What Is the Representation of Sexual and Gender Minority Identities Among Orthopaedic Professionals in the United States?

BACKGROUND: There is substantial corroborating evidence that orthopaedic surgery has historically been the least diverse of all medical and surgical specialties in terms of race, ethnicity, and sex. Growing recognition of this deficit and the benefits of a diverse healthcare workforce has motivated policy changes to improve diversity. To measure progress with these efforts, it is important to understand the existing representation of sexual and gender minorities among orthopaedic professionals. QUESTIONS/PURPOSES: (1) What proportion of American Academy of Orthopaedic Surgeons (AAOS) members reported their identity as a sexual or gender minority? (2) What demographic factors are associated with the self-reporting of one's sexual orientation and gender identity? METHODS: The AAOS published the updated membership questionnaire in January 2022 to collect information from new and existing society members regarding age and race or ethnicity and newly added categories of gender identity, sexual orientation, and pronouns. The questionnaire was updated with input from a committee of orthopaedic surgeons and researchers to ensure face validity. The AAOS provided a deidentified dataset that included the variables of interest: membership type, gender identity, sexual orientation, pronouns, age, race, and ethnicity. Of 35,427 active AAOS members, 47% (16,652) updated their membership questionnaire. To answer our first study question, we calculated the prevalence of participants who self-reported as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority identity (LGBTQ+) and other demographic characteristics of the 16,652 respondents. Categorical demographic data are described using frequencies and proportions. Median and IQR were used to describe the central tendency and variability. To answer our second study question, we conducted a stratified analysis to compare demographic characteristics between those who self-reported LGBTQ+ identity and those who did not. Visual methods (quantile-quantile plots) and statistical tests (Kolmogorov-Smirnov and Shapiro Wilk) confirmed that the age of AAOS member was not normally distributed. Therefore, a Kruskal Wallis test was used to determine the statistical associations between age and self-reported LGBTQ+ status. Chi-square tests were used to determine bivariate statistical associations between categorical demographic characteristics and self-reported LGBTQ+ status. A multivariable logistic regression model was developed to identify the independent demographic characteristics associated with respondents who self-reported LGBTQ+ identity. Further stratified analyses were not conducted to protect the anonymity of AAOS members. An alpha level of 5% was established a priori to define statistical significance. RESULTS: Overall, 3% (109 of 3679) and fewer than 1% (3 of 16,182) of the AAOS members (surgeons, clinicians, allied healthcare providers, and researchers) who updated their membership profiles reported identifying as a sexual (lesbian, gay, bisexual, queer) or gender minority (nonbinary or transgender), respectively. No individual self-identified as transgender. Five percent (33 of 603) of women and 3% (80 of 3042) of men self-identified as a sexual minority (such as lesbian, gay, bisexual, or queer). AAOS members who self-identified as LGBTQ+ were younger (OR 0.99 [95% confidence interval (CI) 0.98 to 0.99]; p < 0.001), less likely to self-identify as women (OR 0.86 [95% CI 0.767 to 0.954]; p < 0.001), less likely to be underrepresented in medicine (OR 0.49 [95% CI 0.405 to 0.599]; p < 0.001), and less likely to be an emeritus or honorary member (OR 0.75 [95% CI 0.641 to 0.883]; p < 0.003). CONCLUSION: The proportion of self-reported LGBTQ+ AAOS members is lower than the 7% of the general US population. The greater proportion of younger AAOS members reporting this information suggests progress in the pursuit of a more-diverse field. CLINICAL RELEVANCE: The study findings support standardized collection of sexual orientation and gender identity data to better identify and address diversity gaps. As orthopaedic surgery continues to transform to reflect the diversity of musculoskeletal patients, all orthopaedic professionals (surgeons, clinicians, allied healthcare providers, and researchers), regardless of their identities, are essential in the mission to provide equitable and informed orthopaedic care. Sexual and gender minority individuals may serve as important mentors to the next generations of orthopaedic professionals; individuals from nonminority groups should serve as important allies in achieving this goal.

Knowledge, Attitudes, and Practices in the Orthopaedic Care of Sexual and Gender Minority Youth: A Survey of Two Pediatric Academic Hospitals.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) children and adolescents continue to experience unmet healthcare needs, partly because of clinician biases, discrimination, and inadequate education. Although clinician attitudes and knowledge related to sexual and gender minority health have been well studied in other medical specialties, these have been scarcely studied in orthopaedics. QUESTIONS/PURPOSES: (1) What are pediatric orthopaedic healthcare professionals' attitudes (perceived importance, openness, comfort, and confidence) toward caring for sexual and gender minority youth? (2) What do pediatric orthopaedic healthcare professionals know about caring for this patient population? (3) What factors are associated with clinician attitude and/or knowledge? (4) What existing initiatives to improve orthopaedic care for this population are clinicians aware of at their home institutions? METHODS: All 123 orthopaedic healthcare professionals at two pediatric academic hospitals in the Midwestern and Northeastern United States were sent a 34-question, internet-based, anonymous survey. The survey queried respondent demographics, attitudes, knowledge, and practice behaviors at their home institutions related to the care of sexual and gender minority youth. Respondent attitudes were queried using the Attitudes Summary Measure, which is a survey instrument that was previously validated to assess clinicians' attitudes regarding sexual and gender minority patients. Items used to assess knowledge and practice behaviors were developed by content experts in LGBTQ health and/or survey design, as well as orthopaedic surgeons to improve face validity and to mitigate push-polling. Attitude and knowledge items used a 5-point Likert scale. Sixty-six percent (81 of 123) of clinicians completed the survey. Of those, 47% (38 of 81) were physicians, 73% (59 of 81) were licensed for fewer than 20 years, 63% (51 of 81) were women, and 53% (43 of 81) described themselves as liberal-leaning. The response proportions were 73% (38 of 52) among eligible physicians specifically and 61% (43 of 71) among other clinicians (nurse practitioners, physician assistants, and registered nurses). To assess potential nonresponse bias, we compared early responders (within 2 weeks) with late responders (after 2 weeks) and found no differences in responder demographics or in questionnaire responses (all p > 0.05). The main outcome measures included responses to the attitude and knowledge questionnaire, as well as the existing practices questionnaire. To answer our research questions regarding clinician attitudes knowledge and awareness of institutional initiatives, we compared participant responses using chi-square tests, the Student t-test, and the McNemar tests, as appropriate. To answer our research question on factors associated with questionnaire responses, we reported data for each question, stratified by hospital, years since licensure, and political leaning. Comparisons were conducted across strata using chi-square tests for Likert response items and ANOVA for continuous response items. All p values less than 0.05 were considered significant. RESULTS: Of the respondents who reported feeling comfortable treating lesbian, gay, and bisexual (sexual minority) youth, a small proportion reported feeling confident in their knowledge about these patients' health needs (99% [80 of 81] versus 63% [51 of 80], 36% reduction [95% confidence interval 23% to 47%]; p < 0.001). Similarly, of those who reported feeling comfortable treating transgender (gender minority) youth, a smaller proportion reported feeling confident in their knowledge of their health needs (94% [76 of 81] versus 49% [37 of 76], 45% reduction [95% CI 31% to 59%]; p < 0.001). There was substantial interest in receiving more education regarding the health concerns of LGBTQ people (81% [66 of 81]) and being listed as an LGBTQ-friendly clinician (90% [73 of 81]). Factors that were associated with select attitude and knowledge items were duration of licensure and political leaning; gender identity, institutional affiliation, educational degree, or having LGBTQ friends and family were not associated. Many respondents were aware of the use of clinic intake forms and the electronic medical record to collect and provide patient gender identity and sexual orientation data at their practice, as well as signage and symbols (for example, rainbow posters) to cultivate LGBTQ-welcoming clinic spaces. CONCLUSION: There were varying degrees of confidence and knowledge regarding the health needs of sexual and gender minority youth among pediatric orthopaedic healthcare professionals. There was considerable interest in more focused training and better use of medical technologies to improve care for this population. CLINICAL RELEVANCE: The study findings support the further investment in clinician training opportunities by healthcare administrators and orthopaedic associations related to the care of sexual and gender minority patients, as well as in the expansion of medical documentation to record and report important patient information such as pronouns and gender identity. Simultaneously, based on these findings, clinicians should engage with the increasing number of educational opportunities, explore their personal biases, and implement changes into their own practices, with the ultimate goal of providing equitable and informed orthopaedic care.

Fracture through tracking pin sites following a robotic-assisted total knee arthroplasty.

The use of computer-navigated, robotic-assisted total knee arthroplasty (TKA) is expanding as the result of widespread efforts to improve the precision of implant placement and to restore mechanical, anatomic, and kinematic alignment. The procedure requires placement of femoral and tibial pins to mount the robotic tracking system. Fractures through tracking pin sites following robotic-assisted TKA are rare; only 30 cases have been reported to our knowledge. It is probable that this complication will become more frequent as the use of robotic-assisted TKAs continues to grow. We report the case of a 67-year-old female who suffered a fracture of the femur through two pin sites 3 months after a robotic-assisted TKA. We believe that this report is the first case in the radiologic literature. Our case demonstrates some of the difficulties of recognizing this complication and raises questions about appropriate post-operative imaging.

Validation of a Novel Magnetic Resonance Imaging Classification for Osteochondritis Dissecans of the Knee.

BACKGROUND: The novel Kocher classification is a 3-group magnetic resonance imaging (MRI) classification system for osteochondritis dissecans (OCD) of the knee that was shown to have comparable reliability to that of the established 5-group Hefti classification. The purpose of this study was to evaluate the validity and clinical utility of this simplified system as an alternative to the Hefti classification. METHODS: Demographic data and arthroscopic findings were retrospectively collected from medical and surgical records of 144 consecutive knees in children with arthroscopically diagnosed knee OCD. OCD lesions on preoperative MRIs and surgical reports (serving as the reference standard) were assessed by independent raters and assigned both a Kocher and Hefti classification. Agreement between MRI classification and arthroscopic findings for both systems was assessed using weighted kappa (kw) coefficients. Validation, accuracy, sensitivity, and specificity were measured by comparing a dichotomized Kocher classification for MRI and arthroscopy, and by estimating Cohen kappa (kc) coefficients. Agreement between arthroscopic findings and treatment type was measured using the Spearman correlation coefficient. RESULTS: Inter-rater reliability between the 2 MRI raters was substantial for the Kocher classification [ka=0.66; 95% confidence interval (CI)=0.56-0.75] and moderate for the Hefti classification (ka=0.57; 95% CI=0.47-0.67). There was no difference detected in the agreement statistics for Kocher versus Hefti classifications (P=0.89). Binary agreement using dichotomized Kocher classifications was worse than the 3-group category classification. When dichotomized, combining Kocher grades 1 and 2 demonstrated moderate agreement (kc=0.41; 95% CI=0.25-0.58), and combining grades 2 and 3 demonstrated fair agreement (kc=0.34; 95% CI=0.21-0.48). There was a strong correlation between arthroscopy-based finding and treatment category for both the Kocher classification (r=0.85; 95% CI=0.80-0.89) and the Hefti classification (r=0.82; 95% CI=0.75-0.86). CONCLUSION: The validity and clinical utility of the newer 3-group Kocher classification for knee OCD is comparable to that of the well-established 5-group Hefti classification. Both systems help determine lesion stability and characteristics on MRI, which correlate closely to arthroscopic findings. This simplified classification system, with less uncertainty, provides a foundation for further outcomes research to develop an evidence-based algorithm for effective surgical management of OCD lesions of the knee. LEVEL OF EVIDENCE: Level II-diagnostic study.

Utility of Stability and Tear Location in a Classification System for Discoid Meniscus Surgical Planning.

BACKGROUND: Despite the presence of multiple classification systems for discoid meniscus, no system has yet to demonstrate utility in predicting the need for meniscal repair. The purpose of this study was to correlate characteristics associated with meniscal repair and propose a model that can inform preoperative planning and initial counseling of surgical plans and expectations. METHODS: Medical and operative records of 434 knees with lateral discoid meniscus in children and adolescents treated between 1991 and 2016 were reviewed retrospectively to determine the surgical procedure performed (saucerization with or without meniscal repair), discoid meniscal morphology and stability, and location and type of any associated tear. Univariate associations between discoid meniscal characteristics and surgery type were calculated and a logistic regression model of surgery type was generated. RESULTS: In univariate models, unstable menisci (93%, or 179/204, P<0.001) and menisci with tears extending peripherally (75%, or 85/204, P<0.001) were more likely to receive surgery with repair. In isolation, instability demonstrated 89% sensitivity and 94% specificity in predicting surgery with repair. A logistic regression model including stability, tear, and their interaction (stability×tear) showed that that the odds of unstable lateral discoid menisci receiving surgery with repair was 114 times higher than stable menisci (P<0.001) while lateral discoid menisci with peripherally extending tears had 6.4 times higher odds of receiving repair than those that had an isolated central tear (P<0.001). CONCLUSION: Stability and tear location of lateral discoid menisci were associated with surgical treatment in univariate and logistic regression models. The proposed classification system, in which menisci are classified by stability [Stable (S0), Unstable (S1), morphology (Incomplete (M0), Complete (M1))], and tear [No tear (T0), Central tear, isolated (T1), or Central tear, peripheral extension (T2)], is easily remembered and predicts surgical repair for discoid menisci. This scheme can serve to inform preoperative planning and initial counseling of primary surgical management and postoperative expectations. Subsequent research should develop a system that predicts meniscal survival and patient outcomes following the index operation. LEVEL OF EVIDENCE: Level III.

Incidence and Risk Factors for Heterotopic Ossification in a Matched Cohort Adolescent Population Undergoing Hip Arthroscopy.

BACKGROUND: Heterotopic ossification (HO) is a known complication after hip arthroscopy in adults, positively associated with larger cam resection, male sex, older age, and obesity, and negatively associated with nonsteroidal anti-inflammatory drug (NSAID) use and capsular closure. However, it has not been well-documented in adolescents. The purpose of this study was to determine the incidence and risk factors for the development of HO in adolescent patients undergoing hip arthroscopy. METHODS: Clinical and operative records from a pediatric institution were queried to identify patients aged 21 years or younger who underwent hip arthroscopy between 2008 and 2018. The 27 cases that developed HO were matched 1:4 on age and sex with 107 controls. The bivariate analysis assessed the relationship between demographic and perioperative factors on the development of HO. Multivariable logistic regression evaluated the association between prophylactic NSAID use (indomethacin 75 mg, 3 wk) and HO, controlling for surgeon and extent of cam resection (change in alpha angle). RESULTS: Twenty-seven of 595 (4.5%) hips that underwent hip arthroscopy developed HO within 2 years of surgery. Prophylactic indomethacin was not significantly associated with developing HO [30% (8/27), P=0.83], after controlling for surgeon and extent of cam resection-nor were age, sex, and body mass index percentile. Of patients who developed HO, a smaller proportion underwent reoperation for HO excision among those who received prophylactic indomethacin than those who did not [13% (1/8) vs. 63% (12/19), P=0.03]. CONCLUSIONS: The incidence of HO within 2 years of hip arthroscopy in this adolescent population was 4.5%. Although studies in the adult hip arthroscopy population have pointed to a protective role of NSAIDs (eg, indomethacin) in radiographic HO, the effect was less certain in this adolescent sample. Larger studies are important to further evaluate the role of prophylactic NSAIDs and variations in arthroscopic technique in developing HO. LEVEL OF EVIDENCE: Level III-therapeutic, case-control study.

Surgical Management of Medial Discoid Meniscus in Pediatric and Adolescent Patients.

BACKGROUND: Medial discoid meniscus (MDM) is an exceedingly rare anatomic abnormality that presents similarly to other meniscal pathologies. Symptomatic MDM is typically managed arthroscopically with mixed short-term and long-term outcomes, although the existing knowledge about MDM is limited. The purpose of this study was to describe the presentation and surgical treatment of MDM in pediatric and adolescent patients. METHODS: Medical records of 12 knees with MDM in 8 pediatric and adolescent patients treated between 1991 and 2016 were reviewed retrospectively for patient characteristics, clinical manifestations, radiographic findings, operative techniques, and surgical outcomes. RESULTS: Of the 446 knees diagnosed arthroscopically with discoid menisci, lateral discoid meniscus was noted in 434 knees (97.3%) and MDM was present in 12 knees (2.7%). The MDM series included 8 patients of mean age 13.8 years (range: 7.8 to 19.8), of which 5 were males (63%), and 4 (50%) had bilateral involvement. Of the 11 knees with available clinical records, all cases presented symptomatically (pain, mechanical symptoms); 10 (91%) had concurrent physical exam findings. On intraoperative examination, discoid morphologies were described as complete in 4/8 knees (50%) or incomplete in 4/8 (50%), with associated instability in 6/12 (50%). Meniscal tears were reported in 9 cases (75%)-primarily, horizontal cleavage tears. Saucerization was performed in 11 knees (92%), with medial meniscal repair in 7 (58%), when indicated. Retear of the medial meniscus occurred in 4/11 knees (36%) at a mean of 25.8 months postoperation; 2 knees required revisions. One knee developed arthrofibrosis and underwent arthroscopic lysis of adhesions. CONCLUSIONS: MDM is a rare diagnosis, representing 3% of all discoid menisci, with a nonspecific clinical manifestation. Operative management of symptomatic MDM typically involves saucerization and meniscal repair, when indicated, for concurrent tears. Symptom resolution is common short-term, but long-term outcomes include recurrent meniscal tears. Subsequent observational studies are important to evaluate long-term outcomes, such as arthritic changes, with the advancement of arthroscopic techniques for meniscal preservation. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Symptomatic Discoid Meniscus in Children and Adolescents: A Review of 470 Cases.

BACKGROUND: Discoid meniscus is a congenital variant, typically involving the lateral meniscus, that comprises a spectrum of meniscal shapes and degrees of instability in an estimated 1% to 15% of the population. The purpose of this study was to describe the clinical and operative course of a large cohort of children and adolescents patients with symptomatic lateral discoid meniscus. METHODS: Medical records of 470 knees with symptomatic lateral discoid meniscus in 401 patients ages 18 years or younger diagnosed at a single institution between 1991 and 2016 were reviewed retrospectively for patient characteristics, treatment course (nonoperative and/or operative), and complications. Surgical reports were reviewed in the operative group. RESULTS: The series included 401 patients of mean age 11.6 years (range: 1 mo-18.9 y), of which 222 (55%) were female, and 69 (17%) had bilateral involvement. Of 470 knees, 83 (18%) were initially managed nonoperatively. Of these, 32 knees (39%) failed nonoperative management and were converted to surgical treatment at a median of 7.9 months (interquartile range: 4.0-15.1). In total, 419 knees were managed surgically with saucerization (partial meniscectomy) with or without meniscal repair/stabilization; 84 knees (20%) required at least one concurrent nonmeniscal procedure. Discoid meniscus tears were reported in 264/419 knees (63%) intraoperatively; horizontal cleavage tears were most common. Reoperation was required for 66/379 cases (17%) with clinical follow-up, at a median of 19.6 months (range: 9.2-34.9) after index saucerization; 60/379 cases (16%) had ongoing pain and/or mechanical symptoms at final follow-up. CONCLUSION: With a failure rate of 39% (32/83 knees), nonoperative management for discoid lateral meniscus frequently convert to surgical treatment. During surgery, meniscus tearing and instability are common and should be anticipated. Postoperatively, 33% (126/379) of knees with clinical follow-up underwent either reoperation, or had ongoing symptoms of the knee at final follow-up. Discoid mensical retear is the most common complication (94%, 62/66) prompting repeat surgery, and should be discussed with families before the index operation. LEVEL OF EVIDENCE: Level IV-descriptive case series.

Novel Magnetic Resonance Imaging Classification of Osteochondritis Dissecans of the Knee: A Reliability Study.

BACKGROUND: Current advanced imaging classification systems for osteochondritis dissecans (OCD) of the knee grade severity of disease by identifying certain lesion characteristics. The most widely used are the Hefti and Nelson systems. A novel classification presents a simpler 3-group approach to diagnose knee OCD by magnetic resonance imaging (MRI), compared with the Hefti (5-group) and Nelson (4-group) classifications. The purpose of this study was to compare the reliability of this novel classification with that of the more complex, established systems-an initial step in establishing validity and clinical utility. METHODS: In total, 120 standardized knee MRIs of patients with established knee OCD were preselected to capture the spectrum of lesion types, with regard to both progression and location of the lesion. Each of the MRIs were independently classified by 2 readers into the novel, Hefti, and Nelson classification systems. A random sample was rereviewed by 1 rater 6 weeks after initial review. The inter-rater and intrarater agreements were evaluated by estimating Krippendorff α. RESULTS: In total, 106 knees were classified by the novel, Hefti, and Nelson classification systems, as 14 of the knees lacked the necessary MRI sequences. There were no differences in inter-rater and intrarater agreement across classification systems. Krippendorff α for inter-rater agreement was 0.51 (95% confidence interval, 0.33-0.66) for the Hefti classification, 0.50 (0.34-0.64) for the Nelson classification, and 0.49 (0.32-0.65) for the novel classification. The intrarater agreement was 0.88 (0.75-0.97) for the Hefti classification, 0.94 (0.86-0.99) for the Nelson classification, and 0.98 (0.94-1.00) for the novel classification system. CONCLUSIONS: The novel classification for knee OCD demonstrated near-perfect intrarater agreement and moderate inter-rater agreement, consistent with the current, well-established classification systems. Pending a subsequent study on validity and clinical utility, this simpler classification system may offer an alternative, noninvasive diagnostic method to guide clinical treatment. LEVEL OF EVIDENCE: Level IV.

Long-term Minimum 15-Year Follow-up After Lateral Discoid Meniscus Rim Preservation Surgery in Children and Adolescents.

BACKGROUND: Discoid meniscus is a congenital variant typically affecting the lateral meniscus of the knee. Historically, surgical intervention when symptomatic consisted of total meniscectomy; however, after degenerative changes were observed, current treatments now focus on rim preservation with arthroscopic saucerization and meniscal repair for instability, when indicated. The purpose of our study was to examine long-term patient-reported outcomes of lateral discoid meniscus (LDM) treated with meniscal-preserving techniques. METHODS: Ninety-eight patients treated arthroscopically for LDM at a single institution at a minimum of 15 years ago were retrospectively identified and contacted by mailers and telephone to participate. Subjective functional outcomes and patient satisfaction data were collected using a questionnaire that included the validated International Knee Documentation Committee Subjective Knee Evaluation Form, Lysholm Score, Marx Activity Rating Scale, Tegner Activity Score, and Western Ontario and McMaster University Osteoarthritis Index Osteoarthritis Index. Patient and surgical characteristics and patient-reported outcomes were summarized by mean and SD, median and interquartile range (interquartile range), or frequency and percent, as appropriate. RESULTS: Of the 46 patients contacted (response rate of 46/98 eligible), 25 (54%) completed the questionnaires. The mean (±SD) age at initial surgery was 10.8 (±3.4) and 30.3 (±3.7) years at final follow-up. The mean (±SD) follow-up time from initial surgery was 19.5 (±2.8) years (range, 16 to 27). Patient-reported outcomes included: International Knee Documentation Committee 77.4±17.2, Lysholm 78.6±21, Western Ontario and McMaster University Osteoarthritis Index 7.6±11.3, Tegner Activity 7 (of 10), and Marx Activity Rating Scale 8 (of 10). Eleven (44%) cases underwent subsequent LDM-related surgery on the ipsilateral knee(s). There were no cases of total knee replacement. CONCLUSIONS: Overall, patient-reported outcomes were favorable at a minimum of 15-year follow-up after rim-preserving saucerization of LDM. While two thirds of patients were satisfied with their surgical outcomes, nearly half of patients underwent revision saucerization with or without meniscal repair. Subsequent long-term follow-up studies with objective outcome measures are important to further elucidate the natural history of LDM and understand how rim-preserving procedures may prevent the development of degenerative processes. LEVEL OF EVIDENCE: Level IV-case series, prognostic study.

Antimony and sleep-related disorders: NHANES 2005-2008.

BACKGROUND: Antimony is used as a flame-retardant in textiles and plastics, in semiconductors, pewter, and as pigments in paints, lacquers, glass and pottery. Subacute or chronic antimony poisoning has been reported to cause sleeplessness. The prevalence of short sleep duration (<7h/night) has been reported to be 37.1% in the general US population, and obstructive sleep apnea (OSA) affects 12-28 million US adults. Insufficient sleep and OSA have been linked to the development of several chronic conditions including diabetes, cardiovascular disease, obesity and depression, conditions that pose serious public health threats. OBJECTIVE: To investigate whether there is an association between antimony exposure and sleep-related disorders in the US adult population using the National Health and Nutrition Examination Survey (NHANES) 2005-2008. METHODS: We performed multivariate logistic regression to analyze the association of urinary antimony with several sleep disorders, including insufficient sleep and OSA, in adult (ages 20 years and older) participants of NHANES 2005-2008 (n=2654). RESULT: We found that participants with higher urinary antimony levels had higher odds to experience insufficient sleep (≤6h/night) (OR 1.73; 95%CI; 1.04, 2.91) as well as higher odds to have increased sleep onset latency (>30min/night). Furthermore, we found that higher urinary antimony levels in participants were associated with OSA (OR 1.57; 95%CI; 1.05, 2.34), sleep problems, and day-time sleepiness. CONCLUSION: In this study, we found that urinary antimony was associated with higher odds to have insufficient sleep and OSA. Because of the public health implications of sleep disorders, further studies, especially a prospective cohort study, are warranted to evaluate the association between antimony exposure and sleep-related disorders.

Acrolein metabolites, diabetes and insulin resistance.

Acrolein is a dietary and environmental pollutant that has been associated in vitro to dysregulate glucose transport. We investigated the association of urinary acrolein metabolites N-acetyl-S-(3-hydroxypropyl)-l-cysteine (3-HPMA) and N-acetyl-S-(carboxyethyl)-l-cysteine (CEMA) and their molar sum (∑acrolein) with diabetes using data from investigated 2027 adults who participated in the 2005-2006 National Health and Nutrition Examination Survey (NHANES). After excluding participants taking insulin or other diabetes medication we, further, investigated the association of the compounds with insulin resistance (n=850), as a categorical outcome expressed by the homeostatic model assessment (HOMA-IR>2.6). As secondary analyses, we investigated the association of the compounds with HOMA-IR, HOMA-ß, fasting insulin and fasting plasma glucose. The analyses were performed using urinary creatinine as independent variable in the models, and, as sensitivity analyses, the compounds were used as creatinine corrected variables. Diabetes as well as insulin resistance (defined as HOMA-IR>2.6) were positively associated with the 3-HPMA, CEMA and ∑Acrolein with evidence of a dose-response relationship (p<0.05). The highest 3rd and 4th quartiles of CEMA compared to the lowest quartile were significantly associated with higher HOMA-IR, HOMA-ß and fasting insulin with a dose-response relationship. The highest 3rd quartile of 3-HPMA and ∑Acrolein were positively and significantly associated with HOMA-IR, HOMA-ß and fasting insulin. These results suggest a need of further studies to fully understand the implications of acrolein with type 2 diabetes and insulin.

Retained wooden splinter migrated within a digital flexor tendon sheath: Ultrasonographic diagnosis for presurgical planning.

A 29-year-old right-handed woman presented to an outside emergency department with right small finger pain, swelling, and concern for a retained wooden splinter. Diagnosis and treatment were delayed for 2 weeks due to the inability to identify the foreign body clinically or radiographically. Ultimately, ultrasonography by a fellowship-trained specialist was used to localize the wooden splinter. It was embedded within the flexor tendon sheath but had migrated away from its initial point of entry. The patient underwent subsequent surgical extraction, irrigation, and debridement. Two weeks following surgery, she had regained full range of motion through her digit without signs of infection. This case highlights the use of diagnostic ultrasound to identify a radiolucent foreign body, such as a wooden splinter, and to guide subsequent surgical extraction.

Management of Meniscus Pathology with Concomitant Anterior Cruciate Ligament Injury.

PURPOSE OF REVIEW: The purpose of this review is to summarize current clinical knowledge on the prevalence and types of meniscus pathology seen with concomitant anterior cruciate ligament (ACL) injury, as well as surgical techniques, clinical outcomes, and rehabilitation following operative management of these pathologies. RECENT FINDINGS: Meniscus pathology with concomitant ACL injury is relatively common, with reports of meniscus pathology identified in 21-64% of operative ACL injuries. These concomitant injuries have been associated with increased age and body mass index. Lateral meniscus pathology is more common in acute ACL injury, while medial meniscus pathology is more typical in chronic ACL deficiency. Meniscus tear patterns associated with concomitant ACL injury include meniscus root tears, lateral meniscus oblique radial tears of the posterior horn (14%), and ramp lesions of the medial meniscus (8-24%). These meniscal pathologies with concomitant ACL injury are associated with increased rotational laxity and meniscal extrusion. There is a paucity of comparative studies to determine the optimal meniscus repair technique, as well as rehabilitation protocol, depending on specific tear pattern, location, and ACL reconstruction technique. There has been a substantial increase in recent publications demonstrating the importance of meniscus repair at the time of ACL repair or reconstruction to restore knee biomechanics and reduce the risk of progressive osteoarthritic degeneration. Through these studies, there has been a growing understanding of the meniscus tear patterns commonly identified or nearly missed during ACL reconstruction. Surgical management of meniscal pathology with concomitant ACL injury implements the same principles as utilized in the setting of isolated meniscus repair alone: anatomic reduction, biologic preparation and augmentation, and circumferential compression. Advances in repair techniques have demonstrated promising clinical outcomes, and the ability to restore and preserve the meniscus in pathologies previously deemed irreparable. Further research to determine the optimal surgical technique for specific tear patterns, as well as rehabilitation protocols for meniscus pathology with concomitant ACL injury, is warranted.

Use of Social Media in Orthopaedic Surgery Training and Practice: A Systematic Review.

Background: Social media use has grown across healthcare delivery and practice, with dramatic changes occurring in response to the coronavirus (COVID-19) pandemic. The purpose of this study was to conduct a comprehensive systematic review to determine the current landscape of social media use by (1) orthopaedic surgery residencies/fellowship training programs and (2) individual orthopaedic surgeons and the change in use over time. Methods: We searched 3 electronic databases (PubMed, MEDLINE, and Embase) from their inception to April 2022 for all studies that analyzed the use of social media in orthopaedic surgery. Two reviewers independently determined study eligibility, rated study quality, and extracted data. Methodology was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results: Twenty-eight studies were included, of which 11 analyzed social media use by orthopaedic surgery residency and fellowship training programs and 17 examined its use by individual orthopaedic surgeons. Among residency and fellowship programs, Instagram was identified as the most common platform used, with 42% to 88% of programs reporting program-specific Instagram accounts, followed by Twitter/X (20%-52%) and Facebook (10%-38%). Social media was most commonly used by programs for recruitment and information dissemination to prospective residency applicants (82% and 73% of included studies, respectively). After the start of the COVID-19 pandemic, there was a 620% and 177% increase in the number of training programs with Instagram and Twitter/X accounts, respectively. Individual use of social media ranged from 1.7% to 76% (Twitter/X), 10% to 73% (Facebook), 0% to 61% (Instagram), 22% to 61% (LinkedIn), and 6.5% to 56% (YouTube). Conclusions: Instagram, Twitter/X, and Facebook are the premier platforms that patients, residency applicants, and institutions frequent. With the continued growth of social media use anticipated, it will be critical for institutions and individuals to create and abide by guidelines outlining respectful and professional integration of social media into practice. Level of Evidence: Level IV.

Management and subsequent outcomes of patellar sleeve injuries: A retrospective case series of 90 pediatric and adolescent patients.

Purpose: This study aims to report the epidemiology of patellar sleeve injuries, describe diagnostic findings and treatment, and assess functional outcomes following different treatments. Methods: A medical database was queried from 1990 to 2016 to identify patients ≤18 years presenting to a single pediatric institution with a patellar sleeve injury. Patients with significant comorbidities or previously operatively treated for ipsilateral knee injuries were excluded. Standard demographic data, mechanism of injury, skeletal maturity, injury-related radiographic parameters, along with treatment paradigms, post-treatment clinical and radiographic findings, and patient-reported outcomes were collected. Results: A total of 90 patients, mean age of 10.7 years (range: 7-17) was included, of which 69 (77%) were male. Seventy-three percent of all injuries occurred while playing sports (particularly football/basketball/soccer), with "direct blow" or "landing" being the most prevalent mechanisms of injury. Twenty-six (29%) underwent operative treatment, with transosseous suture fixation being the most popular surgical technique (73%). Of the 64 (71%) non-operatively treated patients, 18 (39%) were placed in a hinged knee brace locked in extension with the remainder split between casting and standard knee immobilizer. Compared to the non-operative cohort, a higher percentage of the operative group had a pre-treatment extensor lag (p < 0.001) and greater fragment displacement (p < 0.001) with patella alta (p < 0.001) on imaging. There was no difference in outcome scores (Pedi-IKDC/Lysholm) or patella alta on radiographs between groups. Post-treatment surveys indicated no difference in residual pain or ability to return to sport. Conclusion: This large case series provides valuable epidemiologic, clinical, and radiographic data describing patellar sleeve fractures, along with outcomes following non-operative and operative treatments. Level of evidence: IV.

Iliac Crest Allograft with Plate Osteosynthesis for a Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Donor-Site Fracture: A Case Report.

CASE: A 20-year-old man sustained a comminuted bone-patellar tendon-bone donor-site fracture 17 days after a contralateral anterior cruciate ligament revision reconstruction. Successful fixation was achieved by using a tricortical iliac crest allograft bone plug with mesh plate osteosynthesis. At 6 months of follow-up, the patient had full range of motion without pain. CONCLUSION: Patellar fractures after bone-patellar tendon-bone harvest may be treated successfully with mesh plate osteosynthesis and a tricortical iliac crest allograft bone plug. This unique fixation option addresses bone loss and restores the extensor mechanism while avoiding autograft donor site morbidity.

Management of Scaphotrapeziotrapezoid Osteoarthritis: A Critical Analysis Review.

¼ The scaphotrapeziotrapezoid (STT) joint is a common location of degenerative osteoarthritis (OA) in the wrist.¼ STT OA may occur in isolation or with concomitant thumb carpometacarpal joint (CMCJ) OA or scapholunate advanced collapse (SLAC) and other wrist OA patterns.¼ Nonoperative management strategies include activity modification, bracing, anti-inflammatory medications, occupational therapy, and injections.¼ Surgical treatment may be determined by whether the STT OA occurs in isolation or with concomitant thumb CMCJ or SLAC OA and includes STT arthrodesis, distal scaphoid excision with or without interposition or implant arthroplasty, trapeziectomy with proximal trapezoid excision, four-corner fusion in combination with scaphoid/radial column excision, and proximal row carpectomy.

Surgical Stabilization for Recurrent Patellar Instability in Competitive Wrestlers: Outcomes, Reoperations, and Return to Play at 6-Year Mean Follow-up.

BACKGROUND: The extent to which recurrent patellar instability (RPI) affects wrestlers has not been thoroughly examined. PURPOSE: To assess return to wrestling (RTW), patient-reported outcomes, and reoperation rates after patellofemoral stabilization surgery (PFSS) for RPI in a cohort of competitive wrestlers. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: All competitive wrestlers with a history of RPI and subsequent PFSS performed at a single institution between 2000 and 2020 were identified. Primary PFSS procedures included medial patellofemoral (MPFL) reconstruction (n = 31; 50%); MPFL repair (n = 22; 35.5%); or other PFSS (n = 9; 14.5%), such as tibial tubercle osteotomy, lateral retinacular release, and/or medial retinacular reefing. Exclusion criteria included revision PFSS or concomitant anterior cruciate ligament reconstruction or multiligament knee injury. Surgical failure was defined as subsequent patellar dislocation despite operative management or need for secondary PFSS. RESULTS: Ultimately, 62 knees in 56 wrestlers with a mean age of 17.0 years (range, 14.0-22.8 years) were included at a mean follow-up of 6.6 years (range, 2.0-18.8 years). RTW occurred in 55.3% of wrestlers at a mean ± SD 8.8 ± 6.7 months. Among PFSS types, no differences were observed in rates of RTW (P = .676), postoperative pain (P = .176), Tegner activity level (P = .801), International Knee Documentation Committee (P = .378), Lysholm (P = .402), or Kujala scores (P = .370). RPI was the most common postoperative complication (n = 13; 21.0%). MPFL reconstruction had the lowest rate of RPI (6.5% vs 27.3% [repair] vs 55.6% [other]; P = .005) and surgical failure (9.7% vs 31.8% [repair] vs 55.6% [other]; P = .008). Kaplan-Meier survivorship free from surgical failure of the entire cohort was 91.9% at 1 year, 77.7% at 5 years, and 65.7% at 15 years. MPFL reconstruction had the highest survivorship when compared with MPFL repair and other PFSS up to 10 years after the index surgery (90.3% vs 64.1% vs 27.8%; P = .048). CONCLUSION: RPI remains a concern for competitive wrestlers after PFSS. MPFL reconstruction may serve as a more durable surgical treatment option with lower rates of RPI and failure when compared with other PFSS procedures at up to 10 years after surgery.