired NFL players: a systematic review.

OBJECTIVE: Despite robust research endeavors exploring post-play health implications in former NFL players, the impact of former-player status on long-term cardiovascular health has not yet been elucidated. The purpose of this systematic review is to describe the available research on the cardiovascular health in former NFL players. METHODS: Relevant studies were included from the PubMed, Scopus, and Embase databases. Studies were evaluated in accordance with PRISMA guidelines. Two independent reviewers conducted the title/abstract screenings and risk of bias determinations. The results of the studies were extracted for inclusion in the review. RESULTS: Sixteen studies met inclusion criteria. Though evidence was discordant among studies, former NFL players appeared to possess more favorable metabolic profiles and decreased mortality compared to community controls. Of note, 90% of former players were found to be overweight or obese. CONCLUSION: Though cardiovascular disease is the leading cause of death among former NFL players, they possess comparable metabolic and cardiovascular profiles to community controls. Further research is necessary to ascertain the impact of NFL play on cardiovascular health and develop tailored preventative care strategies for former players.

A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND: Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field. QUESTIONS/PURPOSES: (1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population? METHODS: A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant. RESULTS: Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range. CONCLUSION: Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery. CLINICAL RELEVANCE: Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

Reimagining the Path of an Unmatched Orthopaedic Residency Application: A Survey of Program Directors.

Background: Few evidence-based suggestions are available to help applicants and mentors improve reapplication outcomes. We sought to provide program directors' (PDs) perspectives on actionable steps to improve reapplicants' chances for a match. Methods: The PDs were asked to rank positions unmatched applicants can pursue, steps these applicants can take for the next application cycle, and reasons why reapplicants do not match. Results: Responses from 66 of 123 PDs were received (53.6% response rate). Obtaining new recommendation letters and rotating with orthopaedics were the highest 20 ranked steps unmatched applicants can take. No curriculum vitae (CV) improvement, poor interview, and poor letters of recommendation were the most important reasons hindering applicants from matching when reapplying. Conclusions: Steps reapplicants could prioritize include obtaining new recommendation letters, rotating in orthopaedics, and producing new research items. CV strengthening and improving interview skills address the 2 main reasons why unmatched applicants failed in subsequent attempts. Level of Evidence: Level IV.

Superficial Surgical Site Infections in Primary Total Joint Arthroplasty: A Retrospective Analysis of Topical Anti-Biofilm Therapy.

Introduction Surgical site infections (SSI) following orthopedic procedures can cause significant morbidity and mortality, particularly in total joint arthroplasty. Biofilm formation in surgical wounds has made it difficult to prevent and treat these infections. SURGX® Antimicrobial Wound Gel (Next Science, Jacksonville, Florida, USA) was developed to disrupt biofilm formation but has not been evaluated in prophylactic use in total joint arthroplasty to prevent superficial SSI. Methods A retrospective chart review was performed at a single institution comparing the rate of SSI in patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). SSI data were collected from patients with standard postoperative dressings (Group A: Control) and patients with SURGX® applied as part of a standardized dressing following THA/TKA (Group B: Study). Rates of SSI were compared.  Results SURGX® was administered to 120 patients, including 91 TKAs and 29 THAs. The overall infection rate in this cohort was 2.5%. No superficial site infections developed. The control group constituted 566 patients, with 386 TKAs and 180 THAs. The infection rate was 1.24%, which included one superficial infection. Binary logistic regression did not show different odds of developing infections with the use of SURGX® (OR = 2.23, 95% CI: 0.54-9.13, p = 0.27). Conclusion In our small retrospective study, Next Science SURGX® Antimicrobial Wound Gel did not demonstrate a statistically significant difference in the rate of superficial SSI in total joint arthroplasty; however, Group B did not have any superficial SSI.

Diversity in Orthopaedic Surgery Residencies Based on Allopathic Medical School Affiliation.

Orthopaedic surgery is one of the most competitive and least diverse specialties in medicine. Affiliation of an orthopaedics with an allopathic medical school impacts research opportunities and early exposure to clinical orthopaedics. The purpose of this study is to examine the potential effect allopathic medical school affiliation has on orthopaedic surgery resident demographics and academic characteristics. Methods: All 202 Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics programs were divided into 2 groups: Group 1 consisted of residency programs without an affiliated allopathic medical school, and Group 2 consisted of programs with an affiliated allopathic medical school. Affiliations were determined by cross-referencing the ACGME residency program list with the medical school list published by Association of American Medical Colleges (AAMC). Program and resident characteristics were then compiled using AAMC's Residency Explorer including region, program setting, number of residents, and osteopathic recognition. Resident characteristics included race, gender, experiences (work, volunteer, and research), peer-reviewed publications, and US Medical Licensing Examination Step 1 scores. Results: Of the 202 ACGME-accredited orthopaedics residencies, Group 1 had 61 (30.2%) programs, and Group 2 had 141 (69.8%) programs. Group 2 had larger programs (4.9 vs. 3.2 resident positions/year; p < 0.001) and 1.7 times the number of residency applicants (655.8 vs. 385.5; p < 0.001). Most Group 2 residents were allopathic medical school graduates, 95.5%, compared with 41.6% in Group 1. Group 1 had 57.0% osteopathic medical school graduates, compared with 2.9% in Group 2. There were 6.1% more White residents in Group 1 residencies (p = 0.025), and Group 2 residencies consisted of 3.5% more Black residents in relation to Group 1 (p = 0.03). Academic performance metrics were comparable between the 2 groups (p > 0.05). Conclusion: This study demonstrated that candidates who successfully match into an orthopaedic surgery residency program achieve high academic performance, regardless of whether the program was affiliated with an allopathic medical school. Differences may be influenced by increased representation of minority faculty, greater demand for allopathic residents, or stronger emphasis on promotion of diversity in those residency programs. Availability of Data and Material: Available on reasonable request. Level of Evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Teaching of Cost-Effective Care in Orthopaedic Surgery Residency Training: A Survey of Residency Programs in the US.

Costs of healthcare in the US continue to rise at rates that are unsustainable. Prior studies, most of which come from non-surgical specialties, indicate that a variety of strategies to teach this material are utilized but without consensus on best practices. No studies exist regarding the teaching of cost-effective care in orthopaedic residency training programs. The goal of this study was to assess the landscape in this area from the perspective of program leadership. Methods: A survey was developed that was sent to orthopaedic residency program leadership via email through their interaction with the COERG. Additional programs were included to enhance diversity of responding programs. The survey, based on those published from other areas of medicine, included questions about the experiences of the respondents in learning about cost-effective care, as well as how faculty and residents learned about this topic. Results: Seventy one percent (30) of respondents noted that their faculty did not receive formal training in cost-effective care, and education in this area was likely to come from the department, especially review of practice data (12, 44%). Only 19% (8) of respondents agreed with the statement that "the majority of teaching faculty in our program consistently model cost-effective healthcare to residents". Few of the programs (10, 24%) had formal curricula for residents regarding cost-effective care, and the primary mode of education in cost-effective care was through informal discussions with faculty (17, 43%). Few residents (3, 13%) were able to easily find the costs of tests or procedures. Discussion: There is not consistent education in cost-effective care for orthopaedic surgery program leadership, faculty, or trainees. The results of this survey demonstrate a need for discussion of best practices, including increasing access to cost data at a local level, and engaging with the AOA, CORD, and the American Academy of Orthopaedic Surgeons more broadly in the development of standard education modules for faculty and residents, to improve the current and future delivery of cost-effective musculoskeletal care.

Elective Hand Surgery Is Delayed among Private Insurance Holders.

OBJECTIVES: Patients with private healthcare plans often defer nonemergent or elective procedures toward the end of the year once they have met their deductible. No previous studies have evaluated how insurance status and hospital setting may affect surgical timing for upper extremity procedures. Our study aimed to evaluate the influence of insurance and hospital setting on end-of-the-year surgical cases for elective carpometacarpal (CMC) arthroplasty, carpal tunnel, cubital tunnel, and trigger finger release, and nonelective distal radius fixation. METHODS: Insurance provider and surgical dates were gathered from two institutions' electronic medical records (one university, one physician-owned hospital) for those undergoing CMC arthroplasty, carpal tunnel release, cubital tunnel release, trigger finger release, and distal radius fixation from January 2010 to December 2019. Dates were converted into corresponding fiscal quarters (Q1-Q4). Using the Poisson exact test, comparisons were made between the case volume rate of Q1-Q3 and Q4 for private insurance and then for public insurance. RESULTS: Overall, case counts were greater in Q4 than the rest of the year at both institutions. There was a significantly greater proportion of privately insured patients undergoing hand and upper extremity surgery at the physician-owned hospital than the university center (physician owned: 69.7%, university: 50.3%; P < 0.001). Privately insured patients underwent CMC arthroplasty and carpal tunnel release at a significantly greater rate in Q4 compared with Q1-Q3 for both institutions. Publicly insured patients did not experience an increase in carpal tunnel releases during the same period at both institutions. CONCLUSIONS: Privately insured patients underwent elective CMC arthroplasty and carpal tunnel release procedures in Q4 at a significantly greater rate than publicly insured patients. This finding suggests private insurance status, and potentially deductibles, influence surgical decision making and timing. Further work is needed to evaluate the impact of deductibles on surgical planning and the financial and medical impact of delaying elective surgeries.

Beirut massive blast explosion: A unique injury pattern of the wounded population.

INTRODUCTION: On August 4, 2020, a massive explosion of a warehouse holding 2,700 metric tons of ammonium nitrate took place in the port of Beirut, Lebanon. This incident, which is considered as one of the largest industrial disasters lead to the death of at least 220 people and more than 6000 injuries. Hospitals near the blast were damaged significantly which made it difficult to treat injured patients. The objective of this study is to report the epidemiology and characteristics of the injuries and their initial management that could be useful for healthcare workers and policymakers in case of a similar massive accident in the future. MATERIALS AND METHODS: A retrospective study was conducted. All charts of patients admitted to the emergency room and outpatient clinics on the day of the blast and during the following 2 weeks were thoroughly reviewed. Due to initial chaos during triage, direct phone contact with patients was utilized in certain situations to confirm their identity or for further information. All acute injuries were recorded based on the region, severity, degree of emergency, initial and later management, type of injured organs, and surgical procedures. RESULTS: A total of 159 patients presented to our facility. 153 patients presented to the ER on the same day of the blast. The mean age was 47.07 years and around 60% of the patients were males (n = 93). Most of the patients presented either from zone 1 (n = 67, 42%) or zone 3 (n = 68, 43%). The majority of injuries were secondary injuries due to glass (n = 131, 82.3%), with the head (34%) and upper extremities (31.2%) being most commonly affected. A total of 94 patients (62.6%) underwent a type of imaging and 64 patients (40.2%) had at least one surgery performed during their hospitalization in which 71% of the surgeries being related to the limbs. CONCLUSION: This study demonstrated a unique injury pattern due to this type of blast. Injuries were mostly due to glass shrapnel. Contrary to bomb blasts, most injuries were located in the head and upper extremities rather than on the lower extremities.

Orthopedic consequences of modern gladiators: a systematic review of lower extremity musculoskeletal issues in retired NFL players.

OBJECTIVES: The stressors that National Football League (NFL) athletes face are well-described and documented with regard to multisystem afflictions and injury prevalence. However, the majority of literature discusses the short-term effects rather than long-term outcomes of playing professional football. The purpose of this study was to characterize the long-term musculoskeletal issues in the retired NFL population. METHODS: Publications from CENTRAL, Scopus, Medline, PubMed, Embase, and Google Scholar were searched from database inception to February 2021. A total of 9 cohort studies evaluating lower extremity arthritis in retired NFL athletes were included for review. Two reviewers extracted data from the individual studies, including demographic information (age, body mass index, length of career, position), injury descriptions (location of injury, number of injuries, diagnoses), and procedure (total knee and or hip arthroplasty) frequency. RESULTS: Arthritis in retired NFL players was more than twice as prevalent than the general United States male population (95% CI: 2.1-2.3). Ankle osteoarthritis was directly correlated with the number of foot and ankle injuries. Players <50 years of age had a 16.1 and 13.8 times higher risk of undergoing TKA and THA, respectively, when compared to the general population. In older age groups, this trend held with retired NFL players being at least 4.3 and 4.6 times more likely than members of the general population to undergo TKA and THA, respectively. CONCLUSION: This review demonstrates that the effects of NFL-related lower extremity injuries extend beyond the players' careers and present a higher risk for early-onset osteoarthritis and overall frequency of undergoing total knee and hip arthroplasty.

Does Construct Type Matter? A Retrospective Review Comparing Outcomes of Distal Radius Fractures Treated with Standard Volar Plating versus Fragment-Specific Fixation.

Background Treatment of intra-articular distal radius fractures (DRFs) rests on anatomic internal fixation. Fragment-specific fixation (FSF) is applied when fracture pattern is too complex for standard volar plating (SVP), oftentimes with potential increased risk of complications. We hypothesized that patients undergoing FSF would achieve less wrist range of motion (ROM) with higher risk of complications compared with SVP. Methods We conducted a retrospective review of 159 consecutive patients undergoing DRF fixation from 2017 to 2020. Patients < 18 years old, < 8 weeks' follow-up, open fractures, ipsilateral trauma, and fractures requiring dorsal spanning plate were excluded. Patient demographics, specific construct type, AO fracture classification, ROM, and complications were assessed. ROM was calculated using average flexion, extension, supination, and pronation. t -Tests were used to determine differences in ROM among construct types. Results Ninety-two patients met all inclusion criteria: 59 underwent SVP and 33 underwent FSF. Average wrist ROM for patients undergoing SVP was 57 degrees/50 degrees flexion-extension and 87 degrees/88 degrees supination-pronation; average ROM for patients undergoing FSF was 55 degrees/49 degrees flexion-extension and 88 degrees/89 degrees supination-pronation. No significant differences were identified when comparing final wrist flexion ( p = 0.08), extension ( p = 0.33), supination ( p = 0.35), or pronation ( p = 0.21). Overall reoperation rate was 5% and higher for FSF (12%) versus SVP (2%). Highest reoperation rate was observed in the double volar hook cohort (80%; N = 4). Conclusion Construct type does not appear to affect final ROM if stable internal fixation is achieved. SVP and FSF had similar complication rates; however, double volar hook constructs resulted in increased reoperations likely from fixation failure and plate prominence. Level of Evidence Level IV, retrospective review.

Is it necessary to fuse to the pelvis when correcting scoliosis in cerebral palsy?

BACKGROUND: Neuromuscular scoliosis is commonly associated with a large pelvic obliquity. Scoliosis in children with cerebral palsy is most commonly managed with posterior spinal instrumentation and fusion. While consensus is reached regarding the proximal starting point of fusion, controversy exists as to whether the distal level of spinal fusion should include the pelvis to correct the pelvic obliquity. AIM: To assess the role of pelvic fusion in posterior spinal instrumentation and fusion, particularly it impact on pelvic obliquity correction, and to assess if the rate of complications differed as a function of pelvic fusion. METHODS: This was a retrospective, cohort study in which we reviewed the medical records of children with cerebral palsy scoliosis treated with posterior instrumentation and fusion at a single institution. Minimum follow-up was six months. Patients were stratified into two groups: Those who were fused to the pelvis and those fused to L4/L5. The major outcomes were complications and radiographic parameters. The former were stratified into major and minor complications, and the latter consisted of preoperative and final Cobb angles, L5-S1 tilt and pelvic obliquity. RESULTS: The study included 47 patients. The correction of the L5 tilt was 60% in patients fused to the pelvis and 67% in patients fused to L4/L5 (P = 0.22). The pelvic obliquity was corrected by 43% and 36% in each group, respectively (P = 0.12). Regarding complications, patients fused to the pelvis had more total complications as compared to the other group (63.0% vs 30%, respectively, P = 0.025). After adjusting for differences in radiographic parameters (lumbar curve, L5 tilt, and pelvic obliquity), these patients had a 79% increased chance of developing complications (Relative risk = 1.79; 95%CI: 1.011-3.41). CONCLUSION: Including the pelvis in the distal level of fusion for cerebral palsy scoliosis places patients at an increased risk of postoperative complications. The added value that pelvic fusion offers in terms of correcting pelvic obliquity is not clear, as these patients had similar percent correction of their pelvic obliquity and L5 tilt compared to children whose fusion was stopped at L4/L5. Therefore, in a select patient population, spinal fusion can be stopped at the distal lumbar levels without adversely affecting the surgical outcomes.

Comparing complications of outpatient management of slipped capital femoral epiphysis and Blount's disease: A database study.

BACKGROUND: Currents trends in pediatric orthopaedics has seen an increase in surgeries being successfully completed in an outpatient setting. Two recent examples include slipped capital femoral epiphysis (SCFE) and Blount's disease. Surgical indications are well-studied for each pathology, but to our knowledge, there is an absence in literature analyzing safety and efficacy of inpatient vs outpatient management of either condition. We believed there would be no increase in adverse outcomes associated with outpatient treatment of either conditions. AIM: To investigate whether outpatient surgery for SCFE and Blount's disease is associated with increased risk of adverse outcomes. METHODS: The 2015-2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric Registries were used to compare patient characteristics, rates of complications, and readmissions between outpatient and inpatient surgery for SCFE and Blount's disease. RESULTS: Total 1788 SCFE database entries were included, 30% were performed in an outpatient setting. In situ pinning was used in 98.5% of outpatient surgeries and 87.8% of inpatient surgeries (P < 0.0001). Inpatients had a greater percent of total complications than outpatients 2.57% and 1.65% respectively. Regarding Blount's disease, outpatient surgeries constituted 41.2% of the 189 procedures included in our study. The majority of inpatients were treated with a tibial osteotomy, while the majority of outpatients had a physeal arrest (P < 0.0001). Complications were encountered in 7.4% of patients, with superficial surgical site infections and wound dehiscence being the most common. 1.6% of patients had a readmission. No differences in complication and readmission risks were found between inpatients and outpatients. CONCLUSION: The current trend is shifting towards earlier discharges and performing procedures in an outpatient setting. This can be safely performed for a large portion of children with SCFE and Blount's disease without increasing the risk of complications or readmissions. Osteotomies are more commonly performed in an inpatient setting where monitoring is available.

Routine Postoperative Computed Tomography Scans Following Posterior Pelvic Fixation of Pelvic Ring Fractures: A Survey of (OTA) Orthopaedic Traumatologists.

OBJECTIVE: To assess practices related to ordering computed tomography (CT) scans routinely after posterior pelvic ring fixation and revision surgery rates. DESIGN: A 20-question cross-sectional survey. PARTICIPANTS: Fellowship-trained orthopaedic traumatologists. MAIN OUTCOME MEASUREMENTS: (1) Percentage of surgeons ordering a routing postoperative CT after posterior pelvic ring fixation, (2) Revision surgery rates based on routine CT scan results. RESULTS: Responses were received from 57 surgeons. Practices varied regarding postoperative CT scans, with 20 surgeons (35%, group A) routinely ordering them and 37 surgeons (65%, group B) not ordering them on all patients. Group A were younger and with less years of experience than those in Group B. Most group A surgeons report a revision surgery rate of <1% based on results of the postoperative CT. Group A report routine postoperative scans were obtained to assess reduction, instrumentation placement, and for educational purposes. Group B did not obtain routine postoperative CTs because of the following: unlikely to change postoperative treatment course, adequate reduction and instrumentation placement assessed intraoperatively and by postoperative radiographs, and increased radiation exposure and cost to patients. Group B did report obtaining postop CT scans on select patients, with postoperative neurological deficit being the most common indication. CONCLUSIONS: The routine use of postoperative CTs following posterior fixation of pelvic ring fractures is a controversial topic. Although we recognize the role for postoperative CT scans in select patients, our study questions the clinical utility of these scans in all patients and in conclusion do not recommend this protocol.

Catching Fire: Are Operating Room Fires a Concern in Orthopedics?

OBJECTIVE: Operating room (OR) fires are considered "never events," but approximately 650 events occur annually in the United States. Our aim was to detail fires occurring during orthopedic procedures via a questionnaire because of the limited information present on this topic. METHODS: A 25-question survey on witnessing surgical fires, hospital policies on surgical fires, and surgeons' perspective on OR fires was sent to 617 orthopedic surgeons in 18 institutions whose residency program is a member of the Collaborative Orthopaedic Educational Research Group. The response rate was 28%, with 172 surgeons having completed the survey. RESULTS: Twelve of the 172 orthopedic surgeons surveyed reported witnessing at least 1 surgical fire in an OR setting. Electrocautery was the leading ignition source, causing fires in 7 events. A saw, laser, and light source were reported to have caused 1 fire each. Regarding fuel source for the fires, bone cement was a common culprit (n = 4), followed by gauze (n = 3). Oxygen delivery to patients was via a closed system in most cases (n = 9). No patient harm was reported in any of these cases.Just under half of the respondents (47.7%) reported not receiving any formal OR fire prevention or response training. The most common answer for frequency of concern about a surgical fire was "never" (42.4%). CONCLUSIONS: Fires pose a risk in surgery, even in an orthopedics setting. Room oxygen can supply enough oxidizing power for a fire to occur, especially with the ubiquitous nature of ignition sources and fuels in the OR. Prevention is key with these events. Operating room personnel education must be sought, and surgeons should be mindful of the fire components in the OR.

Co-occurrence of Blount's disease and Legg-Calvé-Perthes disease: is obesity a factor?

Legg-Calvé-Perthes disease (LCPD) and Blount's disease share a similar presenting age in addition to similar symptoms such as limp or knee pain. A little overlap is mentioned about both diseases. We sought to present cases of children having both conditions to discuss the implications of this co-occurrence on diagnosis and management. After institutional review board approval, we retrospectively reviewed records of four children who developed both Blount's disease and LCPD. Patient details and outcomes were analyzed. Radiographs were evaluated for the lateral pillar classification, Stulberg classification, tibial metaphyseal-diaphyseal angle and tibiofemoral angle. Two of the cases were initially diagnosed with Blount's disease and subsequently developed Perthes, one case presented initially with both disorders and the final case had Perthes followed by Blount's. Three children were obese and one was overweight. The common symptom to all patients was an abnormal gait, which was painless in two children and painful in two. Blount's disease required surgery in three children. Radiographs showed Lateral Pillar B, B/C border and C hips, and the final Stulberg was stage II (n = 2) or stage IV (n = 2). Obesity is associated with Blount's disease and LCPD, so obese children can be at an increased risk of developing both disorders. Therefore, a child with Blount's disease who has persistent, recurrent or worsening symptoms such as gait disturbance or thigh or knee pain might benefit from a careful physical exam of the hips to prevent a delayed or even missed LCPD diagnosis.

Perceptions of the Universal Interview Offer Day in the Orthopaedic Surgery Residency Interview Process.

INTRODUCTION: The American Orthopaedic Association's Council of Orthopaedic Residency Directors recommended implementing a universal offer day (UOD) in the 2020 residency match. Although this decision was an attempt to benefit applicants, it is important to assess how this endeavor was perceived. METHODS: Questionnaires for applicants and program directors asked about the perception of the UOD and the experience with it. Responses were included from 383 applicants (43% response rate) and 84 program directors (45% response rate). RESULTS: Applicant Survey: Most of the students (81.5%) were worried or very worried about the interview offer process. Most of the applicants (64.0%) stated that the UOD decreased their stress. The majority (93.2%) indicated that they would like to see the UOD continue in future years. Program Director Survey: Most of the program directors (83.1%) mentioned that they would like to see the UOD continued, and 86.8% indicated that they would participate in a similar process if implemented in future cycles. DISCUSSION: Benefits of a standardized interview offer date include decreased stress and fewer clinical interruptions. Advantages can also extend to scheduling conflicts and over-interviewing. These favorable results, along with positive experiences from other specialties implementing a UOD, encourage the continued use of this approach for offering interviews. DATA AVAILABILITY: N/A. TRIAL REGISTRATION NUMBERS: N/A.

Successful Surgical Repair of Acute Quadriceps Tendon Rupture Utilizing Cortical Button Fixation: A Case Report.

BACKGROUND Timely diagnosis and surgical treatment are often needed to restore function of the extensor mechanism after rupture of the quadriceps tendon. Several techniques for quadriceps tendon repair have been reported, including suture anchors and bone tunnels. Cortical button fixation, or the use of an adjustable cortical fixation device, is a local and biomechanically strong internal brace technique used to treat ligament and tendon injuries. This report is of a 69-year-old man who experienced a quadriceps tendon rupture while golfing and underwent a successful surgical repair using cortical button fixation. CASE REPORT A 69-year-old man sustained an injury after slipping while golfing. He had immediate left knee pain and inability to bear weight. Radiographs demonstrated patella baja with an acute superior pole avulsion fracture of the patella, consistent with rupture of the quadriceps tendon. Surgical repair was discussed. Technique: After soft tissue debridement, the quadriceps tendon was debrided from the frayed and edematous edges. Two Krackow-type stitches were placed with #2 Fibertape and passed through 2 cortical buttons. Two bone tunnels were drilled from the superior to the inferior poles of the patella, bicortically. The cortical button was passed and appropriately tensioned. CONCLUSIONS Although acute quadriceps tendon rupture is commonly treated with transosseous suture repair and suture anchor repair, this report demonstrates that cortical button fixation was a successful procedure with strong biomechanical properties, resulting in the early return of function and range of motion.

Late Deep Infections Complicating Percutaneous Pinning of Supracondylar Humerus Fractures.

OBJECTIVES: Complications following treatment of supracondylar humerus fractures are typically seen shortly postoperatively. Late complications occurring years after percutaneous pinning are rare but can be indolent and have permanent sequelae. We present cases of children presenting with late deep infections to discuss their diagnosis and treatment. METHODS: After institutional review board approval, we retrospectively reviewed records of three children who developed deep infections at least one year after percutaneous pinning of their supracondylar humerus fracture. Patient details and outcomes were analyzed. Radiographs and magnetic resonance imaging were reviewed along with each patient's clinical course and treatment. RESULTS: We report 3 cases of osteomyelitis and/or septic arthritis presenting at least one year after supracondylar humerus fractures treated with closed reduction and percutaneous pinning. The patients required several irrigation and debridement procedures with placement of antibiotic beads in addition to a prolonged course of antibiotics. CONCLUSION: Delayed deep infections can occur after closed reduction and percutaneous pinning of supracondylar humerus fractures in children. Vigilance is required to diagnose and treat such occurrences, and prolonged follow-up is needed to monitor for recurrent or intractable infections.