Background The disparity between surgical demand and clinician availability in low- and middle-income countries (LMIC) represents a global health challenge, contributing to preventable morbidity and mortality. Although non-profit organizations can perform short-term outreach trips to address immediate needs, their temporary nature may fail to achieve sustained impact. Formal capacity building initiatives, which aim to empower local health systems to independently address unmet surgical demands are needed. This study aims to 1) identify the barriers/facilitators to capacity building in orthopaedic surgical outreach and 2) match targeted implementation strategies that can enhance the effectiveness of these initiatives. Methods We conducted semi-structured interviews with 20 stakeholders from LMIC and high-income countries (HIC) from six organizations with experience in over 44 countries to identify barriers/facilitators to implementation of capacity building initiatives. Interview transcripts were analyzed using the Consolidated Framework for Implementation Research (CFIR). The Expert Recommendations for Implementing Change (ERIC) mapping tool was used to match barriers with implementation strategies. We subsequently conducted a modified nominal group technique with a consortium of seven surgeons with global surgical outreach expertise to evaluate each strategy's feasibility, cross-context applicability, and prioritization. Following discussions, panelists independently voted on the strategies, requiring a ≥80% consensus for inclusion. Results A total of 34 barriers and 31 facilitators to implementation were identified. Examples of barriers included high cost and lack of an implementation leader while facilitators included longitudinal partnerships and access to technology. 38 strategies were matched to these barriers. Examples of strategies include identify and prepare champions, conduct educational meetings, and conduct local needs assessments. Conclusions This study highlights common barriers to the implementation of capacity building efforts in global surgical outreach and provides a strategy matching tool for capacity building initiatives. Utilization of these strategies improve implementation, ultimately supporting the long-term success and effectiveness of capacity building in LMIC.

Purpose Surgical options are limited for distal humerus and proximal ulna injuries with articular bone loss in physiologically young patients. Osteochondral grafts are a potential treatment option between open reduction internal fixation and arthroplasty that does not impart lifelong activity restrictions and has longer longevity. Feasible graft harvest sites that match the surface geometry of the distal humerus and proximal ulna are unknown. This study assesses the surface geometry of potential grafts with known well-defined donor site morbidity for the reconstruction of distal humerus and proximal ulna articular defects. Methods Osteochondral autograft harvest sites include the radial head, pisiform, trapezium, fibular head, and proximal and distal phalanx of the hallux. Between 2015 and 2022, 12 patients, who were in the hospital for problems unrelated to the current study and coincidentally had computed tomography (CT) scans of an intact elbow and an intact autograft harvest site, were identified at Massachusetts General Brigham. Fifteen elbow CT scans and 25 harvest site CT scans were analyzed. Three-dimensional segmentations of the graft harvest sites were constructed using Materialise (Mimics 13.0; 3-matic). The average morphological differences in surface geometry of subchondral bone between each site were quantified using surface topographic mapping. Results Viable autograft harvest sites with <2 mm difference in surface morphology for the distal humerus include hallux proximal phalanx (1.65 ± 0.85 mm), whereas for the proximal ulna include fibular head (0.72 ± 0.63 mm), radial head (1.01±0.67 mm), and hallux proximal phalanx (1.01 ± 1.19 mm). Conclusions Based on geometric characteristics, several viable osteochondral graft options exist for intra-articular injuries to the ulnohumeral joint. These findings may guide future cadaveric and in vivo studies to assess the effect of autograft reconstruction on elbow stability, elbow function, and donor site morbidity. Type of study/level of evidence Therapeutic IV.

PurposeTenosynovial biopsy at the time of carpal tunnel release affords a unique opportunity for the early diagnosis of amyloidosis. We aimed to build a risk score to stratify patients likely to have undiagnosed amyloidosis.MethodsWe conducted a prospective cohort study of 320 adult patients with carpal tunnel syndrome undergoing carpal tunnel release. Patients underwent tenosynovial biopsy at the time of surgery. The primary outcome measure was a positive biopsy for amyloid deposition as assessed by Congo red and sulfated Alcian blue staining. We generated a risk score by assigning points to each variable independently associated with a positive biopsy in a logistic regression model, with weights proportional to parameter estimates (log odds ratio).ResultsThe cohort mean age was 63 years, and 65% were female. Forty-nine out of 320 subjects (15.3%) had positive tenosynovial biopsies for amyloidosis. In the logistic regression model, independent predictors of a positive biopsy included age 70 to 79 years (odds ratio [OR] 14.6, 95% confidence interval [CI] 1.83–115.7) and age ≥ 80 years (OR 33.9, 95% CI 4.1–279.3) compared with age < 50 years, male sex (OR 2.6, 95% CI 1.3–5.3), and history of trigger digit (OR 2.4, 95% CI 1.2–4.9). We assigned weights proportional to the log odds ratios from the logistic model to generate a summary amyloidosis risk score based on age, sex, and history of trigger digit. A score of 0 corresponds to 2.5% risk and 6 to 75% risk.ConclusionsThe likelihood of a positive biopsy for amyloidosis is independently associated with older age, male sex, and history of trigger digit.Clinical relevanceA routine biopsy strategy maximizes sensitivity for the early detection of amyloidosis with a 15% positive biopsy rate. We furthermore present a risk score for a selective biopsy strategies with associated sensitivities and specificities.

Resident education is critical in the development, growth, and recruitment of young surgeons into the field of hand surgery. However, the increased emphasis on efficiency and productivity in clinical care, growth of hand fellowships, and wide-awake hand surgery can pose specific challenges to resident education. In this review, we explore barriers to resident education in hand surgery and discuss opportunities for improvement. We also provide a list of updated resources for resident education in hand surgery and review best practices in resident education to help educators and trainees alike.

Orthopaedic surgery is the least diverse surgical specialty based on race and ethnicity. Pediatric orthopaedics has become more diverse than other orthopaedic subspecialties, but there remains room for improvement. Strategies to improve diversity in orthopaedics focus on diversifying the candidate pipeline for orthopaedic residency, reducing attrition among residents from diverse backgrounds, creating supportive and enriching work environments for all team members, and promoting data-driven diversity initiatives. All of these are underpinned by the belief, supported by recent interdisciplinary research, that diverse teams improve decision-making, support employee retention and satisfaction, and objectively enhance institutional performance, which can thus result in improved patient care when employed in pediatric orthopaedics. Key Concepts: (1) Both identity diversity and cognitive diversity should be considered when building teams striving for excellence and high performance. (2) Research on patient perceptions and preferences supports having a diverse physician workforce. (3) Discrimination, harassment, and bullying occur in the workplace for professionals who are underrepresented in medicine. (4) Orthopaedics has an upstream pipeline and retention problem. Pediatric orthopaedics appears relatively better in gender representation, but racial/ethnic diversity remains limited, and leadership representation lags behind membership demographics. (5) Data-driven strategies to design, implement, and evaluate diversity, equity, and improvement initiatives are in line with traditional evidence-based decision-making and the use of professional expertise to advance our profession.

Background: Surgical outreach to low- and middle-income countries (LMICs) by organizations from high- income countries is on the rise to help address the growing burden of conditions warranting surgery. However, concerns remain about the impact and sustainability of such outreach. Leading organizations (e.g., the World Health Organization) advocate for a capacity-building approach to ensure the safety, quality, and sustainability of the local health-care system. Despite this, to our knowledge, no guidelines exist to inform such efforts. We aimed to develop clinical practice guidelines (CPGs) to support capacity-building in orthopaedic surgical outreach utilizing a multistakeholder and international voting panel. Methods: We followed a modified American Academy of Orthopaedic Surgeons (AAOS) CPG development process. We systematically reviewed the existing literature across 7 predefined capacity-building domains (partnership, professional development, governance, community impact, finance, coordination, and culture). A writing panel composed of 6 orthopaedic surgeons with extensive experience in surgical outreach reviewed the existing literature and developed a consensus-based CPG for each domain. We created an international voting panel of orthopaedic surgeons and administrators who have leadership roles in outreach organizations or hospitals with which outreach organizations partner. Members individually reviewed the CPGs and voted to approve or disapprove each guideline. A CPG was considered approved if >80% of panel members voted to approve it. Results: An international voting panel of 14 surgeons and administrators from 6 countries approved all 7 of the CPGs. Each CPG provides recommendations for capacity-building in a specific domain. For example, in the domain of partnership, the CPG recommends the development of a documented plan for ongoing, bidirectional partnership between the outreach organization and the local team. In the domain of professional development, the CPG recommends the development of a needs-based curriculum focused on both surgical and nonsurgical patient care utilizing didactic and hands-on techniques. Conclusions: As orthopaedic surgical outreach grows, best-practice CPGs to inform capacity-building initiatives can help to ensure that resources and efforts are optimized to support the sustainability of care delivery at local sites. These guidelines can be reviewed and updated in the future as evidence that supports capacity-building in LMICs evolves.The global burden of disease warranting surgery is substantial, and morbidity and mortality from otherwise treatable conditions remain disproportionately high in low- and middle-income countries (LMICs) 1,2 . It is estimated that up to 2 million (about 40%) of injury-related deaths in LMICs could be avoided annually if mortality rates were reduced to the level of those in high-income countries (HICs) 3 . Despite this, progress toward improved access to safe, timely surgery in resource-poor areas has been slow. Historically, nongovernmental organizations (NGOs) have tried to address unmet surgical needs through short-term outreach trips; however, growing criticism has highlighted the limitations of short-term trips, including limited follow-up, an increased burden on the local workforce, and further depletion of local resources 4–6 . In light of ongoing concerns, public health priorities have shifted toward models that emphasize long-term capacity-building rather than short-term care delivery. Capacity-building is an approach to health-care development that builds independence through infrastructure development, sustainability, and enhanced problem-solving while taking context into account 7,8 .

INTRODUCTION:This study aimed to assess the relationship between preoperative international normalized ratio (INR) levels and major postoperative bleeding events after total shoulder arthroplasty (TSA). METHODS:The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. A final cohort of 2405 patients with INR within 2 days of surgery were included. Patients were stratified into four groups: INR ≤ 1.0, 1.0 < INR ≤ 1.25, 1.25< INR ≤ 1.5, and INR > 1.5. The primary outcome was bleeding requiring transfusion within 72 hours, and secondary outcome variables included complication, revision surgery, readmission, and hospital stay duration. Multivariable logistic and linear regression analyses adjusted for relevant comorbidities were done. RESULTS:Of the 2,405 patients, 48% had INR ≤ 1.0, 44% had INR > 1.0 to 1.25, 7% had INR > 1.25 to 1.5, and 1% had INR > 1.5. In the adjusted model, 1.0 < INR ≤ 1.25 (OR 1.7, 95% CI 1.176 to 2.459), 1.25 < INR ≤ 1.5 (OR 2.508, 95% CI 1.454 to 4.325), and INR > 1.5 (OR 3.200, 95% CI 1.233 to 8.302) were associated with higher risks of bleeding compared with INR ≤ 1.0. DISCUSSION:The risks of thromboembolism and bleeding lie along a continuum, with higher preoperative INR levels conferring higher postoperative bleeding risks after TSA. Clinicians should use a patient-centered, multidisciplinary approach to balance competing risks.

BackgroundThe presence of subjective mechanical symptoms, such as clicking or popping, is common in patients presenting for shoulder pain and dysfunction, with unclear clinical significance. The primary objective of this study was to assess whether subjective mechanical symptoms in the affected shoulder were associated with full-thickness rotator cuff tearing in a consecutive, prospective cohort of patients undergoing shoulder magnetic resonance imaging (MRI) for suspected rotator cuff pathology.MethodsA prospective cohort study was performed of 100 consecutive patients with suspected rotator cuff tendinopathy and/or tearing who underwent shoulder MRI. The presence of subjective shoulder mechanical symptoms, including clicking or popping, was documented prior to MRI. Indications for MRI included weakness on isolated testing of rotator cuff muscle(s) or symptoms refractory to conservative treatment including at least a 6-week course of physical therapy. The primary outcome variable was the presence of full-thickness rotator cuff tearing; secondary outcome variables included any (full-thickness or partial-thickness) rotator cuff tearing and biceps long head subluxation. Radiographic parameters, including critical shoulder angle, Goutallier grade, tear retraction, and tear size were quantified. One patient was lost to follow-up, and 99 patients completed MRI imaging.ResultsIn our cohort, 60% of patients reported subjective mechanical symptoms in the affected shoulder. Full-thickness rotator cuff tearing was identified in 42% of patients, any rotator cuff tearing in 69% of patients, and biceps long head subluxation in 14% of patients. Subjective mechanical symptoms were not associated with full-thickness rotator cuff tearing, any rotator cuff tearing, biceps long head subluxation, critical shoulder angle, Goutallier grade, tear size, or tear retraction. Older age was associated with full-thickness and any rotator cuff tearing. As a diagnostic test for full-thickness rotator cuff tearing, subjective shoulder mechanical symptoms has a sensitivity of 64%, a specificity of 44%, and Youden’s index of 0.08, consistent with poor diagnostic accuracy.ConclusionsSubjective mechanical symptoms in the affected shoulder are a common complaint in patients with suspected rotator cuff pathology. Patients may be reassured that a sensation of clicking or popping alone does not necessarily entail structural shoulder derangement.

BACKGROUND:Humeral nonunions have devastating negative effects on patients' upper extremity function and health-related quality of life. The objective of this study was to identify factors independently associated with 30-day complication, hospital readmission, and reoperation after surgical treatment of humeral nonunions. MATERIALS AND METHODS:A retrospective case-control study was performed using the American College of Surgeons National Surgical Quality Improvement Program database by querying the Current Procedural Terminology codes for patients who underwent humeral nonunion repair from 2011 to 2020. The study outcomes were 30-day complication, hospital readmission, and reoperation. RESULTS:Of the 1306 patients in our cohort, 135 patients (10%) developed a complication, 66 patients (5%) were readmitted to the hospital, and 44 patients (3%) underwent reoperation during the 30-day postoperative period. Multivariable logistic regression analysis showed that older age, longer operative time, partially dependent functional status, congestive heart failure, bleeding disorder, and contaminated wound classification were associated with 30-day complication after humeral nonunion repair. Older age and disseminated cancer were associated with 30-day reoperation after humeral nonunion repair. Disseminated cancer was associated with 30-day readmission after humeral nonunion repair. CONCLUSION:Using a large database over a recent 10-year period, we identified demographic and comorbid factors independently associated with episode of care adverse events after humeral nonunion repair. Patients 50 years or older had approximately three times the incidence of complications, readmissions, and reoperations in the first month after humeral nonunion repair compared with patients younger than 50 years. Our findings are relevant for preoperative risk stratification and counseling. [Orthopedics. 2024;47(4):e181-e187.].

Abstract Background In cases of proximal humeral fractures, fracture severity and the patient’s osteoporotic condition should be assessed to achieve the best possible treatment outcomes. The Tingart measurement is commonly used to assess bone quality, but it can be problematic if the measurement area is affected by the fracture. Recently, the deltoid tuberosity index (DTI) has been developed as another index to evaluate bone quality. The aim of this study was to compare the efficacy of the DTI obtained by X-ray imaging with computed tomography (CT) in assessing bone quality for proximal humeral fractures. Methods Fifteen patients with proximal humeral fractures were included, and the images were assessed twice by two independent evaluators with an interval of 1 month between each assessment. According to DTI values measured by X-ray, values greater than 1.4 were considered positive for osteoporosis, while values less than or equal to 1.4 were considered negative. The inclusion criteria were patients over 18 years old with a proximal humeral fracture who underwent anteroposterior radiography and CT. Pathological fractures, pre-existing humeral fractures, and metabolic diseases were excluded. Results There was good agreement between the CT and X-ray measurements. However, there were significant differences between them, with the CT measure being higher than the X-ray measure in 46.7% of the evaluations. The best cut-off points for diagnosing osteoporosis were found to be the same for CT and DTI: 1.4. CT diagnosis had an accuracy of 73.3%, a sensitivity of 65.2%, and a specificity of 78.4% when compared to X-ray diagnosis. False-positive diagnoses were 14.3%, and false-negative diagnoses were 13.3%. Conclusions CT can be considered a good method for diagnosing osteoporosis in proximal humeral fractures. The findings of this study allow the surgeon to use the CT as a new tool to make the diagnosis of osteoporosis and to define the patient under risk for surgical procedure.

Purpose Arthroscopy is an efficacious and popular treatment modality in developed nations for a variety of musculoskeletal conditions. However, arthroscopy requires specialized training, complex infrastructure, and expensive equipment, occasionally causing barriers to use in developing countries. Consequently, the utilization of resources to perform and teach arthroscopy in low- and middle-income countries (LMICs) is controversial. Through this investigation, we assessed the current capacity and barriers to arthroscopy use and training in these settings. Methods Focused interviews were conducted with surgeons from Haiti (low-income) and Romania (middle-income) regarding their experience with arthroscopy. Based on responses, a multiple-choice survey was developed and administered to orthopaedic trainees and practicing orthopaedic surgeons during national orthopaedics conferences in each country. Results Fifty-eight orthopaedists in Haiti, and 29 in Romania completed the survey. Most (91% from Haiti; 79% from Romania) reported that learning arthroscopy is essential or important for orthopaedic training in their country. Yet only 17% from Haiti compared to 69% from Romania indicated their primary hospital has the equipment necessary for arthroscopy. In Haiti, equipment was the main barrier to use of arthroscopy, followed by training, while in Romania, the main barrier was training, followed by equipment. Simulations and telemedicine were ranked as top choices of effective methods for learning arthroscopy. Conclusions Regardless of their country’s resource limitations, most participants place high value on the practice of arthroscopy and arthroscopic training. The results from this study highlight a hierarchy of needs in developing nations. Furthermore, local providers report a strong belief in the need for arthroscopic treatment to benefit their patients, and a clear desire for further training and development of these techniques. By identifying similarities and differences by location, we may better tailor global orthopaedic training initiatives and partnerships in LMICs.

Purpose The environmental impact of common ambulatory hand surgeries has been an area of growing interest in recent years. There were 2 objectives of this study: (1) to quantify the carbon footprint of carpal tunnel surgery and its principal driving components; and (2) to compare the carbon footprints of open carpal tunnel release (oCTR) and endoscopic carpalMethods We performed a life cycle assessment to quantify the environmental impacts of 2 surgical procedures: oCTR and eCTR. Patients were retrospectively identified by querying the eCTR procedures in 28 patients were included in the life cycle assessment. The boundaries of the life cycle assessment were the start and end times of the procedures. The environmental impacts were estimated using the carbon footprint, expressed in the equivalent mass of carbon dioxide released into the atmosphere (kgCO2-eq). The facility-related, processing-related, solid waste-related, and total kgCO2-eq were calculated.Results The average carbon footprint of carpal tunnel release was 83.1 kgCO2-eq and was dominated by processing-related and facilities-related factors. The average carbon footprint of eCTR (106.5 kgCO2-eq) was significantly greater than that of oCTR (59.6 kgCO2-eq).Conclusions Endoscopic carpal tunnel release leaves a greater carbon footprint than oCTR, and its environmental impact is dominated by facility-related and central processing-related factors.(J Hand Surg Am. 2023;48(1):46-52. Copyright & COPY; 2023 by the American Society for Surgery of the Hand. All rights reserved.)Type of study/level of evidence Economic and Decision Analyses IV.

Purpose The incidence of and associated risk factors for implant removal following the plateand-screw fixation of metacarpal shaft fractures have not been well described. The primary objective of our study was to identify implant-related radiographic parameters associated with implant removal in patients treated with the plate-and-screw fixation of isolated, displaced metacarpal fractures at 2 years of follow-up. The secondary objective of our study was to identify patient-related factors associated with implant removal. Methods A retrospective study of all patients who underwent open treatment of a metacarpal fracture with a plate-and-screw construct from January 1, 2000, to April 30, 2019, at 2 level-1 trauma centers was conducted. After the application of exclusion criteria, we identified 138 patients with a single isolated metacarpal fracture of a nonthumb digit treated with open reduction and internal fixation using a plate-and-screw construct. Our study endpoint was the removal of the plate-and-screw construct or a minimum of 2 years of follow-up without the removal of the hardware. Twenty-three patients achieved our study endpoint as determined using their electronic medical records, and 58 additional patients were reached via telephone to confirm their implant removal status. A bivariate analysis was used to screen for factors associated with implant removal, and variables significant in the bivariate screen were included in a multivariable stepwise logistic regression model. Results Twenty-three out of 81 patients (28%) in our final cohort underwent implant removal by the final follow-up visit. In the logistic regression analysis, the distance between the plate and metacarpophalangeal joint, the distance between the plate and carpometacarpal joint, and active smoking were independently associated with implant removal.Conclusions The proximity of metacarpal plates to adjacent joints is associated with subsequent implant removal. Patients may be counseled about the higher risk of implant removal when periarticular metacarpal plating is performed. (J Hand Surg Am. 2023;48(7):739.e1-e8.Copyright (c) 2023 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Prognosis IV.

Background: A growing number of nongovernmental organizations from high-income countries aim to provide surgical outreach for patients in low- and middle-income countries in a manner that builds capacity. There remains, however, a paucity of measurable steps to benchmark and evaluate capacity-building efforts. Based on a framework for capacity building, the present study aimed to develop a Capacity Assessment Tool for orthopaedic surgery (CAT-os) that could be utilized to evaluate and promote capacity building. Methods: To develop the CAT-os tool, we utilized methodological triangulation—an approach that incorporates multiple different types of data. We utilized (1) the results of a systematic review of capacity-building best practices in surgical outreach, (2) the HEALTHQUAL National Organizational Assessment Tool, and (3) 20 semistructured interviews to develop a draft of the CAT-os. We subsequently iteratively used a modified nominal group technique with a consortium of 8 globally experienced surgeons to build consensus, which was followed by validation through member-checking. Results: The CAT-os was developed and validated as a formal instrument with actionable steps in each of 7 domains of capacity building. Each domain includes items that are scaled for scoring. For example, in the domain of partnership, items range from no formalized plans for sustainable, bidirectional relationships (no capacity) to local surgeons and other health-care workers independently participating in annual meetings of surgical professional societies and independently creating partnership with third party organizations (optimal capacity). Conclusions: The CAT-os details steps to assess capacity of a local facility, guide capacity-improvement efforts during surgical outreach, and measure the impact of capacity-building efforts. Capacity building is a frequently cited and commendable approach to surgical outreach, and this tool provides objective measurement to aid in improving the capacity in low and middle-income countries through surgical outreach.

Background The surgical burden in low- and middle-income countries (LMICs) as reported by the number of surgical cases per capita is great. To improve global health and help address this burden, there has been a rise in surgical outreach to LMICs. In high-income countries, an electronic health record (EHR) is used to document and communicate data critical to the quality of care and patient safety. Despite this, there is little guidance or precedence on the data elements or processes for utilizing an EHR on outreach trips. We validated data elements and process steps for utilizing an EHR for hand surgery outreach trips. Methods We conducted a literature review to identify data elements collected during surgical outreach trips. A future-state process map for the collection and documentation of data elements within an EHR was developed through literature review and semistructured interviews with experts in global outreach. An expert consortium completed a modified RAND/University of California at Los Angeles Delphi process to evaluate the importance and feasibility of each data element and process step. Results In total, 65 data elements (e.g., date of birth) and 24 process steps (e.g., surgical site marking) were validated for use in an EHR for hand surgery outreach trips to LMICs. Conclusion This validated portfolio of data elements/process steps can serve as the foundation for pilot testing of an EHR to document and communicate critical patient data on hand surgery outreach trips. Utilization of an EHR during outreach trips to LMICs may serve to improve the safety and quality of care provided. The validated data elements/process steps can serve as a guide for EHR development and implementation of other surgical specialties.

BACKGROUND:We aimed to describe the demographic, injury-related, and treatment-related characteristics of patients who undergo fasciotomies for acute hand compartment syndrome. METHODS:A cohort of 53 adult patients with acute hand compartment syndrome treated with fasciotomy at 2 tertiary care referral centers over a 10-year time period from January 1, 2006, to June 30, 2015, were retrospectively identified. We reviewed the electronic medical record for patient-related variables (eg, age, sex, smoking status, diabetes mellitus), injury-related variables (eg, mechanism of injury, presence of fractures), and treatment-related variables (eg, compartments released, number of operations, use of split-thickness skin grafts, and time from injury to surgery). RESULTS:The mean age of our cohort was 45 years, and 33 patients (62%) were men. The mechanism of injury varied widely, but the most common causative mechanisms were crush injury (25%), prolonged decubitus (17%), and infection (11%). Associated hand fractures were present in 15 (28%) patients. The surgically released compartments varied; the dorsal interosseous compartments (83%), thenar compartment (75%), and hypothenar compartment (74%) were most frequently released, while the adductor pollicis compartment (43%) and Guyon canal (28%) were least frequently released. CONCLUSIONS:The demographics of acute hand compartment syndrome have evolved in the last 25 years compared with the prior literature, partly as a result of the opioid epidemic leading to a rise in "found down" compartment syndrome. Treating providers should recognize crush injury, prolonged decubitus, and infection as the most common causes of acute hand compartment syndrome.

I believe that we may be at or near the high-water mark of affirmative action in America. This past June, the U.S. Supreme Court ruled on 2 major affirmative action cases, Students for Fair Admissions v. University of North Carolina and Students for Fair Admissions v. President and Fellows of Harvard College. As was widely expected, the Court ruled in a way that will roll back diversity, equity, and inclusion (DEI) initiatives across America. Even if the Supreme Court had ruled otherwise, change was already clearly in the air. Some individual states have passed anti-DEI measures, explicitly limiting the right of state institutions of higher learning to consider race when judging academic applications, and, in some cases, forcibly eliminating DEI officers, officials, or programs within state institutions. In this light, the current issue of JBJS Open Access includes 2 AOA Critical Issues in Education articles that we have deemed appropriate to publish together. Both articles were somewhat controversial during the editing process, with our expert reviewers split on whether to publish them at all. The difference of opinion came down partly to academic quality—which was addressed through the revision process—while it also may have exposed the unease that many of us are feeling in this transitional time. I’d like to lean into that discomfort a little. At a minimum, these papers will be interesting purely as historical documents. The article by Harris et al., “Match Rates Among Underrepresented Minority and Female Applicants to Orthopaedic Surgery Residency Programs from 2011 to 2021: How Are We Doing?” may turn out to be the literal measure of the high-water mark. The authors chronicle clear increases in underrepresented applicants and matriculants to orthopaedic training; however, the recent Supreme Court decisions could reverse this trend toward increased diversity in our specialty. Of course, the diversity decline may not happen at all, and it won’t be instant in any event. The study by Terle et al., “Diversity-Related Positions in Orthopaedic Surgery Residency Programs,” will be useful as a baseline if the collapse of affirmative action nationally leads to a rollback of DEI programs, particularly in state institutions. The authors have surveyed programs’ self-identified initiatives for increasing diversity. I’ve encouraged the authors to conduct a follow-on survey in a year or two, depending on how the Supreme Court rulings change things, or on how the environment evolves naturally. Regardless of a reader’s opinion on affirmative action, these changes are unquestionably newsworthy. I will continue to encourage high-quality scholarship on this topic.

I have been given a remarkable privilege. As only the second editor of the AOA Critical Issues in Education channel, I have the opportunity to help shape what this part of JBJS Open Access will look like for years to come. As I start my second year in this role, I would like to share a bit of my vision for this channel: AOA Critical Issues in Education should be the definitive place to publish education research and innovation in orthopaedic surgery. The Journal of Bone & Joint Surgery is proud to think of itself as the journal of record for orthopaedic surgery, in both the United States and internationally. There is nothing modest about that statement. Living up to it requires a sustained commitment to attracting the very best articles in the orthopaedic field and improving them through rigorous peer review and editing. This high standard is applied to all journals in the JBJS portfolio, including JBJS Open Access. A large and dedicated team of staff, editors, and thoughtful peer reviewers work together to make it happen. I would particularly like to acknowledge the small-but-growing group of education experts who have served as reviewers over the last year. Thank you for saying “Yes” to my invitations to review. You are what makes this an excellent journal. The JBJS Open Access AOA Critical Issues in Education channel evolved from the Topics in Training section of the JBJS print journal. The expansion to an open access format was intended to allow innovation in the type and variety of articles that JBJS could publish, without sacrificing excellence. This dual mission of excellence and innovation creates a perfect opportunity for this channel to try new things. Here is one new direction in which I would like to take the channel: case reports in surgical education—that is, brief articles describing specific educational initiatives that have been introduced within individual institutions. In this issue of JBJS Open Access, we are proud to present the case report “Orthopaedic Surgery First-Year Resident Surgical Skills Month Curriculum” by Siebler and colleagues. The authors describe with clarity and care their effort to create a bootcamp-style skills program. It is not exactly a new idea—a skills curriculum has been a mandatory part of the American Board of Orthopaedic Surgery curriculum for more than a decade. However, JBJS recognizes that, in reality, many institutions may just be getting started with a serious skills program of their own. Although the article by Siebler et al. presents the experience of only a single program, it is useful as an example. Like a clinical case report, it may help to guide other programs that find themselves in a similar situation. I would encourage other submissions like this one. From time to time, we will be happy to publish the best of them.

Background: The objective of this study was to assess whether resident involvement in distal radius fracture open reduction internal fixation (ORIF) affect 30-day postoperative complication, hospital readmission, reoperation and operative time. Methods: A retrospective study was performed using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database by querying the Current Procedural Terminology (CPT) codes for distal radius fracture ORIF from 1 January 2011 to 31 December 2014. A final cohort of 5,693 adult patients who underwent distal radius fracture ORIF during the study period were included. Baseline patient demographics and comorbidities, intraoperative factors, including operative time and 30-day postoperative outcomes, including complications, readmission and reoperations, were collected. Bivariate statistical analyses were performed to identify variable associated with complication, readmission, reoperation and operative time. The significance level was adjusted using a Bonferroni correction as multiple comparisons were performed. Results: In this study of 5,693 patients who underwent distal radius fracture ORIF, 66 patients had a complication, 85 patients were readmitted and 61 patients underwent reoperation within 30 days of surgery. Resident involvement in the surgery was not associated with 30-day postoperative complication, readmission or reoperation, but was associated with longer operative time. Moreover, 30-day postoperative complication was associated with older age, American Society of Anesthesiologists (ASA) classification, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension and bleeding disorder. Thirty-day readmission was associated with older age, ASA classification, diabetes mellitus, COPD, hypertension, bleeding disorder and functional status. Thirty-day reoperation was associated with higher body mass index (BMI). Longer operative time was associated with younger age, male sex and the absence of bleeding disorder. Conclusions: Resident involvement in distal radius fracture ORIF is associated with longer operative time, but no difference in rates of episode-of-care adverse events. Patients may be reassured that resident involvement in distal radius fracture ORIF does not negatively impact short-term outcomes. Level of Evidence: Level IV (Therapeutic).

Background: The use of reverse shoulder arthroplasty (RSA) to treat displaced, unstable 3-and 4-part proximal humerus fractures (PHFs) has traditionally been reserved for patients over 70 years old. However, recent data suggest that nearly one-third of all patients treated with RSA for PHF are between 55-69 years old. The purpose of this study was to compare outcomes for patients younger than 70 versus patients older than 70 years of age treated with RSA for a PHF or fracture sequelae.Methods: All patients who underwent primary RSA for acute PHF or fracture sequelae (nonunion, malunion) between 2004 and 2016 were identified. A retrospective cohort study was performed comparing outcomes for patients younger than 70 versus older than 70. Bivariate and survival analyses were performed to evaluate for survival complications, functional outcomes, and implant survival differences.Results: A total of 115 patients were identified, including 39 patients in the young group and 76 cases in the older group. In addition, 40 patients (43.5%) returned functional outcomes surveys at an average of 5.51 years (average age range: 3.04-11.0 years). There were no significant differences in complications, reoperation, implant survival, range of motion, DASH (27.9 vs 23.8, P=0.46), PROMIS (43.3 vs 43.6, P=0.93), or EQ5D (0.75 vs 0.80, P=0.36) scores between the two age cohorts.Conclusion: At a minimum of 3 years after RSA for a complex PHF or fracture sequelae, we found no significant difference in complications, reoperation rates, or functional outcomes between younger patients with an average age of 64 years and older patients with an average age of 78 years. To our knowledge, this is the first study to specifically examine the impact of age on outcome after RSA for the treatment of a proximal humerus fracture. These findings indicate that functional outcomes are acceptable to patients younger than 70 in the short term, but more studies are needed. Patients should be counseled that the long-term durability of RSA performed for fractures in young, active patients remains unknown.