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.

The Effects of Sociodemographic Factors on Baseline Patient-Reported Outcome Measures in Patients with Foot and Ankle Conditions.

BACKGROUND: Racial and ethnic care disparities persist within orthopaedics in the United States. This study aimed to deepen our understanding of which sociodemographic factors most impact patient-reported outcome measure (PROM) score variation and may explain racial and ethnic disparities in PROM scores. METHODS: We retrospectively reviewed baseline PROMIS (Patient-Reported Outcomes Measurement Information System) Global-Physical (PGP) and PROMIS Global-Mental (PGM) scores of 23,171 foot and ankle patients who completed the instrument from 2016 to 2021. A series of regression models was used to evaluate scores by race and ethnicity after adjusting in a stepwise fashion for household income, education level, primary language, Charlson Comorbidity Index (CCI), sex, and age. Full models were utilized to compare independent effects of predictors. RESULTS: For the PGP and PGM, adjusting for income, education level, and CCI reduced racial disparity by 61% and 54%, respectively, and adjusting for education level, language, and income reduced ethnic disparity by 67% and 65%, respectively. Full models revealed that an education level of high school or less and a severe CCI had the largest negative effects on scores. CONCLUSIONS: Education level, primary language, income, and CCI explained the majority (but not all) of the racial and ethnic disparities in our cohort. Among the explored factors, education level and CCI were predominant drivers of PROM score variation. LEVEL OF EVIDENCE: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Economic Analysis and Patient Satisfaction Associated With Outpatient Total Ankle Arthroplasty.

BACKGROUND: Total ankle arthroplasty (TAA) is a rapidly growing treatment for end-stage ankle arthritis that is generally performed as an inpatient procedure. The feasibility of outpatient total ankle arthroplasty (OTAA) has not been reported in the literature. We sought to establish proof of concept for OTAA by comparing outpatient vs inpatient perioperative complications, postoperative emergency department (ED) visits, readmissions, patient satisfaction, and cost analysis. METHODS: From July 2010 to September 2015, a total of 36 patients underwent TAA. Patients with prior ankle replacement, prior ankle infections, neuroarthropathy, or osteonecrosis of the talus were excluded from the study. All patient demographics, tourniquet times, estimated blood loss, comorbidities, concomitant procedures, complications, return ED visits, and readmissions were recorded. Patient satisfaction questionnaires were collected. Twenty-one patients had outpatient surgery and 15 had inpatient surgery. The cohorts were matched demographically. RESULTS: The average length of stay for the inpatient group was 2.5 days. The overall cost differential between the groups was 13.4%, with the outpatient group being less costly. This correlates to a cost savings of nearly $2500 per case. One patient in the outpatient group had a return ED visit on postoperative day 1 for urinary retention. There were no 30-day readmissions in either group. Seventy-one percent of the outpatient group and 93% of the inpatient group would not change to a different postoperative admission status if they were to have the procedure again. CONCLUSION: Our results show that OTAA was a cost-effective and safe alternative with low complication rates and high patient satisfaction. With proper patient selection, OTAA was beneficial to both the patient and the health care system by driving down total cost. It has the capacity to generate substantial savings while providing equal or better value to the patient. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A new reduction technique for completely displaced forearm and wrist fractures in children: a biomechanical assessment and 4-year clinical evaluation.

BACKGROUND: Most pediatric distal radius fractures are treated with closed methods, however, in recent years an increasing number of fractures are treated with operative management. Multiple reduction techniques are described in the orthopaedic literature but no recent advances have been made in the closed management of these injuries. We describe the efficacy of new, single-provider manual reduction technique that improves reduction efficacy and we separately show its biomechanical superiority to other common techniques. METHODS: Review the results of a new reduction technique, known as the Lower Extremity-aided Fracture Reduction (LEAFR) maneuver, used on a specific cohort of consecutively treated patients at a single institution over a 4-year period with bayoneted distal radius fractures. Intention-to-treat methodology and descriptive statistics are utilized to analyze accuracy of reduction, need for operative intervention, residual deformity, and complications. In addition, perform a biomechanical comparison between the LEAFR maneuver, the 2 person traction counter-traction method and finger traps. RESULTS: The technique allowed 24 consecutively treated, bayoneted distal radius fractures to be reduced from average translational and shortening deformities of 11.4 and 6.5 mm to 2.1 and 0.4 mm, respectively (P<0.0001). Two (8%) of the 24 patients had failure to eliminate bayonet displacement, whereas only 3 patients (12.5%) ultimately required operative intervention. No cases of growth arrest were noted. A biomechanical assessment of the maneuver showed the ability to generate an average of 597.8 Newtons (N) of axial traction which is statistically significant in comparison to other accepted methods of reduction. CONCLUSIONS: The LEAFR is a clinically effective and biomechanically sound technique for reduction of bayoneted distal radius fractures in children. It is a simple, reproducible technique not reliant on equipment or additional skilled providers. In addition, it results in decreased rates of operative management and represents advancement in the treatment of pediatric distal radius fractures. LEVEL OF EVIDENCE: Level IV (Retrospective Case Series), Level I (Biomechanical Comparison Study).