A Shadow of Doubt: Is There Implicit Bias Among Orthopaedic Surgery Faculty and Residents Regarding Race and Gender?

BACKGROUND: Orthopaedic surgery continues to be one of the least diverse medical specialties. Recently, increasing emphasis has been placed on improving diversity in the medical field, which includes the need to better understand existing biases. Despite this, only about 6% of orthopaedic surgeons are women and 0.3% are Black. Addressing diversity, in part, requires a better understanding of existing biases. Most universities and residency programs have statements and policies against discrimination that seek to eliminate explicit biases. However, unconscious biases might negatively impact the selection, training, and career advancement of women and minorities who are underrepresented in orthopaedic surgery. Although this is difficult to measure, the Implicit Association Test (IAT) by Project Implicit might be useful to identify and measure levels of unconscious bias among orthopaedic surgeons, providing opportunities for additional interventions to improve diversity in this field. QUESTIONS/PURPOSES: (1) Do orthopaedic surgeons demonstrate implicit biases related to race and gender roles? (2) Are certain demographic characteristics (age, gender, race or ethnicity, or geographic location) or program characteristics (geographic location or size of program) associated with the presence of implicit biases? (3) Do the implicit biases of orthopaedic surgeons differ from those of other healthcare providers or the general population? METHODS: A cross-sectional study of implicit bias among orthopaedic surgeons was performed using the IAT from Project Implicit. The IAT is a computerized test that measures the time required to associate words or pictures with attributes, with faster or slower response times suggesting the ease or difficulty of associating the items. Although concerns have been raised recently about the validity and utility of the IAT, we believed it was the right study instrument to help identify the slight hesitation that can imply differences between inclusion and exclusion of a person. We used two IATs, one for Black and White race and one for gender, career, and family roles. We invited a consortium of researchers from United States and Canadian orthopaedic residency programs. Researchers at 34 programs agreed to distribute the invitation via email to their faculty, residents, and fellows for a total of 1484 invitees. Twenty-eight percent (419) of orthopaedic surgeons and trainees completed the survey. The respondents were 45% (186) residents, 55% (228) faculty, and one fellow. To evaluate response biases, the respondent population was compared with that of the American Academy of Orthopaedic Surgeons census. Responses were reported as D-scores based on response times for associations. D-scores were categorized as showing strong (≥ 0.65), moderate (≥ 0.35 to < 0.65), or slight (≥ 0.15 to < 0.35) associations. For a frame of reference, orthopaedic surgeons' mean IAT scores were compared with historical scores of other self-identified healthcare providers and that of the general population. Mean D-scores were analyzed with the Kruskal-Wallis test to determine whether demographic characteristics were associated with differences in D-scores. Bonferroni correction was applied, and p values less than 0.0056 were considered statistically significant. RESULTS: Overall, the mean IAT D-scores of orthopaedic surgeons indicated a slight preference for White people (0.29 ± 0.4) and a slight association of men with career (0.24 ± 0.3), with a normal distribution. Hence, most respondents' scores indicated slight preferences, but strong preferences for White race were noted in 27% (112 of 419) of respondents. There was a strong association of women with family and home and an association of men with work or career in 14% (60 of 419). These preferences generally did not correlate with the demographic, geographic, and program variables that were analyzed, except for a stronger association of women with family and home among women respondents. There were no differences in race IAT D-scores between orthopaedic surgeons and other healthcare providers and the general population. Gender-career IAT D-scores associating women with family and home were slightly lower among orthopaedic surgeons (0.24 ± 0.3) than among the general population (0.32 ± 0.4; p < 0.001) and other healthcare professionals (0.34 ± 0.4; p < 0.001). All of these values are in the slight preference range. CONCLUSION: Orthopaedic surgeons demonstrated slight preferences for White people, and there was a tendency to associate women with career and family on IATs, regardless of demographic and program characteristics, similar to others in healthcare and the general population. Given the similarity of scores with those in other, more diverse areas of medicine, unconscious biases alone do not explain the relative lack of diversity in orthopaedic surgery. CLINICAL RELEVANCE: Implicit biases only explain a small portion of the lack of progress in improving diversity, equity, inclusion, and belonging in our workforce and resolving healthcare disparities. Other causes including explicit biases, an unwelcoming culture, and perceptions of our specialty should be examined. Remedies including engagement of students and mentorship throughout training and early career should be sought.

Patient Self-Reported Allergies and Their Correlation with Thoracic Outlet Syndrome Outcomes.

OBJECTIVES: Thoracic outlet syndrome (TOS) is an uncommon neurovascular disorder that presents as neck and upper extremity pain secondary to brachial plexus trunk or subclavian vasculature compression. The orthopedic literature has correlated patient-reported allergies to postoperative patient-reported outcome (PRO) scores for a variety of surgical procedures. We sought to evaluate patient-reported allergies and PROs following surgical decompression for TOS. METHODS: A chart review was conducted after identifying patients who underwent surgical thoracic outlet decompression by a single surgeon. Patients were contacted and administered five PRO questionnaires via telephone: the QuickDASH Outcome Measure questionnaire (disabilities of the arm, shoulder, and hand [DASH]), the Cervical Brachial Symptom Questionnaire, the Single Assessment Numeric Evaluation, the 12-Item Short Form Survey, and the Numeric Rating Scale (a visual analogue scale). A bivariate analysis of Pearson's correlation coefficient (r) was used to determine the associations of allergies with questionnaires and demographic variables. RESULTS: Of the 393 patients (128 males and 265 females) identified in the study, 75 (24%) responded and completed all of the questionnaires, 18 (24%) males and 57 (76%) females. A significant correlation was found between the number of allergies reported and the QuickDASH Outcome Measure questionnaire (r = 0.375, P < 0.001), the Cervical Brachial Symptom Questionnaire (r = 0.295, P = 0.01), change in the Single Assessment Numeric Evaluation score (r = -0.310, P < 0.01), change in the visual analogue scale (r = 0.244, P = 0.035), sex (r = 0.245, P = 0.034), and the number of medications (r = 0.642, P < 0.001). CONCLUSIONS: The increased frequency of patient-reported allergies is significantly associated with worse PRO scores for women undergoing TOS surgical decompression. Better understanding this association can help physicians counsel patients on expected outcomes.

Impact of Sling Use on Functional Mobility in a Geriatric Population.

OBJECTIVES: Sling immobilization is commonly used following rotator cuff repair. The purpose of this study was to determine the detrimental impact of sling usage on mobility and balance in an older adult population through validated gait and balance testing. The authors hypothesize that sling use will negatively affect balance and stability. METHODS: This institutional review board-approved and registered randomized prospective clinical trial enrolled patients from 2019 to 2021. Following informed consent, patients were randomized into two groups: a sling worn (group 1) and no sling worn (group 2). Participants were assessed via the Edmonton Frail Scale as well as Tinetti gait and balance scoring. RESULTS: Fifty patients were included in the study, 23 (46%) men and 27 (54%) women, with a mean age of 72.2 years. The balance score median was 16.00 for participants not wearing a sling and 15.00 for participants wearing a sling. The gait score median was 12.00 for participants not wearing a sling and 11.50 for participants wearing a sling. The balance and gait scores were significantly greater when patients were not wearing a shoulder sling with P values of 0.006 and 0.011, respectively. The overall combined gait and balance score was significantly greater, with median values of 27.00 for participants not wearing a sling and 26.00 for participants wearing a sling (P = 0.001). Patients reported little to no anxiety about falling while wearing the sling, with a score of 0.16. CONCLUSIONS: Postoperative sling immobilization negatively affects balance and gait in the geriatric population, potentially increasing the risk of postoperative falls in an already at-risk population.

Eccentric Hamstring Strength Imbalance among Football and Soccer Athletes.

OBJECTIVES: Hamstring strain injuries (HSI) are common among football and soccer athletes. Eccentric strength imbalance is considered a contributing factor for HSI. There is, however, a paucity of data on hamstring imbalances of soccer and American football athletes as they age and advance in skill level. High school athletes will display greater interlimb discrepancies compared with collegiate and professional athletes. In addition, soccer athletes will exhibit greater hamstring asymmetry than American football athletes. METHODS: Hamstring testing was performed on soccer and American football athletes using the NordBord Hamstring Testing System (Vald Performance, Albion, Australia). Age, sex, weight, sport specialization, and sport level were recorded. Maximum hamstring forces (N), torque (N · m), and work (N · s) were measured. Hamstring imbalance (%) was calculated by dividing the absolute value of the difference in leg forces divided by their sum. One-way analysis of variance and independent sample t tests compared measurements between athlete groups. RESULTS: A total of 631 athletes completed measurements, including 88 high school male soccer, 25 college male soccer, 23 professional male soccer, 83 high school female soccer, 28 college female soccer, 288 high school football, and 96 college football athletes. High school soccer players displayed significantly greater imbalances for torque (P = 0.03) and work (P < 0.01) than football athletes. Imbalances for maximum force (P = 0.035), torque (P = 0.018), and work (P = 0.033) were significantly higher for male soccer athletes in high school compared with college- and professional-level athletes. Female high school soccer players had significantly higher imbalance in torque (P = 0.045) and work (P = 0.001) compared with female collegiate soccer players. Football athletes did not experience significant changes in force imbalances between skill levels. CONCLUSIONS: High school soccer athletes exhibit greater hamstring imbalances than football athletes. Higher levels of play in soccer, for both male and female athletes, correlate with less hamstring asymmetry.

Biofilm Growth on Orthopaedic Cerclage Materials: Nonmetallic Polymers Are Less Resistant to Methicillin-Resistant Staphylococcus Aureus Bacterial Adhesion.

BACKGROUND: Data on bacterial adhesion to cerclage cables are sparse. We aimed to compare 5 cerclage products for methicillin-resistant Staphylococcus aureus (MRSA) adhesion to determine the claim: Are nonmetallic polymer cables more resistant to bacterial adhesion than common metallic wires and cables? METHODS: The following 5 cerclage products were compared: (1) monofilament stainless steel (SS) wires; (2) multifilament SS cables; (3) multifilament cobalt chrome cables; (4) multifilament Vitallium alloy (cobalt-chrome-molybdenum [Co-Cr-Mo]) cables; and (5) multifilament nonmetallic polymer cables. Each was cut into 2 cm lengths and placed into 12-well plates. Of the wells, 5 were wire or cables in trypticase soy broth with MRSA, with the remaining wells being appropriate controls incubated for 24 hours at 37° C and 5% CO2 with shaking. Wires and cables were prepared and randomly imaged via scanning electron microscopy, with bacterial counts performed on 3 images of 3 different wires or cables per study group. The scanning electron microscopy technician and counting investigator were blinded. Additionally, SS wire and polymer cables were analyzed by microcalorimetry for metabolic activity and bacterial load. RESULTS: Bacterial attachment differed significantly between study groups in the middle section (P = .0003). Post hoc comparison showed no difference between groups individually (all P > .05) apart from polymer cables (median 551 bacteria) having significantly increased attached bacteria compared to the Vitallium alloy cable (157, P = .0004), SS cable (101, P = .0004), and SS wire (211, P = .0004). There was no difference between polymer and cobalt chrome cables (133, P = .056). Microcalorimetry supported these results, as polymer cables had a shorter time to max heat flow (6.2 versus 7.5 hours, P = .006), increased max heat flow (117 versus 64 uW, P = .045), and increased colony-forming units, indicating an increased bacterial load compared to SS wires. CONCLUSIONS: This in vitro study demonstrated that polymer cables have increased MRSA adhesion compared to common metallic wires and cables. Future studies are necessary to confirm the translation of increased bacterial adherence on polymer cables to increased rates of orthopaedic infections.

Impact of the Percentage of Overlapping Surgery on Patient Outcomes: A Retrospective Cohort Study of 87,000 Surgical Cases.

OBJECTIVES: The primary objective of this study was to analyze the relationship of percentage of surgical overlap with patient outcomes to determine if a detrimental level of overlap exists. BACKGROUND: Overlapping surgery is defined as 1 attending physician supervising 2 or more operative cases simultaneously, without the critical portions of the cases occurring concurrently. To date, no study has examined the relationship of percent overlap, or the percentage of 1 case that is spent overlapping with another, to outcomes, efficiency, safety, and complications. METHODS: This study is a retrospective cohort study conducted at a large tertiary referral center. The primary outcomes of interest included operative duration, in-hospital mortality, 30-day readmission, and patient safety indicators (PSIs). The Cochran-Armitage test for trend was used to evaluate the outcomes of interest. P values of ≤0.05 were considered statistically significant. RESULTS: A total of 87,426 cases were included in this study. There were 62,332 cases without overlap (Group 0), 10,514 cases with 1% to 25% overlap (Group 1), 5303 cases with 26% to 50% overlap (Group 2), 4296 cases with 51% to 75% overlap (Group 3), and 4981 cases with >75% overlap (Group 4). In-hospital mortality decreased as overlap increased ( Ptrend <0.0001). Operative time increased with increasing overlap ( Ptrend <0.0001) while readmission rates showed no statistical significance between groups ( Ptrend =0.5078). Rates of PSIs were lower for Groups 1, 2, and 3 (1.69%, 2.01%, and 2.08%) when compared to Group 0 (2.24%). Group 4 had the highest rate of PSIs at 2.35% ( P =0.0086). CONCLUSION: Overlapping surgery was shown to have reduced in-hospital mortality and similar PSI and readmission rates when compared to nonoverlapping cases. Operative time was shown to increase in overlapping surgeries when compared to nonoverlapping surgeries. The results from this study indicate that the percentage of surgical overlap does not detrimentally affect most patient outcomes, especially with overlap of <75%.

Gender Disparities Among Professional Team Sports Medicine Physicians.

OBJECTIVE: Although recent trends from the Accreditation Council for Graduate Medical Education (ACGME) present encouraging growth of female representation in sports medicine, the field is still lagging behind other specialties. This study investigates gender disparities among physicians providing care for professional sports teams in male and female sports leagues. DESIGN: Information regarding physicians providing sports medicine care to professional teams obtained by database queries (May 2021). Chi-square analysis compared gender data of orthopaedic team physicians with American Orthopaedic Society for Sports Medicine (AOSSM) and American Academy of Orthopaedic Surgeons (AAOS) membership, residency, and fellowship census data. Primary care sports medicine physicians were compared with American Medical Society for Sports Medicine (AMSSM) and primary-care sports medicine fellowship census data. SETTING: Professional sports health care. STUDY POPULATION: Professional league physicians. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Gender, residency, and fellowship training of professional league physicians. RESULTS: Among a total of 608 team physicians, 572 (93.5%) were male and 40 (6.5%) were female. Orthopedic surgeons comprised 64.7% of the physicians. Fourteen (3.6%) team orthopedic surgeons were female. Thirty-five percent of team physicians were primary care sports medicine physicians. Twenty-six primary care sports medicine physicians (11.6%) were female. Orthopaedic female team physician representation overall was comparable with AOSSM and AAOS membership but significantly less than orthopaedic surgery residents and sports medicine fellows ( P < 0.01). Women's National Basketball Association orthopaedic team physicians were more represented than female membership among AOSSM, AAOS, and orthopaedic sports medicine fellows ( P < 0.01). Except for the WNBA, Premiere Hockey Federation, National Women's Soccer League, and United States Football League, female primary care sports medicine physicians were underrepresented in professional sports compared with AMSSM membership and primary care sports fellows ( P < 0.01). CONCLUSION: Overall, female representation is poor among orthopaedic surgeons and primary care physicians providing sports medicine care to professional teams. Leagues encompassing female athletes tend to have better representation of female physicians. LEVEL OF EVIDENCE: IV.

Extensor Mechanism Reconstruction for Chronic Patellar Tendon Tears.

OBJECTIVES: Reconstruction for a chronic patellar tendon rupture in a native knee is an uncommon surgical procedure. Although there have been case series investigating patient-reported outcomes, there is no systematic review of these studies to date. The purpose of this review is to synthesize the literature on this procedure to better understand its outcomes, complications, and surgical technique options. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies that reported outcomes and techniques of patellar tendon reconstruction for chronic disruption in native knees. Searches were conducted through MEDLINE using PubMed, Cochrane Database of Systematic Reviews, and clinicaltrials.gov. RESULTS: Ten studies with 103 patients and 105 knees were included. Results for nonnative (arthroplasty) knees were excluded. The mean patient age was 40.3 years, and the mean postsurgical follow-up time was 53.8 months. Of the 105 knees, 75% received a hamstring tendon graft, whereas 13% received a bone-tendon-bone graft and 7% received a whole extensor mechanism allograft. The mean preoperative range of motion was 113.8°, which improved to 126.0° postoperatively. The mean preoperative Lysholm score was 58.6, which improved to 86.0 postoperatively; 100% of patients returned to their normal work activities and 76% returned to their prior level of physical activity. There were no major complications reported in any of the included studies. CONCLUSIONS: Chronic patellar tendon disruption in a native knee is an uncommon injury that can result in significant limitations for patients. Although more research is needed to better elucidate which graft is best, outcomes after patellar tendon reconstruction for chronic tears appear to be satisfactory with current techniques.

Elective Hand Surgery Is Delayed among Private Insurance Holders.

OBJECTIVES: Patients with private healthcare plans often defer nonemergent or elective procedures toward the end of the year once they have met their deductible. No previous studies have evaluated how insurance status and hospital setting may affect surgical timing for upper extremity procedures. Our study aimed to evaluate the influence of insurance and hospital setting on end-of-the-year surgical cases for elective carpometacarpal (CMC) arthroplasty, carpal tunnel, cubital tunnel, and trigger finger release, and nonelective distal radius fixation. METHODS: Insurance provider and surgical dates were gathered from two institutions' electronic medical records (one university, one physician-owned hospital) for those undergoing CMC arthroplasty, carpal tunnel release, cubital tunnel release, trigger finger release, and distal radius fixation from January 2010 to December 2019. Dates were converted into corresponding fiscal quarters (Q1-Q4). Using the Poisson exact test, comparisons were made between the case volume rate of Q1-Q3 and Q4 for private insurance and then for public insurance. RESULTS: Overall, case counts were greater in Q4 than the rest of the year at both institutions. There was a significantly greater proportion of privately insured patients undergoing hand and upper extremity surgery at the physician-owned hospital than the university center (physician owned: 69.7%, university: 50.3%; P < 0.001). Privately insured patients underwent CMC arthroplasty and carpal tunnel release at a significantly greater rate in Q4 compared with Q1-Q3 for both institutions. Publicly insured patients did not experience an increase in carpal tunnel releases during the same period at both institutions. CONCLUSIONS: Privately insured patients underwent elective CMC arthroplasty and carpal tunnel release procedures in Q4 at a significantly greater rate than publicly insured patients. This finding suggests private insurance status, and potentially deductibles, influence surgical decision making and timing. Further work is needed to evaluate the impact of deductibles on surgical planning and the financial and medical impact of delaying elective surgeries.

Home-based physical therapy results in similar outcomes to formal outpatient physical therapy after reverse total shoulder arthroplasty: a randomized controlled trial.

BACKGROUND: Outcomes following reverse total shoulder arthroplasty (RTSA) are influenced by surgical indications, surgical technique, implant design, and patient variables. The role of self-directed postoperative physical therapy after RTSA is poorly understood. The purpose of this study was to compare the functional and patient-reported outcomes (PROs) of a formal physical therapy (F-PT) program vs. a home therapy program after RTSA. METHODS: One hundred patients were prospectively randomized into 2 groups: F-PT and home-based physical therapy (H-PT). Patient demographic variables, range of motion (ROM) and strength measurements, and outcomes (Simple Shoulder Test, American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, visual analog scale, and Patient Health Questionnaire-2 scores) were collected preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Patient perceptions regarding their group assignment, F-PT vs. H-PT, were also assessed. RESULTS: Seventy patients were included for analysis, with 37 in the H-PT group and 33 in the F-PT group. Thirty patients in both groups had a minimum of 6 months' follow-up. The average length of follow-up was 20.8 months. Forward flexion, abduction, internal rotation, and external rotation ROM did not differ between groups at final follow-up. Strength did not differ between groups with the exception of external rotation, which was greater by 0.8 kilograms-force (kgf) with F-PT (P = .04). PROs at final follow-up did not differ between therapy groups. Patients receiving home-based therapy appreciated the convenience and cost savings, and the majority believed home therapy was less burdensome. CONCLUSION: Formal physical therapy and home-based physical therapy programs after RTSA result in similar improvements in ROM, strength, and PRO scores.

Ultrasound assessment after a subscapularis-sparing approach to total shoulder arthroplasty.

BACKGROUND: Although anatomic total shoulder arthroplasty (ATSA) has favorable outcomes, nearly all techniques involve subscapularis tendon release for shoulder joint access. Such takedown of the subscapularis may be associated with decreased function, instability, and pain. Subscapularis-sparing approaches have the theoretical benefits of improved function, decreased failure of the tendon reattachment site, and early range of motion and rehabilitation. The primary purpose of this study was to use ultrasound to assess the postoperative integrity of the subscapularis tendon and surrounding soft tissues after ATSA with a subscapularis-sparing technique through an extensile anterosuperior skin incision. Our hypothesis was that this subscapularis-sparing approach would have low rates of subscapularis disruption. METHODS: A consecutive cohort of patients who underwent subscapularis-sparing ATSA between 2014 and 2017 were included. Ultrasound was used to evaluate the rotator cuff tendons and deltoid postoperatively, and these were classified as intact, disrupted, or unable to be adequately visualized. Clinical outcome scores, range of motion, and strength measurements were also collected at 1-3 years postoperatively. RESULTS: Thirty-seven subscapularis tendons and 40 supraspinatus and infraspinatus muscles were adequately visualized and included for analysis. Of the subscapularis muscles, 32 (86%) were intact; 38 of the visualized supraspinatus muscles (95%) and 39 of the infraspinatus muscles (98%) were intact. No dehiscence or loss of integrity of the deltoid was noted. Clinical comparison between patients with disrupted subscapularis muscles and patients without such disruption demonstrated no difference in clinical outcome scores and postoperative range of motion but showed less strength in forward flexion, abduction, and external rotation. CONCLUSIONS: The rate of subscapularis disruption using a subscapularis-sparing approach for ATSA was low (14%), but the potential for tendon disruption was not eradicated. Favorable clinical outcomes support this surgical approach as a potential technique for ATSA.

Nerve block with liposomal bupivacaine yields fewer complications and similar pain relief when compared to an interscalene catheter for arthroscopic shoulder surgery: a randomized controlled trial.

BACKGROUND: Following orthopedic surgery, patients frequently experience pain and discomfort. Multiple methods of regional anesthesia are available; however, the optimal technique to adequately manage pain while minimizing complications remains under investigation. This study aims to compare the complication rates and pain relief of single-injection, liposomal bupivacaine brachial plexus nerve block to a conventional, indwelling ropivacaine interscalene catheter (ISC) in patients undergoing arthroscopic shoulder surgery. We hypothesize that liposomal bupivacaine will have fewer patient complications with similar pain relief than an indwelling catheter. METHODS: Patients undergoing arthroscopic shoulder surgery were prospectively assessed after randomization into either ropivacaine ISC or single-injection liposomal bupivacaine brachial plexus nerve block (LB) arms. All patients were discharged with 5 analgesics (acetaminophen, methocarbamol, gabapentin, acetylsalicylic acid, and oxycodone) for as-needed pain relief. Preoperatively, patient demographics and baseline Visual Analog Scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Penn Shoulder Scores were obtained. For the first four days postoperatively, complication rates (nausea, dyspnea, anesthetic site discomfort and/or irritation and/or leakage, and self-reported concerns and complications), pain, medication usage, and sleep data were assessed by phone survey every 12 hours. The primary outcome was overall complication rate. At 12 weeks postoperatively, Visual Analog Scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Penn scores were reassessed. Outcome scores were compared with Mann-Whitney U tests, and demographics were compared with chi-squared tests. Significance was set at P < .05. RESULTS: A total of 63 individuals were allocated into ISC (N = 35) and in the LB arms (N = 28) for analysis. Demographics and preoperative patient-reported outcomes were not different between the arms. Patients in the LB arm experienced fewer (13.1%) overall complications than those in the ISC arm (29.8%) (P < .001), with patients in the ISC arm specifically reporting more anesthetic site discomfort (36.4% vs. 7.1%, P = .007), leakage (30.3% vs. 7.1%, P = .023), and 'other,' free-response complications (ISC: 21.2%; LB: 3.6%; P = .042). No differences were noted in pain, sleep, opioid use, or satisfaction between arms during the perioperative period. More nonopioid medications were consumed on average in the ISC (1.8 ± 1.4) than in the LB arm (1.4 ± 1.3) (P = .001), with greater reported use of acetylsalicylic acid (40.9% vs. 23.4% P < .001) and acetaminophen (69.5% vs. 59.6% P = .013). Patient-reported outcome scores did not differ between groups preoperatively or at 12 weeks. DISCUSSION: Patients receiving liposomal bupivacaine experienced fewer complications than traditional ISCs after arthroscopic shoulder surgery. Analgesia, sleep, satisfaction, and functional scores were similar between the 2 groups.

COVID-19 Impact on Orthopedic Surgeons: Elective Procedures, Telehealth, and Income.

OBJECTIVES: The purpose of this study was to investigate the response in orthopedic surgery to the coronavirus disease 2019 (COVID-19) pandemic across the United States by surveying surgeons about their care setting, timing of restrictions on elective surgery, use of telehealth, and estimated economic impact. METHODS: A survey was distributed via REDCap through state orthopedic organizations between April and July 2020. The 22-question digital survey collected information regarding restrictions on elective procedures, location of care, utilization of telehealth, and estimated reductions in annual income. RESULTS: In this study, 192 participants responded to the survey (average age 49.9 ± 11.0 years, 92.7% male). Responses primarily originated from Alabama (30.2%), Georgia (30.2%), and Missouri (16.1%). The remainder of the responses were grouped into the category "other." Respondents did not vary significantly by state in operative setting or income type (salary, work relative value units, or collections). Most of the participants documented elective procedure restrictions in hospital and ambulatory settings. The highest frequency of closures occurred between March 18 and 20 (47% in hospital, 51% in ambulatory). Of the participants, financial loss estimates varied across states (P = 0.005), with 50% of physicians claiming >50% losses of income in Alabama (24% Georgia, 10% Missouri, 31% other). Regarding telehealth, practices set up for these services before 2020 varied across states. None of the orthopedic practices in Alabama had telehealth before the COVID-19 pandemic (Missouri 25%, Georgia 9%, other 8%, P = 0.06); however, respondents generally were split when considering the anticipation of implementing telehealth into routine practice. CONCLUSIONS: Most practices did implement restrictions for elective clinic visits and procedures early during the pandemic. COVID-19 ultimately will result in a large revenue loss for elective orthopedic practices. Services such as telehealth may help offset these losses and help deliver orthopedic care to patients remotely.

Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis.

BACKGROUND: Amid rising health care costs and recent advances in surgical and anesthetic protocols, the rate of outpatient joint arthroplasty has risen steadily in recent years. Although the safety of outpatient total knee arthroplasty and total hip arthroplasty has been well established, outpatient shoulder arthroplasty is still in its infancy. The purpose of this study was to synthesize the current literature and provide further data regarding the outcomes and safety of outpatient shoulder arthroplasty. METHODS: A systematic review was conducted following the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that evaluated the outcomes of patients undergoing outpatient total shoulder arthroplasty (TSA) or reverse TSA. Meta-analysis was conducted using Mantel-Haenszel statistics to generate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) comparing outpatient and inpatient shoulder arthroplasty. RESULTS: Twelve studies were included, with a total of 194,513 patients, of whom 7162 were outpatients. Of the studies, 8 were level III and 4 were level IV. The average age of the outpatients was 66.6 years, and the average age of the inpatients was 70.1 years. The overall OR for complications was significantly lower in outpatients (OR, 0.40; 95% CI, 0.35-0.45) than in inpatients. There was no significant difference in rates of 90-day readmission (OR, 0.88; 95% CI, 0.75-1.03), revision (OR, 0.96; 95% CI, 0.65-1.41), and infection (OR, 0.93; 95% CI, 0.64-1.35) when comparing outpatients with inpatients. CONCLUSION: Outpatient TSA, in an appropriately selected patient population, is safe and results in comparable patient outcomes to those of inpatient shoulder arthroplasty. Given the expected increase in the number of patients requiring TSA, surgeons, hospital administrators, and insurance carriers should strongly consider the merits of a cost- and care-efficient approach to total shoulder replacement.

Quality Improvement Tools in Total Joint Arthroplasty: A Systematic Review.

Systems review and quality improvement (QI) is a significant need within orthopaedic surgery. The focus of this paper is to systematically review QI principles utilized in total joint arthroplasty to determine most successful QI tools. A systematic search on MEDLINE/Pubmed, Embase, Cochrane Library and other sources was conducted from September 1991 through October 2018. The three primary improved outcomes from each article were recorded along with the date, author and subspecialty. Thirty-four eligible studies related to joint arthroplasty were identified for inclusion in the systematic review. The most common outcomes that were improved in these publications were: length of stay (LOS), cost, medication management, and patient education. Lean, clinical care pathways (CCP), plan-do-check-act (PDCA), and shared decision-making improved those metrics. Four metrics were found that were consistently improved by certain quality improvement tools: LOS, cost, medication management, and patient education. Further research is warranted to continue to build a framework for quality improvement in orthopaedic surgery. (Journal of Surgical Orthopaedic Advances 30(3):125-130, 2021).

What Is the Prevalence of Burnout, Depression, and Substance Use Among Orthopaedic Surgery Residents and What Are the Risk Factors? A Collaborative Orthopaedic Educational Research Group Survey Study.

BACKGROUND: Burnout and depression among healthcare professionals and trainees remain alarmingly common. In 2009, 56% of orthopaedic surgery residents reported burnout. Alcohol and illicit drug use are potential exacerbating factors of burnout and depression; however, these have been scarcely studied in residency populations. QUESTIONS/PURPOSES: (1) What proportion of orthopaedic residents report symptoms of burnout and depression? (2) What factors are independently associated with an orthopaedic resident reporting emotional exhaustion, depersonalization, low personal accomplishment, and depression? (3) What proportion of orthopaedic residents report hazardous alcohol or drug use? (4) What factors are independently associated with an orthopaedic resident reporting hazardous alcohol or drug use? METHODS: We asked 164 orthopaedic surgery programs to have their residents participate in a 34-question internet-based, anonymous survey, 28% of which (46 of 164) agreed. The survey was distributed to all 1147 residents from these programs, and 58% (661 of 1147) of these completed the survey. The respondents were evenly distributed among training years. Eighty-three percent (551 of 661) were men, 15% (101 of 661) were women, and 1% (nine of 661) preferred not to provide their gender. The survey asked about demographics, educational debt, sleep and work habits, perceived peer or program support, and substance use, and validated instruments were used to assess burnout (abbreviated Maslach Burnout Inventory), depression (Patient Health Questionnaire-2), and hazardous alcohol use (Alcohol Use Disorder Identification Test-Consumption). The main outcome measures included overall burnout, emotional exhaustion, depersonalization, low personal accomplishment, depression, and hazardous alcohol and drug use. Using the variables gathered in the survey, we performed an exploratory analysis to identify significant associations for each of the outcomes, followed by a multivariable analysis. RESULTS: Burnout was reported by 52% (342 of 661) of residents. Thirteen percent of residents (83 of 656) had positive screening results for depression. Factors independently associated with high emotional exhaustion scores included early training year (odds ratio 1.15; 95% confidence interval, 1.01-1.32; p = 0.03) unmanageable work volume (OR 3.13; 95% CI, 1.45-6.67; p < 0.01), inability to attend health maintenance appointments (OR 3.23; 95% CI, 1.69-6.25; p < 0.01), lack of exercise (OR 1.69; 95% CI, 1.08-2.70; p = 0.02), and lack of program support (OR 3.33; 95% CI, 2.00-5.56; p < 0.01). Factors independently associated with depersonalization included early training year (OR 1.27; 95% CI, 1.12-1.41; p < 0.01), inability to attend health maintenance appointments (OR 2.70; 95% CI, 1.67-4.35; p < 0.01), and lack of co-resident support (OR 2.52; 95% CI, 1.52-4.18; p < 0.01). Low personal accomplishment was associated with a lack of co-resident support (OR 2.85; 95% CI, 1.54-5.28; p < 0.01) and lack of program support (OR 2.33; 95% CI, 1.32-4.00; p < 0.01). Factors associated with depression included exceeding duty hour restrictions (OR 2.50; 95% CI, 1.43-4.35; p < 0.01) and lack of program support (OR 3.85; 95% CI, 2.08-7.14; p < 0.01). Sixty-one percent of residents (403 of 656) met the criteria for hazardous alcohol use. Seven percent of residents (48 of 656) reported using recreational drugs in the previous year. Factors independently associated with hazardous alcohol use included being a man (OR 100; 95% CI, 35-289; p < 0.01), being Asian (OR 0.31; 95% CI, 0.17-0.56; p < 0.01), single or divorced marital status (OR 2.33; 95% CI, 1.47-3.68; p < 0.01), and more sleep per night (OR 1.92; 95% CI, 1.21-3.06; p < 0.01). Finally, single or divorced marital status was associated with drug use in the past year (OR 2.30; 95% CI, 1.26-4.18; p < 0.01). CONCLUSIONS: The lack of wellness among orthopaedic surgery residents is troubling, especially because most of the associated risk factors are potentially modifiable. Programs should capitalize on the modifiable elements to combat burnout and improve overall wellbeing. Programs should also educate residents on burnout, focus on work volume, protect access to health maintenance, nurture those in the early years of training, and remain acutely aware of the risk of substance abuse. Orthopaedic surgery trainees should strive to encourage peer support, cultivate personal responsibility, and advocate for themselves or peers when faced with challenges. At a minimum, programs and educational leaders should foster an environment in which admitting symptoms of burnout is not seen as a weakness or failure. LEVEL OF EVIDENCE: Level II, prognostic study.

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review.

PURPOSE: To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs). METHODS: A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. RESULTS: A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies. CONCLUSIONS: CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level I through IV studies.

Patient Perception of Orthopedic Surgeon Reimbursement.

Significant attention has been directed at evaluating reimbursement rates to orthopedic surgeons for various surgical procedures. To evaluate patients' understanding of the surgeon reimbursement process, studies using patient surveys have been conducted to determine patients' perceptions of orthopedic surgeon compensation. To date, there has been no systematic review to consolidate the data of these studies. This study aimed to synthesize the findings of these individual studies across multiple subspecialties of orthopedic surgery to evaluate the potential discrepancy between how much patients believe orthopedic surgeons are reimbursed and the actual reimbursement rate. We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies that report findings of patient perceptions of orthopedic surgeon reimbursement for various procedures. Searches were conducted using MEDLINE through PubMed, Embase, and Scopus. Summary estimates of reimbursement discrepancies across subspecialties and overall were reported as unweighted averages of the individual study results within each group. Twelve studies were identified that met inclusion criteria, constituting 4309 surveys. These survey studies measured patients' perceptions of how much orthopedic surgeons are reimbursed for common procedures, including anterior cruciate ligament reconstruction, arthroscopic meniscectomy, carpal tunnel release, rotator cuff repair, multiple spine procedures and total shoulder, hip, and knee arthroplasty. It was found that patients reported reasonable surgeon's fees to be 11.2 times more than actual Medicare reimbursement. Among individual studies, the largest discrepancies were seen in total hip arthroplasty (26 times), whereas the smallest difference was in anterior cruciate ligament reconstruction (1.6 times). On average, patients estimated Medicare reimbursement rates to be 5.9 times higher than the actual surgeon reimbursement. Patients consistently overestimate how much orthopedic surgeons are reimbursed for common orthopedic procedures. The results of this systematic review suggest that patients may value these procedures more than what Medicare reimburses. Such information may help educate the public, direct policy, and increase transparency between orthopedic surgeons and patients.

Check-in Kiosks in the Outpatient Clinical Setting: Fad or the Future?

OBJECTIVES: Check-in kiosks are increasingly used in health care. This project aims to assess the effects of kiosk use upon check-in duration, point of service (POS) financial returns, and patient satisfaction. METHODS: Six kiosks were implemented in a large academic orthopedic clinic, and check-in duration for 8.5 months following implementation and POS returns for 10.5 months before and after implementation were analyzed. Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey and self-devised surveys recorded patient satisfaction. RESULTS: Cumulatively, 28,636 kiosk-based patient encounters were analyzed. Compared with historical norms, check-in duration decreased 2 minutes, 47 seconds (P < 0.001). Daily gross and individual POS returns increased $532.13 and $1.89, respectively (P < 0.001). Satisfaction surveys were completed by 719 of 1376 consecutive patients (52% response rate), revealing 12% improvement (P < 0.001), but Consumer Assessment of Healthcare Providers and Systems Clinician and Group survey responses demonstrated no change (P = 0.146, 0.928, and 0.336). CONCLUSIONS: Kiosks offer to reduce check-in duration and increase POS revenue without negatively affecting patient satisfaction.

Os acromiale: systematic review of surgical outcomes.

BACKGROUND: The literature is unclear as to the optimal surgical management of a symptomatic os acromiale that has failed nonoperative treatment. Surgical options include excision, acromioplasty, and open reduction and internal fixation. The purpose of this study is to summarize the described methods and compare their reported outcomes with the goal to provide direction on how to surgically manage os acromiale. METHODS: We performed a systematic review of the current medical literature. Fifteen studies met all the inclusion criteria. Two hundred eleven total subjects (220 shoulders) underwent surgical treatment for a symptomatic os acromiale. There were 140 men and 71 women with a mean age of 49.6 ± 9.1 years. The mean follow-up duration was 40 ± 11.6 months. Surgical techniques used in the included studies were excision, acromioplasty, and open reduction with internal fixation. Concurrent surgical procedures performed were also included. RESULTS: Meso-os acromiale was the most common type (167 cases, 94.4%). The most common surgical technique was internal fixation (135 cases, 60.8%), with screw fixation being the majority (76 cases, 56.3%). Excision (65 cases, 29.3%) was the second most used technique. The most common concurrent surgical procedure performed was rotator cuff repair (125 cases, 56.3%), followed by distal clavicle excision (31 cases, 14%). CONCLUSIONS: All surgical techniques employed resulted in improvement in postsurgical clinical outcomes without any technique demonstrating superior results. Operative management of a symptomatic os acromiale that has failed initial nonoperative treatment leads to decreased symptoms and improvement in clinical outcomes.