Do Patients Want to Be Involved in Their Carpal Tunnel Surgery Decisions? A Multicenter Study.

PURPOSE: Carpal tunnel syndrome requires multiple decisions during its management, including regarding preoperative studies, surgical technique, and postoperative wound management. Whether patients have varying preferences for the degree to which they share in decisions during different phases of care has not been explored. The goal of our study was to evaluate the degree to which patients want to be involved along the care pathway in the management of carpal tunnel syndrome. METHODS: We performed a prospective, multicenter study of patients undergoing carpal tunnel surgery at 5 academic medical centers. Patients received a 27-item questionnaire to rate their preferred level of involvement for decisions made during 3 phases of care for carpal tunnel surgery: preoperative, intraoperative, and postoperative. Preferences for participation were quantified using the Control Preferences Scale. These questions were scored on a scale of 0 to 4, with patient-only decisions scoring 0, semiactive decisions scoring 1, equally collaborative decisions scoring 2, semipassive decisions scoring 3, and physician-only decisions scoring 4. Descriptive statistics were calculated. RESULTS: Seventy-one patients completed the survey between November 2018 and April 2019. Overall, patients preferred semipassive decisions in all phases of care (median score, 3). Patients preferred equally collaborative decisions for preoperative decisions (median score, 2). Patients preferred a semipassive decision-making role for intraoperative and postoperative decisions (median score, 3), suggesting these did not need to be equally shared. CONCLUSIONS: Patients with carpal tunnel syndrome prefer varying degrees of involvement in the decision-making process of their care and prefer a semipassive role in intraoperative and postoperative decisions. CLINICAL RELEVANCE: Strategies to engage patients to varying degrees for all decisions during the management of carpal tunnel syndrome, such as decision aids for preoperative surgical decisions and educational handouts for intraoperative decisions, may facilitate aligning decisions with patient preferences for shared decision-making.

Implicit and Explicit Factors That Influence Surgeons' Decision-Making for Distal Radius Fractures in Older Patients.

PURPOSE: The purpose of this study was to evaluate factors that influence surgeons' decision-making in the treatment of distal radius fractures in older patients. METHODS: Fourteen clinical vignettes of a 72-year-old patient with a distal radius fracture were sent to 185 orthopedic hand and/or trauma surgeons. The surgeons were surveyed regarding the demographic/practice details, treatment decision (surgical or nonsurgical), and factors that influenced management, including the Charlson Comorbidity Index, functional status, radiographic appearance, and handedness. Multivariable regression analyses were used to assess the effect of both surgeon-described (explicit) and given clinical (implicit) factors on the treatment decision and to evaluate for discrepancies. RESULTS: Sixty-six surgeons completed the survey, and 7 surgeons completed 10-13 vignettes. Surgeons made the explicit determination to pursue nonsurgical treatment based on the presence of comorbidities (odds ratio [OR], 0.02 for surgery; 95% confidence interval [CI], 0.01-0.05), but the observation of the underlying clinical data suggested that the recommendation for surgical treatment was instead based on a higher functional status (OR, 3.54/increase in functional status; 95% CI, 2.52-4.98). Those employed by hospitals/health systems were significantly less likely to recommend surgery than those in private practice (OR, 0.42; 95% CI, 0.23-0.79) CONCLUSIONS: This study demonstrates that the presence of comorbidities, functional status, and practice setting has a significant impact on a surgeon's decision to treat distal radius fractures in older patients. The discrepancy between the surgeon-described factors and underlying clinical data demonstrates cognitive bias. CLINICAL RELEVANCE: Surgeons should be aware of cognitive biases in clinical reasoning and should work through consequential patient decisions using an analytical framework that attempts to reconcile all available clinical data.

Gorham Disease Limited to the Left Upper Extremity Without Hand Involvement.

In this case report, we present a young female patient with a history of Gorham disease, who sustained pathologic fractures of the left radius and ulna after a low-impact fall. Massive osteolysis of the left forearm and wrist was noted on plain radiographs. The patient had had 8 previous left upper-extremity fractures without evidence of disease in any other area of the body.

Has a Prescription-limiting Law in Rhode Island Helped to Reduce Opioid Use After Total Joint Arthroplasty?

BACKGROUND: In the United States, since 2016, at least 28 of 50 state legislatures have passed laws regarding mandatory prescribing limits for opioid medications. One of the earliest state laws (which was passed in Rhode Island in 2016) restricted the maximum morphine milligram equivalents provided in the first postoperative prescription for patients defined as opioid-naïve to 30 morphine milligram equivalents per day, 150 total morphine milligram equivalents, or 20 total doses. While such regulations are increasingly common in the United States, their effects on opioid use after total joint arthroplasty are unclear. QUESTIONS/PURPOSES: (1) Are legislative limitations to opioid prescriptions in Rhode Island associated with decreased opioid use in the immediate (first outpatient prescription postoperatively), 30-day, and 90-day periods after THA and TKA? (2) Is this law associated with similar changes in postoperative opioid use among patients who are opioid-naïve and those who are opioid-tolerant preoperatively? METHODS: Patients undergoing primary THA or TKA between January 1, 2016 and June 28, 2016 (before the law was passed on June 28, 2016) were retrospectively compared with patients undergoing surgery between June 1, 2017 and December 31, 2017 (after the law's implementation on April 17, 2017). The lapse between the pre-law and post-law periods was designed to avoid confounding from potential voluntary practice changes by physicians after the law was passed but before its mandatory implementation. Demographic and surgical details were extracted from a large multi-specialty orthopaedic group's surgical billing database using Current Procedural Terminology codes 27130 and 27447. Any patients undergoing revision procedures, same-day bilateral arthroplasties, or a second primary THA or TKA in the 3-month followup period were excluded. Secondary data were confirmed by reviewing individual electronic medical records in the associated hospital system which included three major hospital sites. We evaluated 1125 patients. In accordance with the state's department of health guidelines, patients were defined as opioid-tolerant if they had filled any prescription for an opioid medication in the 30-day preoperative period. Data on age, gender, and the proportion of patients who were defined as opioid tolerant preoperatively were collected and found to be no different between the pre-law and post-law groups. The state's prescription drug monitoring program database was used to collect data on prescriptions for all controlled substances filled between 30 days preoperatively and 90 days postoperatively. The primary outcomes were the mean morphine milligram equivalents of the initial outpatient postoperative opioid prescription after discharge and the mean cumulative morphine milligram equivalents at the 30- and 90-day postoperative intervals. Secondary analyses included subgroup analyses by procedure and by preoperative opioid tolerance. RESULTS: After the law was implemented, the first opioid prescriptions were smaller for patients who were opioid-naïve (mean 156 ± 106 morphine milligram equivalents after the law's passage versus 451 ± 296 before, mean difference 294 morphine milligram equivalents; p < 0.001) and those who were opioid-tolerant (263 ± 265 morphine milligram equivalents after the law's passage versus 534 ± 427 before, mean difference 271 morphine milligram equivalents; p < 0.001); however, for cumulative prescriptions in the first 30 days postoperatively, this was only true among patients who were previously opioid-naïve (501 ± 416 morphine milligram equivalents after the law's passage versus 796 ± 597 before, mean difference 295 morphine milligram equivalents; p < 0.001). Those who were opioid-tolerant did not have a decrease in the cumulative number of 30-day morphine milligram equivalents (1288 ± 1632 morphine milligram equivalents after the law's passage versus 1398 ± 1274 before, mean difference 110 morphine milligram equivalents; p = 0.066). CONCLUSIONS: The prescription-limiting law was associated with a decline in cumulative opioid prescriptions at 30 days postoperatively filled by patients who were opioid-naïve before total joint arthroplasty. This may substantially impact public health, and these policies should be considered an important tool for healthcare providers, communities, and policymakers who wish to combat the current opioid epidemic. However, given the lack of a discernible effect on cumulative opioids filled from 30 to 90 days postoperatively, further investigations are needed to evaluate more effective policies to prevent prolonged opioid use after total joint arthroplasty, particularly in patients who are opioid-tolerant preoperatively. LEVEL OF EVIDENCE: Level III, therapeutic study.

Opioid-Limiting Regulation: Effect on Patients Undergoing Knee and Shoulder Arthroscopy.

PURPOSE: To determine the effect prescription-limiting legislation passed in Rhode Island has had on opioids prescribed following arthroscopic knee and shoulder surgery at various time points, up to 90 days postoperatively. METHODS: All patients undergoing the 3 most common arthroscopic procedures at our institution (anterior cruciate ligament reconstruction, partial meniscectomy, and rotator cuff repair) were included. Patients were selected from 2 6-month study periods (prepassage and postimplementation of the law). The state's Prescription Drug Monitoring Program database was queried for controlled substances filled in the perioperative period (from 30 days preoperatively to 90 days postoperatively). Multiple logistic regressions were used to identify predictors of chronic (>30 days) opioid use. RESULTS: The morphine milligram equivalents (MMEs) prescribed in the initial postoperative script decreased from 319.04 (∼43 5-mg oxycodone tablets) in the prepassage to 152.45 MMEs (∼20 5-mg oxycodone tablets) in the postimplementation group (P < .001). The total MMEs filled in the first 30 days decreased from 520.93 to 299.94 MMEs (∼70 to ∼40 5-mg oxycodone tablets) (P < .001). MMEs filled between 30 and 90 days fell by 22.5% for all patients in this study; however, this change was not statistically significant (P = .263). Preoperative opioid use (odds ratio, 10.85; P < .001) and preoperative benzodiazepine use (odds ratio, 2.13; P = .005) predicted chronic opioid use postoperatively. CONCLUSIONS: State opioid-limiting legislation reduced cumulative MMEs following arthroscopic knee and shoulder surgery in the first 30 days. Further research assessing the impact of this legislation on postoperative pain control, patient satisfaction, and functional outcomes following surgery is warranted. LEVEL OF EVIDENCE: Level III, case-control study.

Which Decisions For Management of Carpal Tunnel Syndrome and Distal Radius Fractures Should Be Shared?

PURPOSE: To evaluate, from the surgeon's perspective, the importance, feasibility, and appropriateness of sharing decisions during an episode of care of carpal tunnel syndrome (CTS) or distal radius fracture in patients aged greater than 65 years. METHODS: A consortium of 9 fellowship-trained hand/upper-limb surgeons used the RAND Corporation/University of California Los Angeles Delphi Appropriateness method to evaluate the importance, feasibility, and appropriateness of sharing 27 decisions for CTS and 28 decisions for distal radius fractures in patients aged greater than 65 years. Panelists rated each measure on a scale of 1 (definitely not important/feasible/appropriate) to 9 (definitely important/feasible/appropriate) in 2 voting rounds with an intervening face-to-face discussion. Panelist agreement and disagreement were assessed using predetermined criteria. RESULTS: Panelists achieved agreement on 16 decisions (29%) as important, 43 (78%) as feasible, and 17 (31%) as appropriate for sharing with patients. Twelve decisions met all 3 of these criteria and were therefore considered important, feasible, and appropriate to share with patients. Examples in CTS included decisions to perform extra confirmatory diagnostic testing, to have surgery, and to perform a steroid injection into the carpal tunnel. Examples in distal radius fracture management included the decision to have surgery, type of pain medication prescribed after surgery, and whether to remove the implant. The remaining 43 decisions did not reach consensus on the importance, feasibility, and appropriateness of sharing with patients. CONCLUSIONS: Using a validated consensus-building approach, we identified 12 decisions made during an episode of care for CTS or distal radius fracture that were important, feasible, and appropriate to share with patients from the surgeon's perspective. These decisions merit inclusion in shared decision-making models (eg, preoperative patient preference elicitation tools or decision aids) to align patient preferences with care decisions. CLINICAL RELEVANCE: Understanding which aspects of care are important, feasible, and appropriate to share with patients may improve patient-centered care by aligning patient preferences with care decisions.

Utility of Prolotherapy for Upper Extremity Pathology.

Prolotherapy is a method of treatment of painful musculoskeletal conditions whereby a sclerosing agent is injected into an area of tendinosis or osteoarthritis to strengthen and repair painful connective tissue. It is a safe, effective, and relatively inexpensive nonsurgical treatment modality. This article provides a history of prolotherapy, discusses its proposed mechanisms of action, and provides a review of the existing literature on prolotherapy as a treatment for upper extremity pathologies, specifically, hand osteoarthritis, lateral epicondylitis, and rotator cuff disease.

The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics. QUESTIONS/PURPOSES: (1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state? METHODS: We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race, gender, language spoken, and income level) also was compared using an interrupted time-series design. RESULTS: There was a 36% absolute reduction (95% CI, 35%-38%; p < 0.001) in uninsured visits (73% relative reduction; 95% CI, 71%-75%; p < 0.001). There was an immediate 28% absolute reduction (95% CI, 21%-34%; p < 0.001) at the time of ACA implementation, which continued to decline thereafter. After controlling for potential confounding variables such as gender, race, age, and income level, we found that patients who were white, men, younger than 65 years, and seen after January 2014 were more likely to have insurance than patients of other races, women, older patients, and patients treated before January 2014. CONCLUSIONS: After the ACA was implemented, the proportion of patients with health insurance at our safety net adult orthopaedic surgery clinic increased substantially. The reduction in uninsured patients was not equal across genders, races, ages, and incomes. Future studies may benefit from identifying barriers to insurance acquisition in these subpopulations. The results of this study could affect orthopaedic practices in the United States by guiding policy decisions regarding health care. LEVEL OF EVIDENCE: Level III, therapeutic study.

Thirty-Day Reoperation and/or Admission After Elective Hand Surgery in Adults: A 10-Year Review.

PURPOSE: Whereas acute complications following elective hand surgery have been assumed to be rare, the incidence of 30-day unplanned reoperation and/or admission for the most common elective procedures has not been well described. Our goal was to calculate the incidence and identify the risk factors associated with these complications in a busy academic practice. METHODS: Our institution's quality assurance database was examined retrospectively for unplanned reoperations and/or admissions within 30 days in adults undergoing elective procedures with 2 senior attending surgeons from February 2006 to January 2016. Each event was categorized by causative factor and charts were reviewed to establish risk factors and cultured organisms. Our billing database was examined for the concomitant procedural volume. RESULTS: In our cohort of 18,081 surgeries (57.6% carpal tunnel or trigger digit releases), 27 patients had an unplanned reoperation and/or admission within 30 days (0.15% total incidence; including carpal tunnel release, 0.10%; trigger digit release, 0.09%; major wrist surgery, 0.74%) including 17 infections (0.09%). These were unevenly distributed over time after surgery with 29.6% occurring within 7 days, 59.2% in 8 to 14 days, 11.1% in 15 to 21 days, and none between 22 and 30 days. CONCLUSIONS: Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent (15 per 10,000 cases) and are most commonly related to infections (63.0%). More invasive surgeries are associated with a higher incidence than simpler procedures, and these complications are most likely to occur within 3 weeks after surgery. These data in elective patients do not cover certain clinically relevant outcomes, such as chronic pain or limited function, and may not be generalizable to all practices. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Carpal Kinematics and Kinetics.

The complex interaction of the carpal bones, their intrinsic and extrinsic ligaments, and the forces in the normal wrist continue to be studied. Factors that influence kinematics, such as carpal bone morphology and clinical laxity, continue to be identified. As imaging technology improves, so does our ability to better understand and identify these factors. In this review, we describe advances in our understanding of carpal kinematics and kinetics. We use scapholunate ligament tears as an example of the disconnect that exists between our knowledge of carpal instability and limitations in current reconstruction techniques.

Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome.

Double crush syndrome (DCS), as it is classically defined, is a clinical condition composed of neurological dysfunction due to compressive pathology at multiple sites along a single peripheral nerve. The traditional definition of DCS is narrow in scope because many systemic pathologic processes, such as diabetes mellitus, drug-induced neuropathy, vascular disease and autoimmune neuronal damage, can have deleterious effects on nerve function. Multifocal neuropathy is a more appropriate term describing the multiple etiologies (including compressive lesions) that may synergistically contribute to nerve dysfunction and clinical symptoms. This paper examines the history of DCS and multifocal neuropathy, including the epidemiology and pathophysiology in addition to principles of evaluation and management.

Quality Measurement: A Primer for Hand Surgeons.

As the government and payers place increasing emphasis on measuring and reporting quality and meeting-specific benchmarks, physicians and health care systems will continue to adapt to meet regulatory requirements. Hand surgeons' involvement in quality measure development will help ensure that our services are appropriately assessed. Moreover, by embracing a culture of quality assessment and improvement, we will improve patient care while demonstrating the importance of our services in a health care system that is transitioning from a fee-for-service model to a fee-for-value model. Understanding quality and the tools for its measurement, and the application of quality assessment and improvement methods can help hand surgeons continue to deliver high-quality care that aligns with national priorities.

Subject-Specific Carpal Ligament Elongation in Extreme Positions, Grip, and the Dart Thrower's Motion.

This study examined whether the radiocarpal and dorsal capsular ligaments limit end-range wrist motion or remain strained during midrange wrist motion. Fibers of these ligaments were modeled in the wrists of 12 subjects over multiple wrist positions that reflect high demand tasks and the dart thrower's motion. We found that many of the volar and dorsal ligaments were within 5% of their maximum length throughout the range of wrist motion. Our finding of wrist ligament recruitment during midrange and end-range wrist motion helps to explain the complex but remarkably similar intersubject patterns of carpal motion.

Accredited hand surgery fellowship Web sites: analysis of content and accessibility.

PURPOSE: To assess the accessibility and content of accredited hand surgery fellowship Web sites. METHODS: A list of all accredited hand surgery fellowships was obtained from the online database of the American Society for Surgery of the Hand (ASSH). Fellowship program information on the ASSH Web site was recorded. All fellowship program Web sites were located via Google search. Fellowship program Web sites were analyzed for accessibility and content in 3 domains: program overview, application information/recruitment, and education. RESULTS: At the time of this study, there were 81 accredited hand surgery fellowships with 169 available positions. Thirty of 81 programs (37%) had a functional link on the ASSH online hand surgery fellowship directory; however, Google search identified 78 Web sites. Three programs did not have a Web site. Analysis of content revealed that most Web sites contained contact information, whereas information regarding the anticipated clinical, research, and educational experiences during fellowship was less often present. Furthermore, information regarding past and present fellows, salary, application process/requirements, call responsibilities, and case volume was frequently lacking. Overall, 52 of 81 programs (64%) had the minimal online information required for residents to independently complete the fellowship application process. CONCLUSIONS: Hand fellowship program Web sites could be accessed either via the ASSH online directory or Google search, except for 3 programs that did not have Web sites. Although most fellowship program Web sites contained contact information, other content such as application information/recruitment and education, was less frequently present. CLINICAL RELEVANCE: This study provides comparative data regarding the clinical and educational experiences outlined on hand fellowship program Web sites that are of relevance to residents, fellows, and academic hand surgeons. This study also draws attention to various ways in which the hand surgery fellowship application process can be made more user-friendly and efficient.

Perceptions of Emergency Medicine Residency and Hand Surgery Fellowship Program Directors in the Appropriate Disposition of Upper Extremity Emergencies.

PURPOSE: To survey emergency medicine (EM) residency and hand surgery fellowship program directors (PDs) to identify consensus in their perceptions of appropriate emergency care of upper extremity emergencies. METHODS: We created a framework to group common upper extremity emergency diagnoses and surveyed PDs to evaluate the training background--EM, general orthopedic or plastic surgery, or hand fellowship--most appropriate to provide acute, point-of-care management for each of these diagnostic groupings. Responses were pooled and consensus was established with greater than 75% agreement between groups. RESULTS: We received 79 responses from hand fellowship PDs (90% response rate) and 151 responses from EM PDs (49% response rate). We identified consensus for the training background that PDs in both specialties felt was appropriate to care for 17 of 21 diagnostic groupings in the framework. CONCLUSIONS: There was a high level of consensus between EM and hand surgery PDs regarding diagnoses that acutely require training in hand surgery versus those that can be managed by an EM physician. Our diagnostic framework may help reduce unnecessary hand surgery consultation and may help to identify patients who do not require more specialized acute care and thus decrease unnecessary transfers. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analyses IV.

In vivo kinematics of the scaphoid, lunate, capitate, and third metacarpal in extreme wrist flexion and extension.

PURPOSE: Insights into the complexity of active in vivo carpal motion have recently been gained using 3-dimensional imaging; however, kinematics during extremes of motion has not been elucidated. The purpose of this study was to determine motion of the carpus during extremes of wrist flexion and extension. METHODS: We obtained computed tomography scans of 12 healthy wrists in neutral grip, extreme loaded flexion, and extreme loaded extension. We obtained 3-dimensional bone surfaces and 6-degree-of-freedom kinematics for the radius and carpals. The flexion and extension rotation from neutral grip to extreme flexion and extreme extension of the scaphoid and lunate was expressed as a percentage of capitate flexion and extension and then compared with previous studies of active wrist flexion and extension. We also tested the hypothesis that the capitate and third metacarpal function as a single rigid body. Finally, we used joint space metrics at the radiocarpal and midcarpal joints to describe arthrokinematics. RESULTS: In extreme flexion, the scaphoid and lunate flexed 70% and 46% of the amount the capitate flexed, respectively. In extreme extension, the scaphoid extended 74% and the lunate extended 42% of the amount the capitates extended, respectively. The third metacarpal extended 4° farther than the capitate in extreme extension. The joint contact area decreased at the radiocarpal joint during extreme flexion. The radioscaphoid joint contact center moved onto the radial styloid and volar ridge of the radius in extreme flexion from a more proximal and ulnar location in neutral. CONCLUSIONS: The contributions of the scaphoid and lunate to capitate rotation were approximately 25% less in extreme extension compared with wrist motion through an active range of motion. More than half the motion of the carpus when the wrist was loaded in extension occurred at the midcarpal joint. CLINICAL RELEVANCE: These findings highlight the difference in kinematics of the carpus at the extremes of wrist motion, which occur during activities and injuries, and give insight into the possible etiologies of the scaphoid fractures, interosseous ligament injuries, and carpometacarpal bossing.

Resilience in Residency and Beyond.

¼ Distinct from the burnout and wellness continuum, resilience is a developed and refined characteristic that propels an individual toward personal and professional success.¼ We propose a clinical resilience triangle consisting of 3 components that define resilience: grit, competence, and hope.¼ Resilience is a dynamic trait that should be built during residency and constantly fortified in independent practice so that orthopaedic surgeons may acquire and hone the skills and mental fortitude required to take on the overwhelming challenges that we all inevitably face.

What Program Characteristics Are Associated with Resident Racial Diversity in Orthopaedic Surgery? An Analysis of Association of American Medical Colleges Data.

In orthopaedic surgery, there are fewer Black or African American (4%) and Hispanic or Latino (4%) residents compared with general surgery, internal medicine, family medicine, and pediatrics (5%-7% Black residents and 7%-9% Hispanic/Latino residents, respectively). There are also fewer underrepresented in medicine minority (URiM) faculty in orthopaedic surgery (6.1%) compared with general surgery (8.9%), otolaryngology (7.8%), internal medicine (9.7%), and obstetrics and gynecology (15.6%). Identifying program characteristics that are associated with the percentage of URiM residents could reveal strategies for improving diversity. Methods: Using Association of American Medical Colleges orthopaedic resident and faculty race/ethnicity data from 2007 to 2016, we analyzed the racial diversity of 166 of 207 residency programs. The primary outcome was program racial diversity, measured as the percentage of URiM residents per program. The top quartile of programs was compared with the other quartiles. Characteristics analyzed included percentage of URiM faculty, affiliation with a university/top 40 medical school/top 40 orthopaedic hospital, geographic region, city type, and city size. We used a multivariable linear regression model to evaluate program characteristics associated with diversity and a linear mixed-effects model with program-specific random effects to evaluate time trends. Results: The mean percentage of URiM residents per program was 9.3% (SD = 10.5%). In the top quartile of programs, URiM residents composed 20.7% ± 2.5% of the program compared with 5.8% ± 0.3% in other quartiles (p < 0.001). After adjusting for program and faculty size, the only factor associated with the number of URiM residents per program was the number of URiM faculty. For every 5 additional URiM faculty members, there was an associated increase in the number of URiM residents per program by 3.6 (95% confidence interval [CI]: 2.3-5.0). There was a small but statistically significant annual increase in the percentage of URiM residents per program of 0.207 (95% CI: 0.112-0.302) percentage points during the study period. Conclusion: URiM representation remains low among orthopaedic residents. Efforts to increase the URiM faculty base represent a potential strategy for programs to increase URiM representation among residents by attracting more diverse applicants.

Hospital Courses Differ Amongst Hip Fracture Patients With or Without Coronavirus-19 Positive Status Upon Admission.

INTRODUCTION: The purpose of this study was to compare the hospital course and disposition of COVID-19 positive versus negative patients following an operatively managed hip fracture. MATERIALS AND METHODS: This retrospective cohort study evaluated patients presenting to a university medical center with a hip fracture who underwent surgical management between February 1, 2020 and April 1, 2021. COVID-19 diagnosis was obtained using PCR testing. Hospital length of stay, disposition, readmission, and mortality were compared between patients with and without COVID-19. RESULTS: 399 total patients were identified who met inclusion criteria, with 14 patients who were COVID-positive (3.1%). There was a 6.1 day increase in length of hospital stay for COVID-19 positive patients compared to those who were COVID negative (p = 0.002), without significant changes in disposition, readmission rates, or mortality. CONCLUSIONS: A positive COVID-19 test at the time of admission can significantly increase hospital admission duration. LEVEL OF EVIDENCE: III, Retrospective Cohort Study.

Safe tourniquet use: a review of the evidence.

Due in part to an emphasis on quality and cost control within healthcare institutions, protocols for healthcare practice are increasingly being developed in an effort to maintain normative guidelines and set acceptable standards. For example, the Association of periOperative Registered Nurses, the National Quality Forum, and the Association of Surgical Technologists have made recommendations regarding tourniquet use. In the institution of the senior authors (C.D. and E.A.), an effort to establish a protocol for tourniquet use prompted a review of the evidence behind standard practices and existing recommendations for safe tourniquet use in the upper and lower extremities. Sparse evidence exists in support of strict limits for tourniquet use, including tourniquet duration, inflation pressure, and reperfusion periods. However, simple principles and general guidelines regarding tourniquet use can be extrapolated to guide safe practice.