The Effects of Autologous Fat Transfer in an In Vitro Model of Basal Joint Osteoarthritis.

PURPOSE: Basal joint osteoarthritis (OA) is a highly prevalent and debilitating condition. Recent clinical evidence suggests that autologous fat transfer (AFT) may be a promising, minimally invasive treatment for this condition. However, the mechanism of action is not fully understood. It is theorized that AFT reduces inflammation in the joint, functions to regenerate cartilage, or acts as a mechanical buffer. The purpose of this study was to better understand the underlying mechanism of AFT using an in vitro model. We hypothesize that the addition of stromal vascular fraction (SVF) cells will cause a reduction in markers of inflammation. METHODS: Articular chondrocytes were expanded in culture. Liposuction samples were collected from human subjects and processed similarly to AFT protocols to isolate SVF rich in adipose-derived stem cells. A control group was treated with standard growth media, and a positive control group (OA group) was treated with inflammatory cytokines. To mimic AFT, experimental groups received inflammatory cytokines and either a low or high dose of SVF. Expression of relevant genes was measured, including interleukin (IL)-1ß, IL-1 receptor antagonist, and matrix metalloproteinases (MMP). RESULTS: Compared to the OA group, significant decreases in IL-1ß, MMP3, and MMP13 expression on treatment day 3 were found in the high-dose SVF group, while MMP13 expression was also significantly decreased in the low-dose SVF group on day 3. CONCLUSIONS: In this study, we found that SVF treatment reduced expression of IL-1ß, MMP3, and MMP13 in an in vitro model of OA. These results suggest that an anti-inflammatory mechanism may be responsible for the clinical effects seen with AFT in the treatment of basal joint OA. CLINICAL RELEVANCE: An anti-inflammatory mechanism may be responsible for the clinical benefits seen with AFT for basal joint arthritis.

Race, But Not Gender, Is Associated With Admissions Into Orthopaedic Residency Programs.

BACKGROUND: Orthopaedic surgery is one of the most competitive but least diverse surgical specialties, with ever-increasing academic achievements (such as test scores) shown by applicants. Prior research shows that white applicants had higher United States Medical Licensing Exam (USMLE) Step 1 and Step 2 Clinical Knowledge scores as well as higher odds of Alpha Omega Alpha status compared with Black, Hispanic, and other applicant groups. Yet, it still remains unknown whether differences in application metrics by race/ethnicity sufficiently explain the underrepresentation of certain racial or ethnic minority groups in orthopaedic residency programs. QUESTIONS/PURPOSES: In this study, we sought to determine (1) the relative weight of academic variables for admission into orthopaedic residency, and (2) whether race and gender are independently associated with admission into an orthopedic residency. METHODS: The Electronic Residency Application System (ERAS) data from the Association of American Medical Colleges (AAMC) and the National Board of Medical Examiners (NBME) of first-time MD applicants (n = 8966) for orthopaedic surgery residency positions in the United States and of admitted orthopaedic residents (n = 6218) from 2005 to 2014 were reviewed. This dataset is the first and most comprehensive of its kind to date in orthopaedic surgery. Academic metrics, such as USMLE Step 1 and Step 2 Clinical Knowledge scores, number of publications, Alpha Omega Alpha status, volunteer experiences, work experience, as well as race and gender, were analyzed using hierarchical logistic regression models. The first model analyzed the association of academic metrics with admission into orthopaedic residency. In the second model, we added race and gender and controlled for metrics of academic performance. To determine how well the models simulated the actual admissions data, we computed the receiver operating characteristics (ROC) including the area under curve (AUC), which measures the model's ability to simulate which applicants were admitted or not admitted, with an AUC = 1.0 representing a perfect simulation. The odds ratio and confidence interval of each variable were computed. RESULTS: When only academic variables were analyzed in the first model, Alpha Omega Alpha status (odds ratio 2.12 [95% CI 1.80 to 2.50]; p < 0.001), the USMLE Step 1 score (OR 1.04 [95% CI 1.03 to 1.04]; p < 0.001), the USMLE Step 2 Clinical Knowledge score (OR 1.01 [95% CI 1.01 to 1.02]; p < 0.001), publication count (OR 1.04 [95% CI 1.03 to 1.05]; p < 0.001), and volunteer experience (OR 1.03 [95% CI 1.01 to 1.04]; p < 0.001) were associated with admissions into orthopaedics while work and research experience were not. This model yielded a good prediction of the results with an AUC of 0.755. The second model, in which the variables of race and gender were added to the academic variables, also had a good prediction of the results with an AUC of 0.759. This model indicates that applicant race, but not gender, is associated with admissions into orthopaedic residency. Applicants from Asian (OR 0.78 [95% CI 0.67 to 0.92]), Black (OR 0.63 [95% CI 0.51 to 0.77], Hispanic (OR 0.48 [95% CI 0.36 to 0.65]), or other race groups (OR 0.65 [95% CI 0.55 to 0.77]) had lower odds of admission into residency compared with white applicants. CONCLUSION: Minority applicants, but not women, have lower odds of admission into orthopaedic surgery residency, even when accounting for academic performance metrics. Changes in the residency selection processes are needed to eliminate the lower admission probability of qualified minority applicants in orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery. Changes including increasing the diversity of the selection committee, bias training, blinding applications before review, removal of metrics with history of racial disparities from an interviewer's candidate profile before an interview, and use of holistic application review (where an applicants' experiences, attributes, and academic metrics are all considered) can improve the diversity landscape in training. In addition, cultivating an environment of inclusion will be necessary to address these long-standing trends in orthopaedic surgery. CLINICAL RELEVANCE: Race, but not gender, is associated with the odds of acceptance into orthopaedic surgery residency despite equivalent academic metrics. Changes in residency selection processes are suggested to eliminate the lower admission probability of qualified minority applicants into orthopaedic residency and to improve the diversity and inclusion of orthopaedic surgery.

MRI of the Extensor Tendons of the Wrist.

OBJECTIVE: This article reviews the normal anatomy of the extensor tendons of the wrist as well as the clinical presentation and MRI appearances of common tendon abnormalities, such as tears, tenosynovitis, intersection syndromes, and associated or predisposing osseous findings. Treatment options are also discussed. CONCLUSION: We review the anatomy and normal MRI appearance of the clinically important dorsal extensor tendons of the wrist, in addition to the spectrum of abnormalities associated with these tendons.

Management of Grade 1 Open Distal Radius Fractures: A Survey of Practicing Surgeons.

Introduction Standard of care management for open fractures historically mandates emergent systemic antibiotic administration, followed by urgent irrigation and debridement in the operating room, regardless of injury severity. However, significant controversy exists regarding the specific implementation and importance of these commonly accepted guidelines. We aimed to define differences in the management of grade 1 open distal radius fractures. Methods An anonymous online survey was distributed to attending surgeon members of either the Orthopaedic Trauma Association (OTA) between January 2019 and April 2019 or the New York Society for Surgery of the Hand (NYSSH) in January 2019. Results A total of 68 attending surgeons responded to the survey. A total of 24 OTA members and 40 NYSSH members replied and were included in the study. Several factors influenced management in addition to the level of contamination. Of the surgeons, 68% stated that litigation was not a major factor of concern. When compared to surgeons who trained in trauma fellowships, more surgeons who trained in hand/upper extremity fellowships considered closed reduction alone as reasonable definitive treatment (when excluding antibiotic administration and debridement considerations, p = 0.024) and oral antibiotics as a supplement to IV antibiotics (p < 0.001). Of the surgeons, 90% would nonoperatively treat a patient who presented with a grade 1 open distal radius fracture greater than 72 hours after injury with stable and acceptable alignment on X-rays. Conclusion Some surgeons are willing to deviate from standard-of-care management protocols.

Factors associated with poor outcomes following unicompartmental knee arthroplasty: redefining the "classic" indications for surgery.

Indications for UKA for isolated osteoarthritis of the knee remain controversial. Two hundred twenty-nine UKA that were performed at our institution were evaluated for which factors were associated with a poor outcome. BMI >35 was correlated with lower KSS scores than patients with BMI <35. In contrast to prior reports, patients younger than 60 years old had higher scores than patients 60 years and older at 2 years. Women had an unacceptably high short-term revision rate for any reason of 6.5%. Popularity for UKA has increased, and a more in depth investigation of predictors of poor outcomes demonstrates that younger patients appear to have better results. Obese patients continue to improve up to 2 years after surgery and should not be precluded from undergoing UKA.

Update on Educational Resources and Evaluation Tools for Orthopaedic Surgery Residents.

Innovations in orthopaedic resident educational resources and evaluation tools are essential to ensuring appropriate training and ultimately the graduation of competent orthopaedic surgeons. In recent years, there have been several advancements in comprehensive educational platforms within orthopaedic surgery. Orthobullets PASS, Journal of Bone and Joint Surgery Clinical Classroom, and American Academy of Orthopaedic Surgery Resident Orthopaedic Core Knowledge each have their own unique advantages in preparation for the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery board certification examinations. In addition, the Accreditation Council for Graduate Medical Education Milestones 2.0 and the American Board of Orthopaedic Surgery Knowledge Skills Behavior program each provide objective assessment of resident core competencies. Understanding and using these new platforms will help orthopaedic residents, faculty, residency programs, and program leadership to best train and evaluate their residents.

Tendon Transection Healing Can Be Improved With Adipose-Derived Stem Cells Cultured With Growth Differentiation Factor 5 and Platelet-Derived Growth Factor.

BACKGROUND: As hand surgeons, tendon injuries and lacerations are a particularly difficult problem to treat, as poor healing potential and adhesions hamper optimal recovery. Adipose-derived stem cells (ADSCs) have been shown to aid in rat Achilles tendon healing after a puncture defect, and this model can be used to study tendon healing in the upper extremity. We hypothesized that ADSCs cultured with growth differentiation factor 5 (GDF5) and platelet-derived growth factor (PDGF) would improve tendon healing after a transection injury. METHODS: Rat Achilles tendons were transected and then left either unrepaired or repaired. Both groups were treated with a hydrogel alone, a hydrogel with ADSCs, or a hydrogel with ADSCs that were cultured with GDF5 and PDGF prior to implantation. Tissue harvested from the tendons was evaluated for gene expression of several genes known to play an important role in successful tendon healing. Histological examination of the tendon healing was also performed. RESULTS: In both repaired and unrepaired tendons, those treated with ADSCs cultured with GDF5/PDGF prior to implantation showed the best tendon fiber organization, the smallest gaps, and the most organized blood vessels. Treatment with GDF5/PDGF increased expression of the protenogenesis gene SOX9, promoted cell-to-cell connections, improved cellular proliferation, and enhanced tissue remodeling. CONCLUSIONS: Adipose-derived stem cells cultured with GDF5/PDGF prior to implantation can promote tendon repair by improving cellular proliferation, tenogenesis, and vascular infiltration. This effect results in a greater degree of organized tendon healing.

Effects of Premixing Betamethasone and Lidocaine on Chondrocyte Inflammation in an In Vitro Model.

BACKGROUND: It is common practice for hand surgeons to premix corticosteroids with a local anesthetic and store the mixture in pre-loaded syringes for rapid use during clinic. However, any possible loss of efficacy with this practice has never been studied. The purpose of this study, therefore, is to determine whether premixing betamethasone sodium phosphate/betamethasone acetate (BSP) and lidocaine (L) at different time intervals from injection has diminishing anti-inflammatory effects on chondrocytes in vitro. METHODS: Human articular chondrocytes were partitioned into six groups: two controls and four experimental conditions. The negative control had growth media only. The positive control had growth media and inflammatory cytokines (interleukin-1ß and oncostatin M). Experimental conditions were additionally treated with BSP alone or BSP mixed with lidocaine (BSP + L) at the time of treatment (0 hours), or at 4 or 24 hours prior. Relative expressions of inflammatory genes were measured. RESULTS: Relative to the positive control, chondrocytes in all experimental conditions decreased expression of TNF-α, MMP-3, and ADAMTS-4. Chondrocytes exposed to BSP only or BSP + L at 4 hours or 24 hours prior to treatment decreased expression of IL-8. Chondrocytes exposed to BSP only or BSP + L at 0 hours or 4 hours prior to treatment decreased expression of MMP-1. There were no significant differences in expression of IL-6 or MMP-13. CONCLUSIONS: Treatment with BSP + L prepared in pre-loaded syringes at varying time intervals up to 24 hours prior to injection does not significantly impact the ability of the mixture to reduce expression of certain key inflammatory mediators in vitro.

The Risk of Lymphedema After Breast Cancer Surgery Should Not Restrict Necessary Hand Surgery Interventions.

BACKGROUND: The purpose of this study was to evaluate the incidence of lymphedema onset or exacerbation in patients undergoing upper extremity interventions, both nonoperative and operative, after breast cancer surgery. METHODS: The study inclusion criteria were the following: (1) prior history of breast cancer surgery or lymphedema from the cancer; (2) upper extremity intervention, ipsilateral to the breast cancer side; and (3) follow-up of at least 1 month. Patients were evaluated for demographic information, type of breast cancer procedure and hand intervention, number of lymph nodes dissected, preexisting lymphedema, exacerbation of lymphedema, and new-onset lymphedema. RESULTS: A total of 161 patients undergoing 385 hand interventions (300 injections, 85 surgeries) were reviewed. Median follow-up was 31 months (range: 1-110). Nineteen patients had preexisting lymphedema ipsilateral to the hand procedure and none experienced an exacerbation of their lymphedema. Three patients developed new-onset lymphedema ipsilateral to their hand intervention at an average follow-up of 30 months (range: 4-67). One patient had a single injection and developed lymphedema over 5 years later. One had 2 injections in the same hand on the same date and developed lymphedema 3 months later. The third patient had 2 injections in the right hand, 1 injection and 1 surgery in the left hand, and developed either lymphedema or swelling due to rheumatoid arthritis in the right hand 1 year after the injections. CONCLUSIONS: Patients who have undergone breast cancer surgery can safely undergo upper extremity intervention with low risk of lymphedema exacerbation or onset.

Exponential Growth in Female Residency Applicants in Orthopaedic Surgery Over the Past 15 Years.

Orthopaedic surgery is recognized as one of the most popular but least diverse medical subspecialties. Although significant efforts have been made in recent years to improve gender diversity, orthopaedic surgery continues to lag behind other surgical subspecialties. A recent study predicted that it would take 217 years for orthopaedic surgery to reach gender parity matching the 36.3% of practicing female physicians in the United States. The purpose of our study was to evaluate the annual percentages of female medical student applicants in orthopaedic surgery over the past 15 years and to determine when this gender parity percentage may be reached among residency applicants. Methods: The Electronic Residency Application Service was queried for orthopaedic residency applicant data from 2007 to 2022. The annual percentage of female applicants as well as the annual change in percentage of female applicants was recorded. A best-fit trendline was calculated and extrapolated to predict future rates of female applicants. Results: The percent of female applicants has increased from 11.8% in 2007 to 23.0% in 2022. Between 2007 and 2022, there were 9 years with annual increases in percentage of females applying into orthopaedic surgery with a statistically significant increase in 4 of those years (2008, 2014, 2019, and 2022). There were 6 years with annual decreases in percentage of females applying to orthopaedic surgery, none of which were statistically significant. The best-fit curve is exponential with a correlation coefficient of 0.8 (p < 0.001). This predicts reaching the predetermined gender parity percentage of 36.3% in 16 years. Conclusion: In the past 15 years, there has been a near-doubling in the percentage of female medical students applying to orthopaedic surgery residency. Although orthopaedic surgery remains the least gender-diverse field of medicine, these trends are encouraging and support the initiatives currently in place including early education and increased mentorship to help close the gender gap in orthopaedic surgery.

The effects of pain, supination, and grip strength on patient-rated disability after operatively treated distal radius fractures.

PURPOSE: The correlation between physician-observed parameters and patient-rated disability in distal radius fractures is complex and poorly understood. Anecdotal clinical experience suggests that supination is an important factor in the return of functional status after distal radius fracture. To explore this relationship, we conducted a retrospective multivariate linear regression analysis of an existing patient database to evaluate the hypothesis that range of motion and other objective parameters are important determinants of patient-rated disability. METHODS: We analyzed a prospectively gathered registry of patients undergoing operative fixation of distal radius fractures using physical examination parameters measured at each follow-up visit and patient-based outcomes including Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and visual analog scale for pain. We constructed a multivariate linear regression model to evaluate the association of range of motion, grip strength, and visual analog scale score with the DASH score. RESULTS: We analyzed data from 190 patients and 611 total clinic visits. Pain, grip strength, and supination were significantly correlated with DASH scores, controlling for all other factors. These 3 variables were able to predict 56% of the variability of the DASH score. Flexion-extension, radial-ulnar deviation, and pronation had no significant correlation to DASH score. CONCLUSIONS: Pain, strength, and supination appear to be important determinants of patient-rated outcomes after distal radius fracture. Pain and strength continuously improve over time up to 2 years after surgery, whereas supination plateaus more quickly, usually within the first 3 to 6 months. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Can the Workplace Limitations Questionnaire Capture Short-term Productivity Losses in Acute Distal Radius Fractures Treated With Operative Fixation Versus Cast Immobilization in the Working Population?

Background: Distal radius fractures (DRFs) contribute substantially to overall morbidity in the elderly population. We believe that accurately capturing total productivity losses is vital to understanding the true economic impact of these injuries in working patients. Methods: We conducted a prospective nonrandomized cohort study and enrolled working patients with DRF treated with either casting or operative fixation. We administered the Workplace Limitations Questionnaire (WLQ, Tufts Medical Center) at the first visit following injury and at 2 weeks, 6 weeks, and 3 months after definitive treatment. The WLQ measures the degree to which employed individuals are experiencing limitations on-the-job due to their health problems and estimates health-related productivity loss. We also calculated the monetary value of work time lost at market value in US dollars. The treatment groups were analyzed for statistical similarity using Student t tests. Results: A total of 30 patients met our study's inclusion criteria. The WLQ index score trended downward in both groups across all time points and was lower in the operative cohort compared with the nonoperative cohort at 6 weeks (1.4% vs 12.9% productivity loss, P = .17). The monetary value of work time lost trended downward across all time points and was lower in the operative cohort compared with the nonoperative cohort ($200.21 vs $2846.90, P = .12). Conclusions: In this pilot study, we successfully applied the WLQ to working patients treated for DRF. The WLQ is effective in capturing short-term productivity losses following DRF and may suggest a decreased at-work burden among patients treated with operative fixation compared with casting.

Orthopaedic Surgeons Have a High Prevalence of Burnout, Depression, and Suicide: Review of Factors Which Contribute or Reduce Further Harm.

Orthopaedic surgeons have the highest prevalence of death by suicide among all surgical subspecialties, comprising 28.2% of surgeon suicides from 2003 to 2017. There is a continuum of burnout, depression, and other mental health illnesses likely contributing to these numbers in our profession. Stigmatization in terms of medical licensing and professional development are currently barriers to seeking mental health treatment. Education on the risk and treatment of burnout, depression, and suicidal ideations should begin early in a surgeon's career. This review documents the issue of physician burnout and depression and makes recommendations regarding necessary changes to counteract mental illness in orthopaedic surgeons.

Management of de Quervain Tenosynovitis: A Critical Analysis Review.

¼: Most cases of de Quervain tenosynovitis can be managed with nonoperative measures, and the mainstay of treatment is corticosteroid injection (CSI). The use of ultrasound may improve the accuracy of injections and can help to identify and localize injections to separate subcompartments. ¼: For patients who are in the third trimester of pregnancy or breastfeeding, there is no contraindication to CSI as studies have shown that it can provide optimal symptomatic relief to the mother without impacting the baby. ¼: When nonoperative treatment is unsuccessful, surgical release of the first dorsal compartment (FDC) can provide excellent symptom relief. Open release performed through a longitudinal incision allows for better visualization of the underlying anatomy, resulting in fewer injuries to underlying structures and a lower incidence of hypertrophic scarring compared with a transverse incision. ¼: For surgeons who are comfortable performing endoscopic techniques, endoscopic FDC release can result in quicker symptom improvement, superior scar cosmesis, and a lower incidence of radial sensory nerve injury. ¼: Studies have shown that FDC release can safely and effectively be performed using the WALANT (wide-awake local anesthesia no tourniquet) technique, which has the potential for cost savings without compromising quality or patient comfort.

Ulnar Neuropathy After Intermittent Prone Positioning for COVID-19 Infection: A Preliminary Report of 3 Cases.

CASE: We describe a preliminary report of 3 cases of ulnar neuropathy after coronavirus disease 2019 (COVID-19) infection and treatment with intermittent prone positioning. CONCLUSION: Ulnar neuropathy may be associated with recent COVID-19 infection. The natural process of the disease and intermittent prone positioning are likely risk factors contributing to this finding. Conservative management seems to lead to improvement of symptoms.

Patient education before hip or knee arthroplasty lowers length of stay.

From April 2006 to May 2007, 261 patients undergoing primary unilateral total hip arthroplasty or total knee arthroplasty were offered voluntary participation in a one-on-one preoperative educational program. Length of stay (LOS) and inpatient data were monitored and recorded, prospectively. Education participants enjoyed a significantly shorter LOS than nonparticipants for both total hip arthroplasty (3.1 +/- 0.8 days vs 3.9 +/- 1.4 days; P = .0001) and total knee arthroplasty (3.1 +/- 0.9 days vs 4.1 +/- 1.9 days; P = .001).

Academic Metrics Do Not Explain the Underrepresentation of Women in Orthopaedic Training Programs.

BACKGROUND: Among medical specialties, orthopaedic surgery persistently has one of the lowest representations of women in residency programs. This study examined whether differences exist in the academic metrics of the orthopaedic residency applicants and enrolled candidates by sex, which may be contributing to the persistent underrepresentation of women. Differences in enrollment rate in orthopaedic residency programs also were analyzed. We hypothesized that academic metrics were similar for female and male applicants and thus do not explain the underrepresentation of women in training programs. METHODS: Academic data of first-time applicants (n = 9,133) and candidates who enrolled in an orthopaedic residency (n = 6,381) in the U.S. from 2005 to 2014 were reviewed. The United States Medical Licensing Examination (USMLE) Step-1 and Step-2 Clinical Knowledge (CK) scores, Alpha Omega Alpha (AΩA) Honor Medical Society status, number of publications, and volunteer experiences were compared by sex and were analyzed over time. RESULTS: From 2005 to 2014, representation of female applicants increased from 12.6% to 16.0%, corresponding with an increase in the percentage of enrolled female residents (from 12.9% to 16.1%); 70.3% of male and 67.1% of female applicants to orthopaedic residency enrolled as residents (p = 0.082). Mean academic metrics increased significantly over time for applicants and enrolled candidates, irrespective of sex. Comparing by sex, the mean USMLE Step-1 scores of male applicants and enrolled candidates were approximately 2% higher than those of female applicants (p < 0.0001). Volunteer experiences of female applicants and enrolled candidates were 12% higher compared with male applicants (p < 0.0001). There was no significant difference in USMLE Step-2 CK scores, number of publications, or AΩA status by sex. CONCLUSIONS: The enrollment rate of male and female applicants in orthopaedic residencies was similar and did not change during the 10-year study period. The academic metrics of applicants and enrolled candidates have increased significantly. The academic metrics were found to be comparable by sex; the differences in USMLE Step-1 scores and volunteer experiences were small relative to the magnitude of accomplishments that these values represent. The growth rate of the proportion of women in orthopaedic residencies lags other surgical subspecialties but appears to be independent of academic metrics.

Underrepresented Minority Applicants Are Competitive for Orthopaedic Surgery Residency Programs, but Enter Residency at Lower Rates.

INTRODUCTION: Orthopaedic surgery residency programs have the lowest representation of ethnic/racial minorities compared with other specialties. This study compared orthopaedic residency enrollment rates and academic metrics of applicants and matriculated residents by race/ethnicity. METHODS: Data on applicants from US medical schools for orthopaedic residency and residents were analyzed from 2005 to 2014 and compared between race/ethnic groups (White, Asian, Black, Hispanic, and Other). RESULTS: Minority applicants comprised 29% of applicants and 25% of enrolled candidates. Sixty-one percent of minority applicants were accepted into an orthopaedic residency versus 73% of White applicants (P < 0.0001). White and Asian applicants and residents had higher USMLE Step 1. White applicants and matriculated candidates had higher Step 2 Clinical Knowledge scores and higher odds of Alpha Omega Alpha membership compared with Black, Hispanic, and Other groups. Publication counts were similar in all applicant groups, although Hispanic residents had significantly more publications. Black applicants had more volunteer experiences. CONCLUSIONS: In orthopaedic surgery residency, minority applicants enrolled at a lower rate than White and Asian applicants. The emphasis on USMLE test scores and Alpha Omega Alpha membership may contribute to the lower enrollment rate of minority applicants. Other factors such as conscious or unconscious bias, which may contribute, were not evaluated in this study.

Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award.

The Displaced Femoral (neck fracture) Arthroplasty Consortium for Treatment and Outcomes study is a prospective, multicenter randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty (THA) in the treatment of displaced femoral neck fractures in previously independent patients. Primary outcomes were measured at 6, 12, and 24 months with the Short Form-36 (SF-36), Western Ontario and McMaster Osteoarthritis Index (WOMAC), and the Harris Hip Score and the Timed "Up & Go" Test. Forty subjects were enrolled. At 24 months, THA patients had significantly less pain on the SF-36 subscale than hemiarthroplasty patients (54.8 +/- 7.9 vs 44.7 +/- 10.5, P = .04) and scored significantly better on the SF-36 mental health subscale (54.9 +/- 9.4 vs 40.9 +/- 10.3, P = .006). Total hip arthroplasty patients also had superior WOMAC function scores (81.8 +/- 10.2 vs 65.1 +/- 18.1, P = .03). Significant differences in outcomes, without a significantly greater incidence of complications, suggest THA is a valuable treatment option for the active elderly hip fracture population.

Displaced femoral neck fractures: is there a standard of care?

Many factors must be considered in treating displaced femoral neck fractures. For younger patients, ORIF is preferred, whereas arthroplasty is the better option for elderly patients. For institutionalized elderly patients with a low activity level or impaired mental status, the choice should be hemiarthroplasty (either unipolar or bipolar). For high-demand, active patients, evidence continues to mount toward THA as the favored treatment option. However, there is a need for larger clinical trials to demonstrate the most cost-effective way to treat sub-populations of an ever-growing number of patients with displaced femoral neck fractures.