JBJS Open Access最新文献

[This corrects the article DOI: 10.2106/JBJS.OA.24.00142.].

Introduction: The orthopaedic surgery physician workforce is predominately White and male and has been identified as the least diverse medical specialty. Increasing efforts toward diversification within orthopaedic surgery are underway. Evaluating the effectiveness of these programs requires a thorough understanding of the current demographic profile of the profession.

Methods: The American Board of Orthopaedic Surgery (ABOS) is the leading board certification organization for orthopaedic surgeons in the United States. The ABOS began collecting self-reported race/ethnicity and sex/gender data of its examinees and diplomates in 2017. This new data set of ABOS was analyzed to describe both the current demographic profile of orthopaedic surgery and trends over time. Underrepresented minority (URM) was defined as a group that is less well represented in orthopaedic surgery than in US census data and includes female, American Indian or Alaska Native, Black or African American, Hispanic/Latino, and Native Hawaiian or Other Pacific Islander categories.

Results: Of the 21,025 currently practicing ABOS diplomates with time-limited ABOS certificates (issued since 1986), 19,912 (94.7%) provided sex/gender data, and 19,876 (94.5%) provided race/ethnicity data. Approximately 84.78% selected male and 8.43% female. The majority identified as White (73.67%), whereas 16.35% selected a URM race/ethnicity category. There have been significant increases in the proportions of female (odds ratio [OR] = 4.72, 95% confidence interval [CI] = 3.64-6.11, p < 0.001) and URM (OR = 2.31, 95% CI = 1.80-2.96, p < 0.0001). Diplomates among orthopaedic surgeons attaining ABOS board Diplomates from 1989 to present. Among the subspecialties, pediatric orthopaedics reported the highest percentage of females (30.4%). Spine had both the lowest percentage of females (2.63%) and the highest percentage of URMs (8.97%). Sports had the lowest percentage of URMs at 5.63%.

Conclusion: Orthopaedic surgery in 2023 remains largely White and male. However, there have been promising trends toward diversification of orthopaedic surgery both in terms of gender and race/ethnicity. Specialties within orthopaedics have a wide variety of demographic profiles.

Level of evidence: Level IV Retrospective Cohort Study. See Instructions for Authors for a complete description of levels of evidence.

Background: Although there is a known correlation between obesity and revision risk following total knee arthroplasty (TKA), there is an ongoing debate regarding the appropriateness of denying TKA solely based on the body mass index (BMI) of a patient. Our aim was to determine whether a patient's American Society of Anesthesiologists (ASA) class predicts their risks of early all-cause revision and revision for periprosthetic joint infection (PJI) following primary TKA, independent of their BMI.

Methods: Data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) were obtained regarding all patients who underwent primary TKA for osteoarthritis in Australia from January 1, 2015, to December 31, 2022. Estimated hazard ratios of all-cause revision and revision for PJI, as well as predicted risks of revision within 3 months, 1 year, and 2 years, as a function of patient ASA class and BMI, were calculated with use of multivariable Cox proportional hazards models.

Results: A total of 274,786 primary TKAs (54.5% female; mean age, 68.3 years) were included in the study, of which 5,401 were revised during the study period. Compared with BMI, ASA class was a stronger predictor of the risks of all-cause revision and revision for PJI following primary TKA. Patients with an ASA class of 3 to 4 had higher risks of all-cause revision and revision for PJI at multiple time points after TKA compared with patients with an ASA class of 1 to 2, regardless of BMI.

Conclusions: Although ASA class and BMI are theoretically interrelated variables, we found that a patient's ASA class was more strongly associated with their risks of early all-cause revision and revision for PJI following primary TKA than their BMI. Employing a BMI threshold in isolation when assessing fitness for TKA may be inappropriate, and surgeons should give greater weight to the other medical comorbidities and general perioperative fitness of the patient. Patients with poorly controlled comorbidities should be referred for medical optimization prior to TKA.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Therapies for cartilage restoration are of great interest, but current options provide limited results. In salamanders, interzone (IZN) tissue can regenerate large joint lesions. The mammalian homolog to this tissue exists during fetal development and exhibits remarkable chondrogenesis in vitro. This study analyzed the potential of equine IZN and adjacent anlagen (ANL) cells to regenerate osteochondral defects.

Methods: Osteochondral defects were created in the knee of immunosuppressed rats and were grafted with cell pellets from either equine fetal IZN, equine fetal ANL, adult fibroblasts, or adult chondrocytes, or they were left untreated. Osteochondral repair was assessed after 2, 6, and 16 weeks.

Results: Untreated lesions unexpectedly failed to represent critical-sized defects and at 2 weeks exhibited new subchondral bone covered by a fibrocartilage layer that thinned over time. Fibroblast-treated defects filled with soft fibrous tissue. Chondrocyte-treated repair tissue exhibited strong proteoglycan and COL2 staining but poor integration to the adjacent bone. Defects treated with IZN, ANL, or chondrocyte pellets developed hyaline cartilage with increasing safranin-O and collagen II staining over time. IZN and ANL repair tissues exhibited some evidence of zonal architecture such as native cartilage and the best bone integration; nonetheless, they developed exuberant growth, often causing patellar instability and osteoarthritis.

Conclusions: IZN or ANL cells exhibited some potential to recapitulate developmental features during cartilage repair. However, identifying regulatory determinants of IZN and ANL-derived overgrowths is necessary.

Clinical relevance: Studies grafting IZN or ANL tissues in larger animal models with regular immune functions may provide additional insights into improving osteochondral regeneration.

Background: This study assesses the effectiveness of large language models (LLMs) in simplifying complex language within orthopaedic patient education materials (PEMs) and identifies predictive factors for successful text transformation.

Methods: We transformed 48 orthopaedic PEMs using GPT-4, GPT-3.5, Claude 2, and Llama 2. The readability, quantified by the Flesch-Kincaid Reading Ease (FKRE) and Flesch-Kincaid Grade Level (FKGL) scores, was measured before and after transformation. Analysis included text characteristics such as syllable count, word length, and sentence length. Statistical and machine learning methods evaluated the correlations and predictive capacity of these features for transformation success.

Results: All LLMs improved FKRE and FKGL scores (p < 0.01). GPT-4 showed superior performance, transforming PEMs to a seventh-grade reading level (mean FKGL, 6.72 ± 0.99), with higher FKRE and lower FKGL than other models. GPT-3.5, Claude 2, and Llama 2 significantly shortened sentences and overall text length (p < 0.01). Importantly, correlation analysis revealed that transformation success varied substantially with the model used, depending on original text factors such as word length and sentence complexity.

Conclusions: LLMs successfully simplify orthopaedic PEMs, with GPT-4 leading in readability improvement. This study highlights the importance of initial text characteristics in determining the effectiveness of LLM transformations, offering insights for optimizing orthopaedic health literacy initiatives using artificial intelligence (AI).

Clinical relevance: This study provides critical insights into the ability of LLMs to simplify complex orthopaedic PEMs, enhancing their readability without compromising informational integrity. By identifying predictive factors for successful text transformation, this research supports the application of AI in improving health literacy, potentially leading to better patient comprehension and outcomes in orthopaedic care.

Introduction: Stereotype threat (ST) is a psychological phenomenon in which perceived fear of confirming negative stereotypes about one's identity group leads to impaired performance. Gender and racial ST has been described in various academic settings. However, it is prevalence in orthopaedic surgery, where women and minorities are underrepresented, has not been examined. This study analyzes the prevalence of ST among orthopaedic surgery residents and fellows.

Methods: US orthopaedic trainees completed a voluntary anonymous survey, which included demographics, perceived program diversity based on percentage of racial-ethnic and gender-diverse faculty and trainees, and a validated, modified version of the Stereotype Vulnerability Scale (SVS). Higher scores indicate greater ST vulnerability. ST prevalence was analyzed with descriptive statistics, and associations between program diversity, resident demographics, and ST vulnerability were compared using nonparametric tests.

Results: Of 1,127 orthopaedic trainees at 40 programs, 322 responded (response rate 28.6%). Twenty-five percent identified as female, and 26% identified as an underrepresented minority in medicine (i.e., Asian, Black, or Hispanic). Asian (12 points), Black (12.5 points), and Hispanic (13.5 points) trainees had significantly higher SVS scores than White trainees (9 points) (p = 0.0003; p < 0.0001; p = 0.0028, respectively). Black trainees at perceived racially nondiverse residencies had the highest mean SVS scores (16.4 ± 1.03 points), while White trainees at perceived racially nondiverse residencies had the lowest SVS scores (9.3 ± 0.3 points), p = 0.011. Women had significantly higher gender stereotype vulnerability than men (p < 0.0001) in both gender-diverse (17.9 ± 0.2 vs. 9.0 ± 0.3 points) and gender nondiverse residencies (16.4 ± 0.4 vs. 9.6 ± 0.2 points).

Conclusion: Minority and female orthopaedic trainees had higher ST vulnerability, especially in programs perceived as lacking racial or gender diversity. While perceived program diversity may offer some protection for minority and women trainees, women trainees still met the threshold for high vulnerability regardless of program gender diversity. Future strategies to mitigate ST should be explored in orthopaedic training.

» Wellness encompasses multiple dimensions of well-being, including physical, mental, emotional, social, and spiritual health. Prioritizing physician wellness is crucial for ensuring high-quality patient care and reducing the risks of burnout, depression, and other mental health issues. Poor wellness among physicians not only affects their personal and professional lives but also has a ripple effect on patient care. It is associated with higher rates of medical errors, lower patient satisfaction, and an increased risk of mental health disorders including anxiety, depression, substance abuse, and suicide. » Burnout is a significant issue among healthcare professionals, particularly physicians. It can lead to severe consequences like increased medical errors, job dissatisfaction, and a decline in both personal and professional well-being. Addressing burnout through coping mechanisms and better work-life balance is essential. Moral injury occurs when physicians are forced to act against their moral beliefs due to systemic flaws, leading to inner conflict. Unlike burnout, which is often attributed to individual resilience, moral injury points to issues within the medical system itself. » Anxiety and depressive disorders can alter an individual's ability to participate in work and daily function. Among orthopedic surgeons, burnout has been described as an occupational hazard associated with medical errors, as well as with physical and mental exhaustion. Orthopedic surgeons face a burnout rate ranging between 40% and 60%. Tragically, they also have the highest suicide rate, comprising 28.2% of surgeon suicides from 2007 to 2013. » More flexible work hours, adequate time off, and efficient workflow are methods that can be used to improve the work environment, as well as providing easy access to mental health counseling and confidential support groups. Research has shown that residents do not utilize employee assistance programs; however, programs with directors that regularly inquire about well-being has led to increased well-being and use of assistance programs and groups.

Background: Tibial shaft fractures are common, causing substantial morbidity. Intramedullary nailing offers advantages but often leads to anterior knee pain and functional issues.

Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic review on outcomes for different surgical approaches-suprapatellar (SP), infrapatellar (IP), medial parapatellar (MPP), and lateral parapatellar (LPP). Searches across Ovid, Embase, and PubMed identified studies from 2000 to 2023, including retrospective and prospective studies, randomized controlled trials, and case series on anterior knee pain and functional outcomes postsurgery. Bias was assessed using Cochrane's RoB2.

Results: Of 27 studies, 8 were noncomparative (3 SP, 3 IP, 1 MPP, 1 LPP), showing varied anterior knee pain and function outcomes. Comparative studies (12 SP vs. IP, 5 MPP vs. IP) indicated better patient-reported outcomes for SP over IP in anterior knee pain and knee function. Comparative data for MPP and LPP remain limited. Overall RoB was low.

Conclusion: SP has better patient-reported outcomes and lower anterior knee pain than IP. MPP and LPP approaches are promising but lack robust comparative data. Further large, prospective trials are needed to clarify optimal approaches for tibial shaft fractures.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: The rate of sexual and gender minority (SGM) orthopaedic surgeons is far less than in other specialties, and the field has, in part, had significant difficulty attracting SGM applicants. To provide a more welcoming environment, identifying where applicants experience discrimination along medical training must be of paramount concern. Our objective was to understand the challenges faced by SGM medical students applying into orthopaedic surgery.

Methods: An anonymous survey was sent to applicants of a single orthopaedic residency program in 2023, soliciting demographics, exposure to lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) mentors, and experiences with discrimination. Data were stratified by sexual orientation, and univariate analysis was conducted using chi-squared tests. Afterward, logistic regressions adjusted for gender, age, and race were performed.

Results: The overall response rate was 15.4% (n = 136/881). Fifteen percent (n = 20/135) identified as LGBTQ. Sixty-one percent of LGBTQ-identifying applicants experienced slurs and/or hurtful comments during orthopaedic rotations and research experiences, compared with 28% of their heterosexual peers (p < 0.001). In adjusted logistic regression models, LGBTQ respondents were 3.8 times more likely to report experiencing a hostile environment during training (p = 0.04) and 4.9 times more likely to have reported facing discrimination (p = 0.04) compared with heterosexual participants. Approximately 58% of respondents reported never having interacted with an LGBTQ-identifying orthopaedic attending, with only 5% reporting frequent interaction.

Conclusion: LGBTQ-identifying orthopaedic surgery applicants experience barriers related to their sexual identity, including derogatory comments, hostile clinical environments, and lack of LGBTQ mentorship. These findings highlight challenges inherent to the residency application process that may disproportionately affect persons from sexual minority groups. The recognition of such challenges can help to optimize the establishment of informed policies regarding mistreatment and practices regarding diversity and inclusion.

Introduction: Private equity (PE) investment in health care has increased more than 250% between 2010 and 2020. This is mirrored by an increasing number of published materials in medical journals. The objective of our study was to identify and characterize trends and key themes seen within publications discussing the topic of PE investment into orthopaedic surgery practices and bias within those publications.

Methods: The inclusion criteria for our study required an article to be published between the years 2003 and June 2024 and to contain the phrase "orthopaedic surgery" or "orthopedics" in addition to "PE" or "PE investment." Based on these parameters, 15 articles met the criteria for inclusion. Articles were then evaluated to assess various themes related to general views expressed regarding PE firms, reasons for PE attraction to orthopaedics, and most cited positives/negatives of PE investment and potential conflicts of interest with respect to underlying relationships/associations with PE firms at the time of publication.

Results: Of the 15 publications meeting the inclusion criteria, 4 (26.7%) expressed positive views on the topic of PE ownership of orthopaedic practices, while 4 (26.7%) expressed a neutral view and 7 (46.7%) expressed a negative outlook. Four (26.7%) of the articles had authors who were either employed or had ownership in a practice that was purchased by a PE firm. Of these 4 articles, none disclosed this potential conflict of interest. Three of the 4 articles had either a positive or neutral view of PE. The most cited reason for PE attraction to orthopaedics was revenue from ancillary services. The most cited upside of PE transactions was the possibility of benefiting from economies of scale, while the most cited downside was the misalignment of incentives.

Conclusion: The plurality of present studies views PE transactions negatively (46.7%). Our research unveiled 4 studies with undisclosed conflicts of interest (26.7%). In addition, orthopaedic surgeons should be wary of the numerous downsides of PE transactions, such as the misaligned incentives between themselves and PE firms.

Clinical relevance: Independent orthopaedic practices should be critical of the literature when evaluating the merits of potential partnerships with PE firms.