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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 6 0.4) and a slight association of men with career (0.24 6 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. Therewere no differences in race IATD-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 6 0.3) than among the general population (0.32 6 0.4; p < 0.001) and other healthcare professionals (0.34 6 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. [ABSTRACT FROM AUTHOR]

This research report explores the correlation between the Defense and Veterans Pain Rating Scale (DVPRS) and other pain-related measures in a civilian population experiencing acute pain. The study found that the DVPRS scores were associated with the Numeric Rating Scale (NRS), PROMIS Pain Interference, and Sleep Disturbance scores, but not physical activity. The DVPRS was deemed a valuable tool for assessing pain intensity, pain interference, and sleep-related impairment. The study suggests the need for further research to investigate potential variations in pain-related measures among different racial and ethnic groups. [Extracted from the article]

Byline: Marc J. Philippon, MD (Steadman Hawkins Research Foundation, Vail, Colorado); Mara L. Schenker (Steadman Hawkins Research Foundation, Vail, Colorado); Karen K. Briggs, MPH, MBA (Steadman Hawkins Research Foundation, Vail, [...]

Morphological and spatial abnormalities of the proximal femur and acetabulum have been recently recognized as causes of femoroacetabular impingement. During joint motion in hips with femoroacetabular impingement, abnormal bony contact occurs, and soft tissue structures (chondral and labral) often fail. Femoroacetabular impingement has been reported to be a contributor to early-onset joint degeneration. Ganz et al have described good midterm success with an open surgical dislocation approach to reconstruct normal joint clearance. The purpose of this report is to discuss relevant literature and describe an arthroscopic approach to treat femoroacetabular impingement. This approach has particular relevance in high-demand patients, particularly in athletes seeking to return to high-level sport. Keywords: femoroacetabular impingement; hip arthroscopy; osteoplasty; labral tear, During the past decade, advances in open surgery, magnetic resonance arthrography (MRA), and arthroscopy of the hip have revealed early degenerative changes frequently not visible on conventional radiographs. (40) In [...]

We examined the impact of metabolic syndrome (MetS) on operative outcomes with orthopedic trauma, particularly among patients with pelvic, acetabular, and lower extremity fractures. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who had operative pelvic, acetabular, and lower extremity trauma from 2006 through 2014. We defined MetS as type 2 diabetes, a history of hypertension requiring medication, and body mass index of 30 kg/m2 or greater. Patients with MetS were compared with unaffected patients and assessed for association with in-hospital complications and mortality. The study population included 37,495 patients; 5.7% (n=2154) had MetS. On multivariable logistic regression, MetS was associated with increased odds of any hospital complication (odds ratio [OR], 1.30; 95% CI, 1.13-1.51; P<.001), Clavien-Dindo grade IV complications (OR, 1.51; 95% CI, 1.23-1.87; P<.001), readmission (OR, 1.39; 95% CI, 1.18-1.63; P<.001), and reoperation (OR, 1.40; 95% CI, 1.11-1.76; P=.004). Conversely, MetS significantly decreased the odds of mortality (OR, 0.67; 95% CI, 0.49-0.92; P=.01). Although MetS is a risk factor for postoperative complications, longer length of stay, and increased readmission after surgical intervention for orthopedic lower extremity trauma, MetS appears to decrease the odds of mortality in this specific patient population, which merits further investigation. [Orthopedics. 2022;45(2):103-108.]. [ABSTRACT FROM AUTHOR]

The sport of motocross entails off-road motorcycle racing and is associated with a high incidence of traumatic injury. While prophylactic knee braces are routinely worn, there has been anecdotal concern that brace use is linked to femoral shaft fractures. While this risk remains unreported in the medical literature, preventing this complication has played a role in new commercial knee brace designs. We present two cases in which two motocross riders sustained transverse femoral shaft fractures at the proximal portion of each respective knee brace. The fracture locations measured on anterior-posterior radiograph were 22 and 21.1 cm proximal to the center of the knee, which is also the recommended proximal extent of motocross knee braces. We propose that the rigid knee brace protects the ligamentous knee structures but may focus undue force on the proximal aspect of the brace. New knee brace designs have incorporated features to dissipate the potentially injurious force to prevent femur fracture. While knee braces undoubtedly help prevent ligamentous knee injury, these cases question the safety of standard brace design and highlight the need for further brace development to better protect the patient’s bony structures, in addition to the knee joint. [ABSTRACT FROM AUTHOR]

The article discusses the application of arthroscopy for the clinical management of femoroacetabular impingement (FAI) in athletes. According to the author, FAI is a common cause of hip pain among athletes. It is also associated with reduced range of motion and decreased performance. The clinical manifestations of FAI are described. The article also explains the surgical techniques for FAI management, along with postoperative management.

The article proposes a method for acetabular rim trimming and detached labral repair. Defining the borders of a tear is the first step in addressing labral tears. One bioabsorbale suture is needed in repairing detached labrum to be able to stabilize fibrocartilage to the acetabular rim. The procedures included in the proposed method are explained.

The article discusses the neuromuscular hip biomechanics and pathology in athletes. It describes the osseous and ligamentous structures contributing to hip stabilization. It discusses the neuromechanical mechanisms that affect hip joint mechanics. It also explains the functional analysis of hip biomechanics and electromyography of hip muscles.

The 5-factor modified frailty index (mFI-5) and the 11-factor modified frailty index (mFI-11) are equally effective in predicting adverse outcomes in the American College of Surgeons National Surgical Quality Improvement Program database. The similarly structured American College of Surgeons Trauma Quality Improvement Program (TQIP) database has not been studied with these two frailty indices. We hypothesized that the mFI-5 and mFI-11 could similarly predict adverse outcomes with TQIP data. The mFI-5 and mFI-11 were calculated for each patient comprising our institutional TQIP registry (2016-2018). Spearman ρ was calculated to assess correlations between the two indices across multiple predefined TQIP patient cohorts. Complications were stratified by frailty score for each index. Multivariable logistic regression models adjusting for age, Glasgow Coma Scale score, and Injury Severity Score were created to assess each mFI's association with any complication and discharge dispositions (home, facility, and expired). There were 8467 patients. Spearman ρ was >0.9 (P < 0.0001) for all patient cohorts except elderly, elderly blunt multisystem, and isolated hip fractures. Increasing frailty scores for both mFIs were associated with greater rates of acute kidney injury (P < 0.0001), myocardial infarction (P < 0.001), severe sepsis (P < 0.05), unplanned return to the intensive care unit (P < 0.0001), and unplanned intubation (P < 0.0001). On separate multivariable logistic regressions, the mFI-5 and mFI-11 were each predictive of any complication (P < 0.0001) and a facility discharge (P < 0.001). Neither the mFI-5 nor the mFI-11 were associated with mortality (P > 0.05). The mFI-5 and mFI-11 are highly correlated across several TQIP patient cohorts. They also are both predictive of complications and discharge dispositions; however, neither index can predict mortality. Given its ease of use, the mFI-5 may be a better option for identifying frail patients and predicting adverse outcomes at the point of care in trauma. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures. Methods: A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed. Results: In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p <.0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p =.0025). Conclusions: Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to build a risk prediction model to identify trauma patients at the time of injury who are at high risk for post-traumatic stress disorder (PTSD) 1 year later. Methods: Patients 18+ with operative orthopedic trauma injuries were enrolled in prospective social determinants of health cohort. Data were collected through initial surveys, medical records at time of injury, and 1-year follow-up phone screenings. Univariate analysis examined associations between factors and PTSD at 1 year. The best fit multivariable logistic regression model led to a novel PTSD risk prediction tool based on weights assigned similar to the Charlson index methods. Results: Of 329 enrolled patients, 87 (26%) completed follow-up surveys; 58% screened positive for chronic PTSD. The best fit model predicting PTSD included age, insurance, violent mechanism, and 2 acute stress screening questions (AUC.89). Using these parameters, the maximum possible TIPPS index was 19. Those with PTSD at 1 year had a mean TIPPS index of 12.9 ± 4.0, compared to 5.9 ± 4.2 for those who did not (P <.001). Discussion: Traumatic injury often leads to PTSD, which can be predicted by a novel risk score incorporating age, insurance status, violent injury mechanism, and acute stress reaction symptoms. Stability in life and relationships with primary care physicians may be protective of PTSD. Level of Evidence: Diagnostic level II. [ABSTRACT FROM AUTHOR]

Background: The emergency department (ED) often represents the first exposure orthopedic trauma patients have to prescription opioids and thus a critical opportunity for prevention of potential long-term opioid use. This study will analyze the impact of opioid prescribing patterns among both ED providers and orthopedic surgery residents on the utilization of opioids during routine orthopedic trauma manipulations. Materials and methods: This retrospective study reviewed opioid utilization among patients with an ankle or distal radius fracture at a large, urban, level 1 trauma center. Data on clinical providers, patient demographics, and injury severity score (ISS) were collected. Total opioid use was reported in oral morphine milligram equivalents (MME). Regression analyses were performed to determine how provider opioid prescribing intensity affected administered MME. Results: Five-hundred and ninety-five patients were included. The mean MME administered was 40.84 (SD 30.0) and was inversely associated with ISS (R = −.05; P =.40). Patients treated by a high-intensity ED prescriber had approximately three times higher odds of receiving over 40.84 MME (OR 2.8, 95% CI 1.33-5.90 P =.07). For those with an ISS score less than 15, the presence of a low-intensity orthopedic resident decreased the odds of receiving over 40.84 MME from 2.25 to 1.78 in the presence of a high-intensity ED prescriber. Conclusion: For isolated orthopedic manipulations in the ED, involvement of a low-intensity prescribing orthopedic resident significantly decreased the quantity of opioids administered for those with lower ISS injuries, thus effectively mitigating the effect of high-intensity prescribing behavior prescriber. [ABSTRACT FROM AUTHOR]

Background: Food insecurity (FI) has been defined as a lack of consistent access to enough food for a healthy active lifestyle. As of 12.7% of the United States are suffering from FI, which has been correlated with increased hospital costs and poorer health outcomes. Currently, limited data exists examining the relationship between trauma populations and FI despite both having similar root causes. We sought to determine this and validate a screening tool for FI in this population. Methods: A cross-sectional survey study of trauma patients was conducted at a level 1 trauma center in Atlanta, Georgia. Survey questions included the first two items of the Core Food Security Module. Zip codes were used to determine FI, defined by the USDA Food Access Research and compared to individual participant survey responses. Binary classification test metrics were calculated to validate the two items as a screening tool in this population. Results: The cohort included 136 patients, of which the majority were black (60.3%) and male (60.3%). Thirty-one respondents affirmed food security (22.8%) despite over half (51.5%) living in a food insecure community. The sensitivity and specificity for this screening to predict FI were 25 and 80%, respectively. Conclusion: Although the specificity is high, this screening tool has a low sensitivity, accuracy, NPV, and PPV to determine food insecurity in this population. Community-level statistics suggests that food insecurity is a significant public problem amongst trauma patients. Prevention efforts should, therefore, aim to address both issues simultaneously. [ABSTRACT FROM AUTHOR]

Background: Frailty has been studied extensively in trauma, but there is minimal research detailing its impact on traumatic brain injury (TBI). We hypothesized that the 11-item modified frailty index (mFI-11) would predict complications and discharge outcomes in patients with TBI.Methods: A retrospective review of our trauma quality improvement program (TQIP) registry was conducted for all patients with TBI. The mFI-11 score was calculated for each patient. Multivariable logistic regression was used to assess the relationship between mFI-11 and cardiovascular, infectious, pulmonary, renal, thromboembolic, and unplanned complications (ie, unplanned intensive care unit [ICU] admission, intubation, or return to the operating room).Results: There were 2352 patients with TBI of whom 61.6% (n = 1450) were not frail, 19.3% (n = 454) were mildly frail, and 19.1% (n = 448) were moderately to severely frail. Higher frailty scores were associated with increasing age (P < .0001) and decreasing injury severity score [ISS] (P = 0.001). Higher frailty scores also correlated with increasing rates of a skilled nursing facility/long-term acute care hospital/rehabilitation discharge (P = .0002). On multivariable logistic regression adjusting for age, Glasgow Coma Scale (GCS) score, ISS, mechanism, and sex, moderate to severe frailty increased the odds of acute kidney injury (odds ratio [OR] 2.06, 95% CI 1.07-3.99, P = .03) and any unplanned event (OR 1.6, 95% CI 1.1-2.3, P = .01).Conclusion: Frailty measured by the mFI-11 is associated with greater rates of discharge to unfavorable locations and increased odds of acute kidney injury and unplanned events among patients with TBI. These findings suggest that frail patients with TBIs require greater vigilance to avoid such unanticipated outcomes. [ABSTRACT FROM AUTHOR]

Background: There is a select number of massive-volume, high-acuity trauma centers (HACs) in the United States. Expertise in polytrauma care has been associated with improved mortality in general surgery trauma, though has not been investigated in orthopaedic trauma. With complex polytrauma proficiency comes the inherent risk of intensive care, complications, and prolonged inpatient stays, without a commensurate increase in allocated resources. The purpose of this study was to compare mortality, complications, and length of stay in polytraumatized orthopaedic patients treated at HACs vs. low-acuity trauma centers (LACs).Methods: The National Trauma Data Bank was queried for orthopaedic injuries with injury severity score (ISS)>15 and mortality, complications, hospital length of stay, ICU length of stay, ventilation duration, and demographics. Hospitals where at least 13% (median percentage of patients with ISS > 15 admitted to all hospitals) of total admissions had an ISS>15 were classified as HAC; all others were LACs.Results: HACs admitted 86.8% of 28,314 patients with ISS>15. On univariate analysis, patients at HACs have 16% decreased odds of in-hospital mortality vs. LACs (p=0.005); the effect increased to 27% (p=0.002) on multivariate analysis. Patients at HACs have 63% greater odds of ICU admission (p<0.001), 48% higher odds of ventilatory support (p=<0.001), 38% increased odds of unplanned reoperation (p=0.007), and 37% increased odds of medical complications (p<0.001). On multivariate analysis, secondary outcome measures showed no significant difference between HACs and LACs. Patients at HACs had 2.8 days longer length-of-stay (p<0.001).Conclusion: Severely injured orthopaedic trauma patients have decreased mortality at HACs, despite having a higher average ISS and a higher prevalence of obesity and active smoking. While there is a higher incidence of ICU admission, mechanical ventilation, complications, and unplanned reoperation on univariate analysis, correction for ISS and patient factors enhances the effect of HACs on mortality, but removes the effect on secondary measures. Thus, HACs are life-saving institutions for polytraumatized orthopaedic patients, and the known resource demand of these hospitals is supported by their favorable outcome profile.Level Of Evidence: IV. [ABSTRACT FROM AUTHOR]

The 5-item modified frailty index (mFI-5) has been shown to predict adverse outcomes in surgery; yet, its role in trauma patients is unclear. We hypothesized that increasing frailty, as indicated by increasing mFI-5 scores, would correlate with worse outcomes and greater mortality in trauma patients. We performed a retrospective review of patients captured by our 2018 Spring and Fall Trauma Quality Improvement Program registry. The mFI-5 was calculated by assigning one point for each comorbidity present: diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and functionally dependent health status. Outcomes included complications, length of stay, mortality, and discharge location. A total of 3364 patients were included; 68.0% (n = 2288) were not frail, 16.5% (n = 555) were moderately frail, and 15.5% (n = 521) were severely frail. Higher frailty scores were associated with greater rates of unplanned intubations (P < 0.01) and unplanned admissions to the intensive care unit (P < 0.01). Rates of nonhome discharge (P < 0.0001) were significantly higher in the severe frailty group compared with the moderate and no frailty groups. On multivariable regression adjusting for demographics and injury details, severe frailty was predictive of any complication (odds ratio [OR], 1.53; 95% confidence interval [95% CI], 1.12-2.11; P < 0.01), failure to rescue (OR, 2.88; 95% CI, 1.47-5.66; P = 0.002), nonhome discharge (OR, 1.88; 95% CI, 1.47-2.40; P < 0.0001), and mortality (OR, 1.83; 95% CI, 1.07-3.15; P = 0.03). Frailty is not only associated with longer hospitalizations but also with more complications, adverse discharge locations, and increased odds of mortality. The mFI-5 is a quick and intuitive tool that can be used to determine an individual's frailty at the time of admission. [ABSTRACT FROM AUTHOR]