Gender Trends in Authorship in 6 Major Orthopaedic Journals

BACKGROUND

Historically, orthopaedic surgery has had low female representation, with <6% of practicing surgeons identifying as female. Although prior literature has illustrated gender disparities in first and last authorship as well as changes in gender representation over time, less attention has been paid to middle authorship. We hypothesized that trends in female authorship would reflect increasing female participation in orthopaedic surgery and orthopaedic subspecialties coinciding with an overall increase in female authorship.

METHODS

Bibliometric information from articles published between 2011 and 2021 in 6 orthopaedic journals was extracted with use of the Web of Science. Collected data included author order, author names, affiliation, and corresponding author address. A gender was assigned with the use of Genderize.io, which is validated software, on the basis of author first name. Statistical analysis was performed with use of an analysis of variance for each journal, and linear regression was performed to determine trends, controlling for year.

RESULTS

Among all included orthopaedic journals, female middle authorship increased by 5 percentage points, female first authorship increased by 4 percentage points, and female last authorship increased by 1 percentage point. Over the study period, the highest rate of female middle authorship (28%) was seen in the Journal of Pediatric Orthopaedics, whereas the lowest rate (16%) was seen in The Journal of Arthroplasty . We found that the 5 highest-producing female last authors were, on average, cited significantly less per publication than their male counterparts in all but 2 journals.

CONCLUSIONS

Gender gaps exist within orthopaedic surgery as well as within its body of literature. Although this study highlights areas of growth, it also promotes further inquiry into research productivity and the availability of opportunity within orthopaedic surgery as a whole. The increase in female middle authorship overall and in each journal demonstrates momentum for future growth for women in the field of orthopaedic surgery.

Association between sleep dysfunction and Patient-Reported Outcomes Measurement Information System scores in patients with rotator cuff tears

OBJECTIVES

The purpose of this study was to utilize Patient-Reported Outcomes Measurement Information System (PROMIS) sleep scores to determine the prevalence of sleep dysfunction and its association with other PROMIS scores in patients with rotator cuff tears (RCT).

METHODS

Patients were retrospectively identified using the International Classification of Diseases-10 codes for RCT pathology, and PROMIS outcomes were assessed at multiple visits between November 2017 and February 2020. Generalized linear mixed effects models were fitted with PROMIS sleep score as the predictor variable and other PROMIS scores as the response variable. Additionally, models were fit using a clinically significant dichotomization of PROMIS sleep scores to assess differences in average PROMIS scores.

RESULTS

The study cohort included 481 patients, 201 (41.8 ​%) of whom had disrupted sleep at first visit. A higher percentage of those with disrupted sleep at first visit were female, nonwhite, and not married compared to those with normal sleep. PROMIS scores at first visit differed by sleep category. Higher PROMIS sleep scores were associated with higher anxiety, depression, fatigue, pain intensity, and pain interference scores and lower physical function, social participation, and upper extremity scores. Relationships were similar when dichotomous PROMIS sleep scores were considered.

CONCLUSION

There was a high prevalence of sleep dysfunction in patients with RCT. Sleep disturbance is associated with increased anxiety, depression, fatigue, pain intensity, pain interference and decreased physical function, social participation, and upper extremity function in patients with RCTs.

LEVEL OF EVIDENCE III

Retrospective Cohort Study.

Inertial Sensor Gait Analysis of Trendelenburg Gait in Patients Who Have Hip Osteoarthritis

BACKGROUND

Gait abnormalities such as Trendelenburg gait (TG) in patients who have hip osteoarthritis (OA) have traditionally been evaluated using clinicians' visual assessment. Recent advances in portable inertial gait sensors offer more sensitive, quantitative methods for gait assessment in clinical settings. This study sought to compare sensor-derived metrics in a cohort of hip OA patients when stratified by clinical TG severity.

METHODS

There were 42 patients who had hip OA and were grouped by TG severity (mild, moderate, and severe) through visual assessment by a single arthroplasty surgeon who had > 30 years of experience. After informed consent, wireless inertial sensors placed at the midpoint of the intercristal line collected gait parameters including pelvic shift, support time, toe-off symmetry, impact, and cadence. Clinical data on hip strength, range of motion, and Kellgren-Lawrence grade were collected.

RESULTS

Worsening TG severity had a higher mean Kellgren-Lawrence grade (2.5 versus 3.2 versus 3.4; P = .014) and reduced passive hip abduction (P = .004). Severe TG group demonstrated predominantly contralateral pelvic shift (n = 9 of 10, 90.0%), while ipsilateral shift was more frequently detected in moderate (n = 10 of 18, 55.6%) and mild groups (n = 9 of 14, 64.3%; P = .021). Contralateral single support time bias was greatest in severe TG (35.7% versus 50.0 versus 90.0%; P = .027). Asymmetric toe-off, impact, and support times were observed in all groups.

CONCLUSIONS

Traditional understanding of TG is that truncal shift occurs to the ipsilateral side. Using sensor-based measurements, the present study demonstrates a shift of the weight-bearing axis toward the contralateral side with increasing TG severity, which has not been previously described. Inertial sensors are feasible, quantitative gait measuring tools, and may reveal subtle patterns not readily discernible by traditional methods.

Microdrilling Resulted in Less Subchondral Bone Destruction Than a Traditional Microfracture Awl for Articular Cartilage Defect Bone Marrow Stimulation

Purpose

The purpose of this study was to compare bone marrow stimulation using micro-computed tomography (micro-CT) analysis of an abrasion arthroplasty technique, drilling k-wire technique, traditional microfacture awl, or a microdrill instrument for subchondral bone defects.

Methods

Eleven cadaveric distal femoral specimens were obtained and divided into 3 common areas of osteochondral defect: trochlea and weightbearing portions of the medial and lateral femoral condyles. Each area of interest was then denuded of cartilage using a PoweRasp and divided into quadrants. Each quadrant was assigned either a 1.6 mm Kirschner wire (k-wire), 1.25 mm microfracture awl, 1.5 mm fluted microdrill, PowerPick, or a curette (abrasion arthroplasty) to create 4 channels into the subchondral bone sing the same instrument. Subchondral bone and adjacent tissue areas were then evaluated using micro-CT to analyze adjacent bone destruction and extension into the bone marrow.

Results

Overall, there was a significantly decreased area of bone destruction or compression using the microdrill (0.030 mm) as compared to the microfracture awl (0.072 mm) and k-wire (0.062 mm) (P < .05). Within the trochlea and the medial femoral condyle, there was significantly decreased bony compression with the microdrill as compared to the awl and k-wire (P < .05); however, when stratified, this was not significant among the lateral femoral condylar samples (P = .08).

Conclusion

Bone marrow stimulation causes bony compression that may negatively impact subchondral bone and trabecular alignment. It is important to understand which tools used for bone marrow stimulation cause the least amount of damage to the subchondral bone.

Clinical Relevance

This study demonstrates the decreased subchondral bony defects seen with the microdrill versus the traditional microfracture awl indicating that when performing bone marrow stimulation, the microdrill may be a less harmful tool to the subchondral bone.

Body Mass Index and American Society of Anesthesiologists Score Predict Perioperative Delays in Different Phases for Total Hip Arthroplasty

Perioperative efficiency has become increasingly important with cost constraints and expanding indications for total hip arthroplasty (THA). We chose to analyze body mass index (BMI) and American Society of Anesthesiologists (ASA) score, in predicting perioperative efficiency. We retrospectively reviewed the institutional database for primary THAs from July 2015 to January 2018. Patient demographics and perioperative times lines were collected. A multivariable model was utilized to evaluate BMI (< 30, ≥ 30) and ASA (< 3, ≥ 3) for all outcomes. A total of 2,934 patients were included with mean age 62.0 (12.2) years, and 1,599 (54.5%) were female. A BMI ≥ 30 was associated with prolonged operative time (p < 0.001) while an ASA ≥ 3 was predictive of post-anesthesia care unit time (p < 0.001), physical therapy hours (p < 0.001), and length of stay (p < 0.001). Both BMI (p = 0.004) and ASA (p < 0.001) were associated with skilled nursing/rehabilitation dispositions. While BMI predicts prolonged operative time, ASA predicts perioperative delays for anesthesia, nursing, and physical therapy. (Journal of Surgical Orthopaedic Advances 32(3):169-172, 2023).

A validated preoperative risk prediction tool for extended inpatient length of stay following anatomic or reverse total shoulder arthroplasty

BACKGROUND

Recent work has shown inpatient length of stay (LOS) following shoulder arthroplasty to hold the second strongest association with overall cost (after implant cost itself). In particular, a preoperative understanding for the patients at risk of extended inpatient stays (≥3 days) can allow for counseling, optimization, and anticipating postoperative adverse events.

METHODS

A multicenter retrospective review was performed of 5410 anatomic (52%) and reverse (48%) total shoulder arthroplasties done at 2 large, tertiary referral health systems. The primary outcome was extended inpatient LOS of at least 3 days, and over 40 preoperative sociodemographic and comorbidity factors were tested for their predictive ability in a multivariable logistic regression model based on the patient cohort from institution 1 (derivation, N = 1773). External validation was performed using the patient cohort from institution 2 (validation, N = 3637), including area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values.

RESULTS

A total of 814 patients, including 318 patients (18%) in the derivation cohort and 496 patients (14%) in the validation cohort, experienced an extended inpatient LOS of at least 3 days. Four hundred forty-five (55%) were discharged to a skilled nursing or rehabilitation facility. Following parameter selection, a multivariable logistic regression model based on the derivation cohort (institution 1) demonstrated excellent preliminary accuracy (AUC: 0.826), with minimal decrease in accuracy under external validation when tested against the patients from institution 2 (AUC: 0.816). The predictive model was composed of only preoperative factors, in descending predictive importance as follows: age, marital status, fracture case, ASA (American Society of Anesthesiologists) score, paralysis, electrolyte disorder, body mass index, gender, neurologic disease, coagulation deficiency, diabetes, chronic pulmonary disease, peripheral vascular disease, alcohol dependence, psychoses, smoking status, and revision case.

CONCLUSION

A freely-available, preoperative online clinical decision tool for extended inpatient LOS (≥ 3 days) after shoulder arthroplasty reaches excellent predictive accuracy under external validation. As a result, this tool merits consideration for clinical implementation, as many risk factors are potentially modifiable as part of a preoperative optimization strategy.

Is there a problem with modular dual mobility acetabular components in revision total hip arthroplasty at mid-term follow-up?

AIMS

Modular dual mobility (MDM) acetabular components are often used with the aim of reducing the risk of dislocation in revision total hip arthroplasty (THA). There is, however, little information in the literature about its use in this context. The aim of this study, therefore, was to evaluate the outcomes in a cohort of patients in whom MDM components were used at revision THA, with a mean follow-up of more than five years.

METHODS

Using the database of a single academic centre, 126 revision THAs in 117 patients using a single design of an MDM acetabular component were retrospectively reviewed. A total of 94 revision THAs in 88 patients with a mean follow-up of 5.5 years were included in the study. Survivorship was analyzed with the endpoints of dislocation, reoperation for dislocation, acetabular revision for aseptic loosening, and acetabular revision for any reason. The secondary endpoints were surgical complications and the radiological outcome.

RESULTS

The overall rate of dislocation was 11%, with a six-year survival of 91%. Reoperation for dislocation was performed in seven patients (7%), with a six-year survival of 94%. The dislocations were early (at a mean of 33 days) in six patients, and late (at a mean of 4.3 years) in four patients. There were three intraprosthetic dissociations. An outer head diameter of ≥ 48 mm was associated with a lower risk of dislocation (p = 0.013). Lumbrosacral fusion was associated with increased dislocation (p = 0.004). Four revision THAs (4%) were further revised for aseptic acetabular loosening, and severe bone loss (Paprosky III) at the time of the initial revision was significantly associated with further revision for aseptic acetabular loosening (p = 0.008). Fourteen acetabular components (15%) were re-revised for infection, and a pre-revision diagnosis of reimplantation after periprosthetic joint infection (PJI) was associated with subsequent PJI (p < 0.001). Two THAs had visible metallic changes on the backside of the cobalt chromium liner.

CONCLUSION

When using this MDM component in revision THA, at a mean follow-up of 5.5 years, there was a higher rate of dislocation (11%) than previously reported. The size of the outer bearing was related to the risk of dislocation. There was a low rate of aseptic acetabular loosening. Longer follow-up of this MDM component and evaluation of other designs are warranted. Cite this article: Bone Joint J 2021;103-B(7 Supple B):66-72.

Varus-Valgus Constrained Implants in Revision Total Knee Arthroplasty: Mean Clinical Follow-Up of Six Years

BACKGROUND

There is scant literature evaluating varus-valgus constrained (VVC) prostheses in contemporary revision total knee arthroplasty (TKA). Therefore, we aimed to evaluate the durability of VVC revision TKA with selective use of cones.

METHODS

A retrospective review of 194 revision TKAs with VVC was performed from August 2005 through February 2018 at a single institution. The final cohort consisted of 168 TKAs with a mean follow-up of 6 years. Stems were used in all but 1 TKA, tibial cones in 48%, and femoral cones in 19%. Anderson Orthopaedic Research Institute classification in femurs was 1 in 57, 2A in 33, 2B in 62, 3 in 16, and in tibias, 1 in 42, 2A in 29, 2B in 81, and 3 in 16.

RESULTS

Survival analysis showed that 93% were free of revision for aseptic component loosening, 76% were free of revision for any reason, and 74% were free of reoperation at 6 years. Anderson Orthopaedic Research Institute 3 femur or tibia, age <65 years, and progressive radiographic changes were associated with an increased risk of revision for aseptic loosening (P < .05). Progressive radiographic changes were seen in 19% of femoral and 16% of tibial constructs. The most common reason for re-revision was periprosthetic joint infection (65%).

CONCLUSION

VVC revision TKA with selective use of cones provided a reasonable outcome as 93% were free of revision for aseptic loosening at 6 years. However, given the rate of patients with progressive radiographic changes and survivorship free of reoperation of 74% at 6 years, long-term follow-up will help assess the durability of these constructs.

Mid-term results of tibial cones : reasonable survivorship but increased failure in those with significant bone loss and prior infection

AIMS

Tibial cones are often utilized in revision total knee arthroplasty (TKA) with metaphyseal defects. Because there are few studies evaluating mid-term outcomes with a sufficient cohort, the purpose of this study was to evaluate tibial cone survival and complications in revision TKAs with tibial cones at minimum follow-up of five years.

METHODS

A retrospective review was completed from September 2006 to March 2015, evaluating 67 revision TKAs (64 patients) that received one specific porous tibial cone during revision TKA. The final cohort was composed of 62 knees (59 patients) with five years of clinical follow-up or reoperation. The mean clinical follow-up of the TKAs with minimum five-year clinical follow-up was 7.6 years (5.0 to 13.3). Survivorship analysis was performed with the endpoints of tibial cone revision for aseptic loosening, tibial cone revision for any reason, and reoperation. We also evaluated periprosthetic joint infection (PJI), risk factors for failure, and performed a radiological review.

RESULTS

The rate of cone revision for aseptic loosening was 6.5%, with an eight-year survival of 95%. Significant bone loss (Anderson Orthopaedic Research Institute grade 3) was associated with cone revision for aseptic loosening (p = 0.002). The rate of cone revision for any reason was 17.7%, with an eight-year survival of 84%. Sixteen percent of knees developed PJI following revision. A pre-revision diagnosis of reimplantation as part of a two-stage exchange protocol for infection was associated with both PJI (p < 0.001) and tibial cone revision (p = 0.001).

CONCLUSION

Mid-term results of tibial cones showed a survivorship free of cone revision for aseptic loosening of 95%. Patients with significant bone loss were more likely to have re-revision for tibial cone failure. Infection was common, and patients receiving cones at reimplantation were more likely to develop PJI and undergo cone revision. Cite this article: Bone Joint J 2021;103-B(6 Supple A):158-164.

Are Patients Taking Benzodiazepines at Increased Risk for Complications Following Primary Total Knee Arthroplasty?

BACKGROUND

Benzodiazepines are commonly taken by patients who are undergoing total knee arthroplasty (TKA), but there is a paucity of studies evaluating any associations. Therefore, we hoped to study if patients taking preoperative benzodiazepines would have increased complications following TKA.

METHODS

Using a nationwide database, from 2010 to 2019, we evaluated patients undergoing primary TKA who either did or did not have a preoperative record of benzodiazepine prescription. We performed a multivariable logistic regression analysis, adjusting for multiple variables (age, gender, obesity, and Charlson comorbidity index), to determine the association of preoperative benzodiazepine use and adverse events in a matched cohort. Furthermore, we stratified patients by one vs multiple preoperative benzodiazepine prescription(s). We evaluated 90-day and 2-year rates of revision, resection, femur fracture fixation, manipulation under anesthesia (MUA), and delirium.

RESULTS

Patients filling more than one preoperative benzodiazepine prescription had increased adjusted odds of 90-day (odds ratio [OR] = 1.198, confidence interval [CI] = 1.086-1.320) and 2-year (OR = 1.188, CI = 1.125-1.254) revision; 90-day resection (OR = 1.430, CI = 1.125-1.817); 90-day (OR = 1.639, CI = 1.255-2.141) and 2-year (OR = 1.646, CI = 1.412-1.919) femur fracture fixation; and 2-year delirium (OR = 2.288, CI = 1.564-3.382). Preoperative benzodiazepine users had decreased adjusted odds of 90-day (OR = 0.670, CI = 0.639-0.702) and 2-year (OR = 0.702, CI = 0.671-0.734) MUA.

CONCLUSION

After controlling for multiple variables, benzodiazepine use was associated with increased rates of revision, resection, femur fracture fixation, and delirium. Furthermore, benzodiazepine use was also associated with a decreased rate of MUA. Orthopaedic professionals can counsel patients taking this group of medications about the associated adverse events. Future studies should assess the use of other muscle relaxants in the prevention of knee stiffness and MUA.

Body Mass Index, American Society of Anesthesiologists Score, and Elixhauser Comorbidity Index Predict Cost and Delay of Care During Total Knee Arthroplasty

BACKGROUND

Body mass index (BMI), American Society of Anesthesiologists (ASA) score, and Elixhauser Comorbidity Index are measures that are utilized to predict perioperative outcomes, though little is known about their comparative predictive effects. We analyzed the effects of these indices on costs, operating room (OR) time, and length of stay (LOS) with the hypothesis that they would have a differential influence on each outcome variable.

METHODS

A retrospective review of the institutional database was completed on primary TKA patients from 2015 to 2018. Univariable and multivariable models were constructed to evaluate the strength of BMI, ASA, and Elixhauser comorbidities for predicting changes to total hospital and surgical costs, OR time, and LOS.

RESULTS

In total, 1313 patients were included. ASA score was independently predictive of all outcome variables (OR time, LOS, total hospital and surgical costs). BMI, however, was associated with intraoperative resource utilization through time and cost, but only remained predictive of OR time in an adjusted model. Total Elixhauser comorbidities were independently predictive of LOS and total hospital cost incurred outside of the operative theater, though they were not predictive of intraoperative resource consumption.

CONCLUSION

Although ASA, BMI, and Elixhauser comorbidities have the potential to impact outcomes and cost, there are important differences in their predictive nature. Although BMI is independently predictive of intraoperative resource utilization, other measures like Elixhauser and ASA score were more indicative of cost outside of the OR and LOS. These data highlight the differing impact of BMI, ASA, and patient comorbidities in impacting cost and time consumption throughout perioperative care.

Same-day Bilateral Total Knee Arthroplasty Did Not Increase 90-day Hospital Returns

PURPOSE

Bilateral total knee arthroplasty (TKA) can be performed in patients with bilateral knee arthritis. Outside of nationwide database studies, which have limitations, few studies have compared outcomes for same-day versus staged TKA. We sought to compare patient outcomes at a single tertiary referral center.

METHODS

The institutional database was queried from March 2014 to December 2017 for primary TKA. Patients undergoing bilateral procedures were stratified by same-day versus staged; length of stay (LOS), disposition, 90-day emergency department (ED) visits, and 90-day readmissions were examined through univariable and multivariable analyses.

RESULTS

A total of 676 patients were evaluated (113 same-day and 563 staged bilateral TKA patients) with mean age 66.0 (8.5) at first surgery and 292.1 (241.6) days between staged procedures. Same-day bilateral TKA patients were younger (p < 0.001), had lower body mass index (BMI) (p = 0.010), and had lower American Society of Anesthesiologists (ASA) scores (p = 0.030). They were more likely to have a prolonged LOS (p < 0.001) and be discharged to skilled nursing facility or rehab facility (p < 0.001). Total LOS for separate hospitalizations in staged procedures was greater than LOS for same-day bilateral TKAs (p < 0.001). There was no difference in 90-day ED visits (p = 0.623) or readmission (p = 0.286). In a multivariable model controlling for age, BMI, and ASA score, same-day bilateral TKA was not significantly associated with ED visits or readmissions.

CONCLUSIONS

Patients undergoing same-day bilateral TKAs were more likely to be discharged to post-acute care facilities, however they did not have increased 90-day readmissions.

Staying ahead of the curve: the use of spinopelvic parameters to predict curve progression and bracing success in adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To investigate radiographic sagittal and spinopelvic parameters of patients with adolescent idiopathic scoliosis (AIS) treated with bracing and assess differences among those treated successfully and unsuccessfully. AIS is a three-dimensional deformity of the spine, sharing an intricate relationship with pelvic morphology. However, the most relevant predictors of curve progression have historically been coronal parameters and skeletal maturity. Sagittal and spinopelvic parameters have not been thoroughly investigated as predictors of curve progression and brace treatment success.

METHODS

Retrospective review of AIS patients who underwent brace treatment. Coronal Cobb angles (CC), pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), thoracic kyphosis (TK), lumbar lordosis (LL), and thoracic spinopelvic angles (T1SP, T9SP) were measured prior to initiation of bracing. The sagittal and spinopelvic parameters of patients requiring surgical treatment due to curve progression were compared to those treated successfully with bracing.

RESULTS

No significant differences were found for age, race, gender, Risser category (0/1 vs 2/3), initial CC, TK, LL, T1SP, or T9SP between cohorts. The cohort requiring surgery had significantly lower PI (p  <  0.001, 42.0 v. 54.6), SS (p  <  0.001, 37.0 v. 44.5), and PT (p  =  0.003, 5.0 v. 10.2) compared to those successfully treated with bracing. Multivariable models controlling for Risser stage and Initial CC revealed the odds for successful brace treatment increases with an increase in PI (OR  =  1.47, CI 1.18-1.83, p  <  0.001), SS (OR  =  1.26, CI 1.07-1.48, p  =  0.006), and PT (OR  =  1.43, CI 1.09-1.86, p  =  0.006) (Table 3). The odds of successful brace treatment is given per one-unit increase for each radiographic measure after adjusting for Initial CC and Risser sign which were forced into each multivariable model.

CONCLUSIONS

Spinopelvic parameters may indicate potential spine adaptability and skeletal maturity. For these reasons, we proposed that spinopelvic parameters may be a potential predictor of curve progression and brace treatment success. Our results demonstrated a higher risk of curve progression with lower PI, PT, or SS which support this hypothesis, however, given the small sample size and high variability, the magnitude of this effect should be viewed with caution and should serve as an impetus to further, larger scale studies to investigate the value spinopelvic parameters in curve progression and bracing efficacy.

LEVEL OF EVIDENCE

IV.

Right Anterior Mini-Incision Approach to Anomalous Right Coronary Artery Repair

The right anterior mini-incision has emerged as an effective minimally invasive approach for adult aortic root and valve operations. However, adoption of minimally invasive techniques has been limited in congenital heart surgery. We report a case of anomalous aortic origin of the right coronary artery repair performed through this approach. Following successful right coronary artery unroofing, the patient had an uncomplicated postoperative hospitalization.