A Cross-Sectional Descriptive Analysis of Diversity, Equity, and Inclusion Presence Among United States Occupational and Environmental Medicine Residency Program Websites.

OBJECTIVE: To evaluate the presence of diversity, equity, and inclusion (DEI) among US occupational and environmental medicine (OEM) residency program websites. METHODS: In January to February 2022, two independent reviewers evaluated the websites of all 24 US accredited OEM residency programs and documented the presence of 10 predetermined DEI metrics and resident/faculty photographs and biographies. RESULTS: Program websites included a median of 1 (0-3) DEI element with 46% of websites containing none of the DEI metrics. Faculty photographs and biographies were included in 83% and 75% of websites, respectively. Resident photographs and biographies were included in 50% and 25% of websites, respectively. CONCLUSIONS: Many OEM residency program websites lack DEI presence. Programs should consider presenting information relevant to DEI on their websites to help attract more diverse applicant pools.

Online Perspectives of Workers Navigating Workers' Compensation Systems: A Content Analysis of the Reddit Social Media Platform.

BACKGROUND: Social media platforms are increasingly used by the general public as a source of information on health-related and legal concerns, among other topics. Reddit.com, one of the top 10 most visited websites in the United States, is a popular social media platform that allows users to anonymously discuss various topics, including workers' compensation (WC). Understanding the candid concerns of workers who are navigating WC systems will allow for the development of more effective educational resources that are tailored to the needs of this population.  Methods: In January-March 2023, a cross-sectional review of anonymous public posts submitted to the r/WorkersComp section of the Reddit social media website between December 2021 and December 2022 was performed. Post content was extracted from a systematic random sample and coded into themes/sub-themes and emotional tones by two independent reviewers. A third reviewer resolved any discrepancies in coding in order to reach consensus prior to data analysis. The data were analyzed using Microsoft Excel 2019 (Microsoft Corporation, Redmond, WA, USA). RESULTS: Content from 200 original posts submitted to r/WorkersComp was reviewed and analyzed. Nearly 94.0% of posts (n =187) specified a state of residence, with posters most frequently residing within the United States in California (32.0%), New York (7.0%), Pennsylvania (5.0%), and Florida (5.0%). The most common primary theme was "medical" (27.0%, n = 54), with questions and comments related to provider complaints, medical care access, referral denials, maximum medical improvement, and independent medical examinations being the most frequent within this category. The second most common primary theme was "legal" (26.5%, n = 53), with questions and comments related to lawyer retainment and settlements being the most frequent within this category. The third most common primary theme was "general" (18.5%, n = 37), with questions and comments related to the general claims process, eligibility for WC, claim denial, and communication issues with claims adjusters being the most frequent within this category. The fourth most common primary theme was "employer" (14.0%, n = 28), with questions and comments related to employer retaliation, job security, and work restrictions being most frequent within this category. Only 37.0% of posts (n = 74) expressed a clear emotional tone, with frustration (13.5%, n = 10), fear (13.5%, n = 10), and confusion (13.5%, n = 10) being the most frequent tones observed in this sample of posts. CONCLUSIONS: Our findings indicate that there are workers who are navigating WC systems who use social media platforms such as Reddit to obtain information and advice on various aspects of WC, including medical issues, legal advice, and employer concerns. These findings may be used to address the information and education needs of workers who are navigating WC systems, which may help attenuate some of the frustrations surrounding the WC claims process.

The development of inflammatory arthritis following SARS-CoV-2 infection: a systematic review of the literature.

BACKGROUND: Given the widespread impact of COVID-19, it is important to explore any atypical presentations and long-term sequelae associated with this viral infection, including the precipitation of inflammatory arthritis. OBJECTIVE: To identify and summarize clinical reports of acute inflammatory arthritis associated with COVID-19. METHODS: A systematic review of the PubMed (MEDLINE), Google Scholar, and Cochrane Central databases through January 31, 2022 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The inclusion criteria were: human subjects and English language. Data extraction and qualitative synthesis of the demographics, clinical presentations, treatments, and outcomes were performed. Quality assessment was performed using the Joanna-Briggs Institute critical appraisal tools. RESULTS: A total of 37 articles collectively describing the cases of 54 patients were included. The mean age was 48.2 years (6-78 years). 53.7% of patients were male and 46.3% were female. The onset of articular symptoms varied considerably, and the majority of cases were described as polyarticular (29). The classification of inflammatory arthritis in the included studies was as follows: reactive (19), post-viral (13), new-onset rheumatoid arthritis (RA) (8), crystal-proven arthropathy flare (4), acute viral (2), new-onset psoriatic arthritis (2), flare of preexisting RA (2), and other (4). Arthritis treatment regimens varied but consisted largely of NSAIDs and corticosteroids with most patients experiencing improvement or resolution of their joint symptoms. CONCLUSION: There is limited low-level evidence suggesting that patients may develop acute arthritis during or after SARS-CoV-2 infection. This review highlights the need for further research to elucidate the relationship between COVID-19 and the development of inflammatory arthritis.

This review paper sought to explore the relationship between COVID-19 disease and acute joint pain/inflammation (arthritis) through a systematic search of the literature. This review found limited low-level evidence suggesting that patients may develop inflammatory arthritis during or after COVID-19 disease. However, there is a need for further research to improve our understanding of the relationship between COVID-19 and the development of inflammatory arthritis.

The Importance of Staging Arthroscopy for Chondral Defects of the Knee.

This study aims to evaluate the role of staging arthroscopy in the diagnosis of knee chondral defects and subsequent surgical planning prior to autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA), and meniscus allograft transplantation (MAT). All patients who underwent staging arthroscopy prior to ACI, OCA, or MAT at our institution from 2005 to 2015 were identified. Medical records were reviewed to document the diagnosis and treatment plan based on symptoms, magnetic resonance imaging (MRI) findings and previous operative records. Operative records of the subsequent staging arthroscopy procedure were reviewed to document the proposed treatment plan after arthroscopy. All changes in treatment plan following staging arthroscopy were recorded. Univariate analyses were performed to identify any significant predictors for likelihood to change. A total of 98 patients were included in our analysis. A change in surgical plan was made following arthroscopy in 36 patients (36.7%). Fourteen patients (14.3%) were found to have additional defects that warranted cartilage restoration surgery. In 15 patients (15.3%), at least one defect that was originally thought to warrant cartilage restoration surgery was found to be amenable to debridement alone. The surgical plan was changed from ACI to OCA in four cases (4.1%) and OCA to ACI in one case (1%). A previously proposed MAT was deemed unwarranted in one case (1%), and a planned meniscal repair was changed to MAT in another (1%). Patient age, sex, and the affected knee compartment were not predictors for a change in surgical plan. Body mass index (BMI) was significantly higher in patients who had a change in surgical plan (29.5 kg/m2) compared with those who did not (26.5 kg/m2). A change in surgical plan was more likely to occur for trochlear lesions (46.4%) compared with other articular surface lesions (p = 0.008). The results of our study indicate that staging arthroscopy is an important step in determining the most appropriate treatment plan for chondral defects and meniscal deficiency, particularly those with trochlear cartilage lesions.

Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair. QUESTIONS/PURPOSES: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function? METHODS: During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures. RESULTS: There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups. CONCLUSION: The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage. LEVEL OF EVIDENCE: Level II, therapeutic study.

Return to Work, Demographic Predictors, and Symptomatic Analysis Among Healthcare Workers Presenting for COVID-19 Testing: A Retrospective Cohort From a United States Academic Occupational Medicine Clinic.

Introduction We sought to determine time to return to work (RTW) among healthcare workers (HCWs) with mild/moderate coronavirus disease 2019 (COVID-19) and identify predictors of COVID-19 test positivity and illness duration.  Methods A retrospective review of HCWs presenting for COVID-19 testing/evaluation in December 2020 was performed to examine demographics, clinical characteristics, and RTW. Results Of 250 exposure incidents, 107 employees (42.80%) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). No significant differences between COVID-19 positive and negative HCWs were noted in terms of key demographics, including age, gender, and CDC risk scores. Cough (77.57% vs 56.64%, p = 0.001), fatigue (66.36% vs 51.05%, p = 0.015), fever/chills (65.42% vs 37.06%, p < 0.001), myalgia (57.01% vs 35.66%, p = 0.008), and change in smell/taste (38.32% vs 13.29%, p < 0.001) were more prevalent among COVID-19 positive versus negative HCWs. Change in smell/taste (p < 0.001, OR 3.592), cough (p = 0.001, OR 2.966), and fever/chills (p = 0.019, OR 2.107) were independently associated with COVID-19 test positivity. Mean time to RTW from symptom onset was 13.09 days for COVID-19 positive HCWs. Female gender (p = 0.020, + 3.20 days), older age (p = 0.014, + 2.22 days), and myalgia (p = 0.021, + 2.23 days) were predictive of longer illness duration. Conclusion Change in taste/smell, cough, and fever/chills were independently associated with COVID-19 test positivity. Among HCWs with mild/moderate COVID-19 infection, the mean time to RTW was approximately 13 days with female gender, older age, and myalgia being predictive of delayed RTW.

Does Prior Anterior Cruciate Ligament Reconstruction Affect Outcomes of Subsequent Total Knee Arthroplasty? A Systematic Review.

BACKGROUND: Anterior cruciate ligament injury may accelerate knee osteoarthritis, and patients with a history of anterior cruciate ligament reconstruction (ACLR) tend to undergo total knee arthroplasty (TKA) at a greater rate than patients without a history of ACLR. PURPOSE: To compare clinical outcomes of TKA in patients with and without a history of ACLR through a systematic review. STUDY DESIGN: Systematic review; Level of evidence, 3. METHODS: A comprehensive search of the PubMed (MEDLINE), Cochrane Central, and SPORTDiscus databases from inception through November 2018 was performed to identify studies directly comparing outcomes of TKA between patients with and without a history of ipsilateral ACLR. Eligible studies were included in this review if they reported at least 1 outcome measure. RESULTS: Included for review were 5 retrospective case-control studies collectively evaluating TKA outcomes in 318 patients (176 males, 142 females) with a history of ACLR and 455 matched controls. The mean age in the ACLR and control groups was 58.5 years and 60.9 years, respectively. The mean follow-up period after arthroplasty was 3.4 years in the ACLR group and 3.3 years in the control group. The mean time between ACLR and arthroplasty was 21.8 years. Three studies noted greater operative time in the ACLR group than in the control group. No differences in intraoperative blood loss were reported. Greater preoperative extension deficits were noted in the ACLR group in 2 studies. Two studies reported increased preoperative Knee Society Score function scores in the ACLR group, but no differences in postoperative subjective outcome scores were noted in any of the studies. One study reported increased incidence of periprosthetic joint infection and a higher total reoperation rate in the ACLR group, and another study reported an increased incidence of manipulation under anesthesia in the ACLR group. CONCLUSION: Short- and midterm subjective scores and functional outcomes of TKA appear to be comparable in patients with and without a history of ACLR, although the risk for reoperation after TKA may be greater in patients with prior ACLR. Surgeons should anticipate increased operative time in patients with a history of ACLR. However, the findings of this review must be interpreted within the context of its limitations.

Does Prior Hip Arthroscopy Affect Outcomes of Subsequent Hip Arthroplasty? A Systematic Review.

PURPOSE: To compare outcomes of hip arthroplasty in patients with and without a history of hip arthroscopy through a systematic review. METHODS: A comprehensive search of the PubMed (MEDLINE) and Cochrane Central databases was performed using combinations of the keywords "hip," "arthroscopy," "arthroscopic," "arthroplasty," "replacement," and "conversion" in December 2017. Level I through III studies directly comparing outcomes of total or resurfacing hip arthroplasty between patients with and without a history of hip arthroscopy were included in this review if they reported at least 1 outcome measure. RESULTS: Seven retrospective case-control studies collectively evaluating arthroplasty outcomes of 235 patients (104 male and 131 female patients) with a history of hip arthroscopy and 374 matched controls met the inclusion criteria. The mean age in the arthroscopy and control groups was 47.2 years and 49.1 years, respectively. The mean follow-up period after arthroplasty was 3.2 years in the hip arthroscopy group and 3.3 years in the control group. The mean time between arthroscopy and arthroplasty was 1.8 years. A posterior approach was used in 83.6% of arthroplasties. No statistically significant differences were noted in intraoperative measures, postoperative complications, or revision rates, with the exception of 1 study that reported an increased operative time among controls. Most studies reported similar subjective outcomes between groups, with a single study noting worse postoperative findings for the Harris Hip Score, Forgotten Joint Score-12, visual analog scale pain score, and patient satisfaction in the prior hip arthroscopy group. CONCLUSIONS: The current literature suggests that short-term and midterm outcomes of hip arthroplasty are comparable in patients with and without a history of hip arthroscopy. However, the available literature is limited given the small sample sizes and therefore greater potential for ß error. Nevertheless, our findings may be useful for surgeons evaluating risks and prognoses in this patient population. LEVEL OF EVIDENCE: Level III, systematic review of Level III studies.

The 50 Most-Cited Articles in Meniscal Allograft Transplantation Research: A Bibliometric Analysis.

OBJECTIVE: To identify the 50 most-cited articles in meniscal allograft transplantation (MAT) research and analyze their characteristics. DESIGN: In September 2017, the Scopus database was queried to identify the 50 most-cited articles in MAT research. Variables analyzed include number of citations, publication year, journal, institution, country of origin, article type, study design, and level of evidence. Citation density was calculated for each article. The correlation between citation density and publication year and the correlation between level of evidence and number of citations, citation density, and publication year were computed. RESULTS: The 50 most-cited articles were published in 12 journals between 1986 and 2011. The number of citations ranged from 59 to 290 (109.3 ± 48.6). Citation density ranged from 2.7 to 17.6 citations per year (7.0 ± 3.3). There was a positive correlation between citation density and publication year ( r = +0.489, P < 0.001). Overall, 56% of the articles were clinical and 44% were basic science. Of the 28 clinical articles, 61% were level IV or V evidence. Level of evidence was not significantly correlated with number of citations ( r = -0.059, P = 0.766), citation density ( r = +0.030, P = 0.880), or publication year ( r = -0.0009, P = 0.996). CONCLUSION: This analysis provides the orthopedic community with a readily accessible list of the classic citations in MAT research and provides insight into the historical development of this procedure. Although there was a moderate positive correlation between citation density and publication year, articles with stronger levels of evidence were not more frequently cited despite the increasing trend toward evidence-based practice.

Outcomes of Surgical Treatment for Anterior Tibial Stress Fractures in Athletes: A Systematic Review.

BACKGROUND: Although most anterior tibial stress fractures heal with nonoperative treatment, some may require surgical management. To our knowledge, no systematic review has been conducted regarding surgical treatment strategies for the management of chronic anterior tibial stress fractures from which general conclusions can be drawn regarding optimal treatment in high-performance athletes. PURPOSE: This systematic review was conducted to evaluate the surgical outcomes of anterior tibial stress fractures in high-performance athletes. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: In February 2017, a systematic review of the PubMed, MEDLINE, Cochrane, SPORTDiscus, and CINAHL databases was performed to identify studies that reported surgical outcomes for anterior tibial stress fractures. Articles meeting the inclusion criteria were screened, and reported outcome measures were documented. RESULTS: A total of 12 studies, published between 1984 and 2015, reporting outcomes for the surgical treatment of anterior tibial stress fractures were included in this review. All studies were retrospective case series. Collectively, surgical outcomes for 115 patients (74 males; 41 females) with 123 fractures were evaluated in this review. The overall mean follow-up was 23.3 months. The most common surgical treatment method reported in the literature was compression plating (n = 52) followed by drilling (n = 33). Symptom resolution was achieved in 108 of 123 surgically treated fractures (87.8%). There were 32 reports of complications, resulting in an overall complication rate of 27.8%. Subsequent tibial fractures were reported in 8 patients (7.0%). Moreover, a total of 17 patients (14.8%) underwent a subsequent procedure after their initial surgery. Following surgical treatment for anterior tibial stress fracture, 94.7% of patients were able to return to sports. CONCLUSION: The available literature indicates that surgical treatment of anterior tibial stress fractures is associated with a high rate of symptom resolution and return to play in athletes, although the high complication rate and potential need for subsequent procedures are important considerations for surgeons and patients.

Sex-Dependent Differences in Preoperative, Radiographic, and Intraoperative Characteristics of Patients Undergoing Hip Arthroscopy: Results From the Multicenter Arthroscopic Study of the Hip Group.

PURPOSE: To compare preoperative, radiographic, and intraoperative findings between male and female patients undergoing hip arthroscopy. METHODS: We performed a retrospective review of a multicenter registry of patients undergoing hip arthroscopy between January 2014 and January 2017. Perioperative data from patients who consented to undergo surgery and completed preoperative patient-reported outcome questionnaires were analyzed to determine the effect of sex on preoperative symptoms, patient-reported outcomes, radiographic measures, and surgical procedures. RESULTS: A total of 1,437 patients (902 female and 535 male patients) with a mean age of 34 years were enrolled in the study. Female patients reported greater pain preoperatively on a visual analog scale (55.42 vs 50.40, P = .001) and deficits in functional abilities as per the modified Harris Hip Score (53.40 vs 57.83, P < .001) and International Hip Outcome Tool 12 (31.21 vs 38.51, P = .001) than male patients. There was a significant difference in the alpha angle (67.6° in male patients vs 59.5° in female patients, P < .001) corresponding with a higher prevalence of cam deformity in male patients (94.6% vs 84.5%, P < .001). Male patients had less range of motion in flexion (-5.67°, P < .001), internal rotation (-8.23°, P < .001), and external rotation (-4.52°, P < .001) than female patients. Acetabular chondroplasty was performed in 58% of male patients versus 40.2% of female patients (P < .001). Acetabuloplasty was performed in 59.1% of male patients versus 43.9% of female patients (P < .001). CONCLUSIONS: Male and female patients undergoing hip arthroscopy differ statistically in terms of preoperative hip function, hip morphology, and self-reported functional deficits, as well as the prevalence of surgical procedures. However, they do not differ significantly in terms of symptom localization, duration, or onset. The observed differences in preoperative functional scores between sexes, although statistically significant, may not represent clinically meaningful differences. LEVEL OF EVIDENCE: Level III, retrospective cross-sectional study.

Intraoperative Radiation Exposure During Hip Arthroscopy.

BACKGROUND: The frequency of hip arthroscopy for the treatment of acute and chronic chondrolabral pathology and femoroacetabular impingement (FAI) has increased exponentially over the past decade. While surgeon and patient radiation exposure has been well documented in other areas of the orthopaedic literature, little is known about the procedure-specific and cumulative doses affecting the hip arthroscopist. PURPOSE: To determine the mean annual radiation exposure to the hip arthroscopist and the mean surgeon exposure per case. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 210 consecutive hip arthroscopies performed in 209 patients by a single surgeon at a single ambulatory surgical center in a cohort consisting of approximately 50% bony (cam and pincer) pathology were prospectively reviewed, documenting the specific procedures performed in each case and the readings from a radiation dosimeter worn by the surgeon during positioning and while performing the procedures. Radiation readings for deep dose-equivalent (DDE), lens dose-equivalent (LDE), and shallow dose-equivalent (SDE) were measured. These readings were compared with the annual radiation dose limit recommendations established by the International Commission on Radiological Protection (ICRP). RESULTS: The total radiation doses for the operative surgeon during all 210 cases were 183 mrem (1.83 mSv) DDE, 183 mrem (1.83 mSv) LDE, and 176 mrem (1.76 mSv) SDE. The mean exposure per case was 0.871 mrem (0.00871 mSv) DDE, 0.871 mrem (0.00871 mSv) LDE, and 0.838 mrem (0.00838 mSv) SDE. The operative surgeon's mean annual exposure, performing 70 hip arthroscopies per year with 55% involving bony work, was 61.0 mrem (0.610 mSv) DDE, 61.0 mrem (0.610 mSv) LDE, and 58.7 mrem (0.587 mSv) SDE. These results are well below the ICRP annual limits of 50,000 mrem (500 mSv) DDE, 2000 mrem (20 mSv) LDE, and 50,000 mrem (500 mSv) SDE. CONCLUSION: For an experienced hip arthroscopist utilizing fluoroscopy during setup and bony resection, the annual and per-patient exposure to radiation remains well below the recommended ICRP limits. CLINICAL RELEVANCE: Considering the increasing annual frequency of hip arthroscopies being performed, information regarding procedure-specific and cumulative doses of radiation exposure affecting the hip arthroscopist may provide valuable safety information for the orthopaedic community.