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.

The Majority of Black Orthopaedic Surgeons Report Experiencing Racial Microaggressions During Their Residency Training.

BACKGROUND: Orthopaedic surgery is the least-diverse surgical specialty based on race and ethnicity. To our knowledge, the impact of this lack of diversity on discriminatory or noninclusive experiences perceived by Black orthopaedic surgeons during their residency training has never been evaluated. Racial microaggressions were first defined in the 1970s as "subtle verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults to the target person or group." Although the term "microaggression" has long been established, more recently, as more workplaces aim to improve diversity, equity, and inclusion, it has entered the medical profession's lexicon as a means of describing the spectrum of racial discrimination, bias, and exclusion in the healthcare environment. QUESTION/PURPOSES: (1) What is the extent of discrimination that is perceived by Black orthopaedic surgeons during residency? (2) What subtypes of racial microaggressions (which encompasses racial discrimination, bias, and exclusion) do Black orthopaedic surgeons experience during residency training, and who are the most common initiators of these microaggressions? (3) What feedback statements could be perceived as racially biased to Black orthopaedic surgeons in residency training? (4) Are there gender differences in the reported types of racial microaggressions recalled by Black respondents during residency training? METHODS: An anonymous survey was administered between July 1, 2020, and September 1, 2020, to practicing orthopaedic surgeons, residents, and fellows in the J. Robert Gladden Orthopaedic Society database who self-identify as Black. There were 455 Black orthopaedic surgeons in practice and 140 Black orthopaedic residents or fellows in the database who met these criteria. Fifty-two percent (310 of 595) of participants responded. Fifty-three percent (243 of 455) were practicing surgeons and 48% (67 of 140) were current residents or fellows. Respondents reported their perception of discrimination in the residency workplace using a modified version of the single-item Perceived Occupational Discrimination Scale and were asked to recall any specific examples of experiences with racial discrimination, bias, or exclusion during their training. Examples were later categorized as different subtypes of racial microaggressions and were quantified through a descriptive analysis and compared by gender. RESULTS: Among survey respondents, 34% (106 of 310) perceived a lot of residency workplace discrimination, 44% (137 of 310) perceived some residency workplace discrimination, 18% (55 of 310) perceived a little residency workplace discrimination, and 4% (12 of 310) perceived no residency workplace discrimination. Categorized examples of racial microaggressions experienced in residency were commonly reported, including being confused for a nonphysician medical staff (nurse or physician's assistant) by 87% (271 of 310) of respondents or nonmedical staff (janitorial or dietary services) by 81% (250 of 310) of respondents. Racially explicit statements received during residency training were reported by 61% (190 of 310) of respondents. Thirty-eight percent (117 of 310) of such statements were reportedly made by patients and 18% (55 of 310) were reportedly made by attending faculty. Fifty percent (155 of 310) of respondents reported receiving at least one of nine potentially exclusionary or devaluing feedback statements during their residency training. Among those respondents, 87% (135 of 155) perceived at least one of the statements to be racially biased in its context. The three feedback statements that, when received, were most frequently perceived as racially biased in their context was that the respondent "matched at their program to fulfill a diversity quota" (94% [34 of 36]), the respondent was unfriendly compared with their peers (92% [24 of 26]), or that the respondent was "intimidating or makes those around him/her uncomfortable" (88% [51 of 58]). When compared by gender, Black women more frequently reported being mistaken for janitors and dietary services at 97% (63 of 65), compared with Black men at 77% (187 of 244; p < 0.01). In addition, Black women more frequently reported being mistaken as nurses or physician assistants (100% [65 of 65]) than Black men did (84% [205 of 244]) during orthopaedic residency training (p < 0.01). Black women also more frequently reported receiving potentially devaluing or exclusionary feedback statements during residency training. CONCLUSION: Perception of workplace discrimination during orthopaedic residency training is high (96%) among Black orthopaedic surgeons in the United States. Most respondents reported experiencing discrimination, bias, and exclusion that could be categorized as specific subtypes of racial microaggressions. Several different examples of racial microaggressions were more commonly reported by Black women. Certain feedback statements were frequently perceived as racially biased by recipients. CLINICAL RELEVANCE: To better understand barriers to the successful recruitment and retention of Black physicians in orthopaedics, the extent of racial discrimination, bias, and exclusion in residency training must be quantified. This study demonstrates that racial discrimination, bias, and exclusion during residency, wholly categorized as racial microaggressions, are frequently recalled by Black orthopaedic surgeons. A better understanding of the context of these experiences of Black trainees is a necessary starting point for the development of a more inclusive workplace training environment in orthopaedic surgery.

The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy.

PURPOSE: The purpose of this study is to further evaluate the construct validity and interobserver reliability of a hip arthroscopy virtual simulator using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) global rating scale. METHODS: Thirty participants (23 male/7 female) completed a diagnostic arthroscopy and a loose body retrieval simulation on the VirtaMed Arthros Hip Simulator (Zurich, Switzerland) twice at a minimum of 1 week apart. Subjects consisted of 12 novices (medical students, postgraduate year [PGY] 1-2), 5 intermediate trainees (PGY3-4), 9 senior trainees (PGY5 and fellows), and 4 attending faculty. Simulator metrics were recorded and then compiled to generate a total simulator score (TSS). The loose body retrieval was graded using the ASSET scoring tool. Inter-rater and intrarater reliability for the ASSET for 2 blinded raters and construct validity of the ASSET and the TSS were calculated. Correlation between the TSS, ASSET and individual simulator metrics was determined. RESULTS: Prior simulation experience (P ≤ 0.01) correlated with higher TSS and higher ASSET, while video game experience correlated with higher TSS on the diagnostic module only (P = 0.004). There was a significant difference in ASSET score among all experience groups (P < 0.04). Novices had the lowest mean ASSET whereas experts had the highest mean ASSET with a difference of 17.4 points. Overall performance on the surgical module significantly correlated with the ASSET score (r = 0.444, P = 0.016). There was a significant positive correlation among higher ASSET and number of loose bodies retrieved, operation time, camera path and grasper path length, and percentage of cartilage injury. ASSET demonstrated excellent intrarater reliability and showed substantial or better inter-reliability in 8 of 9 domains. CONCLUSION: The VirtaMed hip arthroscopy simulator demonstrated good construct validity and excellent reliability for simulator-based metrics and ASSET score. Use of both simulator metrics and ASSET offers a more comprehensive performance assessment on hip arthroscopy simulation than either measure alone. CLINICAL RELEVANCE: As virtual reality simulation for arthroscopy becomes more commonplace in orthopaedic training, evaluation of the most effective objective and subjective measures of performance is necessary to optimize simulation training.

Poor results after pyrocarbon interpositional shoulder arthroplasty.

BACKGROUND: This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA). METHODS: The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated. RESULTS: Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months. CONCLUSION: High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Clinical characteristics and patient-reported outcomes of total shoulder arthroplasty after anterior stabilization: a retrospective matched control study.

BACKGROUND: Instability arthropathy is a known cause of glenohumeral osteoarthritis (OA) among patients with and without prior shoulder stabilization. This study aims to compare the clinical, radiographic, and patient-reported outcome measure (PROM) scores among total shoulder arthroplasty (TSA) patients with and without a history of shoulder stabilization. METHODS: A case-control study was performed comparing 20 patients with a history of anterior shoulder stabilization (11 open, 9 arthroscopic) who underwent TSA to a matched cohort of 20 TSA patients without a history of shoulder surgery (mean follow-up = 2.8 years). Patients were matched by sex, age, and baseline American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score within 10 points (mean age 59.6 ± 9.6 years). Patient characteristics, operative findings, and preoperative and postoperative radiographic characteristics for both groups were reported. Comparisons were made regarding PROM scores (ASES, 12-Item Short Form Health Survey (SF-12), Shoulder Activity Scale [SAS], numeric rating scale for pain) at baseline, 2 years, and 5 years and patient satisfaction at 2 years. RESULTS: Intraoperative findings of subscapularis scarring or attenuation was common among patients with prior anterior stabilization. The instability cohort did have a higher percentage of B2/B3 glenoid types than the OA cohort (45% vs. 15%), but this was not significantly different possibly because of the small sample size. At 2 years, both instability and OA groups reported significant improvement in pain, function, and activity level. There was no difference between groups on any PROMs or patient satisfaction level. At 5 years, instability patients had significantly lower scores on the ASES and the SF-12 PCS than the OA group. CONCLUSION: There was notable alterations in both soft tissue and bony morphology among patients with prior anterior stabilization. After TSA, both instability and primary OA groups showed significant improvements at 2 years. However, PROMs for instability patients deteriorated at 5 years compared with the control group. Complex bony and soft tissue imbalances may contribute to more unpredictable long-term PROM scores. Thoughtful preoperative consideration of these factors should influence decision making regarding selection of TSA for management of OA in this complex patient cohort.

Intramedullary Fixation for Displaced Clavicle Fractures in the Adolescent Athlete.

The role of intramedullary (IM) fixation of displaced mid-shaft clavicle fractures in adolescents has not been described. This study analyzes characteristics and outcomes of IM fixation in adolescent clavicle fractures. Patients < 18 years with acute, mid-shaft clavicle fractures treated with IM clavicle pins between March 2007 and August 2013 were reviewed. Outcomes of interest were activity level, fracture pattern, time to union, return to sports and complications. Twenty-nine patients (14.8 years (range 11.4-17.9)) underwent IM pin fixation for a displaced, mid-shaft clavicle fracture, including 7 (24.1%) that were multi-fragmentary (length unstable). Complete displacement (> 100%) occurred in 27/29 (93.1%), with average preoperative shortening length of 18 mm. Union occurred in 100% of patients, at a mean duration of 8 weeks. Among student-athletes (25/29, 86.2%), average return to sport was at 18 weeks post-injury. IM pinning offers stable fixation of clavicle fractures in the active adolescent population.(Journal of Surgical Orthopaedic Advances 29(2):81-87, 2020).

Impact of critical shoulder angle in shoulder pathology: a current concepts review.

Background: This review aims to describe the origin and development of critical shoulder angle (CSA) and its correlation with different shoulder pathologies. Current literature is inconclusive in characterizing the role of CSA in predicting pathology and surgical outcomes. Methods: A literature search of both historical and more contemporary research articles on CSA was conducted to compare data points on the impact of CSA on shoulder pathology and postoperative clinical outcomes. This compilation of studies ranges from retrospective reviews to case series as well as cadaveric imaging studies. Results: The CSA is a reliable radiographic measure in predicting shoulder pathology in correctly oriented radiographs. Surgically modifying the CSA with arthroscopic lateral acromioplasty and results has largely shown improved recovery of strength postoperatively as with no increase in postsurgical complication rates. However, it remains unclear whether surgical alteration of CSA has a role in preventing clinical failure after arthroscopic procedures such as acromioplasty and rotator cuff repair as well as following shoulder arthroplasty. Discussion: Stronger conclusions regarding the prognostic utility of CSA are limited by the fact that most studies evaluating CSA are smaller retrospective cohorts. Moving forward, randomized controlled trials being conducted may offer greater insight as to how CSA can improve patient-reported outcomes postoperatively.

Patellar Fracture Forces Are Not Affected by Proximal Versus Distal Bone Block Anterior Cruciate Ligament Reconstruction Harvest Sites in a Cadaveric Model.

Purpose: To quantify the maximum load to fracture in patellae from which bone-patellar tendon-bone (BPTB) and bone-quadriceps tendon (BQT) autografts have been harvested for anterior cruciate ligament reconstruction in a cadaveric model. Methods: Forty-six fresh-frozen patellae were isolated and divided into the BPTB harvest and BQT harvest groups with matching based on donor age and sex. Computed tomography scans were obtained to calculate bone mineral density (BMD) and patellar height, width, and thickness. BPTB and BQT grafts were harvested from the inferior patella and superior patella, respectively, and then ramped to failure in a 3-point bend test configuration to simulate a postoperative fracture produced by a direct impact after a fall. The presence of fracture, fracture pattern, and maximum load to fracture were recorded. Donor demographic characteristics; patellar height, width, and thickness; and maximum load were compared by the Student t test. Pearson correlations were used to determine whether maximum load was affected by BMD or patellar morphology. The level of significance was set at P < .05. Results: Maximum load to fracture was not significantly different (P = .91) between the BPTB (5.0 ± 2.3 kN) and BQT (5.1 ± 2.6 kN) groups. Maximum load to fracture in the BPTB group did not correlate with BMD (P = .57) or patellar measurements (P = .57 for thickness, P = .43 for width, and P = .45 for height). Maximum load to fracture in the BQT group positively correlated with BMD and negatively correlated with patellar height. Maximum load to fracture in the BQT group did not correlate with patellar thickness or width. Fracture through the harvest site was observed in 87% of BPTB specimens and 78% of BQT specimens. Conclusions: The location of the BPTB or BQT autograft harvest site did not significantly affect patellar load to fracture in a cadaveric model. Clinical Relevance: It is important to understand patellar morphology and the effect of BPTB and BQT graft harvest-site locations on the biomechanical strength of the patella after anterior cruciate ligament reconstruction.

Scaphoid Fractures in Adults Aged 50 Years or Older: Epidemiology and Association With Osteopenia and Nonunion.

BACKGROUND: Scaphoid fractures are less commonly reported in adults older than 50 years. The association between bone density and outcomes following scaphoid fractures has not been explored in this patient population. The second metacarpal cortical percentage (2MCP) has been shown to predict low bone density. The purpose of this study is to describe the epidemiology and radiographic characteristics associated with scaphoid fractures in adults older than 50 years, determine the prevalence of osteopenia defined by 2MCP, and evaluate the characteristics associated with scaphoid nonunion in this population. We hypothesized that osteopenia defined by 2MCP would be common in this patient population and associated with scaphoid nonunion. METHODS: Patients older than 50 years with an acute, closed scaphoid fracture were identified. Demographic data, radiographic characteristics, and outcome data were collected. The 2MCP was measured using standard hand radiographs. RESULTS: A total of 111 patients were identified. Most fractures were nondisplaced and occurred in women via low-energy mechanism. Fifty-six patients (50.5%) had osteopenia defined by a 2MCP less than 60%. Nondisplaced fractures achieved union faster than displaced fractures (P < .05). Displaced, unstable fractures were statistically associated with nonunion (P < .001). 2MCP did not correlate with nonunion. CONCLUSIONS: In adults older than 50 years, scaphoid fractures may represent a fragility fracture cohort given they occur more frequently in female patients via low-energy mechanisms and over half of the cohort had osteopenia defined by a 2MCP less than 60%. Displaced and unstable fractures were statistically more likely to go on to nonunion. Nonunion was not found to be associated with osteopenia.

Gender Equity Efforts in Sports Medicine.

Great progress has been made toward gender equality in athletics, whereas true equality has not yet been realized. Concurrently, women orthopedists along with advocate men have paved the way toward gender equity in orthopedics as a whole and more specifically in sports medicine. The barriers that contribute to gender disparities include lack of exposure, lack of mentorship, stunted career development, childbearing considerations and implicit gender bias and overt gender discrimination.

The Role of Inclusion in Increasing Diversity and Retention Across Surgical Residencies: a Literature Review.

PURPOSE OF REVIEW: Across surgical specialties, residencies are incentivized to improve program diversity, most often through recruitment of underrepresented minority (URM), women, LGBTQ, and disabled applicants. However, residency attrition remains high in these groups, highlighting the need for specific inclusion initiatives to improve retention and support for these cohorts. A better understanding of previous efforts at retention is paramount. This paper reviews the existing literature on inclusion and retention efforts in surgical residencies. RECENT FINDINGS: A literature search was conducted using PubMed Central. Published articles were filtered based on date (2018-2023) and relevancy. Articles were evaluated holistically and focused on methods in increasing diversity and inclusion in residency retention. Through formal literature review focusing on pertinent research topic terms (i.e., inclusion, diversity, residency, surgery, retention), efforts that included inclusion initiatives, improving residency retention, and diversifying leadership were overarching themes. In recent years, there have been marked strides and improvements in encouraging resident diversity and inclusion. However, more widespread efforts with proven efficacy are needed in order to improve residency retention and to increase and maintain diversity in leadership in surgery.

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

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

National Patterns in Utilization of Knee and Hip Arthroscopy: An Analysis of Racial, Ethnic, and Geographic Disparities in the United States.

Background: Racial and ethnic disparities in the field of orthopaedic surgery have been reported extensively across many subspecialties. However, these data remain relatively sparse in orthopaedic sports medicine, especially with respect to commonly performed procedures including knee and hip arthroscopy. Purpose: To assess (1) differences in utilization of knee and hip arthroscopy between White, Black, Hispanic, and Asian or Pacific Islander patients in the United States (US) and (2) how these differences vary by geographical region. Study Design: Descriptive epidemiology study. Methods: The study sample was acquired from the 2019 National Ambulatory Surgery Sample database. Racial and ethnic differences in age-standardized utilization rates of hip and knee arthroscopy were calculated using survey weights and population estimates from US census data. Poisson regression was used to model age-standardized utilization rates for hip and knee arthroscopy while controlling for several demographic and clinical variables. Results: During the study period, rates of knee arthroscopy utilization among White patients were significantly higher than those of Black, Hispanic, and Asian or Pacific Islander patients (ie, per 100,000, White: 180.5, Black: 113.2, Hispanic: 122.2, and Asian: 58.6). Disparities were even more pronounced among patients undergoing hip arthroscopy, with White patients receiving the procedure at almost 4 to 5 times higher rates (ie, per 100,000, White: 12.6, Black: 3.2, Hispanic: 2.3, Asian or Pacific Islander: 1.8). Disparities in knee and hip arthroscopy utilization between White and non-White patients varied significantly by region, with gaps in knee arthroscopy being most pronounced in the Midwest (adjusted rate ratio, 2.0 [95% CI, 1.9-2.1]) and those in hip arthroscopy being greatest in the West (adjusted rate ratio, 5.3 [95% CI, 4.9-5.6]). Conclusion: Racial and ethnic disparities in the use of knee and hip arthroscopy were found across the US, with decreased rates among Black, Hispanic, and Asian or Pacific Islander patients compared with White patients. Disparities were most pronounced in the Midwest and South and greater for hip than knee arthroscopy, possibly demonstrating emerging inequality in a rapidly growing and evolving procedure across the country.

Perception of Racial and Intersectional Discrimination in the Workplace Is High Among Black Orthopaedic Surgeons: Results of a Survey of 274 Black Orthopaedic Surgeons in Practice.

INTRODUCTION: There are approximately 573 practicing Black orthopaedic surgeons in the United States, which represents 1.9% overall. The purpose of this study was to describe this underrepresented cohort within the field of orthopaedic surgery and to report their perception of occupational opportunity and workplace discrimination. METHODS: An anonymous survey was administered to 455 practicing orthopaedic surgeons who self-identify as Black. The 38-question electronic survey requested demographic and practice information and solicited perspectives on race and racial discrimination in current orthopaedic practices and general views regarding occupational opportunity and discrimination. RESULTS: The survey was completed by 274 Black orthopaedic surgeons (60%). Over 97% of respondents believe that Black orthopaedic surgeons in the United States face workplace discrimination. Most Black orthopaedic surgeons (94%) agreed that racial discrimination in the workplace is a problem but less than 20% agreed that the leaders of national orthopaedic organizations are trying sincerely to end it. Black female orthopaedic surgeons reported lower occupational opportunity and higher discrimination than Black male orthopaedic surgeons across all survey items. DISCUSSION: This study is the first to report on the workplace environment and the extent of discrimination experienced by Black surgeons, specifically Black orthopaedic surgeons in the United States. Most respondents, particularly female respondents, agreed that racial discrimination and diminished occupational opportunity are pervasive in the workplace and reported experiencing various racial microaggressions in practice.

Ambulatory versus inpatient shoulder arthroplasty: a population-based analysis of trends, outcomes, and charges.

BACKGROUND: The purpose of this study was to evaluate the clinical outcomes and cost of shoulder arthroplasty (SA) performed in ambulatory surgery centers (ASCs) compared with SA performed in hospital-based surgery settings. METHODS: The State Inpatient Databases and the State Ambulatory Surgery Databases were queried for patients undergoing primary or reverse SA between 2010 and 2014 in 5 states in either the inpatient (IP), hospital outpatient department (HOPD), or ASC setting. Outcomes included all-cause readmissions, emergency department visits within the 90-day postoperative period, and charges. Covariates included patient demographic data and procedure details. Risk factors for readmission were calculated using logistic regression analysis. RESULTS: We identified 795 ASC (2%), 183 HOPD (0.5%), 38,114 (97.5%) SA procedures. The outpatient cohort was overall younger and healthier with a lower percentage of diabetes (14.1% vs. 20.2%), cardiopulmonary disease (11.4% vs. 20.4%), and obesity (10.7% vs. 15.6%). The US state and obesity were factors significantly (P < .0001) associated with readmission. The median IP charge was $62,905 (range, $41,327-$87,881) vs. $37,395 (range, $21,976-$61,775) for combined outpatient cases. When outpatient SA was stratified into ASC and HOPD cases, the median charges were $31,790 for ASC cases vs. $55,990 for HOPD cases (P < .0001). After adjustment for multiple covariates, the charges for combined outpatient SA surgery were 40% lower than those for IP SA surgery (P < .0001). CONCLUSION: As the current health care climate shifts toward lower-cost and higher-quality care, this study demonstrates that SAs performed in ASCs have a comparable safety profile to and significant financial advantage over SAs performed in the hospital-based setting.

Obstacles Affecting the Implementation of the O-SCORE for Assessment of Orthopedic Surgical Skills Competency.

OBJECTIVES: There is a need for meaningful and reliable measures of surgical competency in residency education. The goal of the current study is to incorporate the Ottawa Surgical Competency Operating Room Evaluation (O-SCORE) into the process of resident evaluation at our institution and to assess the feasibility and effectiveness of its use through a web-based platform. DESIGN: This is a feasibility study that prospectively assesses the implementation of a web-based O-SCORE at our institution. Over a 16-week period, 19 orthopedic surgery residents (PGY2-PGY5) participated in a quality improvement study, which involved collecting 2 feedback forms per week. Each form consisted of a resident form and a linked attending form. At the conclusion of the 16-week trial period, residents and faculty members were asked to complete a survey about their perceptions of the O-SCORE program. SETTING: An academic medical center. PARTICIPANTS: The study included only residents in postgraduate training years (PGY) 2 through 5 (n = 20) and attendings (n = 37). RESULTS: During the 16-week study period, 608 resident surveys were requested for the 19 participating residents, of which 404 surveys (66.5%) were completed. Faculty completed 207 of 326 surveys for an overall compliance rate of 63.5%. The O-SCORE was able to significantly differentiate between all training years (p < 0.0001) with the exception of PGY3 residents when compared to PGY4 residents. Overall, residents and faculty found the program valuable and feasible. Resident and faculty perception of the value of the O-SCORE correlated with compliance rate of the O-SCORE surveys. CONCLUSIONS: This study demonstrates that implementation of an immediate feedback program utilizing an electronic platform is achievable and offers reproducible construct validity. However, issues affecting compliance among both residents and faculty physicians must temper optimism for the program and should be systematically addressed to allow for successful implementation.

Cortical Button Fixation: A Better Patellar Tendon Repair?

BACKGROUND: Patellar tendon ruptures require surgical repair to optimize outcomes, but no consensus exists regarding the ideal repair technique. Cortical button fixation is a secure method for tendon repair that has not been studied in patellar tendons. HYPOTHESIS: Cortical button repair is biomechanically superior to the standard transpatellar repair and biomechanically equivalent to suture anchor repair. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-three fresh-frozen cadaveric knees were used to compare 3 techniques of patellar tendon repair after a simulated rupture at the inferior pole of the patella. Repairs were performed at 45° of flexion using a standard transpatellar suture repair (n = 7), polyetheretherketone (PEEK) suture anchor repair (n = 8), or cortical button repair (n = 8). All specimens were tested on a custom apparatus to simulate cyclic open kinetic chain quadriceps contraction from extension to 90o of flexion. Outcomes of gap formation up to 250 cycles, maximum load to failure, and mode of failure were evaluated. RESULTS: Cortical button repair had significantly less gap formation than anchor repair after 1 cycle (P < .001) and 20 cycles (P < .01) and significantly less gap formation than suture repair from 1 to 250 cycles (P < .05). Cortical button repair sustained significantly higher loads to failure than anchor repair and suture repair (P < .001). All suture repairs failed through the suture. Anchor repairs failed at the suture-anchor eyelet interface (n = 4) or by anchor pullout (n = 3). Cortical button repairs either failed through the suture (n = 5), secondary failure of the patellar tendon (n = 2), or subsidence of the button through the anterior cortex of the patella (n = 1). CONCLUSION: Patellar tendon repair using cortical button fixation demonstrated mechanical advantages over suture repair and anchor repair in cadaveric specimens. Cortical button fixation showed less cyclic gap formation and withstood at least twice the load to failure of the construct. CLINICAL RELEVANCE: The biomechanical superiority of cortical button fixation may impart clinical advantages in accelerating postoperative rehabilitation.