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Background: Recent reports on the influence of gender on the outcomes of total joint arthroplasty were limited by either lack of longitudinal data or absent stratification by total hip arthroplasty (THA) or total knee arthroplasty (TKA). As a result, there remains a lack of clarity on this topic. Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for all primary, elective THAs and TKAs performed between 2011 and 2017. Differences in demographics, comorbidity profiles, operative time, hospital length of stay (LOS), and 30-day outcomes were compared between male and female patients. Multivariate analyses were performed separately for THA and TKA. Results: A total of 418,885 patients were analyzed; 59.1% were females. Compared with males, females were likely to be older, have a higher body mass index, identify as nonwhite, and require preoperative functional assistance (P < .001). Females had lower rates of diabetes, hypertension, anemia, and kidney disease but a higher rate of chronic steroid use (P < .001). They were also likely to have shorter operative times for both THA and TKA (P < .001). After controlling for the aforementioned differences, female gender was an independent risk factor for readmission, reoperation, and wound infection after THA (P < .001). In contrast, male sex was an independent risk factor for readmission, reoperation, and overall complications after TKA (P < .001). Regardless of the procedure, females were 64%–82% more likely to require an LOS >2 days than males. Discussion: A variable effect of gender was observed on the post–total joint arthroplasty LOS and outcomes depending on the procedure type (THA or TKA). Differences attributed to gender should be accounted for in risk-stratification models. Future studies are also needed to elucidate the underlying causes of gender differences in joint arthroplasty.

The purpose of this was to investigate recent trends in procedure utilization, comorbidity profiles, hospital length of stay (LOS), 30-day outcomes, and risk factors for adverse events (AEs) among Black patients undergoing total hip arthroplasty (THA). Using the American College of Surgeons National Surgery Quality Improvement Program, we retrospectively reviewed all Black patients who underwent elective, primary THA between 2011 and 2017. Mixed effects logistic regression analyses were performed to determine the trends in the study outcomes across each individual year. Multivariate logistic regression analyses were performed to identify independent risk factors for AEs. A total of 11,574 Black patients were analyzed. Over the study period, there was an increase by 109% in THA procedures performed in this racial group. During the same time, there were reductions in the prevalence of anemia, dyspnea, tobacco smoking, and osteonecrosis (p 2 days (68 to 37%, p 35, American Society of Anesthesiologists score > 2, dependent functional status, diabetes, bleeding disorders, chronic kidney disease, and osteonecrosis as the surgical indication. Between 2011 and 2017, there were improving trends in procedure utilization, comorbidity profiles, and LOS among Black patients undergoing primary THA, but the overall rates of 30-day outcomes remained unchanged. We identified a number of risk factors that may help guide preoperative optimization and patient counseling to mitigate postoperative AEs.

By streamlining surgical care and eliminating postoperative hospitalization, the transition to ambulatory total knee arthroplasty (TKA) has the potential to improve efficiency and minimize the costs of care. However, practical, legal, and financial implications remain to be addressed. The Centers for Medicare and Medicaid Services has also yet to address concerns generated by the removal of TKA from the Inpatient-Only List and provide guidance on patient selection. Rolling out regulatory changes that impact high-volume procedures, such as TKA, in a short period of time and without appropriate feedback can only lead to further confusion. As surgeons, we are in a unique business model that requires us to constantly innovate to deliver high quality care, while also taking financial cuts as a result of our innovations.

Introduction The diagnosis of isolated distal tibiofibular syndesmotic ankle instability proves to be a challenge. Although diagnostic imaging has added value, it is limited in the detection of distal syndesmotic ankle instability. The gold standard remains intraoperative testing through arthroscopic probing while externally stressing the ankle in a sagittal direction. However, no validated arthroscopic guidelines have been established to distinguish a stable from an unstable syndesmotic ankle joint. This cadaveric study presents anatomical and biomechanical data that can help surgeons correctly identify isolated distal syndesmotic ankle instability. Objective The purpose of this study is to quantify the necessary forces applied during ankle arthroscopy to evaluate syndesmotic instability in freshly frozen cadaveric ankles. Methods A total of 16 fresh frozen cadaveric (age 58–74 years) ankles were included in the study. A dynamometer was used to measure the force necessary for the shaver tip to be inserted into the distal tibiofibular joint with the ankle in a neutral position. Measurements were performed first with the syndesmosis intact, and again following progressive transection of the syndesmotic ligaments, along with distal fixation. Results Significant differences were noted in the mean force required between the anterior inferior tibiofibular ligament (AITFL)+interosseous ligament (IOL) and no ligament cut methods (p Conclusions This cadaveric study provides biomechanical data that can assist the surgeon in the arthroscopic evaluation of syndesmotic injuries. The data from this study need to be clinically correlated to ultimately assist in improving the outcome of patients with syndesmotic ankle injuries. Our study offers to bridge the gap to the development of arthroscopic tools that can identify the need for surgical fixation to the syndesmosis based on the laxity of specific ankle ligaments that contribute to subtle instability. Level of evidence Level V cadaveric study.

Surgical techniques for the management of recalcitrant osteochondral lesions of the talus have improved; however, the poor healing potential of cartilage may impede long-term outcomes. Repair (microfracture) or replacement (osteochondral transplants) is the standard of care. Reparative strategies lead to production of fibrocartilage, which, compared with the native type II articular cartilage, has decreased mechanical and wear properties. The success of osteochondral transplants may be hindered by poor integration between grafts and host that results in peripheral cell death and cyst formation. These challenges have led to the investigation of biologic adjuvants to augment treatment. In vitro and in vivo models have demonstrated promise for cartilage regeneration by decreasing inflammatory damage and increasing the amount of type II articular cartilage. Further research is needed to investigate optimal formulations and time points of administration. In addition, clinical trials are needed to investigate the long-term effects of augmentation.

Objectives Injuries to the ankle are common, with a significant number of ligamentous injuries involving the syndesmosis. In syndesmotic injuries severe enough to require surgical fixation, the two leading techniques are rigid screw and suture button fixation. The literature has shown that both techniques are effective, but there remains debate on the optimum method of treatment. The goal of this study was to evaluate patient-reported outcomes for these repair methods in a population of athletes. Methods This study was a retrospective cross-sectional study of patients who had undergone rigid screw or suture button fixation for an injury to the ankle syndesmosis. Specifically, a subpopulation of athletes was examined as it was hypothesised that these high-demand patients would have higher patient-reported outcomes with ongoing suture button fixation. Study participants were identified through a search of the medical record and were recruited through mailed letters and phone calls. Participants completed patient-reported outcome questionnaires including the Activities of Daily Living and Sports Subscales of the Foot and Ankle Ability Measure (FAAM) survey, FAAM Sports Subscale survey, Veteran's Rand 12-item Health Survey (VR-12) and a customised athletic activity questionnaire. These patient-reported outcomes were compared between those who underwent screw fixation and those who underwent suture button fixation. Results 32 patients completed the study, with 17 of these designated as ‘athletes' competing in strenuous sports activities that involve jumping, cutting and hard pivoting including football, soccer, basketball, volleyball and gymnastics at the high school level or above. Patients were on average 3.9 years post op (SD 2.2). With the numbers available, no difference in outcomes between patients with rigid screw or suture button fixation was observed in the study as a whole. In a subpopulation of athletes, patients who received suture button fixation had higher FAAM scores compared with those treated with rigid screw fixation (p=0.02). Still, in the subpopulation of athletes, no statistical difference was observed with the available numbers for the other patient-reported outcomes. Conclusion This pilot study of outcomes in an athletic population suggests that athletic patients may benefit from suture button fixation and lays the groundwork for future work examining the use of suture button fixation in high-demand patients. Level of evidence Level III—Retrospective Comparative Study.

Category: Bunion Introduction/Purpose: Hallux Valgus is a complex deformity with several attendant components that are present to varying degrees in each patient. Historically primary attention has been paid to correction of the coronal plane deformity, but recent investigations suggest a substantial contribution to the deformity from the axial rotational abnormality of the metatarsal. While the effect of this metatarsal pronation has been demonstrated, the relative contribution of this parameter compared to other components has not been considered. This study aims to investigate the rotational aspect of the deformity and its contribution to successful radiographic correction of the deformity. Methods: A retrospective review of 100 consecutive Lapidus bunionectomy procedures was performed. There were 80 of patients and 89 feet. patients Results: The average HVA correction was 20.08 degrees and 6.86 degrees for IMA. A total of 68 feet had a positive preop round head sign and correction to a normal MT head shape was observed in 47 feet. A significant increase in recurrence was associated with patients that had persistent MT round sign following correction (p=0.001) and in patients with a higher sesamoid position in the preop period pConclusion: Adequate preoperative radiographic assessment is of the utmost importance to assess the various forces that can contribute to hallux valgus deformity. Newer techniques address coronal and sagittal plane deformity. Failure to correct MT head pronation may lead to increased hallux valgus recurrence, despite sagittal correction measured by improvement of the HVA and IMA angles. Factors that impact time to fusion are also associated with a higher risk of HV recurrence. Sesamoid position and metatarsal head pronation should be considered, and correction of these parameters may be necessary to avoid delayed healing and persistent or recurrent HV.

The University of Pittsburgh Medical Center successfully implemented an innovative and sustainable tobacco cessation program within busy orthopedic practices, resulting in increased cessation befor...

Plantar fasciitis is one of the most common causes of heel pain. Plantar fasciitis occurs from increased stress on the plantar aponeurosis as a result of progressive, repetitive microtears, and degeneration. Plantar fasciitis is largely a clinical diagnosis based on clinical examination; thus using history and physical examination findings. Initial therapy involves addressing of possible modifiable disease factors. Surgical management of plantar fasciitis is considered after an unsuccessful course of nonoperative management, with open or endoscopic release. This article reviews the diagnostic and treatment management for patients with symptomatic plantar fasciitis.

Lisfranc injuries entail traumatic disruption of any one of the ligamentous or bony components involved in tarsometatarsal joint complex stabilization. Without treatment, severe injuries resulting in tarsometatarsal joint instability are at increased risk for chronic functional disability and pain. In athletes, the literature has demonstrated evidence of improved outcomes (eg, return to play) following open reduction internal fixation for Lisfranc injuries. Of those surgically managed, variability exists among treatment methodology and outcomes. This article aims to provide an overview of Lisfranc joint complex injuries and the pearls and pitfalls associated with operative techniques to improve postoperative outcomes.

Osteochondral lesions of the talus occur in 2%-6% of ankle sprains and may present with concurrent ankle sprains as a result of an inverted ankle. Lesions that are chronic in nature, have failed conservative management, or have displaced fragments or a complete fracture are amenable to surgical intervention. Arthroscopic surgery is the mainstay of evaluation and treatment of osteochondral lesions of the talus. The use of adjunctive biologic treatment has shown great early results as well, and has become increasingly useful to advance healing and return to activity.

As the US population continues to grow in racial and ethnic diversity, we also continue to see healthcare disparities across racial lines. Considerable attention has been given to creating a physician workforce that better reflects the population served by healthcare professionals. To address the low numbers of women and underrepresented minorities in procedural based specialties, Nth Dimensions has sought to address and eliminate healthcare disparities through strategic pipeline initiatives. This is a retrospective observational cohort study of 118 medical students from 29 accredited US medical schools, who were awarded a position in the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%. Through intervention-based change, the authors hypothesize that greater numbers in the residency training cohorts can lead to a greater number of physicians with diverse backgrounds and perspectives. Ultimately, this will enhance quality of care for all patients and improve decision making process that influence healthcare systems. Summary Strategic pipeline programs increase successful recruit women and underrepresented minorities to apply and matriculate into procedure based residency programs. This is a retrospective observational cohort study of 118 medical students who completed the Nth Dimensions Summer Internship program between 2005 and 2012. Overall, 84 NDSI scholars applied and 81 matched into procedure-based specialties; therefore the overall retention rate was 75% and the overall match rate across the eight cohorts was 72.3%.

Foot injuries are the third leading cause of injuries in NCAA athletes that have to be removed from competition, with a large number attributed to the hallux metatarsophalangeal (MTP) joint. In turf toe injuries, one or more structures of the plantar complex of the first MTP joint are injured. Injury classification helps to guide management and aids in determining prognosis. Surgical intervention for turf toe injury is often undertaken after nonoperative management has failed for mild injuries or in the case of severe injuries to restore function and anatomy. This presents a review and surgical consideration of the turf toe injury in athletes.

The tracking of clinical outcomes allows healthcare organizations to identify variations in the delivery of care in order to properly align healthcare practices within an organization. An outcome measure is the result of a test that is used to objectively determine the baseline function of a patient at the beginning of treatment. The most useful outcomes should be measurable based on discrete parameters and time points. Outcomes in healthcare are no longer solely limited to the quality of care provided but also reflect the service as experienced by the patient. Self-reported outcome measures were developed to gather information based on patient experience and perception. Patient-reported outcomes create an environment that fosters shared decision-making. Decisions made with patient input often make the patient feel more at ease because he or she can converse with a clinician about the treatment. With clinical implications at the forefront of outcome research study design, researchers are better equipped to develop the right questions and collect the appropriate data to address the root cause of differences in patient outcomes.

Patient-centered care (PCC) is gaining considerable momentum among health care professionals and policy-making authorities. The need for PCC stems from the innumerable benefits of adopting such a system. The practice of PCC in orthopedic surgery in general, and in total joint replacement in particular, is still in its youth. However, present literature already establishes the need for applying PCC in total joint replacement. Extensive research and effort should be invested to better grasp and define the dimensions of PCC as they relate to total joint replacement.

Under the Patient Protection and Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services' Innovation was chartered to develop new models of health care delivery. The changes meant a drastic need to restructure the health care system. To minimize costs and optimize quality, new laws encourage continuity in health care delivery within an integrated system. Affordable care organizations provided a model of high-quality care while reducing costs. Bundled payments can have a substantial effect on the national expenditures. This article examines new developments in bundle payments, affordable care organizations, and gainsharing agreements as they pertain to arthroplasty.

The US health care system has been fragmented for more than 40 years; this model created a need for modification. Sociopoliticomedical system-related factors led to the Affordable Care Act (ACA) and a restructuring of health care provision/delivery. The ACA increases access to high-quality "affordable care" under cost-effective measures. This article provides a comprehensive review of health reform and the motivating factors that drive policy to empower arthroplasty providers to effectively advocate for the field of orthopedics as a whole, and the patients served.

Background Poor nutritional status is a preventable condition frequently associated with low body mass index (BMI). The purpose of this study is to comparatively analyze low (≤19 kg/m 2 ) and normal (19-24.9 kg/m 2 ) BMI cohorts, examining if a correlation between BMI, postoperative outcomes, and resource utilization exists. Methods Discharge data from the 2006-2012 National Inpatient Sample were used for this study. A total of 3550 total hip arthroplasty (THA) and 1315 total knee arthroplasty (TKA) patient samples were divided into 2 cohorts, underweight (≤19 kg/m 2 ) and normal BMI (19-24.9 kg/m 2 ). Using the Elixhauser Comorbidity Index, all cohorts were matched for 27 comorbidities. In-hospital postoperative outcomes and resource utilization among the cohorts was then comparatively analyzed. Multivariate analyses and chi-squared tests were generated using SAS software. Significance was assigned at P Results Underweight patients undergoing THA were at higher risk of developing postoperative anemia and sustaining cardiac complications. In addition, underweight patients had a decreased risk of developing postoperative infection. Resource utilization in terms of length of stay and hospital charge were all higher in the underweight THA cohort. Similarly, in the underweight TKA cohort, a greater risk for the development of hematoma/seroma and postoperative anemia was observed. Underweight TKA patients incurred higher hospital charge and were more likely to be discharged to skilled nursing facilities. Conclusion Our results indicate that low-BMI patients were more likely to have postoperative complications and greater resource utilization. This serves a purpose in allowing orthopedic surgeons to better predict patient outcomes and improve treatment pathways designed toward helping various patient demographics.

Acrylic bone cement has a variety of applications in orthopedic surgery. Primary uses in total arthroplasties are limited to prostheses fixation and antibiotic delivery. With the large number of total joint arthroplasties expected to continue to rise, understanding the role bone cement plays in the success of total joint arthroplasty can have a significant impact on daily practice. The literature is inconclusive on whether cemented or cementless fixation technique is superior, and choice of fixation type is mainly determined by surgeon preference and experience. Surgeons should understand that if poor techniques exist, short-term outcomes of the replaced joint may be at risk. Statement of clinical significance: This article attempts to clarify some points of bone cement use through a review of the mechanical properties related to bone cement, a comparison to alternative materials, influence of additives, and the effects on surgical outcomes. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:737-744, 2016.

Category: Midfoot/Forefoot Introduction/Purpose: Severe hallux rigidus is the 2nd most common disorder of the 1st metatarsophalangeal (MTP) joint and is present on more than 44% of radiographs taken in those over 80 years of age. Arthrodesis has been the proposed method of fixation for 1st MTP pathology. However, joint preserving alternatives to fusion have also been proposed to maintain joint motion and due to the relatively high nonunion rate (5.4%). However, few reports have investigated if the risk of complications from a fusion impact daily activities and functional outcomes. As such, we investigated the cost and quality associated with treatment of severe MTP arthritis to determine the optimal surgical intervention. Methods: This was a retrospective review of 384 patients from a prospectively collected foot and ankle platform registry in a payor-provider healthcare system. Patients who underwent surgical intervention from July 2015 to November 2017 were identified by CPT codes for MPT arthrodesis (28750) and arthroplasty (28293) as well as key words “hallux” and “rigidus”. Patient reported outcome scores were extracted from the medical records including SF12-M, SF12-P, FAAM, and a binary PASS score. Exclusion criteria included poly-trauma, neurological impairment, and revision procedures. The Mann-Whitney test was performed using Minitab 18 to compare procedure groups for the small samples without a normal distribution, and chi squared analysis was used to analyze the PASS score. Significance was defined by a p-value of Results: A total of 35 patients met inclusion criteria, with 26 arthrodesis and 9 arthroplasty patients. The arthrodesis group had an average age of 63.4 and the arthroplasty group had an average age of 60.1. The arthrodesis group had higher post op scores in measures including SF12-M, SF12-P, FAAM, and PASS. The arthrodesis group also had greater increase in postoperative SF12-P, and FAAM compared to pre-op scores, with the arthroplasty having higher increase in SF12-M. Of these, the differences in PASS score (p=0.02) and the change in SF12-P were significant (p=0.05). Analysis of cost identified 25 logs of MTP arthroplasty with an average cost of $6,538 per case and 79 logs of MTP arthrodesis with an average cost of $5,086. Conclusion: This study suggests that patients treated with arthrodesis for 1st MTP arthritis have improved outcomes with greater cost containment. Although the PASS and SF-12 scores showed significant differences, all of the results including pain scores revealed greater improvement with arthrodesis, with the exception of the SF12 mental. The small cohorts in this study are a limitation, but these, results are consistent with the current literature. However, with both higher outcome scores and lower cost, arthrodesis appears to have significant advantages compared to arthroplasty and further studies can help guide clinical decision making in this patient population.

Objectives: Jones’ fractures, 5th metatarsal metaphyseal-diaphyseal junction fractures, are a debilitating injury for the elite athlete, particularly in cutting/pivoting sports. These injuries are usually managed surgically due to the high rate of nonunion and re-fracture. Despite primary screw fixation, delayed union and nonunion are not uncommon. Bone marrow aspirate concentrate (BMAC), an autologous source of hematopoietic and mesenchymal stem cells, has been used to augment healing due to the poor healing potential in the watershed region. We hypothesize that open reduction internal fixation (ORIF) augmented with BMAC will improve patient-reported outcome measures following Jones’ fractures in athletes. Methods: This study was a prospectively collected and maintained review of elite athletes that underwent intramedullary screw fixation augmented with BMAC for Jones’ fractures at an academic medical institution. All patients were evaluated preoperatively and postoperatively to assess differences in patient reported outcomes including VAS, PROMIS, FAAM, SF-12 scores, return to play, and complications. Student’s t test was used in statistical comparison of the preoperative and postoperative outcome scores. P < 0.05 was considered significant. Results: A total of 41 elite athletes were treated with ORIF with BMAC for a Jones fracture with a mean age of 25.59 years (range 19-42). There were 26 (63%) males and 15 females included in the study. Type of athlete ranged across the following sport activities: football, basketball, soccer, volleyball. Of note, patients had significantly improved with lower visual analog score for pain (mean Δ3.56, p= 0.001), higher FAAM scores (mean Δ 43.6, p< 0.001), and PASS scores (increased from 11% to 85%, p< 0.001) at 6 months. Additionally, patients showed improvement in SF12, PROMIS10, and FAAM scores at 12 months, although this was not statistically significant due to insufficient follow up at this time. The average numbers of days lost to competition was 131 days. All patients that have returned to elite competitive sport activity report minimal to no pain. Conclusion: Intramedullary screw fixation of Jones’ fractures with BMAC results in optimal surgical outcomes in the elite athlete. The use of patient reported outcomes continues to be a focus of quality measures and should guide clinical decision making for surgical intervention, return to play, and to assess impact of treatment. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations.

Background: Bone bruises are frequently found on magnetic resonance imaging (MRI) after anterior cruciate ligament (ACL) injury and have been related to the force associated with the trauma. Yet, little is known about the bone bruise distribution pattern of skeletally immature (SI) patients, as the presence of an open physis may play a role in energy dissipation given its unique structure. Purpose: To describe and compare the location and distribution of tibial and femoral bone bruises, observed on MRI, between 2 groups of ACL-injured knees: the first group with an open physis and the second with a closed physis. Additionally, based on the bone bruise distribution pattern, the secondary aim of the study was to propose a new classification of bone bruise in SI patients. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective review was conducted to identify all cases of primary ACL tears in patients ≤16 years old, with MRI within 6 weeks of injury between January 2012 and December 2016. Overall, 106 patients were identified: 53 with open physis (skeletally immature [SI] group) and 53 with closed physis as control (skeletally mature [SM] group). MRI scans were reviewed to assess for the presence and location of bone bruises. Longitudinal bone bruise distribution was described as epiphyseal and metaphyseal in both femur and tibia. The proposed classification for tibia and femur has 2 parts: the location of the bone bruise in the (I) lateral, (II) medial, or (III) medial and lateral parts of the bone; and if the bone bruise (a) does not or (b) does cross the physis. For the tibia, if the bone bruise is also present in the central portion, a letter C is added. Results: The SI group had significantly fewer bone bruises cross the physis and extend into the metaphysis than did the SM group for both the tibia (25% vs 85%, respectively; P < .0001) and the femur (4% vs 42%; P < .0001). The most common patterns observed in the SI group were type IIICa in the tibia (medial/lateral and central, not extending into the metaphysis: 42%) and type Ia in the femur (lateral, not extending into the metaphysis: 59%). Conclusion: The data from this study shows that patients with an open physis at the occurrence of an acute ACL rupture have unique bone bruise patterns as compared with those with a closed physis. In the SI patients, the bone bruise pattern is significantly less frequently observed in the tibial and femoral metaphysis.

Foot and ankle injuries are one of the most common injuries within the athletic population. For masters athletes, years of repetitive motions inevitably contribute to degeneration of the most dependent structures of the body, the foot and ankle. As a result, competitive activity results in injuries related to stress and fatigue. Particularly, acute rupture of the Achilles tendon and/or chronic tendinopathy can lead to decreased performance and the need for operative intervention. Similarly, the plantar fascia may become irritated and inflamed and require intensive therapy or surgery for the athlete to continue high-level performance. Overuse and persistent load may cause debilitating stress fractures that are difficult to manage. Many of these conditions are managed through conservative measures and an emphasis on maintenance to control the symptoms of the respective condition. However, the masters athlete represents a unique population that may require surgical intervention once all other measures have been exhausted to allow them to continue high-level activity, even in a mature period of life.

Category: Bunion, Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a degenerative disease of the first metatarsophalangeal joint. Severe, end-stage hallux rigidus can become debilitating with surgical intervention becoming necessary once conservative measures and shoe modifications have failed. Joint salvage procedures include metatarsal phalangeal (MTP) arthrodesis and MTP arthroplasty. The purpose of this study was to assess for differences in patient reported outcomes in two cohorts who underwent fusion or joint reconstruction. Methods: This study was a retrospective review of prospectively collected data of 385 patients from an academic medical institution. Patients who underwent surgical intervention from July 2015 to November 2016 were identified based on CPT codes for MTP arthrodesis (28750) and arthroplasty (28293). We extracted outcome scores including SF12-M, SF12-P, FAAM, and VAS scores. Exclusion criteria included poly-trauma, revision procedures, and lack of pre and post-operative outcome scores. Mann- Whitney t-test was performed using GraphPad Prism version 7.0b for Mac to compare procedure groups, with significance define by a p-value of 0.05. Results: A total of eighteen patients met the inclusion criteria, with 6 who underwent arthroplasty and 12 arthrodesis. The average age was 63.7 amongst the cohort, with a total of 16 female and 2 males. Patients who underwent arthrodesis had better outcomes across all parameters. When comparing preoperative and postoperative scores, arthrodesis patients showed greater improvement of SF12-M (arthrodesis 9 vs arthroplasty -2, p=0.05), and SF12-P (9 vs -16, respectively p=0.05) scores. Arthroplasty patients were more likely to have a decrease in their SF-12 scores. VAS scores and FAAM scores showed no statistical difference between the two cohorts. Postoperative VAS scores were worse in 33% of arthroplasty patients despite surgical intervention, compared to 10% of arthrodesis patients. Conclusion: Our results suggests that both procedures provide a statistically significant difference in pain with several patients having a Global Rate of Change that is “very much better”. However, fusion of the metatarsophalangeal joint results in improved pain and functional outcomes for patients with severe hallux rigidus. These findings are consistent with current reports in the literature, which are mostly case series reports. Larger studies are needed to provide appropriate power and better support the findings of this study.

Category: Sports Introduction/Purpose: Injuries to the ankle syndesmosis are commonly seen in the general population as well as in athletes [1]. Literature is mixed on the effectiveness of the two fixation techniques – rigid screw and suspensory fixation [2]. Specifically, data is lacking in an athletic population. Hypothesis: We hypothesize that in patients treated with rigid screw fixation, athletes will have a higher incidence of hardware-associated pain, screw breakage, and screw removal compared to non-athletes. Methods: This study was a retrospective review of a patients from eight orthopedic surgeons within the UPMC system. All patients underwent surgical stabilization of the ankle syndesmosis with a rigid screw. Exclusion criteria included age 45 years, polytrauma, injury to the ankle articular surface, neurological impairment, chronic medical conditions, and other disabilities. Athlete status was assigned based on mention of participation in athletic activity at the high school level or higher in the electronic medical record. The incidence of hardware-associated pain, screw breakage, and screw removal in athletes vs. non- athletes were evaluated using chi-squared and fisher’s exact tests. tests. Results: Fifty-five patients met the eligibility criteria. Of these patients, 21 athletes were identified with 34 being non-athletes. In terms of patient characteristics, the athlete group was 90% male, 48% right sided injury, and with an average age of 26.6 (SD 6.8). The non-athlete group was 59% male, 47% right sided injury, and with an average age of 33.6 (SD 6.6). Athletes were observed to have higher incidence of hardware-associated pain (6 (29%) vs. 6 (18%), p=0.341), screw breakage (8 (38%) vs. 8 (24%), p=0.248), and screw removal (19 (90%) vs. 23 (68%), p=0.100) compared to non-athletes in this study. However, only the comparison for screw removal approached statistical significance. Conclusion: The results suggest that even in an age matched population, athletes may have higher incidence of screw removal. This study did not have sufficient power to demonstrate a statistical difference in hardware-associated pain or screw breakage, although these did occur at a higher rate in the athlete population. A larger study will be needed to demonstrate statistical significance. Nevertheless, these results suggest that it may make sense to use the suspensory fixation method in athletes in order to avoid a second surgery for hardware removal.

Category: Lesser Toes, Midfoot/Forefoot, Sports Introduction/Purpose: Treatment of fractures to the 5th metatarsal metaphyseal-diaphyseal junction, known as Jones’ fractures, can present challenges in the elite athlete significantly prolonging return to play. Non-operative treatments in elite athletes result in a high incidence of nonunion and secondary fracture. Primary screw fixation remains the standard of care for athletes. However, delayed union and nonunion are still very common despite surgical fixation due to the fracture occurring in a watershed area with decreased healing potential. Bone marrow aspirate concentrate (BMAC) is an autologous source of hematopoeitic and mesenchymal stem cells that has been used in the treatment of poor healing fractures. We hypothesize that open reduction internal fixation (ORIF) augmented with BMAC will improve patient-reported outcome measures following Jones’ fractures in athletes. Methods: This study was a retrospective review of elite athletes that underwent intramedullary screw fixation augmented with BMAC for Jones’ fractures at an academic medical institution. All patients were assessed preoperatively and postoperatively to determine their pain outcomes based on their visual analog score (VAS). Student’s t test was used in statistical comparison of the preoperative and postoperative outcome scores. P < 0.05 was considered significant. Results: A total of 16 elite athletes were treated with ORIF with BMAC for a Jones fracture with a mean age of 22.2 years (range 19–26). There were 9 males and 7 females included in the study. Type of athlete ranged across various sport activities, with all patients functioning at a collegiate and/or professional level of elite athletics. The mean visual analog score for pain decreased from 6.2 preoperatively (range 3-8) to 2.75 postoperatively (range 1-6 p = 0.06). All patients have returned to elite competitive sport activity with reports of minimal to no pain. Conclusion: Intramedullary screw fixation of Jones’ fractures with BMAC results in optimal surgical outcomes in the elite athlete. A higher powered and long-term study with validated patient-reported outcomes is needed to confirm our observations.

Even with the most accurate individualized, anatomic approach to anterior cruciate ligament (ACL) reconstruction, the potential for graft failure still exists, with reported retear rates as low as 5%, and even higher in female athletes or patients reconstructed with allograft. ACL graft healing is dependent on several factors, including anatomic placement, appropriate graft choice, proper technique, recovery time, and the biological environment of nature. If the double-bundle concept is followed and individualized for each patient's anatomic morphology, the ACL will biologically reform. The use of adult stem cells may help to contribute to the biological environment and aid in a faster healing time and quicker return to the preoperative state. There is a need for long-term studies and further research in human models to determine the optimal indication and environment for tissue healing with stem cell treatment.

Single-stage revision total knee arthroplasty has become an increasingly common treatment option for patients with failed knee prostheses. Periprosthetic knee infection is the leading and most devastating cause of revision total knee arthroplasty. Although periprosthetic knee infection has been extensively studied in the orthopaedic literature, the role of single-stage revision total knee arthroplasty for the treatment of periprosthetic knee infection warrants further research. As healthcare reform shifts from a volume-based to a value-based system, it is imperative that orthopaedic surgeons understand the procedural indications, risks, and benefits of single-stage revision total knee arthroplasty.

Two-stage revision total knee arthroplasty (TKA) is the standard of care for patients who require a revision procedure for the mangement of a late or chronic periprosthetic knee infection. A careful examination of two-stage revision TKA is warranted as the number of patients who require revision TKA in the United States continues to rise. Surgeons should understand the intricacies involved in two-stage revision TKA, including the indications, procedural variations, and current deliberations on two-stage revision TKA in the literature. Surgeons also should understand the alternative treatments for periprosthetic knee infections.

INTRODUCTION Hip fractures are a common source of morbidity, mortality, and cost burden for elderly patients. We conducted a retrospective analysis of patients with hip fracture treated during the day or night at a rural level I academic trauma center and compared the postoperative outcomes and resource utilization for both groups. METHODS Patients aged ≥55 years with hip fractures treated with definitive surgical fixation from April 2011 to April 2013 were included in this study. Patients who underwent surgery between 7 AM and 5 PM were included in the day cohort, while those who underwent surgery between 5 PM and 7 AM were included in the night cohort. A total of 441 patients met the study inclusion criteria. RESULTS Comparison of the baseline characteristics of the two cohorts did not demonstrate significant variance. Although postoperative outcomes and resource utilization trends varied between the day and night cohort, only in-hospital cost was significantly higher in the day cohort (P = 0.04). Postoperative variables, including blood loss, [INCREMENT]hematocrit level, length of surgery, length of stay, time to surgery, in-hospital mortality, and 30-day readmission, did not vary significantly. CONCLUSION Our study demonstrates a significantly higher cost associated with hip fracture procedures performed between 7 AM and 5 PM. In addition, perioperative blood loss and length of surgery were used as markers of physician fatigue; however, no statistically significant difference among these variables was found between hip fracture intervention performed during the day versus at night. LEVEL OF EVIDENCE III, retrospective observational study.

Objectives: Lisfranc injuries are increasingly common among athletes. Tarsometatarsal joint injuries often damage the articular cartilage and increase predisposition for post-traumatic arthritis and functional deformity of the midfoot. Injury-related morbidity in athletes has substantial consequences such as decreased performance and earlier retirement from sports. While open reduction and internal fixation (ORIF) has been established as the standard of care for unstable Lisfranc injuries, there is currently no consensus regarding the optimal technique for stabilization. Extra-articular fixation has been described as a reasonable technique for Lisfranc joint stabilization due to avoidance of iatrogenic articular disruption and subsequent morbidity. The purpose of this study was to assess the pre- and post-operative patient-reported outcomes of athletes with Lisfranc injuries following ORIF using an extra-articular dorsal locking plate. Methods: Following Institutional Review Board (IRB) approval, data was collected prospectively using an institution-based patient-reported outcomes registry. The registry was queried for patients who had undergone open treatment for tarsometatarsal dislocation (CPT 28615) between April 2015 and August 2018. Medical records were reviewed for the following criteria: athlete, 15 - 45 years of age, Lisfranc injury, ORIF, extra-articular dorsal locking plate, and completion of both pre- and post-operative outcomes surveys. 10 athletes were identified. The surveys used were as follows: VAPS, PASS, PROMIS-M, PROMIS-P, SF12-M, SF12-P, FAAM-ADL and FAAM-Sports. A comparison of pre- and post-operative outcomes was performed using paired t-tests. Statistical significance was defined as a p-value Results: 10 athletes (5 male, 5 female) with an average age of 18.2 years were analyzed. Sports included football, gymnastics, soccer, hockey, and basketball. Competition levels included high school and college. All athletes had scheduled hardware removal between 3 - 5 months (average 4.4 months) after the initial ORIF. The FAAM-ADL scores (Δ42.49, p Conclusion: In athletes, extra-articular dorsal plate fixation of the Lisfranc joint demonstrates improvement in post-operative patient reports of function. Broad-statistical significance across all patient-reported measures was likely limited due to the number of participants. Patient-reported outcomes may serve as a guide to assess athlete progress during the post-operative period. Further studies are needed to compare the long-term outcomes of Lisfranc injuries in athletes following various methods of fixation.

Patient-centered care (PCC) is gaining considerable momentum among health care professionals and policy-making authorities. The need for PCC stems from the innumerable benefits of adopting such a system. The practice of PCC in orthopedic surgery in general, and in total joint replacement in particular, is still in its youth. However, present literature already establishes the need for applying PCC in total joint replacement. Extensive research and effort should be invested to better grasp and define the dimensions of PCC as they relate to total joint replacement.

Surgical site infection in total joint arthroplasty is a challenging complication that warrants discussion with regard to prevention and management. Limiting postoperative infection rate is a paramount quest in the orthopedic community. Several preoperative risk factors have been identified in orthopedic literature with regards to likelihood of developing postoperative infection. This article evaluates several factors that predispose total joint arthroplasty patients to infection. Methods of patient surgical preparation designed to decrease postoperative infection, decreasing intraoperative traffic during procedural settings, and elaborate intraoperative prophylactic advancements are assessed. Approaches to decrease postoperative infection by discussing means of lowering rates of postoperative transfusion, wound drainage, and hematoma formation are analyzed.

Within the past 3 decades, a recent trend in the growth of musculoskeletal service lines has been seen nationally. Orthopedics offers an appealing concourse for implementation of service-line care. Within this review, the authors address the components involved in planning and building a musculoskeletal service line. The authors also address methods by which orthopedic surgeons can maintain the efficacy of their service lines by examining how orthopedic surgeons can navigate their service line through recent advents in health care reform. Finally, the authors review successful examples of musculoskeletal service lines currently in practice within the orthopedic community.

The US health care system has been fragmented for more than 40 years; this model created a need for modification. Sociopoliticomedical system-related factors led to the Affordable Care Act (ACA) and a restructuring of health care provision/delivery. The ACA increases access to high-quality "affordable care" under cost-effective measures. This article provides a comprehensive review of health reform and the motivating factors that drive policy to empower arthroplasty providers to effectively advocate for the field of orthopedics as a whole, and the patients served.

Hospital readmission is a focus of quality measures used by the Center for Medicare and Medicaid (CMS) to evaluate quality of care. Policy changes provide incentives and enforce penalties to decrease 30-day hospital readmissions. CMS implemented the Readmission Penalty Program. Readmission rates are being used to determine reimbursement rates for physicians. The need for readmission is deemed an indication for inadequate quality of care subjected to financial penalties. This reviews identifies risk factors that have been significantly associated with higher readmission rates, addresses approaches to minimize 30-day readmission, and discusses the potential future direction within this area as regulations evolve.

As health care reforms continue to improve quality of care, significant emphasis will be placed on evaluation of orthopedic patient outcomes. Total joint arthroplasty (TJA) has a proven track record of enhancing patient quality of life and are easily replicable. The outcomes of these procedures serve as a measure of health care initiative success. Specifically, length of stay, will be targeted as a marker of quality of surgical care delivered to TJA patients. Within this review, we will discuss preoperative and postoperative methods by which orthopedic surgeons may enhance TJA outcomes and effectively reduce length of stay.

Osteolysis is a process mounted by the host immune system that relies on several variables, including patient-related factors, type of insert material, modes of wear, and implant design. Imaging techniques such as radiography, computed tomography (CT) scans, magnetic resonance imaging (MRI), and tomosynthesis aid in diagnosing osteolysis. Surgical options for the treatment of osteolysis include the insertion of bone grafts, bone cement, and prosthetic augmentation. Although no approved pharmacological therapies for the specific treatment of osteolysis exist, the use of bisphosphonates and statins decreases the risk of osteolysis.

Different biomechanical designs are incorporated into various total knee arthroplasty (TKA) implants. The posterior-stabilized prosthesis design utilizes a polyethylene post and femoral cam in place of the posterior cruciate ligament. This produces a more stable component interface, increased range of motion, and potentially a less technical procedure. This study aimed to assess the short-term (>2 year) outcomes associated with the Vega System posterior-stabilized knee prosthesis (Aesculap Implant Systems, Center Valley, Pennsylvania) based on postoperative radiographs using the Knee Society Roentgenographic Evaluation and Scoring System (KSRESS). Thirty-seven TKA patients who had received the Vega posterior-stabilized knee prosthesis and had postoperative radiographs at each follow-up for a minimum of 2 years were enrolled, retrospectively. Two independent observers evaluated the radiographs using KSRESS. Descriptive statistics were used to analyze the data. The average age and body mass index of patients enrolled was 67 years (range, 51–89 years) and 38.5 kg/m 2 (range, 21.2–54 kg/m 2 ), respectively. Patients had radiographic follow-up for an average of 36 months (range, 24–58 months). Comparison between first and last available postoperative radiographs revealed a stable femoral and tibial interface with no significant change in prosthesis alignment over the follow-up period. Assessment of the short-term survivorship of the Vega posterior-stabilized prosthesis using KSRESS revealed no significant change in alignment after 2 years of follow-up; however, mid- to long-term studies assessing this junction are needed. A future prospective study using KSRESS in combination with clinical follow-up is recommended to allow comparison of the Vega posterior-stabilized to other prostheses. [ Orthopedics . 2016; 39(3):S56–S60.]

With the large number of total knee arthroplasties being performed and expectations that these numbers will be on the rise over the coming decades, efforts to provide cost-efficient care are of greater interest. The preferred design of knee arthroplasty implants has changed over time, with the original all-polyethylene tibial (APT) design being replaced by metal-backed tibial (MBT) components, as well as more recent considerations of newer APT designs. Modern APT components have been shown to have similar or superior outcomes than MBT components. Despite their limitations, APT components can be used to reduce the economic burden to the provider, medical institution, and health care system as a whole. There is a paucity of evidence-based literature directly comparing the cost associated with APT and MBT components. The purpose of this report is to review the literature to assess the available data regarding direct and indirect costs of both designs so that orthopedic surgeons can account for economic differences in everyday practice. [ Orthopedics . 2016; 39(3):S61–S66.]

Acrylic bone cement has a variety of applications in orthopedic surgery. Primary uses in total arthroplasties are limited to prostheses fixation and antibiotic delivery. With the large number of total joint arthroplasties expected to continue to rise, understanding the role bone cement plays in the success of total joint arthroplasty can have a significant impact on daily practice. The literature is inconclusive on whether cemented or cementless fixation technique is superior, and choice of fixation type is mainly determined by surgeon preference and experience. Surgeons should understand that if poor techniques exist, short-term outcomes of the replaced joint may be at risk. Statement of clinical significance: This article attempts to clarify some points of bone cement use through a review of the mechanical properties related to bone cement, a comparison to alternative materials, influence of additives, and the effects on surgical outcomes. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:737-744, 2016.

Category: Ankle Arthritis Introduction/Purpose: Ankle arthritis can be a debilitating disease that results in decreased daily activity and chronic morbidity. Many patients elect for surgical intervention to minimize pain and improve function. To curb costs associated with the increasing demand for total joint arthroplasty (TJA) in the growing elderly Medicare population, CMS announced the Comprehensive Care for Joint Replacement (CJR) model, which included total ankle arthroplasty. To provide continued quality care and cost containment, it is necessary to determine the optimal surgical intervention for patients that could fall within the CJR program. Therefore, we sought to determine the impact of surgical fixation on functional outcomes, systemic utilization, and medical expenditures for patients with ankle arthritis. Methods: We reviewed a prospectively collected and maintained database to identify all patients who underwent a total joint replacement from April 2016 to September 2017. Patients were identified based on DRG codes for primary arthritis of a lower extremity joint, then specifically for foot and ankle, as well as CPT codes for ankle arthroplasty (27702) or ankle arthrodesis (27870/28725). Functional outcomes were assessed based on insurance type. The cohorts were matched for age, comorbidities, and gender. Statistical analysis was performed using chi-squared and paired t-test to assess for differences in patient reported outcomes. Descriptive statistical analysis was used to assess for differences in cost between the cohorts. Results: A total of 573 patients were included.There were 48 replacements and 47 fusions. Arthrodesis procedures costs approximately $6,500 less per case than the system costs for patients who underwent arthroplasty procedures. The average length of stay for patients who underwent total ankle arthroplasty was 1.6 days compared to outpatient surgical centers utilized for most arthrodesis patients. Overall, patients reported improved pain and a 30.96 increase in FAAM scores. Most patients had a global rate of change that was “very much better” or “much better” (68%). Based on insurance type, patients who underwent a total ankle replacement in the CJR program had improved outcomes and lower cost than patients commercially insured. Conclusion: With the CJR, there is greater emphasis on the optimal intervention for elective operations. There should be coordinated efforts to optimize quality care, while minimizing financial waste within the healthcare system. The price differential suggests an annual potential for financial savings as high as $325,000 for a system that supports intervention for ~50 cases per year. As such, these results suggest that arthroplasty may be optimal for patients with severe symptomatic ankle arthritis, while most patients have adequate relief with an ankle fusion. More importantly, quality improvement efforts should focus on the impact of surgical intervention on functional activity.

The menisci homogenously distribute load throughout the knee joint. Partial or total removal of the menisci significantly alters the biomechanical properties of the knee, leading to osteoarthritis and articular cartilage (AC) degeneration. Many synthetic and natural materials have been tested to find a scaffold that can withstand the natural mechanical forces on the joint. However, currently there are few meniscus tissue (MT) replacements available for clinical use. This review addresses tissue engineering (TE) of the meniscus, with a primary focus on tissue engineered scaffolds (TESs) as current and future models for meniscus replacement. Our review also discusses implant fixation, an area which we believe must be improved in order for meniscal replacements to be successful in vivo.

Category: Bunion Introduction/Purpose: As the hallux valgus deformity progresses, patients can get mild to moderate arthritis of the metatarsophalangeal (MTP) joint. The degenerative process of MTP arthritis results in reactive tissue formation and proliferation of osseous and cartilaginous structures. For some patients, the results in dorsal bone spurs and pain with great toe dorsiflexion of irritation from shoes. Reconstructive procedures provide a surgical option for patients to address pain and functional limitations, prior to subchondral bone cyst formation and loss of joint space. Patients who underwent cheilectomy alone have been shown to have a high failure rate and progress to advanced disease. A phalangeal dorsiflexion osteotomy has become increasingly more popular amongst foot and ankle surgeons with the hopes of decreasing failure rate and improving early outcomes. Methods: This study was a retrospective review of prospectively collected data from 385 patients treated for hallux rigidus at a large academic medical center between July 2015 and November 2016. All patients underwent either a cheilectomy or cheilectomy with phalangeal osteotomy of the MTP joint. Collected patient reported outcomes (PROs) included in this study were SF12 M, SF12P, FAAM, VAS and PASS scores. Mann-Whitney t-test was performed using GraphPad Prism version 7.0b for Mac to compare procedure groups. Exclusion criteria included poly-trauma, revision of same procedure, and lack of pre or post- operative. Results: Eighteen patients met criteria, 8 underwent cheilectomy and 10 had a cheilectomy with osteotomy procedure. The average age was 51.9 amongst the cohort, with a total of 13 female and 5 males. Patients who underwent cheilectomy with osteotomy procedure had better outcomes across all outcome measure scores. When comparing postoperative scores, cheilectomy with osteotomy patients showed significantly higher scores compared to cheilectomy alone patients: SF12-M (56 vs 36, respectively; p=0.0333), and SF12P (52 vs 30, respectively p=0.0095). VAS scores and FAAM scores showed no statistical difference between the two cohorts. Despite surgical intervention, 50% of patients who received cheilectomy alone reported more pain post-operatively compared to no reports of worsening pain in patients who received cheilectomy with osteotomy. Conclusion: Patients with moderate to severe hallux rigidus demonstrate improved functional outcomes with phalangeal osteotomy in conjunction with cheilectomy compared to cheilectomy alone. Further research with larger cohorts would be beneficial to confirm the reports of this study and expand upon aspects of care that contribute to patient satisfaction and performance.

Background Women and minorities remain underrepresented in orthopaedic surgery. In an attempt to increase the diversity of those entering the physician workforce, Nth Dimensions implemented a targeted pipeline curriculum that includes the Orthopaedic Summer Internship Program. The program exposes medical students to the specialty of orthopaedic surgery and equips students to be competitive applicants to orthopaedic surgery residency programs. The effect of this program on women and underrepresented minority applicants to orthopaedic residencies is highlighted in this article. Questions/purposes (1) For women we asked: is completing the Orthopaedic Summer Internship Program associated with higher odds of applying to orthopaedic surgery residency? (2) For underrepresented minorities, is completing the Orthopaedic Summer Internship Program associated with higher odds of applying to orthopaedic residency? Methods Between 2005 and 2012, 118 students completed the Nth Dimensions/American Academy of Orthopaedic Surgeons Orthopaedic Summer Internship Program. The summer internship consisted of an 8-week clinical and research program between the first and second years of medical school and included a series of musculoskeletal lectures, hands-on, practical workshops, presentation of a completed research project, ongoing mentoring, professional development, and counselling through each participant’s subsequent years of medical school. In correlation with available national application data, residency application data were obtained for those Orthopaedic Summer Internship Program participants who applied to the match between 2011 through 2014. For these 4 cohort years, we evaluated whether this program was associated with increased odds of applying to orthopaedic surgery residency compared with national controls. For the same four cohorts, we evaluated whether underrepresented minority students who completed the program had increased odds of applying to an orthopaedic surgery residency compared with national controls. Results Fifty Orthopaedic Summer Internship scholars applied for an orthopaedic residency position. For women, completion of the Orthopaedic Summer Internship was associated with increased odds of applying to orthopaedic surgery residency (after summer internship: nine of 17 [35%]; national controls: 800 of 78,316 [1%]; odds ratio [OR], 51.3; 95% confidence interval [CI], 21.1–122.0; p < 0.001). Similarly, for underrepresented minorities, Orthopaedic Summer Internship completion was also associated with increased odds of orthopaedic applications from 2011 to 2014 (after Orthopaedic Summer Internship: 15 of 48 [31%]; non-Orthopaedic Summer Internship applicants nationally: 782 of 25,676 [3%]; OR, 14.5 [7.3–27.5]; p < 0.001). Conclusions Completion of the Nth Dimensions Orthopaedic Summer Internship Program has a positive impact on increasing the odds of each student participant applying to an orthopaedic surgery residency program. This program may be a key factor in contributing to the pipeline of women and underrepresented minorities into orthopaedic surgery. Level of Evidence Level III, therapeutic study.