The Journal of the American Academy of Orthopaedic Surgeons最新文献

Toe walking is a common presenting report to an orthopaedic practice. Evaluation of a child with toe walking includes a thorough history and physical examination to elucidate the diagnosis. When no other diagnosis is suspected, a diagnosis of idiopathic toe walking is often given. Despite the high prevalence of the condition, there is notable controversy of the nomenclature of the disease. Recent research has shed more light on both the natural history and the genetic basis. The use of motion analysis, including EMG and multisegment foot model, may help both differentiate children with mild forms of cerebral palsy and evaluate outcomes after treatment. Early treatment for young children with adequate range of motion (ROM) is generally reassurance because most young children with idiopathic toe walking are expected to resolve spontaneously. When the toe walking persists, treatment options include both surgical and nonsurgical management. Nonsurgical management centers on obtaining ROM through stretching and serial casting, followed by gait retraining and bracing treatment. Surgical lengthening at either the Achilles or gastrocnemius level improves the ROM of the ankle and then similarly requires therapy and bracing treatment to obtain a more normalized gait.

Introduction: Industry funding in medicine enhances physician training but can create bias influencing accurate reporting of outcomes. High rates of conflict of interest (COI) disclosure have been found in orthopaedic surgery. However, industry-specific disclosures have not been investigated and small-value compensations previously excluded. Using the nerve allograft industry as a proxy to examine specific patterns of COI between physicians and industries relevant to their publications, we sought to evaluate patterns in industry-specific COI disclosure within the hand and upper extremity surgery literature.

Methods: Literature search for primary studies using nerve allografts in the hand and upper extremity from 2013 to 2021 was conducted. Authors were cross-referenced with their publication's COI statement and payments recorded in the Open Payments Database (OPD). Only payments relevant to the topic or product presented in the publication were included. Payments in all OPD subdivisions were compared.

Results: Fourteen studies with 14 first, 72 middle, and 14 senior authors were included. Disclosed and undisclosed payments totaled $2,848,196 and $2,509,397. Only 28% of the authors had completely accurate COI statements. Research and food and beverage comprised the highest and lowest average rates of accurate disclosure (93.8% and 24.9%). The value of accurately disclosed payments was significantly greater on a per-author basis among senior authors ( P < 0.001). Neither the value of undisclosed payments nor the rate of accurate disclosure differed by authorship position ( P = 0.904 and P = 0.350).

Discussion: When examined in the context of industries specific to publication, the rate of correct COI disclosure is lower than previously reported with small-value compensation a major contributor. Areas of improvement include the following: (1) All authors should be held accountable for correct disclosure; (2) all forms of financial support should be reported; and (3) journals should independently verify disclosures to the OPD. OPD utilization may help verify correct reporting, especially when the industry is related to the area of study, in the interest of maintaining the highest editorial integrity.

Anemia and sickle cell anemia before surgery are often unrecognized medical comorbidities that can and should be addressed. Nearly 6% of the American population meets the criteria for anemia. The elderly, along with patients with renal disease, cancer, heart failure, or diabetes mellitus are more likely to be anemic. The most common form of anemia is due to iron deficiency, which can be easily treated before surgery. Sickle cell anemia occurs in 1 in 365 Black births and 1 in 16,300 Hispanic births, with 100,000 Americans currently living with sickle cell anemia. Patients who have anemia or sickle cell anemia are at increased risk for postoperative complications, including the need for blood transfusions and delayed healing. For those with sickle cell disease, surgeries can precipitate a sickle cell crisis. Patients with sickle cell anemia face barriers in accessing appropriate care; however, these patients can be optimized using preoperative red blood cell transfusions to dilute sickle cells and elevate the hemoglobin level. There should also be careful consideration and monitoring of the pain level of patients with sickle cell anemia in the perioperative period.

Background: The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has continued to generate notable disruption in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine whether there is any difference in patient characteristics, revenue, and clinical outcomes in patients undergoing THA and TKA after the start of the pandemic.

Methods: We reviewed a consecutive series of 26,493 patients undergoing primary and revision THA and TKA by 48 surgeons in a single arthroplasty practice. We compared demographics, comorbidities, outcomes, and surgeon revenue from THA and TKA procedures from March 2020 to February 2021 with a prepandemic group undergoing a procedure from March 2019 to February 2020.

Results: There was a 20% decline in the volume of all cases in the pandemic group ( 11,688 versus 14,664 , P < 0.001). The postpandemic cohort had shorter length of stay (1.58 versus 1.70 days, P = 0.007), had higher rates of home discharge (98% versus 91%, P < 0.001), and were more likely to have their procedure done at an outpatient facility (21% versus 7%, P < 0.001). Even among patients older than 65 years, more pandemic patients underwent a procedure as an outpatient (19% versus 7%, P < 0.001), with no difference in complications or readmissions. Total surgeon charges and payments declined by 17.6% and 16.3%, respectively, during the pandemic ( P = 0.010).

Conclusion: Although the COVID-19 pandemic resulted in a notable reduction in surgical volume and revenue loss for our practice, we found a marked shift of arthroplasty patients to outpatient facilities with increased rates of home discharge without compromising patient safety.

Diaphyseal femur fractures are common in pediatric orthopaedic settings. A patient-specific treatment plan incorporates several factors, including age, weight, fracture pattern, associated injuries, and social considerations. Nonaccidental trauma should be considered in children younger than 3 years. In general, young children are treated with noninvasive immobilization (Pavlik harness or early hip spica casting) while school-aged children are treated with internal fixation. Internal fixation options include flexible intramedullary nails, rigid locked intramedullary nails, and plate osteosynthesis. Flexible intramedullary nails have the best outcomes in children of appropriate weight, aged 5 to 11 years, with stable fracture patterns. Lateral-entry rigid intramedullary nails have been designed for use in older children. External fixation is usually reserved for complex scenarios. Regarding all treatment methods, surgeons should be aware of several technical factors necessary to optimize outcomes.

Introduction: The most impactful resolutions of the Patient Protection and Affordable Care Act (ACA) took effect on January 1, 2014. The clinical and economic effects are widely experienced by orthopaedic surgeons, but are not well quantified. We proposed to evaluate the effect of the ACA on the timing of MRI for knee pathology before and after implementation of the legislation.

Methods: We conducted a retrospective analysis of all knee MRIs done at our institution from 2011 to 2016 (3 years before and after ACA implementation). The MRI completion time was calculated by comparing the dates of initial clinical evaluation and MRI completion. The groups were subdivided based on insurance payer status (Medicare, Medicaid, and commercial payers). The cohorts were compared to determine differences in average completion time and completion rates at time intervals from initial clinic visit before and after ACA implementation.

Results: MRI scans of 5,543 knees were included, 3,157 (57%) before ACA implementation and 2,386 (43%) after. There was a 5.6% increase in Medicaid cohort representation after ACA implementation. Patients waited 14 days longer for MRIs after ACA implementation (116 versus 102 days). There were increased completion times for patients in the commercial payer (113 versus 100 days) and Medicaid (131 versus 96 days) groups. Fewer patients had received MRI after ACA implementation within 2, 6, and 12 weeks of their initial clinic visits.

Discussion: The time between initial clinical evaluation and MRI scan completion for knee pathology markedly increased after ACA implementation, particularly in the commercial payer and Medicaid cohorts. Additional studies are needed to determine the effect of longer wait times on patient satisfaction, delayed treatment, and increased morbidity. As healthcare policy changes continue, their effects on orthopaedic patients and providers should be closely scrutinized.

Level of evidence: Level III-Retrospective cohort study.

Introduction: Peroneal nerve injuries are rare injuries and usually associated with multiligamentous knee injuries (MLKIs) involving one or both cruciate ligaments. The purpose of our study was to perform a multicenter retrospective cohort analysis to examine the rates of peroneal nerve injuries and to see whether a peroneal nerve injury was suggestive of a particular injury pattern.

Methods: A retrospective chart review was conducted in patients who were diagnosed with MLKI at two level I trauma centers from January 2001 to March 2021. MLKIs were defined as complete injuries to two or more knee ligaments that required surgical reconstruction or repair. Peroneal nerve injury was clinically diagnosed in these patients by the attending orthopaedic surgeon. Radiographs, advanced imaging, and surgical characteristics were obtained through a chart review.

Results: Overall, 221 patients were included in this study. The mean age was 35.9 years, and 72.9% of the population was male. Overall, the incidence of clinical peroneal nerve injury was 19.5% (43 patients). One hundred percent of the patients with peroneal nerve injury had a posterolateral corner injury. Among patients with peroneal nerve injury, 95.3% had a complete anterior cruciate ligament (ACL) rupture as compared with 4.7% of the patients who presented with an intact ACL. There was 4.4 times of greater relative risk of peroneal nerve injury in the MLKI with ACL tear group compared with the MLKI without an ACL tear group. No statistical difference was observed in age, sex, or body mass index between patients experiencing peroneal nerve injuries and those who did not.

Conclusion: The rate of ACL involvement in patients presenting with a traumatic peroneal nerve palsy is exceptionally high, whereas the chance of having a spared ACL is exceptionally low. More than 90% of the patients presenting with a nerve palsy will have sustained, at the least, an ACL and posterolateral corner injury.

Level of evidence: IV, Case Series.

Introduction: Studies have previously reported higher complication rates in elective total joint arthroplasty (TJA) for nonagenarians compared with younger cohorts. The purpose of this study was to assess whether nonagenarians were still at increased risk of complications and hospital readmissions by answering three questions: (1) Do nonagenarians have an increased risk of medical complications after TJA compared with octogenarians and septuagenarians? (2) Do nonagenarians have an increased risk of surgical complications after TJA compared with octogenarians and septuagenarians? (3) Do nonagenarians have an increased risk of hospital readmission after TJA compared with octogenarians and septuagenarians?

Methods: A total of 174 patients undergoing primary TJA between 2010 and 2017 were included; 58 nonagenarians (older than 90 years) were matched with 58 octogenarians (age 80 to 84 years) and 58 septuagenarians (age 70 to 74). Groups were matched by sex, diagnosis, surgeon, surgical joint, and year of surgery. Within each group, 31 patients (53%) underwent total hip arthroplasty and 27 patients (47%) underwent total knee arthroplasty. Comorbidities, American Society of Anesthesiologists physical status scores, and Charlson Comorbidity Index scores were captured preoperatively. Complications and readmissions occurring within 90 days postoperatively were evaluated.

Results: Nonagenarians had the highest rate of medical complications (33%) compared with octogenarians (14%) and septuagenarians (3%) (P < 0.001). Rates of surgical complications were not statistically different among nonagenarians (12%), octogenarians (9%), and septuagenarians (10%) (P = 0.830). Rates of hospital readmission were highest in nonagenarian patients (11%), but not statistically different compared with octogenarians (5%) or septuagenarians (2%) (P = 0.118).

Conclusion: Nonagenarians were 3.1 times more likely to have a complication after TJA. The incidence of medical complications was highest in nonagenarians compared with octogenarians and septuagenarians, but rates of orthopaedic complications were similar. Nonagenarians who elect to proceed with TJA should be informed that they have an increased risk of postoperative medical complications compared with younger patients undergoing the same operation.

Level of evidence: Level III, Therapeutic Study.

Introduction: The Orthopaedic In-Training Examination (OITE) is an important metric for orthopaedic residents and residency programs to gauge a resident's orthopaedic knowledge. Because the OITE is correlated with the likelihood of passing part I of the American Board of Orthopaedic Surgery, greater emphasis is being placed on the examination. However, a detailed look at the questions most likely to appear on the spine subsection of the OITE has not been done in the past decade.

Methods: Digital copies of the OITEs during the years 2017 through 2021 were obtained online through the "ResStudy" program within the American Academy of Orthopaedic Surgeons Online Learning Platform. All spine-related questions were categorized into five different categories including type of spine question (knowledge-based, diagnosis, or evaluation/management), anatomical region, imaging modality provided, subject matter, and referenced journal or textbook. The total number and likelihood of each question type to appear on the OITE were defined as mean and percentage of the total number of spine questions, respectively.

Results: A total of 139 spine questions were identified on the OITE during the years 2017 to 2021. The most common type of spine questions were evaluation/management (N = 65) and knowledge-based questions. We identified lumbar (N = 45), cervical (N = 42), thoracolumbar (N = 13), and thoracic (N = 12) as the most commonly tested anatomical regions. Spinal trauma (N = 26), disk disease/disk herniation (N = 16), postoperative complications (N = 15), and scoliosis/sagittal balance (N = 15) were the most commonly tested material. Spine (N = 54) was almost two times more likely to be referenced as the source for the tested material compared with other journals or textbooks.

Conclusions: Understanding the spine topics most likely to appear on the OITE may allow orthopaedic residents and residency programs to supplement educational objectives toward the highest yield spine topics and journals.

Patellofemoral instability (PFI) is a prevalent cause of knee pain and disability. It affects mostly young females with an incidence reported as high as 1 in 1,000. Risk factors for instability include trochlear dysplasia, patella alta, increased tibial tubercle-to-trochlear groove distance, abnormal patella lateral tilt, and coronal and torsional malalignment. Nonsurgical and surgical options for PFI can treat the underlying causes with varied success rates. The goal of this review series was to synthesize the current best practices into a concise, algorithmic approach. This article is the first in a two-part review on PFI, which focuses on the clinical and radiological evaluation, followed by nonsurgical management. The orthopaedic surgeon should be aware of the latest diagnostic protocol for PFI and its nonsurgical treatment options, their indications, and outcomes.