Journal of Bone and Joint Surgery, American Volume最新文献

Background: The impact of radiation exposure on cataracts and hand skin cancer in orthopaedic and spine surgeons remains understudied. This study aimed to investigate the prevalence of cataracts and chronic hand inflammation in orthopaedic and spine surgeons and to assess their association with radiation exposure.

Methods: A cross-sectional analysis was conducted on orthopaedic and spine surgeons attending the 38th Annual Meeting of the Neurospinal Society of Japan or the 31st Annual Meeting of the Japanese Society for the Study of Low Back Pain. Cataractous changes were categorized into none, lens micro-opacity, or cataracts and were detailed alongside the prevalence of chronic hand inflammation, which included longitudinal melanonychia and hand eczema. Participants were divided into quartiles according to hand-exposure opportunities in the operating and fluoroscopy rooms in 2022. Prevalence ratios and 95% confidence intervals (CIs) of chronic hand inflammation in the upper quartiles relative to the first quartile were calculated using modified Poisson regression adjusted for potential confounders.

Results: The median work experience of the 162 participants was 23 years, and the median number of hand-exposure opportunities was 70 (interquartile range [IQR], 20 to 123) in the operating room and 20 (IQR, 0 to 60) in the fluoroscopy room. The prevalence of cataracts was 20% (32 participants), and the prevalence of cataractous changes, including lens micro-opacity, was 40% (64 participants). Chronic hand inflammation was present in 62 participants (38%), of whom 52 had longitudinal melanonychia and 23 had hand eczema. The adjusted prevalence ratios of chronic hand inflammation relative to the lowest quartile of hand-exposure opportunities in the operating room were 0.91 (0.50, 1.66) for quartile 2, 0.72 (0.41, 1.25) for quartile 3, and 1.56 (0.97, 2.50) for quartile 4. For fluoroscopy room exposure, the adjusted prevalence ratios were 2.31 (1.16, 4.58) for quartile 2, 2.03 (1.00, 4.09) for quartile 3, and 2.94 (1.51, 5.75) for quartile 4.

Conclusions: This study highlighted substantial cataractous and chronic hand inflammatory changes in spine surgeons, indicating indirect and direct radiation exposure effects. Therefore, radiation safety and protective measures must be emphasized. Comparative studies with other populations and longitudinal observations are required to better understand the effects of radiation on health.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Sport participation has been associated with favorable outcomes following hip arthroscopy (HA) for femoroacetabular impingement (FAI) at short- and mid-term follow-up; however, few studies have evaluated the 10-year outcomes in this population. The purpose of this study was to compare patient-reported outcome measures (PROMs), the achievement of clinically significant outcomes, and reoperation-free survivorship between patients with and without regular preoperative sport participation who underwent HA for FAI and had a minimum of 10 years of follow-up.

Methods: Data were prospectively collected for patients who underwent primary HA for FAI between January 2012 and September 2013. Patients who participated in weekly sport participation at the time of surgery ("athletes") were matched 1:1 to patients who denied sport participation ("nonathletes"), controlling for age, sex, and body mass index (BMI). Preoperative and 10-year postoperative PROMs were collected, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports (HOS-Sports) subscales, the modified Harris hip score (mHHS), and the visual analog scale for pain (VAS Pain) and satisfaction (VAS Satisfaction). Patient acceptable symptom state (PASS) achievement and reoperation-free survivorship were compared between the groups.

Results: Sixty-four athletes were matched to 64 nonathletes of similar age, sex, and BMI (p ≥ 0.411). In the athlete group, 85.9% were recreational-level athletes. The groups had similar preoperative PROMs, except for the HOS-ADL subscale, where the athlete group demonstrated a higher preoperative score (67.8 ± 16.7 versus 59.9 ± 21.1, p = 0.029). Both groups demonstrated a significant improvement in all PROMs (p < 0.001) at the minimum 10-year follow-up10.3 ± 0.4 years). At the time of the final follow-up, the athlete group demonstrated significantly higher scores across all of the measured PROMs (p ≤ 0.036). Athletes showed a higher cumulative PASS achievement compared with nonathletes for the HOS-ADL subscale (73% versus 50%, p = 0.033), the HOS-Sports subscale (85% versus 61%, p = 0.010), the mHHS (69% versus 43%, p = 0.013), and the VAS Pain (78% versus 51%, p = 0.006). Reoperation-free survivorship frequencies were 87.5% and 82.8%, respectively (p = 0.504).

Conclusions: Athletes who underwent contemporary HA for FAI showed superior PROMs and PASS achievement compared with nonathletes at the 10-year follow-up. Athletes and nonathletes showed reoperation-free survivorship frequencies of 87.5% and 82.8%, respectively.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Tungsten carbide rings are increasingly popular modern jewelry items. Tungsten carbide is an extremely dense, hard metal. Previously described methods to remove tungsten carbide rings include using locking pliers to compress the ring or cutting the ring with a high-speed dental drill.

Methods: A universal mechanical testing system (MTS) machine was used to diametrically compress tungsten carbide rings 9 mm in length and 2.4 mm in thickness with a 23.4-mm outer diameter and a 21.0-mm inner diameter while measuring the force required to fracture the rings. A computer numerical control (CNC) machine was used to cut tungsten carbide rings with a diamond grinding bit with and without a flow of normal saline solution. An infrared thermal camera was used to record the temperature at the site of contact between the ring and the grinding bit and at a site one-quarter of the circumference along the ring.

Results: A mean force with 95% confidence interval of 3.7 ± 1.2 kN was required to fracture the tungsten carbide rings via diametral compression (p = 0.05). The rings failed at a mean displacement with 95% confidence interval of 0.32 ± 0.13 mm (p = 0.05). The maximum temperature observed at the site of contact between the ring and grinding bit averaged 160.2°C including cases with and without coolant. The time to reach maximum temperature and the duration of maximum temperature differed significantly between the cases with and without coolant (p = 0.0007 and p = 0.0108, respectively).

Conclusions: Tungsten carbide rings fractured with minimal displacement using a small amount of force via diametral compression. The brittle fracture pattern of the rings produced minimal comminution. Tungsten carbide rings reached extreme temperatures when cut with a high-speed diamond grinding bit despite cooling with normal saline solution.

Clinical relevance: Previously documented methods to remove a tungsten carbide ring include breaking the ring by compressing it with pliers or cutting it off with a high-speed dental drill. Clinicians should be aware of potential complications of current methods to remove tungsten carbide rings.

Background: Delayed-onset neurologic changes (DONCs) following spinal deformity surgery are poorly understood and are often devastating.

Methods: A retrospective review of cases from 12 hospitals was performed. The clinical and radiographic parameters of patients who experienced a new DONC after spinal deformity correction were evaluated.

Results: Eighteen patients, with a mean preoperative major Cobb angle of 75° ± 24°, were included. The mean age at surgery was 13 ± 2 years, and 6 patients (33%) were male. Seven patients had temporary intraoperative neuromonitoring changes. Fourteen patients (78%) had neurologic changes within 24 hours postoperatively (range, 3 to 24 hours). Of 16 patients with blood pressure data, 8 (50%) had at least 1 documented episode of hypotension surrounding the change in neurologic status. No misaligned implants were seen on axial imaging. Fourteen patients (78%) were treated with vasopressors. Sixteen patients (89%) returned to the operating room, and 11 patients (61%) underwent implant removal. Seven patients (39%) sustained a spinal cord infarct, with only 1 (6%) experiencing recovery beyond an ASIA (American Spinal Injury Association Impairment Scale) score of B. Ten (91%) of the 11 patients without an infarct demonstrated recovery (5 patients with an ASIA score of D and 5 with a score of E).

Conclusions: A DONC is a rare complication of spinal deformity surgery. This study represents the largest documented series of DONCs and highlights the multifactorial and still poorly understood nature of this condition. The primary modifiable risk factor may be hypotension in the postoperative period: 50% of patients had a mean arterial pressure below the 5th percentile for their height, as documented around the time of the neurologic change. Eighty-six percent of patients with a spinal cord infarct had minimal neurologic recovery, whereas nearly all of the patients without an infarct did recover function. The management of this condition may include elevation of blood pressure with temporary implant removal.

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background: Osteoporosis continues to be underdiagnosed and inadequately treated in older hip-fracture patients. Our aim was to improve the rate of osteoporosis treatment with IV bisphosphonate therapy in eligible patients admitted for hip-fracture surgery.

Methods: The present study was designed as a quality improvement initiative using Plan-Do-Study-Act (PDSA) cycles at an academic medical center in Portland, Oregon, over 2.5 years. A protocol was developed (1) to administer IV zoledronate on postoperative day 2 to inpatients aged ≥50 years who underwent surgery for a low-energy hip fracture and (2) to formally diagnose osteoporosis during admission. The protocol was introduced across 3 care settings in a stepped-wedge manner. Outcome measures were the percentage of inpatient zoledronate administered to eligible patients and formal documented diagnosis of osteoporosis. Balance measures included fever after administration and hospital length of stay (LOS). Measures were assessed through quarterly chart review and tracked via control charts.

Results: The rate of zoledronate administration significantly increased from 34.5% (29 of 84) to 74.6% (53 of 71) following the second PDSA cycle (p < 0.001). Documented osteoporosis diagnosis also significantly improved from 51.0% (53 of 104) to 85.7% (96 of 112) following the second PDSA cycle (p < 0.001). No significant differences were shown for hospital LOS, and 1 of 82 patients had medical work-up for post-infusion acute phase reaction after administration.

Conclusions: This initiative was effective at improving osteoporosis diagnosis and treatment among older hip-fracture patients at our institution. Protocol development for administrating inpatient zoledronate after hip fracture is a reliable way to predictably offer bone health care and secondary-fracture prevention to hip-fracture patients and can be adapted and implemented at other institutions.

Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Total hip arthroplasty (THA) is rarely performed in pediatric patients and can be challenging in children because of smaller-sized joints, pathomorphological changes around the hip, residual growth, and higher physical demands. Literature on THA outcomes in this unique population is scarce. We aimed to describe characteristics of pediatric patients who underwent THA, 5- and 10-year implant survival, risk factors for revision, and results of patient-reported outcome measures (PROMs) in a large national cohort.

Methods: Primary THAs (from 2007 through 2022) in pediatric patients (11 to 18 years of age) for non-oncological indications were extracted from the Dutch Arthroplasty Register (LROI). Implant survival was assessed using Kaplan-Meier survival analyses. Functional, quality-of-life, and pain-related PROM scores were described preoperatively and at 3 and 12 months postoperatively and compared using paired t tests.

Results: We included 283 THAs (161 [57%] in female patients) performed in 253 patients. The mean age at surgery (and standard deviation) was 16 ± 1.6 years. The most common indications were osteonecrosis (90 [32%] of the THA procedures), dysplasia (82 [29%]), and osteoarthritis (54 [19%]). The median follow-up was 7 years (range, 2 to 16 years). Fourteen (6% of 234) THAs were revised. The 5- and 10-year cumulative survival rates were 95% (95% confidence interval [CI], 91% to 97%) and 91% (95% CI, 84% to 95%), respectively. There was an insufficient number of events to allow for statistical analyses of potential risk factors for revision. All PROMs had improved significantly at 12 months postoperatively versus preoperatively (p < 0.001).

Conclusions: This study, the largest to date on THA in children (≤18 years of age), showed good short- and mid-term THA survival, approaching that among adults. Combined with the positive PROM results, THA appears to be an effective and satisfactory intervention in cases of debilitating pediatric hip disease. Further studies should focus on long-term survival and risk factors for implant failure.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Orthopaedic surgery is a critical field, impacting global health-care expenditure and patient outcomes. Despite substantial research funding, issues of transparency and reproducibility persist, undermining the credibility of published in-print findings. Data-sharing initiatives aim to address these challenges by promoting accessibility and enhancing research reliability. We aimed to assess the landscape of data-sharing practices within the field of orthopaedic surgery, focusing on the top orthopaedic journals from 2020 to 2023.

Methods: Original research articles from 10 of the top orthopaedic journals were screened and analyzed for data-sharing statements (DSSs). Furthermore, we identified variables that were influential on the inclusion of DSSs in orthopaedic clinical studies, and thematically analyzed DSS content to identify prevalent themes. Lastly, corresponding authors were contacted to assess their willingness to share their data.

Results: Of the 1,084 reviewed articles, only 14% included a DSS. The Journal of Bone & Joint Surgery demonstrated the highest proportion of articles with a DSS. Over time, clinical trials exhibited an increasing trend in DSS adoption, contrasting with consistently low rates among cohort studies. Thematic analysis identified the gatekeeper role and conditional data availability as predominant themes in orthopaedic DSSs. Of the 115 emails sent to corresponding authors, only 22 (19.1%) yielded responses, and of those who responded, only 12 (54.5%) expressed a willingness to share their data.

Conclusions: Our findings underscore a substantial disparity in data-sharing practices across orthopaedic journals, highlighting the need for standardization and mandates for DSSs. Adopting the Transparency and Openness Promotion (TOP) Guidelines can enhance accountability and foster a culture of open science within the field. By addressing these shortcomings, orthopaedic journals can improve research reproducibility and advance scientific knowledge effectively.

Background: In recent years, orthopaedic surgeons have attempted to decrease opioid consumption through multimodal pain management. However, a limited effort has been made to eliminate opioids entirely in the perioperative period. The purpose of this study was to compare the efficacy and safety of a novel opioid-free pain management pathway with that of an opioid-containing pathway across 5 common orthopaedic subspecialty surgical procedures.

Methods: In a 1:1, unblinded fashion, 315 patients were randomized to a perioperative pain management pathway that was either opioid-free (n = 157) or opioid-containing (n = 158). Pain was measured with a numeric rating scale (NRS) for pain of 0 to 10 at 6 hours, 12 hours, 24 hours (the primary outcome assessing noninferiority), 2 weeks, 6 weeks, and 1 year after the surgical procedure. Data on patient characteristics, deviations from the pain management pathway, morphine milligram equivalents (MME), readmissions, adverse events, and patient-reported outcomes were collected.

Results: There were 315 patients in the final group, with a mean age of 63.6 years. Of the patients in the study, 59.7% were female, 85.7% were White, 12.4% were Black/African-American, 1.0% were Hispanic/Latino, 0.6% were American Indian, and 0.3% were unknown. At 24 hours, the median NRS for pain in the opioid-free group (2 [interquartile range (IQR), 0 to 4]) was statistically noninferior (p < 0.0001) to the opioid-containing group (4 [IQR, 2 to 6]). Pain levels were significantly lower in the opioid-free group than in the opioid-containing group at 12 hours (p = 0.0173) and 2 weeks (p = 0.0003). Pain scores at 6 hours, 6 weeks, and 1 year were similar. Patients in the opioid-free group reported significantly greater comfort at 24 hours (p = 0.0392) and higher satisfaction with pain control (p = 0.0355) at 6 weeks. There were no reported adverse events or unplanned readmissions. Demographic characteristics were similar between the 2 groups.

Conclusions: Across 5 common orthopaedic subspecialty procedures, an opioid-free pain management pathway was safe and effective and provided noninferior pain control at 24 hours compared with the opioid-containing pathway.

Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: In Ethiopia, orthopaedic services are limited, and many injured children undergo traditional bonesetting (TBS) despite its association with limb- and life-threatening complications. We sought to identify the risk factors for amputation and a prolonged hospitalization of >7 days in children who presented to hospitals after undergoing TBS.

Methods: Over a 15-month period, we prospectively enrolled children who presented to 8 Ethiopian hospitals after undergoing TBS. Separately for each outcome (amputation and prolonged hospitalization), we used multivariable logistic regression to evaluate associations between the outcome and 16 covariates, including demographic and injury characteristics, parent or guardian preference for TBS, and TBS topical treatments and immobilization methods.

Results: We enrolled 460 children (mean age, 9.0 ± 4.0 years; 75% male) representing 8 Ethiopian regions and diverse demographic and socioeconomic backgrounds. Elbow injuries (194 patients; 42.2%) and closed fractures and/or dislocations (364 patients; 79.1%) were most common. TBS treatments included topical inorganic (190 patients; 41.3%) or organic (82 patients; 17.8%) material application and rigid (166 patients; 36.1%) or soft (182 patients; 39.6%) immobilization. Twenty-six children (5.7%) underwent an amputation, and 102 (22.2%) had a prolonged hospitalization. The odds of amputation were higher for children from rural communities (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 2.01 to 22.41) and for children with only non-osseous injuries (AOR, 5.76; 95% CI, 1.56 to 21.28). The odds of prolonged hospitalization were higher for children who were 11 to 17 years old (AOR, 2.77; 95% CI, 1.18 to 6.50) and for children with open fractures with a grade of ≥2 (AOR, 4.52; 95% CI, 1.33 to 15.28) but were lower for children from households with secondary education or higher (AOR, 0.40; 95% CI, 0.21 to 0.79). TBS with rigid immobilization increased the odds of amputation (AOR, 5.84; 95% CI, 1.74 to 19.60) and prolonged hospitalization (AOR, 2.20; 95% CI, 1.02 to 4.73). TBS organic topical treatment (with mud, leaves, or butter) increased the odds of amputation (AOR, 3.88; 95% CI, 1.40 to 10.73).

Conclusions: For children who underwent TBS prior to hospital presentation, rigid splinting by bonesetters increased the odds of amputation and prolonged hospitalization. TBS organic topical treatments also increased the odds of amputation. Training bonesetters to avoid these dangerous practices may prevent devastating complications for children in Ethiopia.

Level of evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.