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Background: The role of physician credentialing has been widely considered in quality and outcome improvement studies. However, the association between surgeon characteristics and health-care costs remains unclear.

Methods: Our objective was to determine the association of orthopaedic surgeon characteristics with health outcomes and costs, utilizing Medicare data. We used 100% Fee-for-Service Medicare data from 2015 to 2019 to identify all patients ≥65 years of age who underwent 2 common orthopaedic surgical procedures, total hip and knee replacement. After determining whether the patients had been readmitted after discharge from their initial admission for surgery, we computed 3 metrics of total medical expenditure: the costs of the initial surgery admission and 30-day and 180-day episode-based bundles of care. Hierarchical linear regression and logistic regression models were used to evaluate patient and surgeon characteristics associated with care costs and the likelihood of readmission.

Results: We identified 2,269 surgeons who performed total knee replacements on 298,934 patients and 1,426 surgeons who performed total hip replacements on 204,721 patients. Patient characteristics associated with higher initial surgery costs included increasing age, female sex, racial minority status, and a higher Charlson Comorbidity Index. Surgeon characteristics associated with lower readmission rates included practice in the Northeast region and a higher patient volume; having malpractice claims was associated with higher readmission rates.

Conclusions: A higher volume of patients treated by the orthopaedic surgeon was associated with lower overall costs and readmission rates. Information on surgeons' malpractice claims and annual volume should be made publicly available to assist patients, payer networks, and hospitals in surgeon selection and oversight. These results could also inform the guidelines of physician credentialing organizations.

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

Background: During the 2022 to 2023 orthopaedic surgery residency application cycle, "signaling" was added, allowing applicants to communicate strong interest to 30 programs of their choosing. This study's purpose was to evaluate signaling's impact on the 2022 to 2023 application cycle.

Methods: A cross-sectional survey was distributed to applicants who applied to a single residency program. We evaluated how many interviews the average applicant received, what proportion of interviews came from programs they had signaled, and what percentage of applicants matched at a program they had signaled. We stratified data by American Orthopaedic Association status, United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, research items, sex, and race.

Results: This survey was distributed to 611 applicants, with 124 (20.3%) responding to the survey. Ninety-five respondents (76.6%) matched. The percentage of applicant interviews that came from signaled programs was 78.7%. Ninety-one percent of matched applicants matched at a program they signaled. Sixty-three percent of matched applicants performed an away rotation at their matched programs. Forty-five percent of applicants felt that signaling incentivized reducing the programs they applied to, and applicants gave signaling a high favorability rating of 4/5. Applicants with Alpha Omega Alpha status received more interviews per application (0.18 ± 0.11 vs. 0.10 ± 0.10, p < 0.001) and more interviews from programs they did not signal (74% of interviews from signaled programs vs. 90% of interviews from signaled programs, p < 0.001). Higher Step 1 and Step 2 scores were associated with more interviews per application (Step 1: 0.16 ± 0.12 vs. 0.12 ± 0.08, p = 0.032) (Step 2: 0.16 ± 0.11 vs. 0.12 ± 0.09, p = 0.032).

Conclusion: Orthopaedic residency applicants received most of their interviews from programs that they signaled, with an overwhelming majority matching at signaled program. Alpha Omega Alpha status and high USMLE scores were associated with more interviews granted per application, regardless of signaling status. Signaling seems to be a favorable option for orthopaedic applicants. Data from future application cycles will help further evaluate signaling's impact on the orthopaedic match.

Background: An unstable trochanteric femoral fracture is a serious injury, with a 1-year mortality rate of 5.4% to 24.9%, for which there is currently no standard treatment method. The lag screw insertion site is one of the primary contact areas between the cortical bone and an intramedullary nail. We hypothesized that a posterolateral fracture causes intramedullary nail instability when the posterolateral fracture line interferes with lag screw insertion. The purpose of the present study was to investigate the effect of posterolateral fracture line morphology on intramedullary nail stability by simulating unstable trochanteric femoral fractures with a posterolateral fracture fragment.

Methods: Eighteen custom-made synthetic osteoporotic bone samples were used in the present study. Nine samples had a posterolateral fracture line interfering with the lag screw insertion hole (Fracture A), and the other 9 had a fracture line 10 mm away from the hole (Fracture B). Cyclic loading (750 N) was applied to the femoral head 1,500 times. Movement of the end cap attached to the intramedullary nail was recorded. The amplitudes of motion in the coronal plane (coronal swing motion), sagittal plane (sagittal swing motion), and axial plane (total swing motion) were evaluated. The change in the neck-shaft angle was evaluated on photographs that were made before and after the test. Medial cortical displacement was measured before and after the test.

Results: Two Fracture-A samples were excluded because the amplitude of sagittal swing motion was too large. The mean values for coronal, sagittal, and total swing motion were 1.13 ± 0.28 mm and 0.51 ± 0.09 mm (p < 0.001), 0.50 ± 0.12 mm and 0.46 ± 0.09 mm (p = 0.46), and 1.24 ± 0.24 mm and 0.69 ± 0.11 mm (p < 0.001) for Fractures A and B, respectively. The mean neck-shaft angle change was -8.29° ± 2.69° and -3.56° ± 2.35° for Fractures A and B, respectively (p = 0.002). The mean displacement of the medial cortex was 0.38 ± 1.12 mm and 0.12 ± 0.37 mm for Fractures A and B, respectively (p = 0.57).

Conclusions: This study showed that an unstable trochanteric femoral fracture with a posterolateral fracture line that interferes with the lag screw insertion holes is a risk factor for increased intramedullary nail instability.

Introduction: Orthopaedic applicants have increased the average number of publications on their residency application to compete with the growing competitiveness of the field. The purpose of this study was to assess whether research productivity before orthopaedic residency and caliber of one's institution is correlated with academic productivity during residency.

Methods: Scopus was used to extract publication metrics. Quantity and quality (how often the publications were cited) were analyzed at 2 different time periods: before and during residency. All subjects in the study had graduated an ACGME-accredited orthopaedic surgery residency in 2021. Military residents, international medical graduates, and residents not listed on their department's website were excluded. Residents were categorized as both high (≥2 publications) or low (<2 publications) publishers according to their pre-residency publications. They were also categorized based on their program's Jones et al. research productivity ranking.

Results: For the 758 residents, the median number of publications was 0 (Interquartile Range [IQR]: 0-2) and 3 (IQR: 1-6) before and during residency, respectively. High publishing medical students had more publications during training than low publishers (6 [IQR: 3-14] and 2 [IQR: 1-4], p < 0.001). Residents at higher ranked programs also had more publications (4 [IQR: 2-9] and 2 [IQR: 0-4], p < 0.001). High publishing students now training at lower ranked institutions had more publications during residency than low publishers who trained at more productive institutions (4 [IQR: 1-9] and 3 [IQR: 1-6], p < 0.001).

Conclusion: Having 2 or more publications before residency is correlated with an increased number of publications during residency. While attending a higher academically productive program is associated with increased resident publications, a high publishing medical student would be expected to have more publications during residency than a low publishing student, regardless of program rank. Notably, most matched applicants continue to have zero publications before matriculation.

Background: Social media use has grown across healthcare delivery and practice, with dramatic changes occurring in response to the coronavirus (COVID-19) pandemic. The purpose of this study was to conduct a comprehensive systematic review to determine the current landscape of social media use by (1) orthopaedic surgery residencies/fellowship training programs and (2) individual orthopaedic surgeons and the change in use over time.

Methods: We searched 3 electronic databases (PubMed, MEDLINE, and Embase) from their inception to April 2022 for all studies that analyzed the use of social media in orthopaedic surgery. Two reviewers independently determined study eligibility, rated study quality, and extracted data. Methodology was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results: Twenty-eight studies were included, of which 11 analyzed social media use by orthopaedic surgery residency and fellowship training programs and 17 examined its use by individual orthopaedic surgeons. Among residency and fellowship programs, Instagram was identified as the most common platform used, with 42% to 88% of programs reporting program-specific Instagram accounts, followed by Twitter/X (20%-52%) and Facebook (10%-38%). Social media was most commonly used by programs for recruitment and information dissemination to prospective residency applicants (82% and 73% of included studies, respectively). After the start of the COVID-19 pandemic, there was a 620% and 177% increase in the number of training programs with Instagram and Twitter/X accounts, respectively. Individual use of social media ranged from 1.7% to 76% (Twitter/X), 10% to 73% (Facebook), 0% to 61% (Instagram), 22% to 61% (LinkedIn), and 6.5% to 56% (YouTube).

Conclusions: Instagram, Twitter/X, and Facebook are the premier platforms that patients, residency applicants, and institutions frequent. With the continued growth of social media use anticipated, it will be critical for institutions and individuals to create and abide by guidelines outlining respectful and professional integration of social media into practice.

Level of evidence: Level IV.

Background: Type-II dens fractures have long been described in the literature as occurring in a bimodal distribution, peaking in young adulthood as well as in older adulthood; however, the origin of this claim is unclear. The primary goal of this study was to examine the incidence of type-II dens fractures and assess for bimodality.

Methods: This is a retrospective cross-sectional review of the National Trauma Data Bank (NTDB) records on traumatic type-II dens fractures between October 2015 and December 2016. Rates were obtained from the NTDB, and the incidence per 100,000 was ascertained by utilizing U.S. Census data from 2016. Subgroupings by gender and Black or White race were also examined.

Results: Dens fractures occur unimodally, peaking around 89 years of age overall, skewed left by high rates in older White adults. The Black subgroup demonstrated trimodality, with the fracture incidence peaking at 25, 62, and 82 years of age. Rates among Black and White patients were similar until age 65, after which dens fractures occurred disproportionately in White patients. Fractures prior to age 75 occurred predominantly in men.

Conclusions: The evidence derived in this study challenges the common belief that type-II dens fractures occur bimodally across the entire population. However, there remains utility in considering younger and older patients as distinct groups for the purposes of management.

Background: There remain arguments regarding whether fatty degeneration of the rotator cuff muscles improves following rotator cuff repair. The purpose of this study was to prospectively investigate changes in fatty degeneration of the rotator cuff muscles, quantitatively measured on magnetic resonance imaging (MRI) with use of transverse relaxation time (T2) mapping techniques, and to assess the relationship between these changes and clinical outcomes.

Methods: Patients were included if they were scheduled for arthroscopic rotator cuff repair using the suture-bridge technique between June 2014 and December 2015, underwent preoperative MRI including the T2 mapping sequence, and consented to participate in the study. Exclusion criteria consisted of trauma within 2 months before preoperative MRI, isolated subscapularis tears, patch augmentation, neuromuscular disease, and a follow-up duration of <2 years. MRI scans were acquired preoperatively and at 2 years postoperatively, and T2 values of the supraspinatus and infraspinatus muscles were measured, with smaller T2 values indicating less fat content. Shoulders were evaluated on the basis of active range of motion (ROM), Constant and University of California Los Angeles Shoulder Rating Scale scores, shoulder external rotation strength with the arm at the side, and rotator cuff integrity on postoperative MRI.

Results: A total of 103 patients (103 shoulders) with a mean age of 65 ± 9 years (range, 42 to 83 years) were included, of whom 52 were male and 51 were female. There were 13 partial, 18 small, 35 medium, 33 large, and 4 massive tears. Concomitant subscapularis tears were observed in 35 shoulders. Overall, ROM, clinical scores, and external rotation strength significantly improved postoperatively. Retears were found in 27 shoulders (26%). External rotation strength significantly improved postoperatively only in shoulders without a retear. Among shoulders without a retear, the postoperative T2 values of the supraspinatus and infraspinatus were significantly smaller than the preoperative values (p < 0.001 for both); however, no improvement was seen in shoulders with a retear.

Conclusions: Shoulders with successful repair demonstrated significantly smaller T2 values postoperatively as well as significantly improved external rotation strength. Fatty degeneration of the cuff muscles can be reversed, at least in part, and muscle strength improves in shoulders with successful repair.

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

Background: Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them.

Methods: We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes.

Results: The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3.

Conclusions: Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries.

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

Background: Patients with persistent glenohumeral osteoarthritis symptoms despite nonoperative management may pursue anatomic total shoulder arthroplasty (TSA). TSA revision rates are higher in patients with preoperative eccentric (asymmetric posterior erosion) compared with concentric (symmetric) glenoid deformity. If posterior rotator cuff deficiency demonstrated preoperatively in patients with eccentric deformity persists after TSA, it may manifest as relative weakness in external compared with internal rotation secondary to deficient activity of the shoulder external rotator muscles. Persistent posterior rotator cuff deficiency is hypothesized to contribute to TSA failures. However, it remains unknown whether rotational strength is impaired after TSA in patients with eccentric deformity. Our goal was to determine if patients with eccentric deformity exhibit relative external rotation weakness that may be explained by posterior rotator cuff deficiency after TSA.

Methods: Patients who were >1 year after TSA for primary glenohumeral osteoarthritis and had had preoperative eccentric or concentric deformity were prospectively recruited. Torque was measured and electromyography was performed during maximal isometric contractions in 26 three-dimensional direction combinations. Relative strength in opposing directions (strength balance) and muscle activity of 6 shoulder rotators were compared between groups.

Results: The internal (+) and external (-) rotation component of strength balance did not differ in patients with eccentric (mean internal-external rotation component of strength balance: -7.6% ± 7.4%) compared with concentric deformity (-10.3% ± 6.8%) (mean difference: 2.7% [95% confidence interval (CI), -1.3% to 6.7%]; p = 0.59), suggesting no relative external rotation weakness. Infraspinatus activity was reduced in patients with eccentric (43.9% ± 10.4% of maximum voluntary contraction [MVC]) compared with concentric (51.3% ± 10.4% of MVC) deformity (mean difference: -7.4% [95% CI, -13.4% to -1.4%] of MVC; p = 0.04).

Conclusions: A relative external rotation strength deficit following TSA was not found, despite evidence of reduced infraspinatus activity, in the eccentric-deformity group. Reduced infraspinatus activity suggests that posterior rotator cuff deficiencies may persist following TSA in patients with eccentric deformities. Longitudinal study is necessary to evaluate muscle imbalance as a contributor to higher TSA failure rates.

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