Open Reduction Internal Fixation vs Primary Arthrodesis for Lisfranc Fracture-Dislocations: A Cost Analysis.

Background: Lisfranc fracture-dislocation is an uncommon but serious injury that currently lacks universal consensus on optimal operative treatment. Two common fixation methods are open reduction and internal fixation (ORIF) and primary arthrodesis (PA). The objective of this study is to analyze the cost difference between ORIF and PA of Lisfranc injuries, along with the contribution of medical services to overall costs. Methods: This was a retrospective cost analysis of the MarketScan database from 2010 to 2020. MarketScan is an insurance and commercial claims database that integrates deidentified patient information. It captures person-specific clinical utilization, expenditures, and enrollment across inpatient and outpatient services. Patients undergoing primary ORIF (CPT code 28615) vs PA (28730 and 28740) for Lisfranc fracture-dislocation were identified. The primary independent variable was ORIF vs PA of Lisfranc injury. Total costs due to operative management was the primary objective. The utilization of and costs contributed by medical services was a secondary outcome. Results: From 2010 to 2020, a total of 7268 patients underwent operative management of Lisfranc injuries, with 5689 (78.3%) ORIF and 1579 (21.7%) PA. PA was independently associated with increased net and total payment and coinsurance, clinic visits, and imaging, and patients attended significantly more PT sessions. Conclusion: Using this large database that does not characterize severity or extent of injury, we found that treatment of Lisfranc fracture-dislocation with ORIF was associated with substantially lower initial episode of treatment costs compared with PA. Specific excessive cost drivers for PA were clinic visits, PT sessions, and imaging. Level of Evidence: Level III, retrospective cohort study.

Trends in Extended Oral Antibiotic Prophylaxis Utilization Following Primary and Revision Total Hip Arthroplasty From 2010 to 2022.

BACKGROUND: In patients considered high-risk for infection, extended oral antibiotic (EOA) prophylaxis has been demonstrated to reduce rates of prosthetic joint infection following total hip arthroplasty (THA). Although national guidelines regarding their use have not yet been created, the increase in literature surrounding EOA prophylaxis suggests a potential change in practice patterns. The purpose of this study was to investigate the trends in utilization of EOA prophylaxis following THA from 2010 to 2022 and identify prescription patterns. METHODS: A total of 646,059 primary THA and 51,879 aseptic revision THA patients were included in this study. Patients who underwent primary or aseptic revision THA between 2010 and 2022 were identified in a national administrative claims database. Rates and duration of EOA prescriptions were calculated. A secondary analysis examined rates of utilization across demographics, including patients considered high risk for infection. RESULTS: From 2010 to 2022, utilization of EOA increased by 366% and 298% following primary and revision THA, respectively. Of patients prescribed postoperative antibiotics, 30% and 59% were prescribed antibiotics for more than 7 days following primary and revision THA, respectively. Rates of utilization were similar between high-risk individuals and the general population. CONCLUSIONS: Rates of utilization of EOA prophylaxis after THA have increased significantly since 2010. As current trends demonstrate a wide variation in prescription patterns, including in length of antibiotic duration and in patient population prescribed, guidelines surrounding the use of EOA prophylaxis after THA are necessary to promote antibiotic stewardship while preventing rates of periprosthetic joint infection.

Turf Toe Injuries in the Athlete: an Updated Review of Treatment Options, Rehabilitation Protocols, and Return-to-Play Outcomes.

PURPOSE OF REVIEW: First metatarsophalangeal joint sprains or turf toe (TT) injuries occur secondary to forceful hyperextension of the great toe. TT injuries are common among athletes, especially those participating in football, soccer, basketball, dancing, and wrestling. This review summarizes the current treatment modalities, rehabilitation protocols, and return-to-play criteria, as well as performance outcomes of patients who have sustained TT injuries. RECENT FINDINGS: Less than 2% of TT injuries require surgery, but those that do are typically grade III injuries with damage to the MTP joint, evidence of bony injury, or severe instability. Rehabilitation protocols following non-operative management consist of 3 phases lasting up to 10 weeks, whereas protocols following operative management consist of 4 phases lasting up 20 weeks. Athletes with low-grade injuries typically achieve their prior level of performance. However, among athletes with higher grade injuries, treated both non-operatively and operatively, about 70% are expected to maintain their level of performance. The treatment protocol, return-to-play criteria, and overall performance outcomes for TT injuries depend on the severity and classification of the initial sprain. For grade I injuries, players may return to play once they experience minimal to no pain with normal weightbearing, traditionally after 3-5 days. For grade II injuries, or partial tears, players typically lose 2-4 weeks of play and may need additional support with taping when returning to play. For grade III injuries, or complete disruption of the plantar plate, athletes lose 4-6 weeks or more depending upon treatment strategy.

Match Rates Among Underrepresented Minority and Female Applicants to Orthopaedic Surgery Residency Programs from 2011 to 2021: How Are We Doing?

Background: Orthopaedic surgery residency programs have traditionally had less representation of underrepresented minority (URM) and female trainees compared with other medical specialties. Widespread efforts have been implemented to increase the diversity of orthopaedic surgery residency programs; however, it is not known whether URM and female applicants are increasingly likely to match as a result. Thus, we aimed to study the independent association between URM and female applicants and matching into orthopaedic surgery over the past decade. Methods: Applicant-level data from the Electronic Residency Application Service were reviewed from 2011 to 2021 with variables including demographic variables, URM status, and matriculation to an orthopaedic surgery residency program. Multivariate logistic regression was used to identify the likelihood of matriculating into orthopaedic surgery when controlling for number of applications, top 40 medical school status, AOA status, and MD/other degree. Results: Twelve thousand one hundred eleven applicants were identified from 2011 to 2021 with a match rate of 70% overall. Two thousand fifty-six applicants (17%) were female and 1,926 (16%) classified as URM. The total number of applications increased from 1,074 in 2011 to 1,229 in 2021. The adjusted odds ratio (OR) associated with matching among all applicants decreased from 0.75 in 2011 to 0.64 in 2021, p < 0.001, and the OR of non-URM male and female applicants also decreased (female: 0.79-0.69, p < 0.001; male: 0.78-0.65, p < 0.001). The OR of URM male applicants did not change significantly (0.57-0.55, p = 0.60). The OR for URM female applicants, however, increased significantly from 0.46 to 0.61, p < 0.001. Over the entire time frame, the odds of matching were significantly lower for URM applicants compared with non-URM applicants (both male and female). Conclusions: Overall, the adjusted odds ratio of matching into orthopaedic surgery among female URM applicants has increased over the past decade, indicating successful efforts to improve the diversity of orthopaedic surgery training programs. The odds of URM male applicants have remained relatively constant, and the odds of URM male and female applicants were significantly lower than all non-URM applicants. Level of Evidence: III.

Assessing the Impact of COVID-19 on the 2021 Orthopaedic Surgery Match Outcomes.

The purpose of this study was to assess the influence of the COVID-19 pandemic on the 2021 orthopaedic surgery residency match outcomes. Because in-person away rotations and interviews were canceled during the 2020 to 2021 application cycle, we hypothesized that applicants would match at their home program at a higher rate in 2021 than in previous years. Methods: We queried allopathic orthopaedic surgery residency websites and social media accounts for names of residents and medical school information for cohorts matching from 2017 through 2021. To assess availability of and participation in virtual away rotations, we administered a survey to Accreditation Council for Graduate Medical Education-accredited allopathic orthopaedic surgery residency programs. The primary outcome was the annual proportion of applicants matching at the program affiliated with their medical school ("home program"). Subgroup analyses were stratified by Doximity reputation ranking and availability of a virtual away rotation. Results: We identified 2,632 residents who matched between 2017 and 2020 and 698 residents who matched in 2021. Overall home program match rate and likelihood of home matching were higher in 2021 compared with 2017 to 2020 (28% vs. 20%; odds ratio [OR] = 1.51, 95% confidence interval [CI] 1.24-1.82, p < 0.001). The increase in the home match rate at programs ranked in the top 30 (27% vs. 20%, p = 0.034) was similar to the increase at programs ranked outside the top 30 (28% vs. 20%, p < 0.001). Of the 66 (48%) programs that responded to the survey, 16 (24%) offered a virtual away rotation. Programs with a higher Doximity ranking were more likely than lower-ranked programs to offer a virtual away rotation (OR = 6.75, 95% CI 1.95-23.4, p = 0.003). Home match rates did not differ significantly between programs that offered a virtual away rotation and those that did not (26% vs. 32%, p = 0.271). Conclusions: A higher proportion of orthopaedic surgery residency applicants matched at their home program in 2021 compared with previous years. Limitations on in-person activities due to the COVID-19 pandemic may have contributed to this rise. Level of Evidence: N/A.

Emergency Department Visits for Ankle Fractures Through COVID-19: An Analysis of the National Electronic Injury Surveillance System.

Background: Societal changes that occurred during the COVID-19 pandemic may have altered the epidemiology of ankle fractures. The aim of this study was to assess trends in emergency department visits for ankle fractures from 2019 to 2020 in the United States. Methods: The National Electronic Injury Surveillance System (NEISS) database is a sample of hospitals in the United States stratified and weighted based on emergency department (ED) size, which was used to generate national estimates (NEs). The NEISS database was queried for patients who sustained an ankle fracture. Patients before COVID-19 (BC) (July 2019-December 2019) were compared to those during COVID-19 (DC) (July 2020-December 2020). Results: This study assessed 3350 (NE: 131,672) patients. Of these, 1683 (NE: 67,292) patients presented BC and 1667 (NE: 64,380) DC, representing a 4% decrease. The rate of alcohol-related ankle fractures increased (1.9% BC vs 2.6% DC; P < .001). The fraction of ankle fractures at school (3% BC vs 0.7% DC; P < .001) and during sports (19% BC vs 14% DC; P < .001) decreased. ED visits for ankle fracture leading to hospitalization marginally increased (23% BC vs 24% DC). The top 3 ankle fracture causes during COVID-19 were stairs (NE: 18,026, 28%), floors (ie, falling on floor) (NE: 4635, 7.2%), and skateboards (NE: 2832, 4.40%). The 3 largest increases in ankle fracture causes during COVID-19 were skateboards (+2.80%), floors (+1.10%), and powered scooters (+0.80%). Conclusion: There was a decrease in ankle fractures during the COVID-19 pandemic compared to the year before. Alcohol-related fractures increased as did fractures resulting in hospitalization. Ankle fractures caused by skateboards, powered scooters, and mopeds increased during COVID-19, whereas fewer occurred in school or during sports, consistent with restrictions to group activities. These findings may aid in proper health care budgeting in times of national and global crises. Level of Evidence: Level III, retrospective comparative study.

Revisiting Cemented Femoral Fixation in Hip Arthroplasty.

➤: The primary means of femoral fixation in North America is cementless, and its use is increasing worldwide, despite registry data and recent studies showing a higher risk of periprosthetic fracture and early revision in elderly patients managed with such fixation than in those who have cemented femoral fixation. ➤: Cemented femoral stems have excellent long-term outcomes and a continued role, particularly in elderly patients. ➤: Contrary to historical concerns, recent studies have not shown an increased risk of death with cemented femoral fixation. ➤: The choice of femoral fixation method should be determined by the patient's age, comorbidities, and bone quality. ➤: We recommend considering cemented femoral fixation in patients who are >70 years old (particularly women), in those with Dorr type-C bone or a history of osteoporosis or fragility fractures, or when intraoperative broach stability cannot be obtained.

Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database.

BACKGROUND: Racial disparities in outcomes after orthopaedic surgery have been well-documented in the fields of arthroplasty, trauma, and spine surgery; however, little research has assessed differences in outcomes after surgery for oncologic musculoskeletal disease. If racial disparities exist in the treatment of patients with pathologic long bone fractures, then they should be identified and addressed to promote equity in patient care. QUESTIONS/PURPOSES: (1) How do wait times between hospital admission and operative fixation for pathologic fractures of long bones differ between Black and non-Hispanic white patients, after controlling for confounding variables using propensity score matching? (2) How does the proportion of patients with 30-day postoperative complication differ between these groups after controlling for confounding variables using propensity score matching? METHODS: Using the National Surgical Quality Improvement Program database, we analyzed 828 patients who underwent fixation for pathologic fractures from 2012 to 2018. This database not only provides a large enough sample of pathologic long bone fracture patients to conduct the present study, but also it contains variables such as time from hospitalization to surgery that other national databases do not. After excluding patients with incomplete data (4% of the initial cohort), 775 patients were grouped by self-reported race as Black (12% [94]) or white (88% [681]). Propensity score matching using a 1:1 nearest-neighbor match was then used to match 94 Black patients with 94 white patients according to age, gender, BMI, American Society of Anesthesiologists physical status classification, anemia, endstage renal disease, independence in performing activities of daily living, congestive heart failure, and pulmonary disease. The primary outcome of interest was the number of days between hospital admission and operative fixation, which we assessed using a Poisson regression and report as an incidence risk ratio. The secondary outcomes were the occurrences of major 30-day postoperative adverse events (failure to wean off mechanical ventilation, cerebrovascular events, renal failure, cardiovascular events, reoperation, death), minor 30-day adverse events (reintubation, wound complications, pneumonia, and thromboembolic events), and any 30-day adverse events (defined as the pooling of all adverse events, including readmissions). These outcomes were analyzed using a bivariate analysis and logistic regression with robust estimates of variance and are reported as odds ratios. Because any results on disparities rely on rigorous control of other baseline demographics, we performed this multivariable approach to ensure we were controlling for confounding variables as much as possible. RESULTS: After controlling for potentially confounding variables such as age and gender, we found that Black patients had a longer mean wait time (incidence risk ratio 1.5 [95% CI 1.1 to 2.1]; p = 0.01) than white patients. After controlling for confounding variables, Black patients also had greater odds of having any postoperative adverse event (OR 2.1 [95% CI 1.1 to 3.8]; p = 0.02), including readmission (OR 3.3 [95% CI 1.5 to 7.6]; p = 0.004). CONCLUSION: The racial disparities in pathologic long bone fracture care found in our study may be attributed to fundamental racial biases, as well as systemic socioeconomic disparities in the US healthcare system. Identifying and eliminating the racial, socioeconomic, and sociocultural biases that drive these disparities would improve care for patients with orthopaedic oncologic conditions. One possible way to reduce these disparities would be to implement standardized surgical care pathways for pathological long bone fractures across different institutions to minimize variation in important aspects of care, such as time to surgical fixation. Further insight is needed on the types of standardized care pathways and the implementation mechanisms that are most effective. LEVEL OF EVIDENCE: Level III, therapeutic study.

Effect of Shortened Preclinical Curriculum on Medical Student Musculoskeletal Knowledge and Confidence: An Institutional Survey.

PURPOSE: Musculoskeletal education is underrepresented in American medical school curricula, and many medical schools have recently shifted toward a condensed preclinical period. Given that musculoskeletal diseases represent a large and growing social and economic burden, it is imperative that medical students be properly prepared to care for patients with musculoskeletal disorders, regardless of intended specialty. METHODS: A survey was sent to all medical students enrolled full-time at our institution during the 2018 to 2019 academic year. First year students had not yet received musculoskeletal instruction, second-year students had completed a shortened musculoskeletal curriculum of 49 total hours, and third- and fourth-year respondents had completed a longer 78 hour musculoskeletal curriculum. Respondents were asked to rank their confidence in their musculoskeletal knowledge, their interest in orthopaedics, followed by the well-validated Freedman and Bernstein musculoskeletal knowledge assessment and a demographics section asking had respondents completed an orthopaedic surgery clinical rotation, if they had other clinical orthopaedic experience, class year, intended clinical specialty, and gender. RESULTS: There were 179 responses to the survey, comprising 53 first-year, 54 second-year, and 72 third- and fourth-year students. The longer musculoskeletal curriculum was associated with significantly improved performance compared to the shorter musculoskeletal curriculum (p < 0.0001). Completion of a clinical orthopedics rotation was associated with significantly improved performance than not completing a rotation (p < 0.001), regardless of if non-rotators had other orthopedic experience (p = 0.001) or if they did not (p < 0.001). There was no difference in score (p = 0.94) or musculoskeletal knowledge confidence (p = 0.09) between males and females. Intending to pursue orthopedics was associated with significantly higher scores (p < 0.001) and significantly higher confidence (p = 0.02). CONCLUSIONS: As shortening preclinical musculoskeletal curricula worsens musculoskeletal performance, medical schools should consider requiring orthopedic clinical rotations to maintain musculoskeletal competency of graduates.

Necrotizing Fasciitis in a Patient on Long-Term Intramuscular Interferon-Beta for Multiple Sclerosis: A Case Report.

CASE: Immunomodulatory injections are becoming common long-term treatments for neuromuscular diseases such as multiple sclerosis (MS), although they carry a risk of local site infection. We describe a case of a 57-year-old man who developed necrotizing fasciitis of the anterior thigh secondary to intramuscular (IM) injections of interferon-beta-1A for MS, ultimately developing septic shock and requiring serial debridements for source control. CONCLUSIONS: This is the first reported case of necrotizing fasciitis from chronic IM injections for MS and deserves particular attention because of the immunosuppressive nature of the injections. In patients with underlying predisposing factors for infection, such as decubitus ulcers, it may be prudent to reconsider the administration route. Patients in hypermetabolic states should be closely monitored for impaired response to infections.

Visibility of Tinted Chlorhexidine Gluconate Skin Preparation on Varied Skin Pigmentations.

Preoperative skin preparation with antimicrobial agents decreases the risk of surgical site infection, but concerns have been raised about the visibility of a common surgical preparatory agent (ChloraPrep; Becton, Dickinson & Co, Franklin Lakes, New Jersey), depending on skin pigmentation. Poor visibility may lead to failure to identify inadequately prepared skin, increasing the risk of surgical site infection. This study was conducted to determine whether different tints of ChloraPrep and different skin pigmentations affect the ability of orthopedic surgeons to identify the adequacy of skin preparation. The forearms of volunteers in 4 skin pigmentation categories (fair, medium-fair, medium-dark, and dark) were prepared with Hi-Lite Orange and Scrub Teal ChloraPrep, with 1 forearm prepared adequately and 1 prepared inadequately. Videos showing the forearms were obtained and compiled into a survey that was sent to orthopedic surgeons, who were asked to assess the adequacy of skin preparation. When the 4 pigmentation categories were aggregated, no difference was noted between Hi-Lite Orange and Scrub Teal tints in rates of correct identification of adequate skin preparation by respondents. When the preparation tint was not controlled for, respondents correctly identified the adequacy of skin preparation for fair and medium-fair pigmentations, but not for medium-dark and dark skin pigmentations. The Hi-Lite Orange tint was significantly easier to identify on fair and medium-fair skin pigmentations, and the Scrub Teal tint was easier to identify on medium-dark and dark skin pigmentations. To reduce the risk of surgical site infection, surgeons should use Hi-Lite Orange on patients whose skin is fair or medium-fair and Scrub Teal on patients whose skin is medium-dark or dark. [Orthopedics. 2017; 40(1):e44-e48.].