Diversity and Inclusion in Orthopaedic Surgery from Medical School to Practice: AOA Critical Issues.

ABSTRACT: Orthopaedic surgery has historically been one of the least diverse fields in medicine in the U.S. Despite having been declared a critical issue by the American Orthopaedic Association, a lack of diversity and inclusion across all metrics remains a persistent problem. In order to balance representation within orthopaedic surgery, a multiyear and multilevel approach should be considered across the life cycle of a surgeon. Talented individuals from diverse backgrounds must be identified and given early exposure to orthopaedic surgery. They must be nurtured, mentored, and retained. Representation at the medical student, resident, and faculty level is vital to ensuring diversity across the next generation of surgeons.We cannot alter representation within orthopaedics unless we broaden the candidate selection pool. Medical school classes provide the selection pool for residency, residency provides the candidates for fellowship, fellowships provide the candidates for employment, and employment provides the pool for promotion to leadership positions. Through each progression, there is a loss of underrepresented applicants, which leads to a lack of balanced representation in orthopaedic surgery. With stronger efforts to identify and retain individuals at each phase of a surgeon's career, we hope to mitigate the loss of talented and diverse individuals from this field.We challenge the paradigm of increasing diversity that focuses only on the resident selection level. Instead, efforts must begin at the medical student level. Efforts for early and meaningful exposure to the field through a musculoskeletal curriculum and rotations as well as connection through mentorship and sponsorship are vital for retention. At each ascending level of education, reinvestment in each individual is critical. Exposure, mentorship, retention, and promotion should lead to a more diverse and rich future. To achieve this, deliberate and longitudinal action should be instituted to increase diversity within orthopaedics.

Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery.

➤: The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs). ➤: Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal. ➤: There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery. ➤: There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered. ➤: The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered. ➤: The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.