Correction: Pang et al. Nanotechnology-Enhanced Orthopaedic Surgery. J. Nanotheranostics 2024, 5, 167–187

Objectives:Orthopaedic injury and surgery is relatively common in National Collegiate Athletic Association (NCAA) athletes and can have devastating career consequences. However, there is a paucity of data regarding predictors of orthopaedic surgery in collegiate athletes. The purpose of this study was to analyze player-related predictors of orthopaedic surgery, including that of the shoulder, hip, and knee, in NCAA athletes.Methods:All NCAA Division I collegiate athletes at a single institution who began participation from the 2003-2004 through 2008-2009 seasons were retrospectively identified. Player-related factors, including gender, sport, and any pre-college upper or lower extremity orthopaedic surgery, were elicited through pre-participation evaluations (PPEs). Athletes who underwent an orthopaedic surgery in college were identified through the Sports Injury Monitoring System and medical records. All patient-related independent variables were included in a multiple Cox regression model. Exposure time was calculated from the date of PPE to the date of surgery (event) or to the end of the collegiate athletic career (censored). Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated. Significance was set at P < 0.05.Results:In total, 1,142 athletes in 12 sports (baseball/softball, basketball, football, golf, gymnastics, rowing, swimming & diving, soccer, tennis, track & field/cross country, volleyball, water polo) were identified. There were 262 documented orthopaedic surgeries, including those involving the shoulder (n = 34), hip (n = 25), and knee (n = 72), in 182 athletes. Using the multiple Cox regression model, pre-college lower extremity surgery was an independent predictor of orthopaedic (P = 0.004, HR = 1.88) and knee (P < 0.001, HR = 3.91) surgery, and type of sport was an independent predictor of orthopaedic (P < 0.001), shoulder (P = 0.002), and knee surgery (P < 0.001) (Table 1). Participation in gymnastics, basketball, and volleyball were the strongest predictors of orthopaedic surgery. Similarly, participation in volleyball, gymnastics, and baseball/softball were the strongest predictors of shoulder surgery, and participation in basketball, football, and volleyball were the strongest predictors of knee surgery. Lastly, athletes with a history of a pre-college orthopaedic surgery were more susceptible to another surgery in the same extremity during college (P = 0.046, HR = 2.18). Gender was not a significant predictor of any surgery. No independent predictors of hip surgery were identified.Conclusion:NCAA athletes who underwent a pre-college lower extremity surgery were more likely to undergo orthopaedic and knee surgery during their collegiate careers. Those in overhead sports (e.g., volleyball, baseball/softball) were more likely to undergo shoulder surgery, and those in cutting and jumping sports (e.g., basketball, football) were more likely to undergo knee surgery. Furthermore, athletes with a history of a pre-college orthopaedic surgery were more likely to undergo another surgery in the same extremity during college, suggesting inadequate rehabilitation or less than full return of function after surgery. The time lost from athletic participation due to an orthopaedic surgery and its potential career impact underscores the need for injury prevention and improved surgical outcomes in the amateur athlete.

Sex diversity in orthopaedic surgery lags behind other surgical specialties. Women comprise 13.2% of orthopaedic residents and 15% of full-time faculty, despite 47.8% of graduating medical students being women. The purposes of this study were to demonstrate how orthopaedic surgery has been less successful in recruiting women compared with general surgery and to identify the sex-specific factors that influenced orthopaedic surgery residents to choose their specialty. A search of graduate medical data was performed to compare the recruitment of women into orthopaedic and general surgery. Next, a seven-question survey was e-mailed to 2629 orthopaedic residents by the American Academy of Orthopaedic Surgeons. Questions were formulated to detect why orthopaedic surgery residents chose their specialty. Data were collected over six weeks and responses were analyzed with use of one-tailed t tests to make comparisons of responses on the basis of sex. The historical data search showed that the percentage of female representation in both orthopaedic and general surgery has increased since 1968, but it has increased significantly faster in general surgery than in orthopaedic surgery (p &lt; 0.0001). Five hundred and twenty-nine (20%) of the 2629 orthopaedic surgery residents who were contacted responded to the survey. Of the respondents, 114 (22%) were female and 415 (78%) were male. Several significant differences were found in the responses between the sexes. These include the timing of the decision to enter orthopaedic surgery and positive influences in choosing orthopaedic surgery as a specialty. Additionally, women, significantly more than men, believed that more of their peers entered general surgery because of greater acceptance by senior faculty in that field (p &lt; 0.0001). To our knowledge, this study is the first to survey residents on their perceptions of orthopaedic surgery and to identify factors that may hinder the recruitment of women into orthopaedic surgery. Our data show that increased exposure to orthopaedic content during medical school and increased female mentorship may help recruit more women into the orthopaedic surgery workforce.

Racial discrepancies among patients in the United States undergoing orthopedic trauma surgery have not been investigated. Issues relating to socioeconomic status and access to care have played a role in the health outcomes of racial groups. In orthopedic surgery, recent joint arthroplasty literature has shown significant racial differences in the use of elective joint arthroplasty. Furthermore, studies also suggest increased rates of early complication in racial minority groups. In general, little information exists on the postoperative outcomes of racial minority groups in orthopedic surgery. We retrospectively queried the National Surgical Quality Improvement Program database to identify patients undergoing orthopedic trauma surgery between 2008 and 2016. Patients of all ages who underwent orthopedic trauma surgery were identified using Current Procedural Terminology codes. Patients classified as either Black or White were included in the study. Demographic data, comorbidities, and basic surgical data were compared between the groups. Adverse outcomes in the initial 30 days postoperative were also examined. Higher frequencies of deep wound infection (0.5% vs 0.3%, P=.002) were noted among Black patients, with decreased mortality (0.3% vs 0.6%, P=.004) and postoperative transfusion (2.7% vs 3.8%, P<.001) rates, compared with White patients. Clear differences exist in the demographic, surgical, and outcome data between Black and White patients undergoing orthopedic trauma surgery. More epidemiological studies are required to further investigate racial differences in orthopedic trauma surgery. [Orthopedics. 2022;45(2):71-76.].

Impact of Specialty on Cases Performed During Spine Surgery Training in the United States

‘The brain may devise laws for the blood’ William Shakespeare, Merchant of Venice (1598)1 Prevention of venous thromboembolism (VTEp) is an integral part in the care of orthopaedic patients. VTE the leading cause of preventable mortality in hospital2 and orthopaedic surgery confers particularly high-risk.3 VTE currently complicates 2%–7% of all orthopaedic surgery.2 Symptomatic VTE results in reduced quality of life and causes mortality in 6%–12% of cases.4 VTE may increase length of stay (LOS) in hospital and confers large economic costs.5 Biological rationale supports the efficacy of direct oral anticoagulants (DOACs) for VTEp in orthopaedic surgery. Orthopaedic surgery accentuates all aspects of Virchow's Triad due to trauma-induced thromboplastin upregulation, intraoperative torniquet use, immobilization, bed rest and polymethylmethacrylate cement.6 DOACs prevent subsequent coagulation by inhibiting Factor Xa or II.6 Factor Xa inactivation is also the mechanism of action for low-molecular-weight heparins (LMWH) which are commonly used for VTEp after orthopaedic surgery.3 However, DOACs act directly on coagulation factors, unlike LMWH which is reliant on the presence of antithrombin III. DOACs do not require dose adjustment in obesity and avoid the gastrointestinal and renal side-effects of aspirin. The disadvantage of DOACs is that they are not all reversible and have a longer washout time than LMWH. DOACs have already demonstrated utility for VTEp in alternative domains. Most notably, DOACs are now suitable first-line options for VTEp after hip and knee arthroplasty. LMWHs such as enoxaparin, had historically been the gold-standard for VTEp after arthroplasty.7 However rivaroxaban and apixaban have demonstrated superior VTEp than LMWH in recent meta-analyses of randomized controlled trials (RCT).8, 9 Rivaroxaban was associated with a greater bleeding risk than LMWH.8, 9 This is important to note as, even minor bleeding is a concern to orthopaedic surgeons as it may increase risk of infection. However, apixaban has demonstrated a lesser bleeding risk than LMWH.8, 9 Meanwhile, aspirin has shown significantly increased VTE and mortality rates when compared to DOACs and LMWH.10, 11 Apixaban and rivaroxaban have also demonstrated reduced rates of symptomatic VTE than LMWH without increased incidences of major bleeding, when used for VTEp in oncology.12 Studies from the last decade have consistently demonstrated the benefits of DOACs over LMWH for VTEp in orthopaedic trauma surgery.13, 14 A recent systematic review and meta-analysis reported significantly reduced deep venous thrombosis rates when Factor Xa inhibiting DOACs were compared to LMWH for VTEp after lower limb fracture surgery.14 DOACs were also not inferior to LMWH for prevention of mortality, pulmonary embolism and bleeding, both major and minor. A RCT not included in the aforementioned study demonstrated reduced VTE risk with no increase bleeding risk, including minor bleeding, when rivaroxaban was compared to LMWH.13 Therefore the increased bleeding with rivaroxaban in some arthroplasty data is not reflected in orthopaedic trauma. Aspirin has not demonstrated effective VTEp after orthopaedic trauma surgery when compared to LMWH.15 The results of these studies have not yet effected an update to international guidelines for VTEp after orthopaedic trauma surgery (Table 1). DOACs also offer large economic savings, superior patient experience and improved adherence when compared to LMWH. In analyses for total hip replacement and total knee replacement, dabigatran, rivaroxaban and apixaban demonstrate saving of €152 and €116, €177 and €85, €223 and €135 per patient respectively.5 DOACs are administered orally compared to LMWH administration by subcutaneous injection. LMWH has subsequently been associated with high rates of non-adherence after hospital discharge.16 This is particularly concerning as the majority of VTE occurs following hospital discharge.17 Evidence suggests DOACs are the first choice over LMWH for VTEp after orthopaedic trauma surgery due to reduced rates of VTE, equivocal bleeding risk and mortality, reduced cost and improved patient experience. Where bleeding risk is high, apixaban may be used instead of rivaroxaban. Where risk of reoperation is high, DOACs should be avoided as they are not reversible. Open access publishing facilitated by The University of Adelaide, as part of the Wiley - The University of Adelaide agreement via the Council of Australian University Librarians. Bhuvanesh Ravichandran: Investigation; methodology; writing – review and editing. Brandon Stretton: Conceptualization; formal analysis; investigation; methodology; writing – review and editing. Joshua G. Kovoor: Conceptualization; formal analysis; investigation; methodology; writing – review and editing. Stephen Bacchi: Formal analysis; supervision; writing – review and editing. Joseph N. Hewitt: Investigation; resources; writing – review and editing. Christopher D. Ovenden: Formal analysis; investigation; supervision; writing – review and editing. Aashray K. Gupta: Conceptualization; investigation; resources; supervision; writing – review and editing. Ruurd L. Jaarsma: Conceptualization; supervision; validation; visualization; writing – review and editing. Guy J. Maddern: Conceptualization; supervision; validation; visualization; writing – review and editing. Ameya Bhanushali: Writing – review and editing.

Background:A career in hand surgery in the United States requires a 1-year fellowship after residency training. Different residency specialty programs may vary in case volume. The purpose of this study was to characterize variation in hand surgery training within and between orthopaedic and plastic surgery residents.Methods:Publicly available hand surgery case logs for graduating orthopaedic and plastic surgery residents during the 2010 to 2011 to 2018 to 2019 academic years were obtained through the Accreditation Council of Graduate Medical Education. Student t-tests were used to compare mean case volumes among several categories between plastic surgery (PRS) and orthopaedic surgery (OS) residents. Intraspecialty variation was assessed by comparing the 90th and 10th percentiles in each category.Results:A total of 6,254 orthopaedic and 1,070 plastic surgery graduating residents were included. The mean hand surgery case volume for orthopaedic residents (OS 247.0) was significantly lower than that for plastic surgery residents (PRS 412.0) (P < 0.0001). Orthopaedic residents performed more trauma cases (OS 133.2, PRS 54.5; P < 0.0001) but fewer nerve repairs (OS 3.3, PRS 28.5 P < 0.0001) and amputations (OS 6.4, PRS 15.8; P < 0.0001). Nerve decompression case volumes were similar between the two specialties (OS 50.2, PRS 47.3; P = 0.34). Case volumes among orthopaedic residents varied considerably in amputations and among plastic surgery residents in replantation/revascularization procedures.Conclusions:Orthopaedic surgery residents performed significantly more trauma cases than plastic surgery residents did, but fewer overall cases, nerve repairs, and amputations, while nerve decompression volumes were similar between specialties. This information may help inform residency and fellowship directors regarding areas of potential training deficiency.

Trends of Underrepresented Minorities and Female Trainees in Orthopedic, Plastic, and Hand Surgery: Did We Do Better in 2023?

The SARS-COV-2 (COVID-19) pandemic has placed unprecedented challenges on the health care system in the United States with New York City at its epicenter. By the end of the 8 week (4/23/2020) since the virus's emergence in New York City, there have been 142,432 confirmed COVID-19 cases and 10,977 deaths attributed to complications from COVID-19-related illnesses. Secondary to policies enacted by the New York State government to limit spread of the virus, Orthopedic Surgery departments at hospitals around the area have witnessed an abrupt change in clinical demands. At a local level one trauma hospital in Queens, New York, Orthopedic Surgery elective cases have been cancelled, trauma consult volume has experienced a sharp decline, and both residents and attendings have been repurposed to meet the new clinical demands of this medical crisis. Our own orthopedic surgery service has adopted care for patients normally admitted to an internal medicine service in a novel Ortho-Medical COVID-19 management team. We prepared this primer to make our experience with caring for COVID-19 patents available as a reference for other surgical subspecialty services preparing to adjust the clinical focus of their hospital teams during this or future pandemics. LEVEL OF EVIDENCE:: Level V.

Orthopedic Anesthesiology 2022.

Prospective residents interested in hand surgery must decide to apply for hand surgery fellowships sponsored by different specialties. This study compares case volumes reported during plastic surgery and orthopaedic hand surgery fellowships. The American Council for Graduate Medical Education case logs of accredited hand surgery fellowships were analyzed for hand surgery cases (2012 to 2013 to 2020 to 2021). The reported case volume was compared by specialty. Temporal trends were described, intrapathway variabilities calculated, and interpathway differences calculated with Student t -tests. Two hundred plastic surgery (13%) and 1,323 orthopaedic (87%) hand surgery fellows were included. The number of orthopaedic hand surgery fellowships increased from 58 in 2012 to 2013 to 70 in 2020 to 2021 (21% increase), whereas the number of plastic surgery fellowships was stable at 16. Orthopaedic hand surgery fellows reported more hand surgery cases (764 ± 22 versus 628 ± 226), arthroscopy cases (53 ± 54 versus 23 ± 38), and miscellaneous hand surgery cases (42 ± 23 versus 31 ± 18) than plastic surgery hand fellows. Plastic surgery hand fellows reported more cases in wound closure with graft, wound reconstruction with flap, nerve injury, and vascular repair. Overall, orthopaedic surgery offered more experience in 15 case categories (58%), while plastic surgery offered more experience in five case categories (19%). Six case categories (23%) had no difference between specialties. Although orthopaedic hand surgery fellowship affords more cases overall, plastic surgery hand fellowships have unique strengths in wound reconstruction with grafts and flaps, nerve injury, and vascular repair. Ultimately, results from this study create a benchmark to improve future training opportunities for hand surgery fellows and orthopaedic surgery residents.

Variation in inpatient hospital and physician payments among patients undergoing general versus orthopedic operations

Purpose. To report on the development of a program to treat and rehabilitate children with chronic orthopaedic disabilities in the sub-Saharan African context incorporating orthopaedic reconstructive surgery within community-based rehabilitation (CBR) programs.Method. Practice of rehabilitation descriptive report.Results. In a six-year period between 1996 and 2002, a comprehensive project addressing the rehabilitative and orthopaedic surgery needs of children with motor impairments was established in Uganda. Using the principles of CBR, more than 5000 children annually were assisted with 875 receiving orthopaedic reconstructive surgery. CBR proved a powerful tool in creating awareness and facilitating access to care amongst rural populations living in the circumstances of extreme poverty. By networking the services of several non-governmental development organizations, government agencies, service providers and community groups, a large number of children could be reached in an integrated way. The ‘recipe for success’ of rehabilitation required access to and integration of all of the following ingredients: CBR, a transportation system, rehabilitation hostels, physiotherapy, orthopaedic surgery, and orthopaedic appliance technology.Conclusions. CBR played a vital role in ensuring access to rehabilitative care and the success of orthopaedic reconstructive surgery.

Opioid use disorder is a significant cause of morbidity, mortality, and health care costs. A transitional pain service (TPS) approach to perioperative pain management has been shown to reduce opioid use among patients undergoing orthopedic joint surgery. However, whether TPS also leads to lower health care use and costs is unknown. We designed this study to estimate the effect of TPS implementation relative to standard care on health care use and associated costs of care following orthopedic surgery. We evaluated postoperative health care use and costs for patients who underwent orthopedic joint surgery at 6 US Department of Veterans Affairs medical centers (VAMCs) between 2018 and 2019 using difference-in-differences analysis. Patients enrolled in the TPS at the Salt Lake City VAMC were matched to control patients undergoing the same surgeries at 5 different VAMCs without a TPS. We stratified patients based on history of preoperative opioid use into chronic opioid use (COU) and nonopioid use (NOU) groups and analyzed them separately. For NOU patients, TPS was associated with a mean increase in the number of outpatient visits (6.9 visits; P < .001), no change in outpatient costs, and a mean decrease in inpatient costs (-$12,170; P = .02) during the 1-year follow-up period. TPS was not found to increase health care use or costs for COU patients. Although TPS led to an increase in outpatient visits for NOU patients, there was no increase in outpatient costs and a decrease in inpatient costs after orthopedic surgery. Further, there was no added cost for managing COU patients with a TPS. These findings suggest that TPS can be implemented to reduce opioid use following joint surgery without increasing health care costs.

Orthopedic surgery and surgery for cancer are major risk factors for venous thromboembolism (VTE). Deep vein thrombosis (DVT) can occur in up to 50% of patients after major orthopedic surgery. The rate of VTE after cancer surgery varies according to the type of surgery, with rates as high as those after orthopedic surgery in certain settings. Use of thromboprophylaxis in these high-risk settings is well established and recent studies inform the type and duration of thromboprophylaxis. With major orthopedic surgery, there has been a shift from use of low molecular weight heparins (LMWHs) to direct oral anticoagulants (DOACs) along with renewed interest in aspirin as a thromboprophylaxis agent. Recent studies have also informed optimal thromboprophylaxis strategies after nonmajor orthopedic surgery. Use of thromboprophylaxis after major cancer surgery for cancer is established and recent evidence has focused on the potential benefits of extended-duration thromboprophylaxis. This review will summarize emerging evidence for thromboprophylaxis after orthopedic and cancer surgery with a view to providing clinicians with concise and actionable guidance for best practice.

BackgroundMusculoskeletal disorders represent a significant global health burden, frequently leading to chronic pain, functional impairment and disability. Conventional treatment modalities, including rehabilitation, pharmacotherapy and surgical intervention, are often associated with suboptimal outcomes and prolonged recovery. Adipose-derived stem cells (ADSCs) have gained considerable attention due to their regenerative capacity, accessibility and immunomodulatory properties. Preclinical studies of ADSCs have demonstrated promising effects in skeletal muscle regeneration. However, the evidence from human orthopaedic shoulder surgery remains inconclusive. This scoping review aims to map the process of adipose tissue-derived treatments in orthopaedic surgery, especially shoulder surgery.Methods and analysisA scoping review will be conducted using the Joanna Briggs Institute methodology to systematically map existing evidence on the clinical use of ADSCs in orthopaedic shoulder surgery. The search strategy will use the Population–Concept–Context framework and will be applied across four bibliographic databases (Embase, MEDLINE, CENTRAL and Scopus) and ClinicalTrials.gov, with additional grey literature searches. Studies will be limited to adults (≥18 years) undergoing shoulder surgery. Both clinical and patient-reported outcomes will be extracted. Article screening and data extraction will be performed independently by two reviewers using Covidence software, with discrepancies resolved through consensus or third-party arbitration.DiscussionThe extensive mapping will provide a comprehensive synthesis of current evidence on the application of ADSCs in orthopaedic surgery, including preparation methods, intraoperative techniques, postoperative follow-up and outcome measures. Special attention will be paid to heterogeneity in clinical practice, methodological limitations and reported patient-centred outcomes. This review will also identify gaps in the literature and inform future research priorities.Ethics and disseminationThis scoping review does not require ethics approval, as we will only include information from previously conducted studies and will not involve human participants.