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Background: The appropriate initial management of pediatric trigger thumb (PTT) remains controversial. Some providers advocate for prolonged nonoperative management, whereas others may offer surgical release to provide a reliable and expedient resolution. The goal of this study was to elucidate the practice patterns of surgeons with different fellowship training who treat patients with PTT. We hypothesized that an association between surgeon specialty training and treatment algorithm would be identified., Methods: A cross-sectional survey was sent to mailing lists of 3 professional organizations whose members represent most providers caring for pediatric hand patients. Respondents were asked their training background and treatment recommendations for several clinical scenarios. Responses were compared across subspecialties., Results: Of the respondents, 444 completed a fellowship in hand surgery, 167 completed a pediatric orthopedic fellowship, and 155 completed an additional congenital hand fellowship. Providers with hand fellowship training were more likely to offer surgical intervention as a first-line treatment for a 3-year-old patient with a flexible trigger thumb than those who completed a pediatric orthopedic fellowship ( P = .001), and more likely to offer surgical intervention to a 3-year-old patient with an intermittent ( P = .007), painful ( P = .015), or locked ( P = .012) trigger thumb than those providers who completed additional training in congenital hand surgery. No statistically significant differences in practice patterns were appreciated for children aged 6 and 18 months., Conclusion: Variability was appreciated in practice patterns for initial treatment recommendation for a patient presenting with PTT. Subspecialty training does appear to affect treatment recommendations for clinical scenarios involving a 3-year-old patient with PTT, although this trend is not observed when treating younger patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Orthopaedic surgeons play a critical role in ensuring the health and safety of professional athletes. Despite the privilege of treating elite athletes, there exists great financial exposure to individual physicians in the event of a malpractice lawsuit., Hypothesis/purpose: The purpose of this study was to evaluate and model malpractice liability exposure of the sports medicine surgeon caring for athletes in the National Football League (NFL), Major League Baseball (MLB), and National Hockey League (NHL) with respect to player position and additional supplemental malpractice insurance needs. It was hypothesized that routine liability coverage cannot adequately address the demands of caring for elite athletes in professional sports leagues., Study Design: Economic and Decision Analysis; Level of evidence, 3., Methods: In total, 2447 NFL, 992 MLB, and 980 NHL player contracts from the 2022-2023 season were aggregated from a publicly available online database. Position, team, total contract value, and mean yearly salary were noted. Risk ratios were calculated with respect to 1 million US dollars (USD) and 3 million USD of annual occurrence-based malpractice liability awards and used to generate a "covered-to-treat" analysis. Supplemental malpractice liability insurance was quantified., Results: Assuming 1 million and 3 million USD occurrence-based awards covered by malpractice liability insurance, team physicians can fully treat 17.3% and 50.0% of NFL players, 43.2% and 59.7% of MLB players, and 13.6% and 41.0% of NHL players, without incurring additional personal financial risk, from a risk-based medicolegal model. Liability policies of 52.6 million, 108.1 million, and 64.1 million USD are required to treat 95% of NFL, MLB, and NHL players, respectively. Positions carrying the greatest risk ratios are quarterback (QB) (9.9) in the NFL, right field (15.1) in the MLB, and center (5.7) in the NHL., Conclusion: Sports medicine specialists caring for elite athletes face potential personal financial risk due to insufficient medicolegal coverage. While coverage may vary among different practice settings including private, academic, or public state institutions, medical malpractice risk is crucial in partnerships between sports franchises, hospitals, players, agents, and physicians to protect sports medicine physicians and offer the highest-quality care., Competing Interests: One or more of the authors has declared the following potential conflicts of interest or source of funding. P.N.R. has received consulting fees from Pacira, Stryker, and BICMD; consulting fees and royalties from Globus; support for education from Smith+Nephew; and hospitality payments and grant from Arthrex; he also declares ownership in Intelligent Health Analytics and Overture Resurfacing. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Background: Arthroplasty is commonly performed in the management of osteoarthrosis of the hand and wrist by orthopedic or plastic surgeons with a fellowship in hand. The differences between operative outcomes between the 2 groups have not been described. Therefore, we analyzed a national database to determine acute outcomes between orthopedic and plastic surgery when performing arthroplasty for osteoarthrosis of the hand and wrist., Methods: A retrospective cross-sectional analysis was performed by including patients with osteoarthrosis of the hand and wrist by International Classification of Diseases codes. Demographic, operative, and outcome variables were collected. Pearson χ 2 and Fischer exact tests were used for categorical variables, while a Mann-Whitney U test was performed for continuous variables. Multivariate regression analysis was performed to determine strength of predictors., Results: There were 3721 patients who received arthroplasty for osteoarthrosis of the hand and wrist from 2007 to 2020. Most cases were performed by orthopedic surgeons (82.7%); however, there were an increasing number of surgeries performed by plastic surgeons. Most cases were performed on the intercarpal or carpometacarpal joints (81.7%). The incidence of acute complications was low (1.9%) with superficial surgical site infections (SSIs) being the most common complication. Univariate analysis found that plastic surgery may result in higher chances of superficial SSIs, but multivariate analysis indicated that there were no significant differences between the 2 groups., Conclusion: There were no significant differences on multivariate regression analysis between plastic and orthopedic surgeons, suggesting that both can perform arthroplasty of the hand and wrist without safety concerns., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Women have historically been underrepresented in orthopaedics. This study analyzes the geographic distribution of female orthopaedic foot and ankle (OFA) surgeons, as well as geographic patterns between their training locations and current practices., Methods: American Orthopaedic Foot and Ankle Society (AOFAS) data regarding fellowship completion from 1988 to 2021 were analyzed. Internet searches were then performed to identify medical school, residency, and current practice locations of individual surgeons. States were categorized into regions and divisions based on US Census Bureau guidelines., Results: Of the 1088 OFA surgeons analyzed, 166 (15.26%) were women and 922 (84.74%) were men. The South has a higher number of female OFA surgeons; however, this region and the Midwest have the lowest percentages of female representation. The West and Northeast had significantly higher percentages of female representation and higher retention rates for women. There was high variability in the number and percentage of female OFA surgeons in divisions both within and between regions., Conclusion: Although the number of female OFA surgeons has increased, their representation remains low. Geographically, the East South Central division of the United States consistently had the least number of OFA surgeons, whereas the South Atlantic division had the highest. Level of Evidence: Not applicable., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Foot and ankle surgeries in the United States (US) are currently performed by orthopaedic surgeons or podiatrists with specialty surgical training. With the trend in healthcare now placing increased emphasis on quality and standardizing patient care, this study aimed to characterize the distribution, volume, and trends of certain foot and ankle surgeries performed in the US by both orthopaedic surgeons and podiatrists., Materials and Methods: A retrospective analysis was performed using the Marketscan Claims Database (Truven Health Analytics, Ann Arbor, Michigan) which covers most privately insured patients under the age of 65 in the USA from 2005 to 2014. We searched current procedural terminology (CPT) codes for total ankle replacement (TAR), triple arthrodesis, hallux valgus correction, pilon fracture open reduction and internal fixation (ORIF), calcaneus fracture ORIF, and ankle fracture ORIF. We recorded the timing and nature of procedures along with various features associated with the surgeon and the geographic location of the treatment facility., Results: We found that the number of foot and ankle procedures performed annually is steadily increasing. Orthopaedic surgeons are the main treating surgeon for common foot and ankle traumatic conditions or complex hind foot cases like TAR. On the other hand, our study showed that podiatrists perform almost 9 out of 10 hallux valgus correction surgeries., Discussion: Our study showed the trends in surgical volumes and differences between surgical podiatrists and orthopaedic surgeons and the evolution of these volumes over a ten year period and differences in surgical repertoire between orthopaedists and podiatrists. Levels of Evidence: Level IV: Case series, Clinical research.

Purpose: The aim of this study was to assess the effects of the COVID-19 pandemic on anxiety, sleep outcomes and change in clinical management practices among orthopaedic surgeons following a nation-wide lockdown., Methods: We conducted an online cross-sectional study using piloted structured questionnaires with self-reported responses from Indian orthopaedic surgeons. Study participants were identified through social networking sites: Facebook and WhatsApp. The extent of anxiety and sleep quality was assessed by the standardised seven-item Generalised Anxiety Disorder (GAD-7) scale, single-item sleep quality scale, questions on unavailability of personal protective equipment, training module on COVID-19 and change in orthopaedic patient management., Results: One hundred male orthopaedic surgeons responded to the survey with majority (79%) in 30-44 years age group. Severe anxiety scores were observed in 8%; moderate, mild and minimal anxiety was observed in 12%, 27% and 53% surgeons respectively. Changes in management practice due to the pandemic was admitted by 65% respondents. We also observed an association between higher anxiety among surgeons and primary or secondary level of healthcare facility: (p = 0.04). Sleep disturbance was significantly associated with change in management practice to non-operative procedures (p = 0.03)., Conclusion: Anxiety among orthopaedic surgeons during the COVID-19 pandemic is related to factors like younger age group, working in a primary or secondary healthcare facility. Early recognition of anxiety is essential to prevent serious psychological sequelae.

Background: Lisfranc joint complex injury may be managed surgically by either an open reduction internal fixation (ORIF) or primary arthrodesis (PA). Published literature advocates PA for purely ligamentous injuries, but many surgeons in actuality refrain from performing PA. The purpose of the study is to assess surgeon practices and behavior in managing Lisfranc injuries due to the influence of peer reviewed literature with the help of the American Board of Orthopaedic Surgery (ABOS) database. Methods: Data were requested from the ABOS database of cases on Lisfranc joint injury requiring either an ORIF or PA from examination year 2004 to 2017 for both part II and maintenance of certification (MOC) examinees. Cases with ICD-9 code 838.03 only were considered as primarily ligamentous and all fracture codes classified under 825 with 838.03 were considered as fracture dislocation. The number of PA and ORIF were recorded for both types of examinees and specific type of Lisfranc joint injury (primarily ligamentous and fracture dislocation). Results: A total of 2010 cases of Lisfranc joint injuries managed surgically by 1230 board-eligible orthopaedic surgeons. Open fractures (93) and non-/malunion fractures were excluded. A total of 1016 primarily ligamentous and 474 fracture dislocation cases were performed by part II examinees. Overall, 288 primarily ligamentous and 139 fracture dislocation cases were performed by MOC examinees. A total of 27 PA were performed in the primarily ligamentous and 17 were performed on fracture dislocation cases. Conclusion: ORIF is commonly performed by newly trained and senior orthopaedic surgeons. There was no change in the number of PA performed on primarily ligamentous injuries in spite of the published literature. Levels of Evidence: Not applicable.

Background: Although a sex-based balance in US graduate medical education has been well-documented, a discrepancy remains in orthopaedic surgery. In orthopaedic sports medicine, the representation of women as team physicians has not previously been characterized., Purpose: To quantify the sex-related composition of team physicians of select National Collegiate Athletic Association (NCAA) Division I collegiate and professional teams. Additionally, the authors assess the sex-related composition of orthopaedic surgeon team physicians specifically and compare these proportions to the sex-related composition of orthopaedic surgeon membership of the American Orthopaedic Society for Sports Medicine (AOSSM)., Study Design: Cross-sectional study., Methods: Publicly available sex-related data were collected for team physicians in select NCAA Division I collegiate conferences and professional sports organizations. Subspecialty characteristics and sex distribution were described by use of percentages. Chi-square tests were used to assess whether sex distributions of team physicians in collegiate and professional sports were (1) representative between the populations of female and male physicians compared with the general public and (2) representative of the sex-based composition of orthopaedic surgeons nationally., Results: Women represented 12.7% (112/879) of all team physicians and 6.8% (30/443) of all orthopaedic surgeons ( P < .0001). More than half (53.9%; 413/767) of male and 26.8% (30/112) of female team physicians were orthopaedic surgeons. In collegiate athletics, women comprised 18.1% of all team physicians and 7.7% of orthopaedic surgeon team physicians. In professional sports, women comprised 6.7% of all team physicians and 6.3% of orthopaedic surgeon team physicians, with the greatest proportion in the Women's National Basketball Association (31.3%)., Conclusion: Women comprise a minority of team physicians in select NCAA Division I collegiate and professional sports organizations. When compared with the composition of AOSSM orthopaedic surgeon membership, expected female orthopaedic surgeon representation varies between conferences and leagues with little statistical significance. Although efforts have been made to increase sex-based diversity in orthopaedic surgery, results of this study suggest that barriers affecting female orthopaedic surgeons as team physicians should be identified and addressed.

Background: Mixed results exist regarding the benefit of orthobiologic injections. The purpose of this study was to assess the variability in costs for platelet-rich plasma (PRP) and stem cell (SC) injections and evaluate for variables that influence pricing., Hypothesis: There will be significant variability in the cost of PRP and SC injections throughout the United States., Study Design: Descriptive epidemiology study., Level of Evidence: Level 3., Methods: Calls were made to 1345 orthopaedic sports medicine practices across the United States inquiring into the availability of PRP or SC knee injections and associated costs. In addition to pricing, the practice type, number of providers, and population and income demographics were recorded. Univariate statistical analyses were used to identify differences in availability and cost between variables., Results: Of the contacted offices that provided information on both PRP and SC availability (n = 1325), 268 (20.2%) offered both treatments, 550 (41.5%) offered only PRP injections, 20 (1.5%) offered only SC injections, and 487 (36.8%) did not offer either treatment. The mean ± SD cost of a PRP injection was $707 ± $388 (range, $175-$4973), and the mean cost of an SC injection was $2728 ± $1584 (range, $300-$12,000). Practices offering PRP and SC injections tended to be larger (PRP, 12.0 physicians per practice vs. 8.1 [ P < 0.001]; SC, 13.6 vs 9.7 [ P < 0.001]). Practices that offered PRP injections were located in areas with higher median household income ( P = 0.047). Variables associated with higher cost of PRP injections included city population ( P < 0.001) and median income of residents ( P < 0.001)., Conclusion: While the majority of sports medicine practices across the United States offer some type of orthobiologic injection, there exists significant variability in the cost of these injections., Clinical Relevance: This study demonstrates the significant variability in costs of orthobiologic injections throughout the country, which will allow sports medicine physicians to appreciate the value of these injections when counseling patients on available treatment options.

Background: Indication for intervention in Dupuytren disease is influenced by many factors, including location and extent of disease, surgeon preference, and comfort level with different treatment techniques. The aim of this study was to determine current Dupuytren disease management trends. Methods: A questionnaire was sent through the American Society for Surgery of the Hand to all members. In addition to demographic data, questions focused on indications for different procedural interventions based on location of disease, age, and activity level of the patient. Results: Approximately 24% of respondents completed the survey. Respondents were mostly orthopedic surgeons in private practice who do not work with residents or fellows. Respondents preferred collagenase over needle aponeurotomy and limited fasciectomy for primary Dupuytren disease involving only the metacarpophalangeal (MCP) joint. Limited fasciectomy was the preferred treatment for primary Dupuytren disease involving the MCP and proximal interphalangeal joints. For a patient amenable to any treatment option, the majority would use collagenase, although 87.1% felt that fasciectomy offered the longest disease-free interval. Furthermore, given the option of a young, working patient, 42.7% would use collagenase, while plastic and general surgeons were more likely to treat this patient with limited fasciectomy. More plastic surgeons (vs orthopedic) believe that limited fasciectomy yields the longest disease-free interval. For a patient amenable to any surgical option, orthopedic surgeons prefer collagenase, whereas plastic hand surgeons prefer a limited fasciectomy. Conclusion: There are several procedural options for the treatment of Dupuytren disease. This study details current practice patterns among hand surgeons and reveals the increasingly prevalent use of collagenase.

Background: Social media is an effective tool to enhance reputation and brand recognition and is being used by more than 40% of patients when selecting a physician. This study aimed to evaluate the use of social media in hand surgeon practices, and to assess the impact that one's social media presence has on physician-rating website scores (PRWs). Methods: Randomly selected hand surgeons from across the United States were identified. Sequential searches were performed using the physicians name + the respective social media platform (Facebook, LinkedIn, YouTube, Twitter, Instagram, personal website, group website). A comprehensive social media utilization index (SMI) was created for each surgeon. Utilizing descriptive statistics, we assessed the effect of social media on the PRW. Results: A total of 116 board-certified hand surgeons were included in our study. The sample identified 10.3% of the population used Facebook, 1.7% used Twitter, 25.8% used YouTube, 22.4% used LinkedIn, 27.5% used a personal website, and 36.2% used a group website, 0% used Instagram. The average SMI was 1.53 ± 1.42 (0-6). Physicians with a personal website received higher Healthgrades scores than those without one ( P < .05). Analysis of SMI demonstrated that hand surgeons with an index less than 3 received lower Healthgrades scores compared to those with an SMI above 3 ( P < .001). Conclusion: Hand surgeons underutilize social media platforms in their practice. A personal website is single most important social media platform to improve HealthGrades score in hand surgeons.

Background: The aim of the study is to investigate current management strategies for lateral epicondylitis by fellowship-trained upper extremity surgeons. Methods: A 17-question survey of treatment approaches and outcomes related to lateral epicondylitis was sent to 3354 surgeons using the American Society for Surgery of the Hand and American Shoulder and Elbow Surgeons member databases. Results: Six hundred twelve upper extremity surgeons completed the survey. The 6 most frequently prescribed nonoperative treatments for lateral epicondylitis were home exercise program/stretching (81%), nonsteroidal anti-inflammatory drugs (75%), steroid injection (71%), counterforce bracing (68%), formal physical therapy (65%), and wrist brace (47%). Less commonly performed nonoperative treatment measures included platelet-rich plasma injection (16%), Tenex procedure (6%), and iontophoresis (2%). Conclusions: There is a lack of consensus in the literature for the management of lateral epicondylitis, which is reflected by individual variation in clinical treatment among the experts. Future prospective randomized control studies are needed to establish evidence-based practice standards for this common diagnosis.

Background: The purpose of this study was to determine the factors that affect hand surgeon operating room (OR) turnover time. We hypothesized that surgeon presence in the OR, decreased American Society of Anesthesiologists (ASA) class, smaller case type, and earlier case time, as well as other factors, decreased OR turnover time. Methods: A total of 685 hand surgery cases performed by 5 attending hand surgeons between September 2013 and December 2014 were identified. Turnover time, patient comorbidities (ASA class), surgeon, prior OR surgical procedure, current OR surgical procedure, location of the surgery (ambulatory surgical center [ASC] vs orthopedic specialty hospital [OSH]), time of surgery, and order of OR cases were recorded. The effect of surgeon routine variables, OR case factors, and patient health status on OR turnover was analyzed. Results: Turnover time was significantly shorter in cases where the surgeon remained in the OR during turnover (27.5 minutes vs 30.4 minutes) and when the surgeon incentivized OR staff (24 minutes vs 29 minutes). The ASC was found to have shorter turnover times than the OSH (27.9 minutes vs 36.4 minutes). In addition, ASA class, type of prior OR procedure, type of current OR procedure, and case order all significantly affected turnover time. Comparison of OR turnover time among the 5 surgeons revealed a statistically significant difference at the OSH but not at the ASC. Conclusion: OR turnover time is significantly affected by surgeon routine, location of surgery, patient ASA class, procedure type, and case order. Interestingly, the effect of hand surgeon routine on OR turnover time may be amplified at an academic OSH versus an ASC., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.