Introduction: Private equity (PE) has had an increasing influence in health care, including procedural subspecialties such as orthopaedic surgery. No studies yet have characterized the orthopaedic practices that are acquired by PE firms. Methods: This cross-sectional study analyzed PE acquisitions of orthopaedic practices in the United States between January 1, 2016, and December 31, 2023. A combination of PitchBook and manual web searches was used to identify PE acquisitions. The Medicare Data on Provider Practice and Specialty were used to identify Tax Identification Numbers of practices and the unique providers of each practice at time of affiliation. Results: Eighty-nine orthopaedic practices were identified from 2016 to 2023, accounting for 4.8% of orthopaedists by 2023. More than three-quarters of acquisitions took place from 2021 to 2023 (77.5%). Nearly half of acquisitions were in the South (47.2%). At time of acquisition, 36.6% of providers in the practices were surgeons, 10.0% were nonsurgical physicians, and 53.4% were ancillary providers, such as advanced practice providers and therapists. The most represented subspecialties included sports (24.8%) and arthroplasty (18.2%), and the least represented were pediatrics (0.7%) and tumor (0.3%). Conclusion: PE involvement in orthopaedics skyrocketed in 2021. Practices targeted by PE firms typically included a multidisciplinary mix of providers, more than half of whom were nonphysician adjuncts, with a geographic predilection for the South. Orthopaedic subspecialties with historically higher reimbursements and outpatient volumes were overrepresented in PE-acquired practices. Future work should examine the resulting influence of PE in orthopaedics, including provider turnover, practice patterns, and clinical outcomes. Level of Evidence: Level III . See Instructions for Authors for a complete description of levels of evidence.
Background: Those who live in rural areas generally exhibit higher prevalence of musculoskeletal conditions than urban populations. Already limited access to local orthopaedic care is becoming more challenging, as orthopaedic surgeons in these areas tend to be older and nearing retirement, while few graduating residents are selecting rural practice. However, little data exist on why orthopaedic residents are not choosing rural practice despite the clear need. Methods: A 22-question survey was created in REDCap. A letter of invitation to participate was sent to interested program directors through the AOA Collaborative Orthopaedic Education Research Group (COERG). Questions included those related to community of origin, level of interest in rural practice, and areas in which more information is needed. Results: One hundred seven orthopaedic surgery residents from 16 programs completed the survey. Only 6 respondents plan to practice in rural areas. Thirty-two reported no interest in rural practice. Sixty-nine respondents were unsure about rural practice. No significant differences in rural interest were found based on gender or parental status. The only demographic factor impacting interest in rural practice was coming from a rural background. Factors leading to interest or disinterest in rural practice were similar. Those indicating that they were unsure wanted more information regarding impact on families, call, compensation, and case volume and complexity. Conclusion: Addressing the gap in rural orthopaedic care is complex, but there are opportunities such as outreach to rural students to encourage them to consider medicine and then orthopaedic surgery as a career, as well as education sessions and rotations during residency training to expand rural interest. Clinical Relevance: Understanding the factors that lead to orthopaedic residents pursuing (or not) practice in rural areas is important in addressing access to musculoskeletal care in these areas.
Background: This study compared femoral-canal administration of tranexamic acid (TXA), which is a modified intraosseous regional administration (IORA) technique, with intravenous (IV) TXA and combined IORA+IV-TXA across prosthesis designs in tourniquet-assisted, manual total knee arthroplasty (TKA). Methods: This single-center study comprised 2 consecutive prospective, randomized, placebo-controlled, triple-blind cohorts: a previously reported cruciate-retaining (CR) cohort followed by a posterior-stabilized (PS) cohort. Within each cohort, patients undergoing primary, unilateral, manual TKA were randomized to IORA-TXA, IV-TXA, or IORA+IV-TXA. The primary outcome was total blood loss (TBL). Secondary outcomes included transfusion, inflammatory and coagulation markers, pain, knee function, and complications. Pooled and prosthesis-stratified analyses were performed, including treatment-by-prosthesis interaction testing. Results: Among 202 randomized participants (mean age, 69.1 years [SD, 6.5]; 162 women [80%]; CR, 97; PS, 105), TBL differed significantly among groups. Compared with IV-TXA (578.7 ± ±277.4 mL), TBL was lower with IORA-TXA (429.2 ± 293.9 mL, p = 0.010) and IORA+IV-TXA (354.3 ± 252.1 mL, p < 0.001). The treatment-by-prosthesis interaction for TBL was not significant (p = 0.289). Transfusion occurred in 1 participant in the IV-TXA group and none in the IORA-TXA or IORA+IV groups. Statistically significant differences were observed in the selected early inflammatory and clinical outcomes, primarily involving the combined regimen; however, these differences did not translate into clinically meaningful differences in pain scores, range of motion, or KOOS-JR scores by 90 days. No statistically detectable differences in complications were observed. Conclusions: In tourniquet-assisted manual TKA, femoral-canal IORA-TXA reduced TBL compared with IV-TXA, and IORA+IV-TXA showed the lowest mean TBL. These findings should be interpreted within the pre–tourniquet-release IV-TXA protocol; evidence was insufficient to establish corresponding reductions in transfusion or clinically meaningful functional benefits by 90 days. Level of Evidence: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
Background: Across the female lifespan, the incidence of anterior cruciate ligament (ACL) tears has demonstrated a bimodal age distribution, and this may be related to fluctuating lifetime estrogen. However, this relationship—and the role of hormone replacement therapy (HRT) and its potentially modifying effect on ACL tear risk—has been underreported. The purpose of this study was to (1) characterize the ACL tear risk pattern in women compared with men in a national database and (2) assess the relationship between HRT and the risk of ACL tear among midlife women. Methods: A retrospective cohort study was conducted using the Merative © MarketScan Commercial database. The data set was queried for women 40 to 55 years of age with insurance claims between January 1, 2019, and December 31, 2023. The exposure of interest was any systemic supplemental estrogen. The primary outcome was any ACL tear following the index date. The nearest neighbor 5:1 propensity score was used to generate matched groups with and without exposure to supplemental estrogen. Results: Of 384,582 included individuals, 16,751 were taking HRT. Analysis of aggregate ACL tear events, normalized by person-time, demonstrated a bimodal distribution in women, with peaks during adolescence (16-20 years old) and midlife (40-50 years old). Conditional logistic regression analysis demonstrated that women in the supplemental estrogen-exposed group had a significantly higher risk of any ACL tear (OR: 1.26, 95% CI: 1.02-1.55) and ACL reconstruction (OR: 1.5, 95% CI: 1.07-2.11) compared with the control group. Conclusions: Estrogen-containing HRT was associated with significantly increased risk of ACL tear when controlling for age, comorbidities, and perimenopausal or menopausal status. The relationship between HRT and ACL tear risk is likely multifactorial, and these findings support the need for further prospective studies to better characterize this relationship. Level of Evidence: Level III —Retrospective, observational cohort. See Instructions for Authors for a complete description of levels of evidence.
Background: Calcific myonecrosis is a benign sequela of limb trauma most commonly affecting the lower leg decades after initial injury. This study aimed to systematically review the literature published on the topic and add another case to the existing body. Methods: A search of the PubMed, Embase, and Web of Science databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eligible studies were assessed for quality, and data on study characteristics, patient information, and outcomes were collected. Results: Forty studies were included in the final review, comprising data from 61 patients with 65 total masses. The mean age at presentation was 63.0 ± 12.5 years with a male predominance (80.3%). Most lesions (n = 56) occurred in the lower leg, and 90% of patients had a prior trauma with average latency of 39.4 ± 15.6 years. Of the 65 masses, 16 were treated non-operatively, 4 with biopsy only, 22 with surgery only, and 23 with biopsy and surgery. Common presenting symptoms were a progressively enlarging (n = 39) or stable (n = 8) mass, pain (n = 22), or infection-associated symptoms (n = 24). The complication rate was 40.7% after biopsy and 28.9% after surgery. Non-operative management was not associated with complications. Conclusions: Nonoperative management is recommended for asymptomatic calcific myonecrosis, and biopsy should be avoided due to high associated complication rate. Further research should aim to build the body of literature on this rare condition to enable high quality statistical analyses in the future.
