What are the Trends in Racial Diversity Among Orthopaedic Applicants, Residents, and Faculty?

BACKGROUND: Orthopaedic surgery has recruited fewer applicants from underrepresented in medicine (UIM) racial groups than many other specialties, and recent studies have shown that although applicants from UIM racial groups are competitive for orthopaedic surgery, they enter the specialty at lower rates. Although previous studies have measured trends in orthopaedic surgery applicant, resident, or attending diversity in isolation, these populations are interdependent and therefore should be analyzed together. It is unclear how racial diversity among orthopaedic applicants, residents, and faculty has changed over time and how it compares with other surgical and medical specialties. QUESTIONS/PURPOSES: (1) How has the proportion of orthopaedic applicants, residents, and faculty from UIM and White racial groups changed between 2016 and 2020? (2) How does representation of orthopaedic applicants from UIM and White racial groups compare with that of other surgical and medical specialties? (3) How does representation of orthopaedic residents from UIM and White racial groups compare with that of other surgical and medical specialties? (4) How does representation of orthopaedic faculty from UIM and White racial groups compare with that of other surgical and medical specialties? METHODS: We drew racial representation data for applicants, residents, and faculty between 2016 and 2020. Applicant data on racial groups was obtained for 10 surgical and 13 medical specialties from the Association of American Medical Colleges Electronic Residency Application Services report, which annually publishes demographic data on all medical students applying to residency through Electronic Residency Application Services. Resident data on racial groups were obtained for the same 10 surgical and 13 medical specialties from the Journal of the American Medical Association Graduate Medical Education report, which annually publishes demographic data on residents in residency training programs accredited by the Accreditation Council for Graduate Medical Education. Faculty data on racial groups were obtained for four surgical and 12 medical specialties from the Association of American Medical Colleges Faculty Roster United States Medical School Faculty report, which annually publishes demographic data of active faculty at United States allopathic medical schools. UIM racial groups include American Indian or Alaska Native, Black or African American, Hispanic or Latino, and Native American or Other Pacific Islander. Chi-square tests were performed to compare representation of UIM and White groups among orthopaedic applicants, residents, and faculty between 2016 and 2020. Further, chi-square tests were performed to compare aggregate representation of applicants, residents, and faculty from UIM and White racial groups in orthopaedic surgery to aggregate representation among other surgical and medical specialties with available data. RESULTS: The proportion of orthopaedic applicants from UIM racial groups increased between 2016 to 2020 from 13% (174 of 1309) to 18% (313 of 1699, absolute difference 0.051 [95% CI 0.025 to 0.078]; p < 0.001). The proportion of orthopaedic residents (9.6% [347 of 3617] to 10% [427 of 4242]; p = 0.48) and faculty (4.7% [186 of 3934] to 4.7% [198 of 4234]; p = 0.91) from UIM racial groups did not change from 2016 to 2020. There were more orthopaedic applicants from UIM racial groups (15% [1151 of 7446]) than orthopaedic residents from UIM racial groups (9.8% [1918 of 19,476]; p < 0.001). There were also more orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) than orthopaedic faculty from UIM groups (4.7% [992 of 20,916], absolute difference 0.051 [95% CI 0.046 to 0.056]; p < 0.001). The proportion of orthopaedic applicants from UIM groups (15% [1151 of 7446]) was greater than that of applicants to otolaryngology (14% [446 of 3284], absolute difference 0.019 [95% CI 0.004 to 0.033]; p = 0.01), urology (13% [319 of 2435], absolute difference 0.024 [95% CI 0.007 to 0.039]; p = 0.005), neurology (12% [1519 of 12,862], absolute difference 0.036 [95% CI 0.027 to 0.047]; p < 0.001), pathology (13% [1355 of 10,792], absolute difference 0.029 [95% CI 0.019 to 0.039]; p < 0.001), and diagnostic radiology (14% [1635 of 12,055], absolute difference 0.019 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from that of applicants to neurosurgery (16% [395 of 2495]; p = 0.66), plastic surgery (15% [346 of 2259]; p = 0.87), interventional radiology (15% [419 of 2868]; p = 0.28), vascular surgery (17% [324 of 1887]; p = 0.07), thoracic surgery (15% [199 of 1294]; p = 0.94), dermatology (15% [901 of 5927]; p = 0.68), internal medicine (15% [18,182 of 124,214]; p = 0.05), pediatrics (16% [5406 of 33,187]; p = 0.08), and radiation oncology (14% [383 of 2744]; p = 0.06). The proportion of orthopaedic residents from UIM groups (9.8% [1918 of 19,476]) was greater than UIM representation among residents in otolaryngology (8.7% [693 of 7968], absolute difference 0.012 [95% CI 0.004 to 0.019]; p = 0.003), interventional radiology (7.4% [51 of 693], absolute difference 0.025 [95% CI 0.002 to 0.043]; p = 0.03), and radiation oncology (7.9% [289 of 3659], absolute difference 0.020 [95% CI 0.009 to 0.029]; p < 0.001), and it was not different from UIM representation among residents in plastic surgery (9.3% [386 of 4129]; p = 0.33), urology (9.7% [670 of 6877]; p = 0.80), dermatology (9.9% [679 of 6879]; p = 0.96), and diagnostic radiology (10% [2215 of 22,076]; p = 0.53). The proportion of orthopaedic faculty from UIM groups (4.7% [992 of 20,916]) was not different from UIM representation among faculty in otolaryngology (4.8% [553 of 11,413]; p = 0.68), neurology (5.0% [1533 of 30,871]; p = 0.25), pathology (4.9% [1129 of 23,206]; p = 0.55), and diagnostic radiology (4.9% [2418 of 49,775]; p = 0.51). Compared with other surgical and medical specialties with available data, orthopaedic surgery had the highest proportion of White applicants (62% [4613 of 7446]), residents (75% [14,571 of 19,476]), and faculty (75% [15,785 of 20,916]). CONCLUSION: Orthopaedic applicant representation from UIM groups has increased over time and is similar to that of several surgical and medical specialties, suggesting relative success with efforts to recruit more students from UIM groups. However, the proportion of orthopaedic residents and UIM groups has not increased accordingly, and this is not because of a lack of applicants from UIM groups. In addition, UIM representation among orthopaedic faculty has not changed and may be partially explained by the lead time effect, but increased attrition among orthopaedic residents from UIM groups and racial bias likely also play a role. Further interventions and research into the potential difficulties faced by orthopaedic applicants, residents, and faculty from UIM groups are necessary to continue making progress. CLINICAL RELEVANCE: A diverse physician workforce is better suited to address healthcare disparities and provide culturally competent patient care. Representation of orthopaedic applicants from UIM groups has improved over time, but further research and interventions are necessary to diversify orthopaedic surgery to ultimately provide better care for all orthopaedic patients.

Spine Infections Reduced at Dedicated Orthopaedics and Spine Hospital.

BACKGROUND: Previous studies stratified postoperative infection risk by patient comorbidities. However, it is unclear whether the incidence varies by surgical approach in a specialized orthopaedic setting. This study aims to compare infection rates and microbiologic characteristics of postoperative spine infections requiring return to the operating room for debridement by hospital setting: a dedicated orthopaedic and spine hospital versus a general hospital serving multiple surgical specialties. METHODS: The study is a retrospective review of prospectively collected data. Procedures performed between March 2006 and August 2008 at the multispecialty university hospital were compared with cases at an orthopaedic specialty hospital from September 2008 through August 2016. The surgeons, residents, and patients were similar, but the operative venue changed in 2008. RESULTS: The overall general university hospital infection rate was 2.03%, higher than the overall infection rate at the dedicated orthopaedic and spine hospital of 1.31% (P < .0104). The general university infection rate was 2.27% in the final years of practice, compared with 0.91% at the dedicated orthopaedic and spine hospital (P < .0001) during a recent 2-year time frame. Demographic variables did not significantly differ between the 2 settings. The overall proportion of Gram-negative infection rates was not statistically different (21.7% vs 18.6%), despite an increased proportion of Gram-negative infections at the general university hospital following surgery from an anterior approach. Most of the organisms isolated in both facilities were Staphylococcus species. There was no difference in the seasonality of postoperative spine infections in either setting. CONCLUSIONS: In transitioning from a multispecialty university hospital to a dedicated orthopaedic hospital, the incidence of postoperative spine infections was significantly reduced to 0.91%. Despite the change in venue, the proportion of Gram-negative infections (∼20%) following spine surgery did not significantly change. These results suggest improved infection rates during the course of the last 10 years with consistent proportions of Gram-negative infections. LEVEL OF EVIDENCE: 3.

Is Operative Debridement Greater Than 24 Hours Post-admission Associated With Increased Likelihood of Post-operative Infection?

BACKGROUND: The historical "six-hour rule" as a golden hour for timing to debridement has been refuted in modern literature. Current standards prompt a timely debridement; however, in the setting of polytrauma, patients are often resuscitated for periods >24 h, with delayed orthopedic intervention. Therefore, we sought to determine the association between prolonged time to operative debridement (>24 h) and infection. METHODS: We conducted a retrospective review of patients with open fractures that underwent irrigation and debridement at a single institution from 2008 to 2016. Demographic, injury, and operative variables were collected. Infection was defined as the need for intravenous antibiotics and/or repeat irrigation and debridement. Chi-squared test and univariate logistic regression were performed. P < 0.05 was the cutoff for significance. RESULTS: Of 642 patients examined, 56 (8.7%) developed an infection. Prolonged time to debridement was not associated with increased infection rates (P = 1.00). Gustilo-Anderson classification was associated with increased risk of infection (type I: 2.1%, type II: 7.6%, and type III: 14.6%; P < 0.001). In univariate analysis, infection was associated with after-hours surgery (between 7 PM and 7 AM (odds ratio [OR] = 2.02; P < 0.02), definitive fixation more than 24 h post-admission (OR = 3.08; P < 0.001), wound closure more than 24 h post-admission (OR = 4.36; P < 0.001), and more than two operations performed post-admission (OR = 8.73; P < 0.001). Multivariate analysis of these factors found number of operations (OR = 7.13; P < 0.001) and time to definitive wound closure (OR = 4.04; P < 0.001) to be independent predictors of developing an infection. CONCLUSIONS: Our data suggests that there is no association between infection and prolonged time to debridement.

Cosmc is required for T cell persistence in the periphery.

T lymphocytes, a key arm of adaptive immunity, are known to dynamically regulate O-glycosylation during T cell maturation and when responding to stimuli; however, the direct role of O-glycans in T cell maturation remains largely unknown. Using a conditional knockout of the gene (C1GalT1C1 or Cosmc) encoding the specific chaperone Cosmc, we generated mice whose T cells lack extended O-glycans (T cell conditional Cosmc knock out or TCKO mice) and homogeneously express the truncated Tn antigen. Loss of Cosmc is highly deleterious to T cell persistence, with near-complete elimination of Cosmc-null T cells from spleen and lymph nodes. Total T cell counts are 20% of wild type (WT), among which only 5% express the truncated glycans, with the remaining 95% consisting of escapers from Cre-mediated recombination. TCKO thymocytes were able to complete thymic maturation but failed to populate the secondary lymphoid organs both natively and upon adoptive transfer to WT recipients. Our results demonstrate that extended O-glycosylation is required for the establishment and maintenance of the peripheral T cell population.

CyberKnife stereotactic radiosurgery for the treatment of intramedullary spinal cord metastases.

Spinal cord intramedullary metastases are uncommon and treatment options are limited. We reviewed our experience treating these lesions with radiosurgery to assess safety and efficacy, and to define preliminary treatment recommendations. With Institutional Review Board approval, we identified nine patients with 11 metastases treated with radiosurgery at Stanford University Hospital, between 2000 and 2010. We also reviewed all available published series discussing the treatment of spinal cord metastases. Our patients ranged in age from 33 years to 77 years (median 63 years) and included seven women and two men. Tumors ranged in size from 0.12 cm(3) to 6.4 cm(3) (median 0.48 cm(3)). Five were from breast cancer, two were non-small cell lung cancers, one was a cystic adenocarcinoma, and one was from an epithelioid hemangioepithelioma. All patients had neurologic deficits and multiple other metastases. We delivered 14 Gy to 27 Gy (median 21 Gy) in one to five (median 3) fractions. Complete follow-up was available for all nine patients. One patient remains alive 14 months after therapy. Of the eight deceased patients, survival ranged from one month and two days to nine months and six days (median four months and four days). There were no local recurrences or worsened neurological deficits. To our knowledge this is the largest reported series of spinal cord intramedullary metastases treated with radiosurgery. Survival was poor due to systemic disease, but radiosurgery appears to be safe and prevented local recurrences. With fewer sessions than conventional radiation and less morbidity than surgery, we feel radiosurgery is appropriate for the palliative treatment of these lesions.

CyberKnife radiosurgery can control recurrent epidermoid cysts of the central nervous system.

Epidermoid cysts of the central nervous system may be difficult to resect and recurrent lesions may be impossible to control with open surgery. We identified three patients with recurrent epidermoids treated with radiosurgery at Stanford. One patient with a middle fossa lesion that had been resected twice in six years, presented with a 4.5 cubic centimeter recurrence and was treated with radiosurgery. Follow-up scans over three years showed no additional growth. Two patients had spinal lesions. One had undergone numerous, unsuccessful procedures in the three years before the radiosurgical treatment and subsequent open resection of a 3.8 cubic centimeter recurrence. His scans remain unremarkable eight years after treatment. The other, with acaudaequina mass, had required five open resections in 11 years. Following the last resection, the residual was treated radiosurgically. The lesion eventually increased in size, but became symptomatic only after seven years. A second course of radiosurgery was delivered. We believe that stereotactic radiosurgery can be safe for some epidermoid cysts of the central nervous system, decreases their growth rate, and may facilitate subsequent open surgery. It should be considered for select individuals with recurrent or unresectable lesions.