Does Complexity Always Correlate With Compensation? An Analysis of Work Relative Value Units in 3 Common Nerve Decompression Syndromes.

BACKGROUND: Work relative value units (wRVUs) are part of Resource Based Relative Value Scale system. It is expected that a more difficult and time-consuming procedure would yield higher wRVUs. Brachial plexus nerve decompression surgery is a more time-consuming procedure compared with carpal and cubital tunnel procedures. The aim of this study was to analyze physician reimbursement in upper limb decompression procedures by comparing mean operative times, wRVUs per minute, and dollars per minute. METHODS: A retrospective cohort study was conducted from June 2016 to June 2019, including all patients who underwent carpal tunnel, cubital tunnel, and brachial plexus release procedures. Operating time was collected, and calculations of mean operative time, wRVUs per minute, and dollars per minute were performed and compared between groups. RESULTS: A total of 209 cases were included. Carpal tunnel accounted for 75.1% of the cases, followed by cubital tunnel and brachial plexus releases. Brachial plexus release had the highest median operative time (147 minutes), followed by cubital tunnel (57 minutes) and carpal tunnel release (16 minutes, P < 0.0001). Carpal tunnel release procedures had a significantly higher wRVUs per minute (0.310) when compared with cubital tunnel and brachial pleaxus release procedures, 0.127 and 0.077, respectively (P < 0.0001). Same was true for dollars per minute; carpal tunnel procedures yielded significantly more compensation than cubital tunnel and thoracic outlet procedures (P < 0.0001). CONCLUSIONS: More complex and time-consuming procedures yielded a lower reimbursement for physicians. The current work relative unit system does not account adequately for the time spent in each procedure.

Musculoskeletal pathology as an early warning sign of systemic amyloidosis: a systematic review of amyloid deposition and orthopedic surgery.

BACKGROUND: Transthyretin and immunoglobulin light-chain amyloidoses cause amyloid deposition throughout various organ systems. Recent evidence suggests that soft tissue amyloid deposits may lead to orthopedic conditions before cardiac manifestations occur. Pharmacologic treatments reduce further amyloid deposits in these patients. Thus, early diagnosis improves long term survival. QUESTIONS/PURPOSES: The primary purpose of this systematic review was to characterize the association between amyloid deposition and musculoskeletal pathology in patients with common orthopedic conditions. A secondary purpose was to determine the relationship between amyloid positive biopsy in musculoskeletal tissue and the eventual diagnosis of systemic amyloidosis. METHODS: We performed a systematic review using PRISMA guidelines. Inclusion criteria were level I-IV evidence articles that analyzed light-chain or transthyretin amyloid deposits in common orthopedic surgeries. Study methodological quality, risk of bias, and recommendation strength were assessed using MINORS, ROBINS-I, and SORT. RESULTS: This systematic review included 24 studies for final analysis (3606 subjects). Amyloid deposition was reported in five musculoskeletal pathologies, including carpal tunnel syndrome (transverse carpal ligament and flexor tenosynovium), hip and knee osteoarthritis (synovium and articular cartilage), lumbar spinal stenosis (ligamentum flavum), and rotator cuff tears (tendon). A majority of studies reported a mean age greater than 70 for patients with TTR or AL positive amyloid. CONCLUSIONS: This systematic review has shown the presence of amyloid deposition detected at the time of common orthopedic surgeries, especially in patients ≥70 years old. Subtyping of the amyloid has been shown to enable diagnosis of systemic light-chain or transthyretin amyloidosis prior to cardiac manifestations. LEVEL OF EVIDENCE: Level IV.

Arthroscopic Debridement for Primary Degenerative Osteoarthritis of the Elbow Leads to Significant Improvement in Range of Motion and Clinical Outcomes: A Systematic Review.

PURPOSE: The purpose of this investigation was to determine whether arthroscopic debridement of primary elbow osteoarthritis results in statistically significant and clinically relevant improvement in (1) elbow range of motion and (2) clinical outcomes with (3) low complication and reoperation rates. METHODS: A systematic review was registered with PROSPERO and performed using PRISMA guidelines. Databases were searched for studies that investigated the outcomes of arthroscopic debridement for the treatment of primary osteoarthritis of the elbow in adult human patients. Study methodological quality was analyzed. Studies that included post-traumatic arthritis were excluded. Elbow motion and all elbow-specific patient-reported outcome scores were eligible for analysis. Comparisons between preoperative and postoperative values from each study were made using 2-sample Z-tests (http://in-silico.net/tools/statistics/ztest) using a P value < .05. RESULTS: Nine articles (209 subjects, 213 elbows, 187 males, 22 females, mean age 45.7 ± 7.1 years, mean follow-up 41.7 ± 16.3. months; 75% right, 25% left; 79% dominant elbow, 21% nondominant) were analyzed. Elbow extension (23.4°-10.7°, Δ 12.7°), flexion (115.9°-128.7°, Δ 12.8°), and global arc of motion (94.5°-117.6°, Δ 23.1°) had statistically significant and clinically relevant improvement following arthroscopic debridement (P < .0001 for all). There was also a statistically significant (P < .0001) and clinically relevant improvement in the Mayo Elbow Performance Score (60.7-84.6, Δ 23.9) postoperatively. Six patients (2.8%) had postoperative complications. Nine (4.2%) underwent reoperation. CONCLUSIONS: Elbow arthroscopic debridement for primary degenerative osteoarthritis results in statistically significant and clinically relevant improvement in elbow range of motion and clinical outcomes with low complication and reoperation rates. LEVEL OF EVIDENCE: Systematic review of level IV studies.

Fluorescent Imaging Evaluation of Lidocaine Distribution Following Bier Block in the Upper Extremity.

INTRODUCTION: Bier block regional anesthesia has been used as an alternative to general anesthesia for years. Despite multiple theories and multiple techniques to delineate the location of the action of lidocaine during Bier block anesthesia, there has not been a consensus on the location of action. The purpose of this study was to use fluorescent imaging to further investigate the site of action of lidocaine during Bier block. MATERIALS AND METHODS: Three patients with carpal tunnel syndrome underwent open carpal tunnel release with Bier block anesthesia performed in the standard fashion with 1cc of Indocyanine green (IcG) mixed with lidocaine. Fluorescent images were obtained at the time of injection and after 10 minutes to allow patients to reach the level of surgical anesthesia. Repeated imaging was obtained at the time of completion of the procedure or at 30 minutes of tourniquet time. RESULTS: At time 0, IcG was distributed along the superficial venous system of the hand and forearm. At 10 minutes, the distribution of IcG was within the capillary system and infiltrating the dermis. The distribution later saturated the capillary beds and remained present until release of the tourniquet. CONCLUSIONS: The authors demonstrate that some lidocaine action occurs at the cutaneous level during the administration of a Bier block. Due to limited field depth of view provided by the SPY® Elite System (Novadaq Technologies Inc., Mississauga, Canada), we are unable to draw any conclusions as to the distribution of the IcG or lidocaine at the level of the larger nerves at the site of the tourniquet.

Publication Rates of Podium Presentations at an Annual Orthopedic Surgery Resident and Fellow Research Symposium.

Introduction Research is an important aspect of residency and fellowship programs across the country. Developing strategies to foster research productivity is worthwhile. An annual research project is one strategy that some programs implement. Methods All resident and fellow (Sports Medicine, Adult Reconstruction, Spine) presentations at an orthopedic surgery department's annual research symposium from June 2016 through June 2021 were identified. Abstract titles, title keywords, and author names were searched in PubMed and Google Scholar to identify the presence of a peer-reviewed publication. Using the total number of research symposium presentations given, the publication rate was calculated for each year, as well as collectively for 2016 to 2021. In addition to publication rate, first author percent, number of citations, Altmetric score, and journal impact factor were recorded. Current PGY-2 through PGY-5 residents completed a survey to assess the perceived value of the annual research symposium. Results Ninety-eight research symposium presentations were reviewed (69 residents, 29 fellows). Forty (58%) resident studies were published and 28 were first-author publications (70%). Thirteen (45%) fellow studies were published and seven were first-author publications (54%). Combining residents and fellows, the overall publication rate was 54% (53/98), and 66% of these (35/53) were first-author publications. There was a wide range of published manuscript journal impact factors, Altmetric scores, and number of citations. All residents surveyed reported finding value in the research symposium. Conclusion The overall publication rate of presentations at an annual orthopedic surgery department research symposium between 2016 and 2021 was 54%, consistent with publication rates reported at National Orthopedic Surgery Society meetings. All residents reported finding value in the annual research symposium. The results of this study support the academic value of implementing a required annual research project and may provide a useful gauge to inform residency and fellowship curricula at other institutions.

A cadaver study to compare vertebral augmentation with a high-viscosity cement to augmentation with conventional lower-viscosity cement.

STUDY DESIGN: Comparison of extravasations in fractured cadaver vertebrae augmented with commercial low-viscosity versus high-viscosity cements. OBJECTIVE: Use of high-resolution, 3-dimensional (3D) imaging to test the hypothesis that high-viscosity cements can reduce the type and severity of extravasations after vertebral augmentation procedures. SUMMARY OF BACKGROUND DATA: Cement extravasations are one of the primary complications of vertebral augmentation procedures. There is some evidence that high-viscosity cements might reduce extravasations, but additional data are needed to confirm the early findings. METHODS: A range of vertebral fractures were created in fresh human cadavers. One group was then augmented with a low-viscosity polymethylmethacrylate (PMMA)-based cement and the other group injected with high-viscosity PMMA-based cement. High-resolution computerized tomography exams were obtained, and extravasations were assessed using 3D volume renderings. The type and severity of extravasations were recorded and analyzed. RESULTS: The proportion of vertebrae with any type of extravasation through the posterior wall to the spinal canal, into small vessels laterally or anteriorly, through the endplates, or anywhere around the body was not significantly different between the high-viscosity and low-viscosity groups. There was significantly less severe extravasation through the endplates (P=0.02), and a trend toward less severe extravasation through vessels (P=0.06) with the high versus low-viscosity cements. CONCLUSIONS: In agreement with previous research, high-viscosity PMMA-based cement may help to reduce the more severe forms of extravasations after vertebral augmentation procedures in newly fractured vertebrae.

Systematic Comparison of Ligament Reconstruction With Tendon Interposition and Suture-Button Suspensionplasty for Trapeziometacarpal Osteoarthritis.

Ligament reconstruction tendon interposition (LRTI) and suture-button suspensionplasty (SBS) are both common treatment options for trapeziometacarpal osteoarthritis. The primary purpose of this systematic review was to compare the subjective improvement in patient-reported outcomes in regard to disability for patients undergoing LRTI and SBS for trapeziometacarpal osteoarthritis. A secondary purpose was to compare the subjective improvement, objective outcome scores, and complication rates following both procedures. We performed a systematic review using PubMed, Scopus, and Embase to compare the clinical outcomes of LRTI and SBS. Inclusion criteria were level I-IV evidence articles reporting postoperative Disabilities of the Arm, Shoulder, and Hand (DASH) or QuickDASH scores. Study methodological quality, risk of bias, and recommendation strength were assessed. This systematic review included 31 studies for final analysis with 1289 thumbs undergoing LRTI (25 studies) and 113 thumbs undergoing SBS (6 studies). Both procedures demonstrated similar improvement in DASH and/or QuickDASH scores, while key pinch and grip strength inconsistently improved following both procedures. Complication rate was similar between the 2 procedures; LRTI 12% and SBS 13%. Although both LRTI and SBS seem to provide improved short-term patient-reported functional improvement and objective strength, there was significant heterogeneity within the included studies, and those studies discussing SBS were of lower quality evidence than those of LRTI. Thus, to truly delineate whether a difference exists between these 2 techniques for the treatment of first carpometacarpal joint arthritis, larger prospectively designed studies of high-quality evidence are necessary.

#Scoliosis: an analysis of patient perception of scoliosis on TikTok.

Background: Social media presents an opportunity to analyze popular opinion about patient experiences. Idiopathic scoliosis is a spinal pathology commonly identified in younger patients who are the largest users of social media. Objective: To analyze posts on the social media platform, TikTok, to better understand the scoliotic patient condition. Methods: TikTok posts were searched manually by screening for "#Scoliosis." Variables assessed included number of likes, conveyed tone, gender, activities of daily living, incisional scar, imaging, involved spine level, spinal curvature, pain, formal physical therapy, multiple operations/reoperation, brace use, self-image, mobility, and educational/awareness posts. Number of responses per category were evaluated for the total they represented and the percentage of available posts containing those elements. Odds ratios with 95% confidence intervals were calculated for each collected variable. Results: More posts were positive than negative (P < 0.001) and from female users than male users (P < 0.001). Self-image was the most prevalent subject, with many posts not mentioning activities of daily living, incisional scars, imaging, pain, physical therapy, timing, awareness/education, or involved spine levels. Conclusions: More females post about scoliosis than males, with most posts containing positive self-image-related themes. This may represent a positive public attitude about scoliosis; however, further research is needed.

Demographic and Lifestyle Factors Associated with Patient-Reported Acute COVID-19 Vaccine Reactivity.

Patient-reported vaccine reactivity (PRVR) is a major contributor to COVID-19 vaccine hesitancy. PRVR responses to the COVID-19 vaccine may be affected by several modifiable and non-modifiable factors that influence immune function. Understanding the effects of these factors on PRVR can aid in better educating patients on expectations, as well as formulating public health strategies to increase the levels of community vaccination.

Return to Sport and Performance After Thumb Metacarpophalangeal Joint Collateral Ligament Surgery in the National Basketball Association.

Introduction Basketball players are at increased risk of thumb collateral ligament injury (ulnar collateral ligament (UCL) and radial collateral ligament (RCL)). Methods The National Basketball Association (NBA) players with thumb collateral ligament surgery were identified using publicly available data. Performance statistics, ligament injuries (UCL or RCL), return to sport (RTS) time, laterality, and injury dates were recorded. Cases were matched 1:1 with controls based on age (±1 year), body mass index (BMI), NBA experience (±1 year), and performance statistics prior to the index date. RTS was defined as playing in one NBA game postoperatively. Career longevity was evaluated. Summary statistics were calculated, and Student's t-tests (ɑ = 0.001) were performed. Results All 47 players identified with thumb collateral ligament surgeries returned to sport. Thirty-three players (age: 26.9 ± 3.0) had one year of postoperative NBA experience for performance analysis. Career length (case: 9.6 ± 4.1, control: 9.4 ± 4.3, p > 0.001) was not significantly different from controls (p > 0.001). The same season time to RTS (n = 20) was 7.1 ± 2.4 weeks. Off-season or season-ending surgery (n = 13) RTS time was 28.4 ± 18.7 weeks. Neither thumb collateral ligament (UCL, n = 7; RCL, n = 10; unknown, n = 16) had an identifiable difference between the groups when evaluating career length. Career length, games/season, and performance were not different for players who underwent surgery on their dominant thumb (63.6%, 21/33) compared to controls (p > 0.001). Conclusion RTS rate is high in NBA athletes undergoing thumb collateral ligament surgery. Players do not experience decreased performance or career length due to thumb collateral ligament surgery, regardless of a dominant or non-dominant thumb injury.

Return-to-Sport Time and Postoperative Performance in MLB Players Undergoing Wrist Arthroscopy.

BACKGROUND: Wrist injuries are common in sports and can result in prolonged time missed from playing. This study aimed to determine in Major League Baseball-players after arthroscopic wrist surgery the return-to-sport (RTS) rate, postoperative career length, and changes in performance compared with preoperative statistics and matched controls. METHODS: Major League Baseball players who underwent arthroscopic wrist surgery from 1990 to 2019 were identified. Demographic and performance data were collected for each player, and matched controls were identified. Comparisons were made via paired samples Student t tests. RESULTS: Twenty-six players (27 surgeries) were identified. The average age of included players was 28.9 ± 2.9 years with an average professional experience of 5.2 ± 3.4 years. Eighty-four percent of players returned to sport, with an average RTS time of 5.0 ± 2.7 months. A statistically significant (P < .05) decrease was seen in preoperative and postoperative runs scored per season (95.6 ± 91.3 vs 41.0 ± 29.5), batting average (BA) (0.270 ± 0.024 vs 0.240 ± 0.036), and average wins above replacement (WAR) (1.5 ± 1.1 vs 0.8 ± 0.9). CONCLUSION: Major League Baseball players who underwent arthroscopic wrist surgery had an RTS rate of 84% at a mean time of 5.0 months. There was no significant difference in performance statistics between cases postoperatively and matched controls overall, with some differences in performance found when categorized by position. However, a significant decrease in performance among case players was observed between preoperative and postoperative performance, including runs per season, BA, and WAR.

Effects of COVID-19 on Geographical Trends in the Orthopaedic Surgery Residency Match.

Historically, medical students often match within the same geographic location or to an orthopaedic surgery residency program affiliated with their medical school. The objective of this investigation was to determine differences in geographic trends between orthopaedic residents matching before and during the Coronavirus-19 (COVID-19) pandemic. METHODS: This study analyzed 2 groups of orthopaedic residents: Pre-COVID cohort (years 2016-2020) and COVID-impacted cohort (year 2021). A list of accredited orthopaedic surgery residency programs (n = 202) was obtained. Orthopaedic residency program webpages were located (region [n = 4], division [n = 9], state [n = 50]). For each resident, their medical school and year of postgraduate training were recorded. Year 2021 resident information was obtained from the orthopaedic residency program webpages, social media accounts, and medical school match lists. Residency programs affiliated with a medical school were also assigned. Descriptive statistics were performed. Two sample Student t tests with Bonferroni correction applied to p-values (α < 0.05 significant) were performed. RESULTS: There were 4,832 residents analyzed (4,074 in Pre-COVID cohort; 758 in COVID-impacted cohort [758/868 of all positions in 2021 Match]). Statistically significant differences were detected between the COVID-impacted cohort (39.6%, p < 0.001) matching in the same state as their medical school (Pre-COVID 33.1%) and the COVID-impacted cohort (28.0%, p < 0.001) matching to a residency program affiliated with their medical school (Pre-COVID 21.2%). In the COVID-impacted cohort, students who matched in state matched to their home program more frequently (69.3%) compared with the Pre-COVID cohort (60.5%). Geographically, there was a difference in the COVID-impacted cohort (52.5%, p < 0.011) matching in the same division (Pre-COVID 47.5%). No statistically significant differences were identified for residents matching to the same region as their medical school (Pre-COVID 60.1%; COVID-impacted 61%, p = 0.968). CONCLUSION: Residents matching in the same state, in the same division, and to a residency program affiliated with their medical school increased significantly in the COVID-impacted cohort. There was no difference between cohorts matching in the same region as their medical school. Level of Evidence: Observational/Cross-Sectional.

Analysis of Current Orthopedic Surgery Residents and Their Prior Medical Education: Does Medical School Ranking Matter in Orthopedic Surgery Match?

OBJECTIVE: The purpose of this study was to determine the strength of the association between medical school ranking and orthopedic surgery residency ranking using the current cohort of orthopedic surgery residents. DESIGN: We obtained a list of accredited programs from Doximity for orthopedic surgery residency programs and U.S. News & World Report for medical schools. Each orthopedic surgery residency program webpage was evaluated for the presence of an orthopedic surgery residency roster. For each resident, the medical school attended, allopathic or osteopathic degree, and year of post-graduate training was recorded. Orthopedic surgery residency programs and medical schools were assigned to one of four tiers for each based on their respective ranking. Descriptive statistics, Chi squared tests and Pearson residuals were used to analyze the association of orthopedic surgery residency tier and medical school tier. Post-hoc pairwise comparisons were performed utilizing the Bonferroni correction to account for 16 tests, correcting the significance level to p = 0.003. SETTING: 187 orthopedic surgery residency program webpages. PARTICIPANTS: 4123 orthopedic surgery residents. RESULTS: There was a significant association between medical school tier and orthopedic surgery residency tier (X2 [9] = 1214.78, p < 0.001). The post-hoc residual values were statistically significant for 75% (12/16) of tests performed. The majority of Tier 1 orthopedic surgery residents 50.5% (800/1585) attended a Tier 1 medical school. The strongest positive association exists between Tier 1 medical students attending Tier 1 residencies (residual = 23.978, p < 0.001). The strongest negative association with Tier 4 residencies was with Tier 1 medical schools (residual= -15.656, p< 0.001). CONCLUSIONS: Medical school ranking is an important consideration for prospective orthopedic surgery applicants and may become more important with less objective measures of academic performance such as United States Medical Licensing Examination Step 1. LEVEL OF EVIDENCE: Observational.

The Role of N-acetylcysteine in the Treatment of Accidental Submersion of the Hands in Liquid Nitrogen.

N-acetylcysteine (NAC) is a compound with numerous uses, especially in cases which require prevention of cellular damage. To the authors' knowledge, no reports of NAC as treatment for liquid nitrogen (LN2) injuries currently exist. We present a case in which a 40-year-old woman accidentally submerged her hands in LN2 while working in a lab. The patient was treated with NAC, antibiotics, and wound care. Six months post-injury, the patient had full range of motion, full sensation, full function, and no pain. Therefore, NAC, in combination with dressing changes and antibiotics, can be used to successfully treat patients with LN2 burns.

Extensor Tenosynovitis due to Mycobacterium marseillense Infection in a Renal Transplant Recipient.

Renal transplant recipients are at an increased risk of atypical nontuberculous mycobacterial (NTM) infections. Infections caused by NTM are uncommon in the general population, rarely occurring in immunocompetent individuals. NTM infections are an uncommon cause of tenosynovitis. Mycobacterium marseillense is a rare, atypical mycobacteria that has been reported to cause pulmonary and cutaneous infections; however, no previous reports of this pathogen causing tenosynovitis exist. This case reports a 73-year-old male renal transplant recipient who presented with chronic extensor tenosynovitis of the right hand caused by M marseillense. The patient was treated with radical extensor tenosynovectomy and 6 months of antibiotic treatment. A review of literature on tenosynovitis caused by atypical mycobacteria was performed. The patient successfully responded to treatment with no complications or recurrence of infection at the 18-month follow-up. Tenosynovitis of the hand caused by atypical mycobacteria is rare. A high index of suspicion is required to prevent a delay in diagnosis, particularly in immunocompromised individuals.

The Effect of the COVID-19 Pandemic on Orthopaedic Residency Program Social Media Utilization.

The COVID-19 pandemic created an unprecedented challenge for orthopaedic surgery residency applicants when away rotations were canceled and interviews were held virtually. The authors hypothesized that (1) Instagram would have more total social media accounts compared with Twitter or Facebook, (2) most social media accounts on all platforms would be created during 2020, and (3) the average number of Instagram followers would be higher among highly ranked programs. METHODS: A list of Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs (n = 202) that were ranked by reputation was acquired from Doximity. Public Instagram, Facebook, and Twitter profiles of orthopaedic surgery residency programs were identified through a manual search. Variables assessed on each social media platform were all available summary statistics provided by the social media platform. Instagram accounts were categorized into 5 tiers based on numeric reputation ranking, with 40 programs in each tier (except tier 5 with 42 programs). Descriptive statistics were calculated, and continuous data were presented as mean ± standard deviation. Goodness-of-fit regression values were calculated for observed trends. RESULTS: One-hundred seventy-four social media accounts were identified. There was a higher percentage of Instagram accounts (66.1%) compared with Facebook (13.2%) or Twitter (20.7%). From 2010 to 2020, an exponential increase (R2 = 0.88) of social media accounts was observed during 2020. Instagram profiles (77.2%, 98/115 [95 in 2020, 3 in 2021]) were created after the cancelation of away rotations in May 2020. Instagram profiles had 1,029 ± 522.4 average followers, more than Facebook and Twitter. Tier 1 residency programs had the largest average follower count with 1,462.4 ± 584.3 followers. CONCLUSION: Social media presence increased exponentially during 2020. Instagram was the social media platform with the most accounts. Many Instagram accounts were created during 2020, and most were created after away rotations were canceled during the COVID-19 pandemic. Instagram accounts averaged the most followers. Top tier orthopaedic residency programs had a greater number of accounts and average followers than lower tier programs.

Factors Affecting Orthopedic Sports Medicine Surgeons' Online Reputation.

Physician rating websites (PRWs) rate physicians based on experiences of previous patients. Although a high rating is desirable, it may not correlate with quality of care, experience, or other physician-specific variables. This study examined the impact of physician-specific variables, such as American Board of Orthopaedic Surgery Sports Certificate of Added Qualification (CAQ) status, years in practice, sex, and geographic location, on the PRW patient satisfaction rating and number of ratings. A list of orthopedic sports medicine surgeons was obtained from the American Orthopaedic Society for Sports Medicine database. Demographic data were recorded. Surgeon profiles were gathered from the most commonly used PRWs (Healthgrades and Vitals), and a mean rating value was recorded on a 1- to 5-star scale. The t test and analysis of variance were used for comparisons. Multivariable linear regression was used to identify factors contributing to PRW ratings. Female sex had the biggest positive effect on PRW rating (R=0.04, P=.029). The PRW rating was positively affected by the number of ratings (R=0.04, P<.001) and negatively affected by an increase in years of practice (R=0.04, P<.001). Surgeons with fewer than 10 years in practice had higher PRW ratings than surgeons practicing longer than 10 years. The PRW ratings were not affected by sports CAQ status or geographic location. Fewer years in practice, female sex, and greater number of reviews were associated with higher PRW ratings. Number of reviews was the only modifiable factor. There was no observed association between sports medicine CAQ status and PRW rating. [Orthopedics. 2021;44(2):e281-e286.].

Percutaneous Needle Fasciotomy versus Collagenase Injection for Dupuytren's Contracture: A Systematic Review of Comparative Studies.

Introduction The purpose of this study was to review and compare clinical outcomes between percutaneous needle fasciotomy (PNF) and collagenase Clostridium histolyticum (CCH) injection for the treatment of Dupuytren's contracture. Materials and Methods A systematic review was performed including all level I-III evidence studies investigating the clinical outcomes of PNF and CCH injection in the treatment of Dupuytren's contracture. Results Five studies (278 CCH patients, 225 PNF patients; 285 CCH fingers, 246 PNF fingers, 405 males, and 98 females) were analyzed. Two randomized studies were level I evidence, one randomized study was level II, and two nonrandomized studies were level III. Two studies analyzed a total of 205 patients, each demonstrating statistically superior outcomes in one outcome measure (contracture improvement and Michigan Hand Questionnaire (MHQ) satisfaction subscore) with PNF, while the remaining three studies demonstrated no significant differences in outcomes between the two techniques. Three studies reported a statistically higher rate of minor complications (local pain, edema, ecchymosis, lymphadenopathy, pruritis) with CCH, while the remaining two studies demonstrated no significant difference in complication rates. Conclusion For the treatment of Dupuytren's contracture, there is some evidence that suggests superior clinical outcomes of PNF compared with CCH and a higher minor complication rate with CCH.

Limb Occlusion Pressure Versus Standard Pneumatic Tourniquet Pressure in Open Carpal Tunnel Surgery - A Randomized Trial.

INTRODUCTION: Pneumatic tourniquets are used extensively in orthopedic hand/wrist surgery. Complications, while rare, are associated with elevated pressure and duration of tourniquet use. Limb occlusion pressure (LOP) is the minimum tourniquet pressure at which arterial blood flow is restricted. Therefore, we performed a cross-sectional double-blinded randomized control trial to assess if there is a difference in post-operative pain at the surgical and tourniquet site between LOP and standard tourniquet pressure and if there is a difference in post-operative opioid usage. METHODS: A total of 44 patients (Age 60±13, 30 female, 14 male) were randomized into two groups (LOP, 191±14 mmHg | STP, 250 mmHg) of 22 patients controlling for gender (15 female, seven male). The primary outcome was a visual analog scale (VAS) for pain at the tourniquet and surgical sites, recorded for the first two weeks post-operative. Daily pain medication usage was recorded and quantified using oral morphine milligram equivalents (MME). A group-by-time generalized mixed-model ANOVA was used to detect within-group and between group (LOP vs STP) differences in VAS at the surgical and tourniquet sites as well as medication use.  Results: LOP significantly decreased post-operative pain medication usage across the first week (-50%; p<0.05). Both groups had similar VAS pain at the surgery site, but the LOP group had 80% reduced pain at the tourniquet site when averaged across the first post-operative week (p<0.05).  Conclusions: The use of LOP compared to STP elicits reduced post-operative pain at the tourniquet site and reduces post-operative pain medication use in the first post-operative week.

Perceptions of Polymethyl Methacrylate Cement Exposure Among Female Orthopaedic Surgeons.

The medical field has long believed that polymethyl methacrylate (PMMA) vapor is dangerous to a growing fetus, and therefore, women who are pregnant should avoid exposure to it. Symptoms of vapor exposure include eye irritation, coughing, respiratory tract irritation, and irritation of exposed mucous membranes. The purpose of this study is to investigate the perceptions of PMMA cement exposure during pregnancy in female orthopaedic surgeons because it influences (1) the currently held beliefs and practices and (2) clinical and career choices. Methods: A 23-question survey was distributed via e-mail to all active members of the Ruth Jackson Orthopaedic Society and the "Women in Orthopaedics" private Facebook group. Questions consisted of the level of training, current usage of PMMA, previous exposure during pregnancy and/or breastfeeding, and beliefs regarding current or future willingness of exposure during pregnancy/breastfeeding. Results: PMMA training was found to have a positive correlation with those who remained in the operating room while pregnant or would do so in the future. Overall responses found that 41.7% would leave the room in the future if PMMA were being used while they were pregnant, with 24.7% leaving if they were breastfeeding. If they were the primary surgeon, 23.7% stated that they would leave and 8.4% stated that PMMA exposure during pregnancy factored into which subspecialty they chose. Conclusion: This survey demonstrates a lack of consensus among practicing female orthopaedic surgeons regarding the risks posed by remaining in a room during pregnancy and breastfeeding while PMMA is in use. Currently held beliefs and education practices should be examined to determine if they match the available literature.