Odum, Susan M.

Background: A 2-stage approach is most commonly used to treat periprosthetic joint infection (PJI). Some successful studies of the 1-stage approach were underpowered, lacked a 2-stage comparative group, and excluded patients with draining sinuses, comorbidities, and/or antibiotic-resistant organisms. Given the morbidity and expense associated with 2-stage treatment, we conducted a prospective, multicenter, randomized trial to compare the results of 1- and 2-stage PJI treatment, specifically including patients with draining sinuses, comorbidities, and resistant organisms. Methods: Patients presenting for surgical treatment of a chronic PJI with a known organism following primary total hip or knee arthroplasty were included (with infection defined by Musculoskeletal Infection Society [MSIS] criteria). Patients with prior revision, culture-negative infection, or fungal infection, or who were immunosuppressed or had soft-tissue involvement precluding wound closure, were excluded. Patients were classified according to the McPherson host staging system. Clinical success was defined as (1) no clinical failure or reinfection with the same or new organism; (2) no reoperation for PJI; and (3) no PJI-related death. A double-instrument setup was used for all patients, as were similar irrigation and antibiotic protocols. A total of 323 patients (166 one-stage; 157 two-stage) were randomized. Groups were similar with respect to demographics and host classification. After excluding patients who died or were lost to follow-up, 258 of the 323 patients had 2-year follow-up (135 one-stage and 123 two-stage). The rate of patient loss to follow-up was similar between the treatment groups. Results: Sixteen patients in the 1-stage group and 9 patients in the 2-stage group died prior to 2-year follow-up. Overall, the 2-year success rate of 1-stage treatment was 97% (131 of 135), while the success of 2-stage treatment was 91% (112 of 123) (p = 0.04). Compared with the 2-stage group, the 1-stage group had 3-times the odds of overall success in a regression analysis (unadjusted odds ratio = 3.22 [95% confidence interval = 1.0 to 10.38]). After adjusting for specific variables (McPherson host grade, resistant organism, and draining sinuses), 1-stage treatment also had 3-times the odds of success. Conclusions: The results of this prospective randomized trial indicated that 1-stage treatment (97% success) was statistically noninferior to 2-stage treatment (91% success) when treating chronic PJI following primary total hip or knee arthroplasty, provided the protocols described here are explicitly followed. Extrapolation to other patient cohorts and clinical situations should be avoided. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background There is substantial corroborating evidence that orthopaedic surgery has historically been the least diverse of all medical and surgical specialties in terms of race, ethnicity, and sex. Growing recognition of this deficit and the benefits of a diverse healthcare workforce has motivated policy changes to improve diversity. To measure progress with these efforts, it is important to understand the existing representation of sexual and gender minorities among orthopaedic professionals. Questions/purposes (1) What proportion of American Academy of Orthopaedic Surgeons (AAOS) members reported their identity as a sexual or gender minority? (2) What demographic factors are associated with the self-reporting of one’s sexual orientation and gender identity? Methods The AAOS published the updated membership questionnaire in January 2022 to collect information from new and existing society members regarding age and race or ethnicity and newly added categories of gender identity, sexual orientation, and pronouns. The questionnaire was updated with input from a committee of orthopaedic surgeons and researchers to ensure face validity. The AAOS provided a deidentified dataset that included the variables of interest: membership type, gender identity, sexual orientation, pronouns, age, race, and ethnicity. Of 35,427 active AAOS members, 47% (16,652) updated their membership questionnaire. To answer our first study question, we calculated the prevalence of participants who self-reported as lesbian, gay, bisexual, transgender, queer, or another sexual or gender minority identity (LGBTQ+) and other demographic characteristics of the 16,652 respondents. Categorical demographic data are described using frequencies and proportions. Median and IQR were used to describe the central tendency and variability. To answer our second study question, we conducted a stratified analysis to compare demographic characteristics between those who self-reported LGBTQ+ identity and those who did not. Visual methods (quantile-quantile plots) and statistical tests (Kolmogorov-Smirnov and Shapiro Wilk) confirmed that the age of AAOS member was not normally distributed. Therefore, a Kruskal Wallis test was used to determine the statistical associations between age and self-reported LGBTQ+ status. Chi-square tests were used to determine bivariate statistical associations between categorical demographic characteristics and self-reported LGBTQ+ status. A multivariable logistic regression model was developed to identify the independent demographic characteristics associated with respondents who self-reported LGBTQ+ identity. Further stratified analyses were not conducted to protect the anonymity of AAOS members. An alpha level of 5% was established a priori to define statistical significance. Results Overall, 3% (109 of 3679) and fewer than 1% (3 of 16,182) of the AAOS members (surgeons, clinicians, allied healthcare providers, and researchers) who updated their membership profiles reported identifying as a sexual (lesbian, gay, bisexual, queer) or gender minority (nonbinary or transgender), respectively. No individual self-identified as transgender. Five percent (33 of 603) of women and 3% (80 of 3042) of men self-identified as a sexual minority (such as lesbian, gay, bisexual, or queer). AAOS members who self-identified as LGBTQ+ were younger (OR 0.99 [95% confidence interval (CI) 0.98 to 0.99]; p < 0.001), less likely to self-identify as women (OR 0.86 [95% CI 0.767 to 0.954]; p < 0.001), less likely to be underrepresented in medicine (OR 0.49 [95% CI 0.405 to 0.599]; p < 0.001), and less likely to be an emeritus or honorary member (OR 0.75 [95% CI 0.641 to 0.883]; p < 0.003). Conclusion The proportion of self-reported LGBTQ+ AAOS members is lower than the 7% of the general US population. The greater proportion of younger AAOS members reporting this information suggests progress in the pursuit of a more-diverse field. Clinical Relevance The study findings support standardized collection of sexual orientation and gender identity data to better identify and address diversity gaps. As orthopaedic surgery continues to transform to reflect the diversity of musculoskeletal patients, all orthopaedic professionals (surgeons, clinicians, allied healthcare providers, and researchers), regardless of their identities, are essential in the mission to provide equitable and informed orthopaedic care. Sexual and gender minority individuals may serve as important mentors to the next generations of orthopaedic professionals; individuals from nonminority groups should serve as important allies in achieving this goal.

Objectives: Meniscus injuries remain a common source of morbidity in patients over the age of 40. Historically, meniscus injuries in this age group have been treated non-operatively or with surgical management limited to debridement procedures. There is strong evidence for repair over meniscectomy in younger patients, however literature remains sparce regarding repair outcomes and re-operation rates for patients over the age of 40. The objectives of this study were to document patient reported outcomes, complications, and re-operation rates for meniscus repairs in patients above the age of 40 and determine what patient demographics or injury characteristics correlated with reoperation. Methods: A retrospective chart review was conducted at a single academic institution after obtaining IRB approval. An initial query of patients over the age of 40, was performed via the CPT code 29882. Inclusion criteria consisted of patient age greater than 40 at time of initial meniscal repair. Exclusion criteria consisted of prior surgery in the ipsilateral knee, meniscal root repair, septic arthritis postoperatively, and any form of knee trauma postoperatively. Patients that met inclusion criteria were chart reviewed for relevant data including demographic information, comorbidities, surgical procedure information such as type of implant used, laterality of meniscus tear, type of tear and pattern, and revision/re-operation data. Patients were then contacted to answer full 100-point KOOS (Knee Injury and Osteoarthritis Outcome Score) questionnaires. Results: 413 total patients met inclusion criteria. The average age at time of surgery was 46 years (IQR, 43-51), and 214 patients were female (51.8%). KOOS scores were reported at a median follow-up of 24-months (IQR, 3-62). Median symptom, pain, activity of daily living (ADL), sport, and quality of life (QoL) subscales were reported as 78.6 (IQR, 60.7-92.9), 87.5 (IQR, 69.4-97.2), 94.1 (IQR, 82-100), 80.0 (IQR, 55-95), and 68.8 (IQR, 40.6-81.3), respectively. A total of 74 patients underwent reoperation (17.8%). There was no significant difference in reoperation rates when stratified by age group (40-49, 50-59, 60-69) (p=0.515). Reoperation rates were not affected by type of implant used for initial meniscus repair (Fast-fix anchor, Omnispan meniscal anchor, Meniscal cinch implant, Fiberwire, MaxBraid suture, Ethibond suture, PDS suture or Bionics meniscal arrow) (p>0.7). Average number of all-inside anchors used for repair was 2 (IQR, 2-3) and did not correlate with reoperation (p=0.49). Location of initial meniscus tear (body or posterior horn) and tear pattern did not correlate with reoperation rates (p>0.36, p>0.28 respectively). A total of 47 patients complained of postoperative stiffness, of which 28 (6.7%) underwent lysis of adhesions and/or arthroscopic debridement (p=.042). Twenty-five patients sustained a meniscal re-tear or injury, of which 17 underwent reoperation with partial or total meniscectomy. Of the total patient cohort, only seven patients ultimately went on to require ipsilateral total knee arthroplasty (1.6%). Conclusions: Patients over the age of 40 who underwent meniscus repair showed favorable reported outcomes at a mean 2-year follow-up. Reoperation rates were associated with postoperative stiffness and repeat injury. Re-operation rates in patients over 40 are comparable to reported rates of younger patients who undergo meniscus repair.