Inclusion of genital, sexual, and gender diversity in human reproductive teaching: impact on student experience and recommendations for tertiary educators.

Western societal norms have long been constrained by binary and exclusionary perspectives on matters such as infertility, contraception, sexual health, sexuality, and gender. These viewpoints have shaped research and knowledge frameworks for decades and led to an inaccurate and incomplete reproductive biology curriculum. To combat these deficiencies in reproductive systems-related education, our teaching team undertook a gradual transformation of unit content from 2018 to 2023, aiming to better reflect real diversity in human reproductive biology. This initiative involved intentional modifications, including clear use of pronoun self-identification by staff. We addressed the historical lack of representation of genital variation and helped students interrogate oversimplified reproductive biology binaries. A novel assignment was also introduced, prompting students to apply reproductive physiology knowledge to propose innovative assisted reproductive technology solutions for diverse demographics. The collective impact of these innovations had a positive effect on student learning. With improved lecture content and inclusive language, the proportion of inclusive group assignment topics chosen by students more than doubled in 2021. By 2022, coinciding with assessment topic changes, the percentage of inclusive assignments topics surpassed 50%. Further development of laboratory activities on intersex genital variation and genital modification raised further understanding of genital, sexual, gender, and cultural diversity. While implementing these changes posed challenges, pushing both staff and students out of their comfort zones at times, collaboration with relevant organizations and individuals with lived experience of queer identity proved integral. Ultimately, these relatively simple adjustments had a substantial impact on student experiences and appreciation for diversity.NEW & NOTEWORTHY We outline the teaching innovations that we have implemented to improve inclusion of diversity in reproductive biology and physiology contexts. This includes improved representation of genital, sexual, and gender diversity considerations in the curriculum. There is a critical need for these innovations as how we teach fundamentally shapes the understanding of our future medical and health professionals and researchers and thus influences the quality of future medical care and research.

Airway-associated adipose tissue accumulation is increased in a kisspeptin receptor knockout mouse model.

Airway-associated adipose tissue increases with body mass index and is a local source of pro-inflammatory adipokines that may contribute to airway pathology in asthma co-existing with obesity. Genetic susceptibility to airway adiposity was considered in the present study through kisspeptin/kisspeptin receptor signalling, known to modulate systemic adiposity and potentially drive airway remodelling. Therefore, the aim of the study was to determine the effects of kisspeptin/kisspeptin receptor signalling in the lung, focusing on airway-associated adipose tissue deposition and impact on airway structure-function. Wild-type, heterozygous and kisspeptin receptor knockout mice were studied at 6 or 8 weeks of age. Lung mechanics were assessed before and after methacholine challenge and were subsequently fixed for airway morphometry. A separate group of mice underwent glucose tolerance testing and bronchoalveolar lavage. At 6 weeks of age, kisspeptin/kisspeptin receptor signalling did not affect body adiposity, airway inflammation, wall structure or function. Despite no differences in body adiposity, there was a greater accumulation of airway-associated adipose tissue in knockout mice. By 8 weeks of age, female knockout mice displayed a non-diabetic phenotype with increased body adiposity but not males. Airway-associated adipose tissue area was also increased in both knockout females and males at 8 weeks of age, but again no other respiratory abnormality was apparent. In summary, airway-associated adipose tissue is decoupled from body adiposity in prepubescent mice which supports a genetic susceptibility to fatty deposits localised to the airway wall. There was no evidence that airway-associated adipose tissue drives pathology or respiratory impairment in the absence of other environmental exposures.

American Orthopaedic Foot and Ankle Society Annual Meeting All-in-person Attendance Results in Immense Carbon Expenditure.

BACKGROUND: Professional society conferences are integral to the medical profession. However, airline travel is a major contributor to greenhouse gas production, and the environmental impact of in-person attendance at an orthopaedic conference has yet to be described. With growing concern about the climate crisis, we sought to quantify the carbon footprint of in-person attendance to help potential attendees more consciously consider in-person attendance, inform strategies to minimize greenhouse gas emissions during travel to annual meetings, and increase awareness about and momentum for efforts in orthopaedic surgery to reduce the carbon footprint of society conferences. QUESTIONS/PURPOSES: (1) What was the magnitude of greenhouse gas production resulting from all-in-person 2019 American Orthopaedic Foot and Ankle Society (AOFAS) annual meeting attendance in Chicago, IL, USA? (2) What was the magnitude of greenhouse gas production resulting from the all-virtual 2020 AOFAS annual meeting, and how does it compare with the 2019 AOFAS annual meeting carbon footprint? (3) To what extent could an alternative in-person meeting model with four or seven hubs decrease greenhouse gas production resulting from round-trip air travel compared with the 2019 AOFAS annual meeting? METHODS: A list of the postal codes and countries of all 1271 registered participants attending the four-day 2019 AOFAS annual meeting in Chicago, IL, USA, was obtained from AOFAS headquarters. The 2019 conference was chosen because it was the last pre-COVID meeting and thus attendance was more likely to resemble that at prepandemic in-person conferences than more recent meetings because of pandemic travel restrictions. We estimated carbon dioxide-equivalent (CO 2 e) production from round-trip air travel using a publicly available internet-based calculator (Myclimate: https://co2.myclimate.org/en/flight_calculators/new ). Emissions produced by the conference venue, car travel, and hotel stays were estimated using published Environmental Protection Agency emission factors. To estimate emissions produced by the all-virtual 2020 AOFAS annual meeting (assuming an equal number of attendees as in 2019), we used the framework published by Faber and summed estimated network data transfer emissions, personal computer and monitor emissions, and server-related emissions. Using the 2019 registrant list, we modeled four-hub and seven-hub in-person meeting alternatives to determine potential decreased round-trip air travel greenhouse gas production. Meeting hub locations were selected by visualizing the geographic distribution of the 2019 registrants and selecting reasonable meeting locations that would minimize air travel for the greatest number of attendees. Registrants were assigned to the nearest hub location. Myclimate was again used to estimate CO 2 e production for round-trip air travel for the hub meeting models. RESULTS: The total estimated emissions of the all-in-person 2019 AOFAS annual meeting (when accounting for travel, conference space, and hotel stays) was 1565 tons CO 2 e (median 0.61 tons per attendee, range 0.02 to 7.7 tons). The total estimated emissions of the all-virtual 2020 meeting (when accounting for network data transfer emissions, personal computer and monitor emissions, and server-related emissions) was 34 tons CO 2 e (median 0.03 tons per attendee). This corresponds to a 97.8% decrease in CO 2 e emissions compared with the in-person conference. The model of a four-hub in-person meeting alternative with meetings in Chicago, Santiago, London, and Tokyo predicted an estimated 54% decrease in CO 2 e emissions from round-trip air travel. The seven-hub meeting model with meetings in Chicago; Washington, DC; Dallas; Los Angeles; Santiago; London; and Tokyo was predicted to diminish the CO 2 e emissions of round-trip air travel by an estimated 71%. CONCLUSION: The 2019 AOFAS annual meeting had an enormous carbon footprint and resulted in many individuals exceeding their annual allotted carbon budget (2.5 tons) according to the Paris Agreement. Hosting the meeting virtually greatly reduced the annual meeting carbon footprint, and our hub-based meeting models identified potential in-person alternatives for reducing the carbon footprint of conference attendance. CLINICAL RELEVANCE: Professional societies must consider our responsibility to decarbonizing the healthcare sector by considering innovative approaches-perhaps such as our multihub proposals-to decarbonize carbon-intensive annual meetings without stalling academic progress.

Scope of the Problem: Ankle Arthroscopy.

Ankle arthroscopy has seen increased utilization and application in recent years. Through the advent of improved instrumentation and techniques, indications have been expanded to include the management of traumatic, degenerative, inflammatory, and neoplastic conditions. It is important to review anterior and posterior ankle arthroscopies along with the history, pertinent anatomy, techniques, indications, and complications as well as gain insight into the future of ankle arthroscopy.

Scope of the Problem: Tendoscopy and Small Joint Arthroscopy of the Foot and Ankle.

It is important to identify and describe practical applications of arthroscopy in the management of foot and ankle pathology. Utilization of the arthroscope provides a minimally invasive means of evaluating and addressing pathology. It obviates the need for a large open approach, which has additional value in the setting of a multiprocedure surgery. In addition to reducing surgical time, arthroscopy provides a potentially enhanced field of view and an adequate working space to address injury. As interest in minimally invasive options grows, the need for safe, effective tendoscopic and arthroscopic options in the foot and ankle increases. A clear and high-yield reference is needed with which to approach these procedures.

Conditional knockout of kisspeptin signaling in brown adipose tissue increases metabolic rate and body temperature and lowers body weight.

The peptide kisspeptin and its receptor, Kiss1r, act centrally to stimulate reproduction. Evidence indicates that kisspeptin signaling is also important for body weight (BW) and metabolism. We recently reported that Kiss1r KO mice develop obesity, along with reduced metabolism and energy expenditure, independent of estradiol levels. Outside the brain, Kiss1r is expressed in several metabolic tissues, including brown adipose tissue (BAT), but it is unknown which specific tissue is responsible for the metabolic phenotype in Kiss1r KOs. We first determined that global Kiss1r KO mice have significant alterations in body temperature and BAT thermogenic gene expression, perhaps contributing to their obesity. Next, to test whether kisspeptin signaling specifically in BAT influences BW, metabolism, or body temperature, we used Cre/lox technology to generate conditional Kiss1r knockout exclusively in BAT (BAT-Kiss1r KO). Unlike global Kiss1r KOs, BAT-Kiss1r KOs (lacking Kiss1r in just BAT) were not hypogonadal, as expected. Surprisingly, however, BAT-Kiss1r KOs of both sexes displayed significantly lower BW and adiposity than controls. This novel BAT-Kiss1r KO phenotype was of greater magnitude in females and was associated with improved glucose tolerance, increased metabolism, energy expenditure, and locomotor activity, along with increased body temperature and BAT gene expression, specifically Cox8b. Our findings suggest that the previously observed obesity and decreased metabolism in global Kiss1r KOs reflect impaired kisspeptin signaling in non-BAT tissues. However, the novel finding of increased metabolism and body temperature and lower BW in BAT-Kiss1r KOs reveal a previously unidentified role for endogenous kisspeptin signaling in BAT in modulating metabolic and thermogenic physiology.

Patterns of preoptic-hypothalamic neuronal activation and LH secretion in female sheep following the introduction and withdrawal of novel males.

The neuroendocrine response of female sheep to a novel male involves neural activation in the hypothalamus. However, if males are removed, the gonadotrophic signal declines, so the neural activity is likely to change. We examined Fos-immunoreactive (IR) cells in hypothalamic tissues from seasonally anovulatory female sheep exposed to males for 2 or 6h, or for 2h followed by 4h isolation from males. Control females were killed in the absence of male exposure. Male introduction increased LH secretion in all females; male removal was associated with a reduction only in mean and basal LH concentrations. Females exposed to males for 2h had more Fos-IR cells in the arcuate nucleus (ARC), ventromedial nucleus of the hypothalamus (VMH) and organum vasculosum of the lamina terminalis (OVLT) than control females. Fos-IR cells in the preoptic area (POA) were only greater than in control females after 6h exposure to a male. Removal of males decreased the number of Fos-IR cells in the ARC, VMH and OVLT, but not in the POA. Thus, hypothalamic neural activation and LH secretion in female sheep are stimulated by males and decline after male removal. However, activation in the POA persists after removal and may explain the incomplete decline in the LH response.

The Impact of Music Therapy in the Postoperative Setting on Overall Patient Satisfaction Using Validated Outcome Scores.

PURPOSE: Previous studies have examined music therapy (MT) as a potential modality to relieve negative postoperative symptoms such as pain. This randomized control trial examined the use of MT on patient satisfaction in the postanesthesia care unit. DESIGN: Fifty patients undergoing outpatient orthopaedic surgery were enrolled and randomized into two groups, those receiving MT postoperatively and a control group who did not. METHODS: After hospital discharge, subjects were assessed with two validated outcome measurements for overall patient satisfaction, the visual analog satisfaction scale and the Patient Judgment of Hospital Quality survey. FINDINGS: The results showed no statistically significant differences between the MT and control group on the Patient Judgment of Hospital Quality survey (MT = 3.42, standard therapy = 3.41, P = .94) and the visual analog satisfaction scale (MT = 91.20, standard therapy = 91.65, P = .88). CONCLUSIONS: MT given in the postoperative setting has no impact on overall patient satisfaction.

The Role of Central Androgen Receptor Actions in Regulating the Hypothalamic-Pituitary-Ovarian Axis.

The androgen receptor (AR) is expressed throughout the hypothalamic-pituitary-gonadal (HPG) axis, and findings from female global AR knockout mice confirm that AR-mediated androgen actions play important roles in regulating female reproductive function. We generated neuron-specific AR knockout mice (NeurARKO) to investigate the functional role of neuronal AR-mediated androgen action in regulating the female HPG axis and fertility. Relative to control females, NeurARKO females exhibited elevated luteinizing hormone (LH) levels at diestrus (p < 0.05) and a compromised serum LH response to ovariectomy and E2 priming (p < 0.01). Furthermore, NeurARKO females displayed reduced Kiss1 mRNA expression in the anteroventral periventricular nucleus at diestrus (p < 0.05) and proestrus (p < 0.05), but elevated Kiss1 (p < 0.05) and neurokinin B (Tac2, p < 0.05) mRNA expression in the arcuate nucleus at proestrus compared to WT controls. Ovarian follicle dynamics were also altered in NeurARKO ovaries at 3 months of age, with a significant reduction in large antral follicle numbers at the proestrus stage compared to control WT ovaries (p < 0.05). Increased follicular atresia was evident in NeurARKO ovaries with a 4-fold increase in unhealthy large preantral follicles (p < 0.01). Despite the findings of aberrant neuroendocrine and ovarian characteristics in the NeurARKO females, estrous cyclicity and overall fertility were comparable between NeurARKO and WT females. In conclusion, our findings revealed that selective loss of neuronal AR actions impacts the kisspeptin/GnRH/LH cascade leading to compromised ovarian follicle dynamics.

Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection.

Osteomyelitis is inflammation of the bone caused by an infectious organism, and is a difficult clinical problem. The pathophysiology, imaging, and classification of osteomyelitis are challenging, varying with the age of the patient (child versus adult), the chronicity of the infection (acute versus chronic), and the route of spread (hematogenous versus contiguous focus), as well as the immune and vascular status of the patient and affected region. The two most common classification schemes are those of Lew and Waldvogel, and Cierny and Mader. Brodie's abscess is seen in subacute osteomyelitis, while sequestrum, involucrum, and cloaca are inter-related entities of chronic osteomyelitis. Imaging workup of suspected osteomyelitis should begin with radiographs, although MRI is the most accurate imaging test. Three patterns of T1 signal change have been described in the setting of suspected osteomyelitis including confluent intramedullary, hazy reticular, and subcortical. The confluent intramedullary pattern is most associated with osteomyelitis, while hazy reticular is rarely associated with hematogenous osteomyelitis, and subcortical is not associated with osteomyelitis. It can be challenging to differentiate neuropathic arthropathy from osteomyelitis. Osteomyelitis tends to involve a single bone subjacent to an ulcer or sinus tract. In contrast, neuropathic arthropathy tends to involve multiple bones of the midfoot. Subchondral cystic change, thin rim enhancement of a joint effusion, and the presence of intra-articular bodies are more indicative of a neuropathic joint without infection. Biopsy can play an important role in diagnosis and treatment of osteomyelitis.

Ontogeny of clock and KiSS-1 metastasis-suppressor (Kiss1) gene expression in the prepubertal mouse hypothalamus.

Kisspeptin is crucial for the generation of the circadian-gated preovulatory gonadotrophin-releasing hormone (GnRH)-LH surge in female rodents, with expression in the anteroventral periventricular nucleus (AVPV) peaking in the late afternoon of pro-oestrus. Given kisspeptin expression is established before puberty, the aim of the present study was to investigate kisspeptin and clock gene rhythms during the neonatal period. Anterior and posterior hypothalami were collected from C57BL/6J mice on Postnatal Days (P) 5, 15 and 25, at six time points across 24h, for analysis of gene expression by reverse transcription-quantitative polymerase chain reaction. Expression of aryl hydrocarbon receptor nuclear translocator-like gene (Bmal1) and nuclear receptor subfamily 1, group D, member 2 (Rev-erbα) in the anterior hypothalamus (containing the suprachiasmatic nucleus) was not rhythmic at P5 or P15, but Bmal1 expression exhibited rhythmicity in P25 females, whereas Rev-erbα expression was rhythmic in P25 males. KiSS-1 metastasis-suppressor (Kiss1) expression did not exhibit time-of-day variation in the anterior (containing the AVPV) or posterior (containing the arcuate nucleus) hypothalami in female and male mice at P5, P15 or P25. The data indicate that the kisspeptin circadian peak in expression observed in the AVPV of pro-oestrous females does not manifest at P5, P15 or P25, likely due to inadequate oestrogenic stimuli, as well as incomplete development of clock gene rhythmicity before puberty.

Ankle Arthritis: You Can't Always Replace It.

End-stage arthritis of the tibiotalar joint is disabling and causes substantial functional impairment. End-stage arthritis of the tibiotalar joint is often the residual effect of a previous traumatic injury. Nonsurgical treatment for end-stage arthritis of the ankle includes bracing, shoe wear modifications, and selective joint injections. For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis. Each treatment option has strong proponents who argue the superiority of their treatment algorithm. Although there is no ideal treatment for ankle arthritis, there are high-quality studies that help guide treatment in patients of varying demographics. Many inherent risks are linked with each treatment option; however, the risks of greatest concern are early implant loosening after arthroplasty that requires revision surgery and the acceleration of adjacent joint degeneration associated with arthrodesis.

Evidence that Neurokinin B Controls Basal Gonadotropin-Releasing Hormone Secretion but Is Not Critical for Estrogen-Positive Feedback in Sheep.

BACKGROUND: Loss-of-function mutations in genes encoding kisspeptin or neurokinin B (NKB) or their receptors cause infertility. NKB is coproduced in kisspeptin neurons in the arcuate nucleus (ARC), and these neurons also produce the NKB receptor (NK3R), allowing autosynaptic function. We tested the hypothesis that NKB action in ARC kisspeptin neurons is aligned with increased pulsatile secretion of luteinizing hormone (LH) and/or activation of the estrogen-induced LH surge in ewes. METHODS: Using in situ hybridization and immunohistochemistry, we examined NKB expression in kisspeptin neurons during the ovine estrous cycle. We infused kisspeptin, senktide (an NK3R agonist), or dynorphin into the lateral ventricle during the luteal phase of the estrous cycle to determine effects on pulsatile LH secretion. Finally, we examined the effect of an NK3R antagonist (MRK-08) in ovariectomized ewes. RESULTS: NKB (Tac3) mRNA expression in mid-ARC kisspeptin neurons was elevated during the mid-to-late follicular phase of the estrous cycle. The number of NKB-immunoreactive cells and NKB/kisspeptin terminals in the median eminence was similar during the estrous cycle. Kisspeptin and senktide increased LH pulse frequency and mean LH levels. Central MRK-08 infusion eliminated the LH pulses but did not prevent an estrogen-positive feedback on LH secretion. CONCLUSIONS: NKB expression in ARC kisspeptin neurons is upregulated during the late follicular phase of the estrous cycle, when the pulsatile secretion of gonadotropin-releasing hormone (GnRH)/LH is maximal. When GnRH/LH secretion is minimal, central senktide infusion induces LH secretion, similar to the response to kisspeptin. Although the increase in LH in response to senktide appeared surge-like, we did not observe any change in the surge following NK3R antagonist treatment. We conclude that NKB plays a role in increasing basal GnRH/LH pulsatility in the follicular phase of the cycle but is not essential for estrogen-induced positive feedback.

Kisspeptin and energy balance in reproduction.

Kisspeptin is vital for the neuroendocrine regulation of GNRH secretion. Kisspeptin neurons are now recognized as a central pathway responsible for conveying key homeostatic information to GNRH neurons. This pathway is likely to mediate the well-established link between energy balance and reproductive function. Thus, in states of severely altered energy balance (either negative or positive), fertility is compromised, as is Kiss1 expression in the arcuate nucleus. A number of metabolic modulators have been proposed as regulators of kisspeptin neurons including leptin, ghrelin, pro-opiomelanocortin (POMC), and neuropeptide Y (NPY). Whether these regulate kisspeptin neurons directly or indirectly will be discussed. Moreover, whether the stimulatory role of leptin on reproduction is mediated by kisspeptin directly will be questioned. Furthermore, in addition to being expressed in GNRH neurons, the kisspeptin receptor (Kiss1r) is also expressed in other areas of the brain, as well as in the periphery, suggesting alternative roles for kisspeptin signaling outside of reproduction. Interestingly, kisspeptin neurons are anatomically linked to, and can directly excite, anorexigenic POMC neurons and indirectly inhibit orexigenic NPY neurons. Thus, kisspeptin may have a direct role in regulating energy balance. Although data from Kiss1r knockout and WT mice found no differences in body weight, recent data indicate that kisspeptin may still play a role in food intake and glucose homeostasis. Thus, in addition to regulating reproduction, and mediating the effect of energy balance on reproductive function, kisspeptin signaling may also be a direct regulator of metabolism.

A Large Ankle Mass in a Figure Skater: A Case Report.

A 19-year-old male competitive figure skater presented to clinic with a 3-year history of right ankle swelling. Exam demonstrated a ~6cm diameter mass over the medial malleolus. MRI revealed a well-circumscribed fluid-filled mass. After failing conservative management, the patient underwent surgical excision. Anatomic pathology revealed a pseudocyst with pseudosynovial metaplasia, consistent with malleolar bursitis. Competitive figure skaters can develop significant medial malleolar bursitis due to excessive shear forces from ill-fitting skates. If non-operative management is ineffective, patients can be managed successfully with surgical excision. The patient made a full recovery and has returned to competitive skating without recurrence.

Reduced voluntary wheel running behaviour in Kiss1r knockout mice.

Kisspeptin and its receptor, Kiss1r, are novel players in the central balance of energy intake and expenditure. Recent evidence also indicates that kisspeptin signalling is important in thermoregulation and generation of the circadian rhythm. We used global Kiss1r knockout mice (Kiss1r KO), which are hypogonadal and develop obesity, to determine the impact of kisspeptin on circadian related behaviour. Voluntary wheel running was examined in Kiss1r KO and wild-type (WT) mice, using gonad intact and gonadectomised (GDX) mice to account for the effects of kisspeptin on gonadal sex steroids. Intact male and female Kiss1r KO mice covered only 10% and 30% of the distance travelled each day by their respective WT controls. In all mice, most of the running activity occurred during the dark phase. GDX WT mice ran significantly less during dark periods than the intact WT. GDX Kiss1r KO male mice ran significantly less than the GDX WT male mice, but the decrease was attenuated compared to intact mice. There was no difference between the female GDX Kiss1r KO and GDX WT. In contrast to the obese phenotype that develops in Kiss1r KO mice, body mass at the end of the study was significantly lower in the GDX Kiss1r KO than it was in the GDX WT mice. The difference in wheel running activity was not associated with any histological change in WAT, BAT, or muscle diameter. No difference in immunohistochemistry expression was seen in lateral hypothalamic orexin neurons or dopamine neurons in the ventral tegmental area / substantia nigra. We observed increased Iba1 expression (activation of microglia) in the arcuate nucleus of male Kiss1r KO mice. Overall, the circadian locomotor activity in male Kiss1r KO mice appears dependant on kisspeptin signalling and the obese phenotype does not develop in Kiss1r KO mice when they engage in voluntary activity.

Emerging Patterns of Foot and Ankle Injuries in Pickleball Players: A Short Report.

BACKGROUND: Pickleball's surging popularity has driven an increase in injuries presenting to medical providers. This study seeks to describe the epidemiology of pickleball foot and ankle injuries including patient demographics, diagnoses, and mechanism of injury. METHODS: A retrospective review from our institutional database identified patients treated in the foot and ankle clinic whose medical records included the search terms "pickleball" and "pickle ball." Only injuries sustained while playing pickleball were included. Patient demographics, diagnosis, mechanism of injury, and treatment were collected. Injury incidence and descriptive analyses were calculated. RESULTS: A total of 198 patients with pickleball foot and ankle injuries were identified. The incidence of injuries increased 6.5-fold from 2019 to 2023. The mean age of patients was 58.3 years (SD = 12.2). Most patients were male (58.6%) and reported a traumatic injury (77.8%). The most common diagnosis was Achilles tendon rupture (39.4%). The most common mechanisms of injury were running or lunging forward (30.9%), planting the foot (16.5%), and inverting the foot and ankle (15.5%). Most injuries were treated nonoperatively (71.2%); however, 62.8% of Achilles tendon ruptures were treated surgically. CONCLUSION: The incidence of pickleball foot and ankle injuries increased dramatically from 2015 to 2023. Injuries occurred more frequently in older, male patients, with Achilles tendon rupture being the most common diagnosis.

Efficiency of Foot and Ankle Surgeries Completed on the Preoperative Stretcher vs Operating Room Table: A Randomized Controlled Trial.

Background: Extremity surgeons frequently operate on the preoperative stretcher rather than the operating room (OR) table. This study sought to identify differences between stretcher-based (SB) and OR table-based (TB) procedures with regard to time efficiency and OR team member preferences. Methods: We conducted a prospective randomized controlled trial comparing the efficiency of SB vs OR TB foot and ankle procedures. Fifty-two patients undergoing a hardware removal, isolated gastrocnemius recession, soft tissue procedure, or foreign body removal at our day surgery unit were included. Start time and exit time were recorded. "Start time" was the number of minutes between the patient entering the OR and first incision. "Exit time" was the number of minutes between the procedure ending and the patient exiting the OR. Surveys were disseminated to OR staff who participated in the included cases. Results: The total measured time in the OR was an average 6 minutes shorter in the Stretcher group compared to the OR Table group (10 minutes vs 16 minutes, P < .001). SB procedures were associated with a significantly shorter start time (median difference = 4 minutes, P = .001), but not exit time (median difference = 1 minute, P = .058). No difference was found in actual surgical time. Thirty (96.8%) OR team members perceived SB procedures as enhancing OR efficiency, and 30 (96.8%) respondents considered SB procedures to be equal or superior to OR TB procedures in terms of patient safety. All would recommend or strongly recommend SB procedures. Conclusion: We found SB foot and ankle procedures to require less room time than OR TB procedures. Particularly for high-volume specialties, an average 6 minutes saved per case may meaningfully improve overall OR efficiency. Most OR team members believed that SB surgery improves OR efficiency and is the safer option for OR team members. Level of Evidence: Level II, randomized controlled trial, survey.

Carbon Footprint of Minor Foot and Ankle Surgery: A Randomized Controlled Trial.

Background: Climate change poses a substantial threat to human health, and operating rooms (ORs) have an outsized environmental impact. The Program for Research in Sustainable Medicine (PRiSM) designed a protocol for minor foot and ankle surgery intended to reduce waste, streamline instrument trays, and minimize laundry. We conducted a randomized controlled trial to compare the carbon footprint of procedures performed using the PRiSM protocol vs a traditional protocol. Methods: Forty adult patients undergoing foreign body removal, hammertoe correction, toe amputation, hardware removal, mass excision, or gastrocnemius recession were randomized to the PRiSM or our "Traditional" protocol. The PRiSM protocol used a smaller instrument tray, fewer drapes and towels, and minimal positioning blankets. No changes were made to surgical site preparation or operative techniques. Environmental impact was estimated using the carbon footprint, measured in kilograms of carbon dioxide equivalents (CO2e). Emissions associated with OR waste, instrument processing, and laundry were calculated. Results: On average, PRiSM cases had a smaller carbon footprint than Traditional cases (17.3 kg CO2e [SD = 3.2] vs 20.6 kg CO2e [SD = 2.0], P < .001). Waste-associated emissions from PRiSM cases were reduced (16.0 kg CO2e [SD = 2.7] vs 18.4 kg CO2e [SD = 1.8], P = .002), as were modeled instrument processing-related emissions (0.34 vs 0.91 kg CO2e). One superficial surgical site infection occurred in each group. Conclusion: We found a small but statistically significant reduction in the environmental impact of minor foot and ankle surgery when using the PRiSM vs Traditional protocol. The environmental impact of these cases was dominated by plastic waste-related emissions. Orthopaedic surgeons should think critically about what components of their surgical setup are truly necessary for patient care, as minor changes in product utilization can have significant impacts on waste and greenhouse gas emissions. Level of Evidence: Level I, randomized controlled trial.