Quantitative Skeletal Imaging and Image-Based Modeling in Pediatric Orthopaedics.

PURPOSE OF REVIEW: Musculoskeletal imaging serves a critical role in clinical care and orthopaedic research. Image-based modeling is also gaining traction as a useful tool in understanding skeletal morphology and mechanics. However, there are fewer studies on advanced imaging and modeling in pediatric populations. The purpose of this review is to provide an overview of recent literature on skeletal imaging modalities and modeling techniques with a special emphasis on current and future uses in pediatric research and clinical care. RECENT FINDINGS: While many principles of imaging and 3D modeling are relevant across the lifespan, there are special considerations for pediatric musculoskeletal imaging and fewer studies of 3D skeletal modeling in pediatric populations. Improved understanding of bone morphology and growth during childhood in healthy and pathologic patients may provide new insight into the pathophysiology of pediatric-onset skeletal diseases and the biomechanics of bone development. Clinical translation of 3D modeling tools developed in orthopaedic research is limited by the requirement for manual image segmentation and the resources needed for segmentation, modeling, and analysis. This paper highlights the current and future uses of common musculoskeletal imaging modalities and 3D modeling techniques in pediatric orthopaedic clinical care and research.

Impact of pathogenic FBN1 variant types on the development of severe scoliosis in patients with Marfan syndrome.

BACKGROUND: Among the several musculoskeletal manifestations in patients with Marfan syndrome, spinal deformity causes pain and respiratory impairment and is a great hindrance to patients' daily activities. The present study elucidates the genetic risk factors for the development of severe scoliosis in patients with Marfan syndrome. METHODS: We retrospectively evaluated 278 patients with pathogenic or likely pathogenic FBN1 variants. The patients were divided into those with (n=57) or without (n=221) severe scoliosis. Severe scoliosis was defined as (1) patients undergoing surgery before 50 years of age or (2) patients with a Cobb angle exceeding 50° before 50 years of age. The variants were classified as protein-truncating variants (PTVs), which included variants creating premature termination codons and inframe exon-skipping, or non-PTVs, based on their location and predicted amino acid alterations, and the effect of the FBN1 genotype on the development of severe scoliosis was examined. The impact of location of FBN1 variants on the development of severe scoliosis was also investigated. RESULTS: Univariate and multivariate analyses revealed that female sex, PTVs of FBN1 and variants in the neonatal region (exons 25-33) were all independent significant predictive factors for the development of severe scoliosis. Furthermore, these factors were identified as predictors of progression of existing scoliosis into severe state. CONCLUSIONS: We elucidated the genetic risk factors for the development of severe scoliosis in patients with Marfan syndrome. Patients harbouring pathogenic FBN1 variants with these genetic risk factors should be monitored carefully for scoliosis progression.

Perioperative point-of-care-testing of plasmacholinesterases identifies older patients at risk for postoperative delirium: an observational prospective cohort study.

BACKGROUND: Postoperative delirium (POD) is a severe perioperative complication that may increase mortality and length-of-stay in older patients. Moreover, POD is a major economic burden to any healthcare system. An altered expression of Acetylcholine- and Butyrylcholinesterases (AChE, BuChE) due to an unbalanced neuroinflammatory response to trauma or an operative stimulus has been reported to play an essential role in the development of POD. We investigated if perioperative measurement of cholinesterases (ChEs) can help identifying patients at risk for the occurrence of POD in both, scheduled and emergency surgery patients. METHODS: This monocentric prospective observational cohort study was performed in a tertiary hospital (departments of orthopaedic surgery and traumatology). One hundred and fifty-one patients aged above 75 years were enrolled for scheduled (n = 76) or trauma-related surgery (n = 75). Exclusion criteria were diagnosed dementia and anticholinergic medication. Plasma samples taken pre- and postoperatively were analysed regarding AChE and BuChE activity. Furthermore, perioperative assessment using different cognitive tests was performed. The type of anaesthesia (general vs. spinal anaesthesia) was analysed. Primary outcome was the incidence of POD assessed by the approved Confusion Assessment Method (CAM) in combination with the expression of AChE and BuChE. RESULTS: Of 151 patients included, 38 (25.2%) suffered from POD; 11 (14%) in scheduled and 27 (36%) in emergency patients. AChE levels showed no difference throughout groups or time course. Trauma patients had lower BuChE levels prior to surgery than scheduled patients (p < 0.001). Decline in BuChE levels correlated positively with the incidence of POD (1669 vs. 1175 U/l; p < 0.001). Emergency patients with BuChE levels below 1556 U/L were at highest risk for POD. There were no differences regarding length of stay between groups or incidence of POD. The type of anaesthesia had no influence regarding the incidence of POD. Only Charlson Comorbidity Index and Mini Nutrition Assessment demonstrated reliable strength in respect of POD. CONCLUSIONS: Perioperative measurement of BuChE activity can be used as a tool to identify patients at risk of POD. As a point-of-care test, quick results may alter the patients' course prior to the development of POD. TRIAL REGISTRATION: https://drks.de/search/de/trial/DRKS00017178 .

Nasolabial morphological changes in patients with unilateral cleft lip and palate using a Korat-modified nasoalveolar moulding appliance with primary correction.

OBJECTIVE: The objective of this study is to measure the morphological changes of the nose and lip in patients with unilateral cleft lip and palate before and after cheiloplasty with primary rhinoplasty (primary correction) in conjunction with Korat-NAM usage. DESIGN: Longitudinal cohort study. SETTING: Cleft Center Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand. SUBJECTS: Twenty-six patients with unilateral cleft lip and palate. INTERVENTIONS: Control group: only active obturator before primary correction. Experimental group: an active obturator and Korat-NAM I before primary correction. A customized endotracheal tube was retained in the nostril for 3 weeks before switching to Korat-NAM II for 1 year. MAIN OUTCOME MEASURES: Six measurements comprising nostril rim length, nostril height, nostril sill width, columella angle, vertical lip height, and horizontal lip length were measured from the patients' photographs. All measurements, except the columella angle, were reported as the cleft side/non-cleft side value ratio. Measurements were taken at the initial appointment, immediately before, 3 weeks after, and 1 year after primary correction. RESULTS: Nostril rim length ratio, nostril height ratio, nostril sill width ratio, columella angle on the cleft side, and vertical lip height ratio were improved using Korat-NAM before and 3 weeks after primary correction. Nostril rim length and height ratios were significantly better than the control group. CONCLUSIONS: Korat-NAM improved nose and lip morphology before primary correction. An overcorrection improved the nose and lip morphology on the cleft side. The nostril rim length and vertical lip height on the cleft side also improved with Korat-NAM II 1 year after primary correction.

Artificial intelligence in total and unicompartmental knee arthroplasty.

The application of Artificial intelligence (AI) and machine learning (ML) tools in total (TKA) and unicompartmental knee arthroplasty (UKA) emerges with the potential to improve patient-centered decision-making and outcome prediction in orthopedics, as ML algorithms can generate patient-specific risk models. This review aims to evaluate the potential of the application of AI/ML models in the prediction of TKA outcomes and the identification of populations at risk.An extensive search in the following databases: MEDLINE, Scopus, Cinahl, Google Scholar, and EMBASE was conducted using the PIOS approach to formulate the research question. The PRISMA guideline was used for reporting the evidence of the data extracted. A modified eight-item MINORS checklist was employed for the quality assessment. The databases were screened from the inception to June 2022.Forty-four out of the 542 initially selected articles were eligible for the data analysis; 5 further articles were identified and added to the review from the PUBMED database, for a total of 49 articles included. A total of 2,595,780 patients were identified, with an overall average age of the patients of 70.2 years ± 7.9 years old. The five most common AI/ML models identified in the selected articles were: RF, in 38.77% of studies; GBM, in 36.73% of studies; ANN in 34.7% of articles; LR, in 32.65%; SVM in 26.53% of articles.This systematic review evaluated the possible uses of AI/ML models in TKA, highlighting their potential to lead to more accurate predictions, less time-consuming data processing, and improved decision-making, all while minimizing user input bias to provide risk-based patient-specific care.

Orthopaedic surgeons' attitude toward physical activity for people after total hip or knee replacement: Northern vs Southern European country.

BACKGROUND: Regular physical activity (PA) is a key factor of lifestyle behavior enhancing general health and fitness, especially in people after total hip or knee replacement (THR and TKR). Orthopaedic surgeons can play a primary role in advocating the benefits of an active lifestyle. Aim of the study was 1) to assess the attitude of orthopaedic surgeons towards PA for people after THR/TKR and 2) to compare the attitude between a Northern European (the Netherlands) and a Southern European (Italy) country and analyze which factors influence the attitude towards PA. METHODS: A cross-cultural study. An (online) survey was distributed among orthopaedic surgeons in Italy and the Netherlands. Chi-square and Mann-Whitney tests were used to compare surgeons' and clinics' characteristics, and questionnaires' scores, respectively. A linear regression analysis was conducted to assess which surgeon characteristics influence attitude towards PA. RESULTS: A cohort of 159 surgeons (103 Italians and 56 Dutch) was analyzed. The median score of overall orthopaedic surgeons' attitude towards PA was positive (57 out of 72). Dutch surgeons showed a more positive attitude compared to Italian surgeons (p < 0.01). Main difference was found in the "Physical activity concern" factor, where Italian surgeons showed more concern about the negative effects of PA on the survival of the prosthesis. The regression analyses showed that "Country" and "Type of clinic" were associated with the surgeons' attitude. CONCLUSIONS: Overall, the orthopaedic surgeons' attitude towards PA for people with THR and TKR was positive. However, Dutch surgeons seem to be more positive compared to the Italian. The country of residence was the item that most influenced attitude. Further investigations are needed to untangle specific factors, such as cultural, socioeconomic, or contextual differences within the variable "country" that may influence orthopaedic surgeons' attitudes towards PA.

Does psychological distress predict risk of orthopaedic surgery and postoperative opioid prescribing in patients with hip pain? A retrospective study.

BACKGROUND: Clinicians and public health professionals have allocated resources to curb opioid over-prescription and address psychological needs among patients with musculoskeletal pain. However, associations between psychological distress, risk of surgery, and opioid prescribing among those with hip pathologies remain unclear. METHODS: Using a retrospective cohort study design, we identified patients that were evaluated for hip pain from January 13, 2020 to October 27, 2021. Patients' surgical histories and postoperative opioid prescriptions were extracted via chart review. Risk of hip surgery within one year of evaluation was analyzed using multivariable logistic regression. Multivariable linear regression was employed to predict average morphine milligram equivalents (MME) per day of opioid prescriptions within the first 30 days after surgery. Candidate predictors included age, gender, race, ethnicity, employment, insurance type, hip function and quality of life on the International Hip Outcome Tool (iHOT-12), and psychological distress phenotype using the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool. RESULTS: Of the 672 patients, n = 350 (52.1%) underwent orthopaedic surgery for hip pain. In multivariable analysis, younger patients, those with TRICARE/other government insurance, and those with a high psychological distress phenotype had higher odds of surgery. After adding iHOT-12 scores, younger patients and lower iHOT-12 scores were associated with higher odds of surgery, while Black/African American patients had lower odds of surgery. In multivariable analysis of average MME, patients with periacetabular osteotomy (PAO) received opioid prescriptions with significantly higher average MME than those with other procedures, and surgery type was the only significant predictor. Post-hoc analysis excluding PAO found higher average MME for patients undergoing hip arthroscopy (compared to arthroplasty or other non-PAO procedures) and significantly lower average MME for patients with public insurance (Medicare/Medicaid) compared to those with private insurance. Among those only undergoing arthroscopy, older age and having public insurance were associated with opioid prescriptions with lower average MME. Neither iHOT-12 scores nor OSPRO-YF phenotype assignment were significant predictors of postoperative mean MME. CONCLUSIONS: Psychological distress characteristics are modifiable targets for rehabilitation programs, but their use as prognostic factors for risk of orthopaedic surgery and opioid prescribing in patients with hip pain appears limited when considered alongside other commonly collected clinical information such as age, insurance, type of surgery pursued, and iHOT-12 scores.

Quality and Dependability of ChatGPT and DingXiangYuan Forums for Remote Orthopedic Consultations: Comparative Analysis.

BACKGROUND: The widespread use of artificial intelligence, such as ChatGPT (OpenAI), is transforming sectors, including health care, while separate advancements of the internet have enabled platforms such as China's DingXiangYuan to offer remote medical services. OBJECTIVE: This study evaluates ChatGPT-4's responses against those of professional health care providers in telemedicine, assessing artificial intelligence's capability to support the surge in remote medical consultations and its impact on health care delivery. METHODS: We sourced remote orthopedic consultations from "Doctor DingXiang," with responses from its certified physicians as the control and ChatGPT's responses as the experimental group. In all, 3 blindfolded, experienced orthopedic surgeons assessed responses against 7 criteria: "logical reasoning," "internal information," "external information," "guiding function," "therapeutic effect," "medical knowledge popularization education," and "overall satisfaction." We used Fleiss κ to measure agreement among multiple raters. RESULTS: Initially, consultation records for a cumulative count of 8 maladies (equivalent to 800 cases) were gathered. We ultimately included 73 consultation records by May 2023, following primary and rescreening, in which no communication records containing private information, images, or voice messages were transmitted. After statistical scoring, we discovered that ChatGPT's "internal information" score (mean 4.61, SD 0.52 points vs mean 4.66, SD 0.49 points; P=.43) and "therapeutic effect" score (mean 4.43, SD 0.75 points vs mean 4.55, SD 0.62 points; P=.32) were lower than those of the control group, but the differences were not statistically significant. ChatGPT showed better performance with a higher "logical reasoning" score (mean 4.81, SD 0.36 points vs mean 4.75, SD 0.39 points; P=.38), "external information" score (mean 4.06, SD 0.72 points vs mean 3.92, SD 0.77 points; P=.25), and "guiding function" score (mean 4.73, SD 0.51 points vs mean 4.72, SD 0.54 points; P=.96), although the differences were not statistically significant. Meanwhile, the "medical knowledge popularization education" score of ChatGPT was better than that of the control group (mean 4.49, SD 0.67 points vs mean 3.87, SD 1.01 points; P<.001), and the difference was statistically significant. In terms of "overall satisfaction," the difference was not statistically significant between the groups (mean 8.35, SD 1.38 points vs mean 8.37, SD 1.24 points; P=.92). According to how Fleiss κ values were interpreted, 6 of the control group's score points were classified as displaying "fair agreement" (P<.001), and 1 was classified as showing "substantial agreement" (P<.001). In the experimental group, 3 points were classified as indicating "fair agreement," while 4 suggested "moderate agreement" (P<.001). CONCLUSIONS: ChatGPT-4 matches the expertise found in DingXiangYuan forums' paid consultations, excelling particularly in scientific education. It presents a promising alternative for remote health advice. For health care professionals, it could act as an aid in patient education, while patients may use it as a convenient tool for health inquiries.

Safety in spinal surgery-Empowering clinicians to report concerns in motor function.

AIMS: Timely identification of neurological deterioration in patients with spinal disorders, through spinal motor assessment, is paramount in achieving early intervention to reduce the risk of permanent deficits. This project was initiated to meet the requirement for safe, timely spinal motor assessment through establishing and addressing clinician's educational needs. DESIGN: Mixed methods study conducted through online survey and concurrent focus groups June 2022-April 2023. METHODS: Pre-intervention online survey and focus groups identified insufficient provision of education targeted at identifying changes in motor function and as a result, clinicians lacked confidence and competence in completing assessments and caring for patients with spinal disorders. An e-learning package was created and shared widely along with additional interventions to support assessment completion. To establish the success of the project a post-intervention online survey was distributed. RESULTS: Survey respondents reported that the e-learning package has influenced their practice to either some extent or to a great extent with 91% reporting increased confidence in completing a spinal motor assessment. Post-intervention results also demonstrated an increase in confidence in caring for spinal surgery patients. CONCLUSION: Through engaging with clinicians to establish and address educational needs, this quality improvement project has successfully increased competence and confidence in this area of spinal care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: This study highlights the importance of targeted education to ensure that clinicians are appropriately skilled to identify neurological deterioration and demonstrates the effectiveness of digital education in providing this. IMPACT: This study addressed concerns around timely identification of deterioration of spinal patients. Study findings were the success in utilizing digital education to increase clinician's confidence and competence and thus enhance patient safety. This research will have an impact on clinical areas caring for patients with spinal disorders. REPORTING METHOD: SQUIRE guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Minimal effect of scanning parameters on ultrasound shear wave elastography variability in tendons.

PURPOSE: Ultrasound shear wave elastography has potential use in assessing tendon tissue; however, reducing measurement variability remains challenging. The primary purpose of this study was to identify the amount of variability accounted for by ultrasound parameter (frequency, harmonics and CrossXBeam) settings on shear wave speed at two testing sites. METHODS: Shear wave elastography images of the Achilles tendon were obtained from individuals with healthy tendons (n = 28) at two testing sites with standardised image acquisition/postprocessing protocols. Images were acquired at a range of frequencies (7-15 MHz) with CrossXBeam (a filtering technique) and harmonics settings toggled on and off. Variance decomposition analysis was performed to identify the amount of variability in shear wave speed accounted for by scan acquisition settings and testing sites. RESULTS: Shear wave speed variance was primarily attributed to participants (56.87% of variance; residual error: 35%). All scanning parameters, testing site and interaction terms each accounted for less than 2.5% of the variance. A statistically significant, negative relationship was observed between shear wave speed and image quality (p = 0.001) suggesting poor image quality yields higher shear wave speed estimates. CONCLUSION: The findings of this study suggest that natural variation in Achilles tendon mechanics between individuals without tendon pathology accounts for most of the shear wave speed variability. Optimising image quality, which may be observed in higher frequencies, should be considered to improve shear wave speed estimation. Clinically, this study highlights the need to take multiple images, maintain consistent ultrasound settings when tracking patient progress over time and use caution when comparing raw values from tendon scans performed in different clinics with shear wave elastography. LEVEL OF EVIDENCE: Level III.

Addressing musculoskeletal curricular inadequacies within undergraduate medical education.

BACKGROUND: Musculoskeletal (MSK) injuries and diseases place a significant burden on the health care system. Despite this, research indicates that physician training in the area of MSK medicine has historically been inadequate, with a majority of medical students feeling that their training in MSK medicine is lacking. The goal of this investigation was to evaluate the efficacy of a new preclinical MSK curriculum that was implemented within a nationally accredited allopathic medical program. METHODS: Retrospective analysis was completed on five consecutive years (2017-2021) of preclinical MSK curricular data for 549 medical students, including mid and end-of-course examinations and end-of-course student satisfaction surveys. Both parametric and non-parametric methods of analysis were used to examine within and between class differences (P < 0.05). RESULTS: The new MSK curriculum covered 15 of 16 "core or must know" topics in MSK medicine, and academic performance was consistently high over the 5-year period of analysis (final course marks ranged from 76.6 ± 7.1 to 81.4 ± 8.1; failures/year: range from 0 to 4), being equal or above levels of student performance observed for other courses delivered during preclinical studies. Likert data from end-of-course surveys demonstrated that feedback was overwhelmingly positive (overall course satisfaction ranged from a low of 3.07/4.00 to a high of 3.56/4.00) and indicated that students felt that the new preclinical MSK curriculum did effectively support medical student learning and knowledge retention. CONCLUSION: Results are expected to help advance the current body of knowledge that is dedicated to improving physician learning and knowledge retention in the area of MSK medicine and provides a curricular model that could be used by other nationally accredited medical programs to help enhance MSK learning at the preclinical levels of physician training.

Do social media use and patient satisfaction scores correlate with online award recognition among hip and knee arthroplasty specialists?

INTRODUCTION: The physician-patient interaction now begins before patients arrive in the office. Online ratings, social media profiles, and online award status are all components of physician online reputation which contributes to the patient's initial impressions. Therefore, it is important to understand the interplay of these factors and determine if there is a consistent trend indicating the value of this information. METHODS: We Identified all (N â€‹= â€‹160) registered American Association of Hip and Knee Surgeons (AAHKS) in New England using the https://findadoctor.aahks.net/tool for Massachusetts (MA), Connecticut (CT), Rhode Island (RI), Vermont (VT), New Hampshire (NH), and Maine (ME) on 6/26/2023. We collected surgeon age, fellowship graduation year, and practice type (i.e. Academic or Private). The average 5-star rating and number of ratings were collected from four websites. Any professional-use Facebook, Instagram, Twitter, LinkedIn, YouTube Channel, Personal Websites, or Institutional Websites were identified and a modified SMI Score was calculated. Finally, Castle Connolly Top Doctor, Local Magazine (e.g. Boston Magazine) Top Doctor, or the presence of having any award was noted for each surgeon. RESULTS: We identified several significant trends indicating that online awards were associated with higher online ratings. Social media presence, as determined by SMI Score, was also correlated with higher ratings overall and a higher likelihood of having an online award. CONCLUSION: Given the observed trends and reported importance patients place on ratings and awards, surgeons may consider increasing online engagement via social media and encouraging patients to share their experience via online ratings.

Patient Perception of Preoperative Nutrition and Recovery After Orthopaedic Surgery.

BACKGROUND: Mounting evidence supports the use of nutritional supplementation to improve patient outcomes. The intent of this study was to utilize an anonymous questionnaire to determine patients' baseline knowledge, attitude, and belief regarding nutrition before total hip (THA) or total knee arthroplasty (TKA). METHODS: After receiving Institutional Review Board approval, an anonymous questionnaire was administered to 300 patients, comprising 184 women (61.3%) and 116 men (38.6%), averaging 67 years (range, 39 to 89). There were 238 TKAs (79.3%), 12 revision TKAs (4%), 44 THAs (14.6%), and 6 revision THAs (2%). RESULTS: Almost all (99.6%) subjects recognized the importance of preoperative nutrition. Most (83.0%) claimed that they knew what to eat preoperatively to optimize their surgical outcomes and expressed high levels of self-reported confidence (98.6%). Women were more likely to report having knowledge of preoperative nutrition (P = .05), and advanced education levels were linked to higher confidence (P = .002). Only 169 (56.3%) subjects reported knowing what supplements to take. When asked, 84% of subjects stated that they would purchase a nutrition program if recommended by their surgeon. Most studies show that an improved diet and appropriate supplementation can optimize nutritional status and potentially improve surgical outcomes. CONCLUSIONS: The results of this study confirm that most patients do not know how to achieve optimal nutrition. Therefore, we believe there is a need for patient education on preoperative nutrition and its benefits.

Motivations and Barriers for Women Orthopaedic Surgeons Considering Arthroplasty Fellowship.

BACKGROUND: Arthroplasty is one of the least gender-diverse orthopaedic subspecialties. While previous studies have looked at factors influencing fellowship choices for women, few studies have attempted to understand the decision for or against arthroplasty specifically. Working to better understand fellowship choice is a critical step in the process of increasing women recruitment. METHODS: An anonymous survey was distributed using REDCap to women orthopaedic surgeons and trainees through listservs, social media groups, and residency programs. Surgeons who had decided on a specific subspecialty or already completed fellowship were included. Responses were obtained from 164 surgeons (72 arthroplasty surgeons, 92 other subspecialties). Chi-squared and Fisher's Exact tests were then performed. RESULTS: The most important factor for those who chose arthroplasty was enjoyment of the surgeries. The biggest concerns from those in the arthroplasty group about the field were work-life balance, ability to become pregnant and/or have a healthy pregnancy, and sex bias from referring physicians. Of those who ultimately chose another subspecialty, 30.4% considered arthroplasty "a little" and 8.7% considered it "strongly." The most important dissuaders for the group that considered arthroplasty were concerns about "boy's club" culture, concerns about the physicality of the surgeries, and a lack of mentors. CONCLUSION: While the decision to choose a career path is multifactorial, our hope is that through the identification of modifiable factors we can increase women representation in arthroplasty. Increasing mentorship, implementing practical solutions to improve work-life balance, supporting healthy pregnancies, and mitigating the physical demands of surgery could help address current disparities.

The Pregnant Arthroplasty Surgeon: A Women in Arthroplasty Committee Editorial.

BACKGROUND: Women orthopaedic surgeons face unique challenges during their careers. There are extremely low numbers of women in the field, particularly in the specialty of adult reconstruction. Factors contributing to low numbers of women entering this subspecialty include increased perceived physical demand relative to other fields, occupational hazards during pregnancy such as exposure to radiation and polymethylmethacrylate bone cement, concerns for work-life balance, and limited number of women within the subspecialty. The following editorial provides a framework to understand and manage the potential occupational hazards to pregnant and lactating surgeons, parental leave, and postpartum return to work. We aim to dispel any unfounded myths and provide evidence-based education that may help overcome these barriers. In doing so, we hope to encourage more women to consider adult reconstruction as a potential career. METHODS: Our primary method consisted of completing an extensive literature review on the past and current articles about the aforementioned barriers which may contribute to the low number of women entering adult reconstruction. After this literature search was completed, we composed a comprehensive editorial that provided evidence-based education and recommendations for medical professionals. CONCLUSIONS: Issues pertaining to parenthood, pregnancy, and lactation pose barriers to success for women in orthopedic surgery. These concerns may dissuade talented women from pursuing a rewarding career in adult reconstruction. Education on these issues is needed to help our early-career colleagues plan and care for their families. Clearly stated and published policies should be made available in all training programs, fellowships, and clinical practices to allow understanding and unbiased implementation. By being more inclusive, adult reconstruction will have access to the best possible surgeons, which will benefit not only patients but the field as a whole.

Recognizing the Sex Disparity in Surgeons Performing Total Knee Arthroplasty.

BACKGROUND: There is an unambiguous sex disparity in the field of orthopaedic surgery, with women making up only 7.4% of practicing orthopaedic surgeons in 2022. This study seeks to evaluate the sex distribution among orthopaedic surgeons engaged in primary total knee arthroplasty (TKA) between 2013 and 2020, as well as the procedural volume attributed to each provider. METHODS: We retrospectively queried the Medicare dataset to quantify all physicians reporting orthopaedic surgery as their specialty and performing primary TKA from 2013 to 2020. Healthcare Common Procedure Coding System codes for primary TKA procedures were used to extract associated utilization and billing provider information. Trend analyses were performed with 2-sided correlated Mann-Kendall tests to evaluate trends in the number of surgeons by sex and the women-to-men surgeon ratio. RESULTS: During the study period, 6,198 to 7,189 surgeons billed for primary TKA. Of this number, an average of 2% were women. The mean number of procedures billed for by men was 39.02/y (standard deviation: 34.54), and by women was 28.76/y (standard deviation: 20.62) (P < .001). There was no significant trend in the number of men or women surgeons who billed for primary TKA during the study period. Trend analysis of the women-to-men ratio demonstrated an increasing trend of statistical significance (P = .0187). CONCLUSIONS: There was a significant upward trend in the women-to-men ratio of surgeons who billed for primary TKA. However, there remains a colossal gender gap, as women only made up 2.4% of surgeons who billed for the procedure. The current study raises awareness of the notable discrepancy in the average number of TKAs performed by women as compared to men. The orthopaedic community should aim to determine ways to increase the number of women arthroplasty surgeons along with the opportunities that women have to perform TKAs.

A Systematic Review of Retracted Publications in Clinical Orthopaedic Research.

BACKGROUND: Retracted publications are an often-overlooked issue affecting the scientific community, and recent data confirms the overall number of retracted publications is rising. While this has previously been looked at within orthopaedic surgery, a contemporary understanding of retractions is required due to the rapid expansion in publications. Our study aimed to assess the retracted publications within clinical orthopaedic research to evaluate for characteristics and trends. METHODS: A systematic review was conducted on December 14, 2023, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. There were 4 databases that were queried to identify retracted publications in clinical orthopaedics that assessed operative and nonoperative orthopaedic interventions (excluding basic science). Articles were independently screened by 2 reviewers; those meeting the inclusion criteria were evaluated for various characteristics, including reasons for retraction based on Committee on Publication Ethics guidelines. RESULTS: There were 233 studies that met the inclusion criteria and were retracted between January 1, 1990, and December 14, 2023. Clinical orthopaedics represented 1.18% of all retracted publications identified through PubMed over this period. There were 87 articles that were retracted in 2023, up from 17 in 2022 (a 412% increase). Retracted studies were published in journals with 2022 impact factors up to 9.3, with an average of 3.1 (SD [standard deviation] 1.9). A total of 39.5% of the retracted studies were published in orthopaedic journals, and 60.9% of the retracted articles were published in exclusively open-access journals. The mean time from electronic publication to retraction was 2.1 years (SD 2.2). Retracted articles have been cited up to 180 times (mean 8.6; SD 20). Reasons for retraction included misconduct (45.9%), plagiarism (11.6%), redundant publication (11.6%), unethical research (10.3%), error (9.4%), and others (10.7%). CONCLUSIONS: The prevalence of retractions in the clinical orthopaedic literature is increasing. Clinical research is the basis for clinical practice guidelines, the gold standard for informing medical decision-making. Retractions may be one harbinger of lower-quality publications; researchers, institutions, and journals together play important roles in maintaining scientific integrity.

2-Octyl-Cyanoacrylate Mesh Dressings for Total Joint Arthroplasty: Dressing Design Influences Risks of Wound Complications.

BACKGROUND: Recent liquid adhesive skin closure systems with a mesh patch and a 2-octyl cyanoacrylate liquid formula have shown promising results in total joint arthroplasty. Chemical accelerators are typically included to promote the rapid polymerization of 2-octyl cyanoacrylate. The goal of the study is to distinguish designs and wound complication differences between 2 similar systems. METHODS: An 18-week retrospective study was conducted from July to December 2023, including 207 total hip arthroplasty and 212 total knee arthroplasty cases from 4 attending surgeons at 1 institution that used 1 of 2 dressing designs. Both dressings had a 2-octyl cyanoacrylate liquid adhesive formula that applied topically to a polyester-based mesh overlaying the wound. Mesh A (used in 274 cases) included an accelerator, a quaternary ammonium salt, on the mesh patch, whereas Mesh B (used in 145 cases) included a similar accelerator within the adhesive applicator. RESULTS: Wound complications (3.2 versus 7.6%; X2 = 3.86; df = 1; P = .049), early periprosthetic joint infections (0 versus 2.8%; X2 = 7.63; df = 1; P = .006), and 90-day reoperations for wound complications (0.4 versus 3.4%; X2 = 6.39; df = 1; P = .011) were significantly lower in patients who received Mesh A versus B, respectively. There was no difference in superficial surgical site infections (0.7 versus 0%; X2 = 1.06; df = 1; P = .302) or allergy rates (3.3 versus 4.1%; X2 = 0.12; df = 1; P = .655) between Mesh A and B. CONCLUSIONS: We observed significantly different performance in wound complications, early postoperative periprosthetic joint infections, and 90-day reoperation between the 2 designs. Having the accelerator in the applicator rather than on the mesh patch may lead to premature polymerization before bonding appropriately with the mesh to create the desired wound closure and seal. LEVEL OF EVIDENCE: Level III.

Passive Biotelemetric Detection of Tibial Debonding in Wireless Battery-Free Smart Knee Implants.

Aseptic loosening is the dominant failure mechanism in contemporary knee replacement surgery, but diagnostic techniques are poorly sensitive to the early stages of loosening and poorly specific in delineating aseptic cases from infections. Smart implants have been proposed as a solution, but incorporating components for sensing, powering, processing, and communication increases device cost, size, and risk; hence, minimising onboard instrumentation is desirable. In this study, two wireless, battery-free smart implants were developed that used passive biotelemetry to measure fixation at the implant-cement interface of the tibial components. The sensing system comprised of a piezoelectric transducer and coil, with the transducer affixed to the superior surface of the tibial trays of both partial (PKR) and total knee replacement (TKR) systems. Fixation was measured via pulse-echo responses elicited via a three-coil inductive link. The instrumented systems could detect loss of fixation when the implants were partially debonded (+7.1% PKA, +32.6% TKA, both p < 0.001) and fully debonded in situ (+6.3% PKA, +32.5% TKA, both p < 0.001). Measurements were robust to variations in positioning of the external reader, soft tissue, and the femoral component. With low cost and small form factor, the smart implant concept could be adopted for clinical use, particularly for generating an understanding of uncertain aseptic loosening mechanisms.

Hippocrates: A Pioneer in Orthopaedics and Traumatology.

PURPOSE: Hippocrates, the ancient Greek physician, is considered the father of Medicine; however, his contributions to Orthopaedics and Traumatology have not been highlighted enough. The present historical review represents an effort to present and categorize his work, in this field, per clinical disorder and anatomical region. METHODS: The "Hippocratic Corpus" original text was thoroughly studied to identify all Hippocrates' contributions in Orthopaedics and Traumatology. Volume III of his works, especially "On Fractures", "On Joints", and "Mochlicon" includes a plethora of information regarding the management of traumas, as well as other disorders and clinical entities of the musculoskeletal system. RESULTS: In particular, Hippocrates describes reduction techniques for fractures, as well as joint dislocations, elaborates on the biology of the fractures' healing process and the basic principles of fracture management and fixation, presents the signs and symptoms of gangrene, teaches the treatment of osseous infections and offers valuable insight on the biomechanics and treatment of spinal diseases. CONCLUSIONS: Hippocrates' contributions in Orthopaedics and Traumatology are unprecedented, making him a true pioneer in this field, while the basic principles that he presented were further studied and confirmed in the 19th and 20th centuries.