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

Background: After-hours hand trauma care is associated with surgeon fatigue, a higher risk of complications, and increased staffing costs. Dedicated trauma operating rooms (DTORs) have been established in orthopaedic and trauma surgery to improve access to care and patient outcomes. The purpose of this study was to measure the impact of a DTOR for hand surgery on the proportion of after-hours cases and wait times from consultation to surgery at a Canadian urban tertiary-care center.

Methods: This retrospective cohort study included adult patients undergoing hand trauma surgery during 2 periods: before DTOR implementation, from August 1, 2018, to January 31, 2020 (n = 599), and after DTOR implementation, from August 1, 2022, to January 31, 2024 (n = 541). The main outcomes were the proportion of emergency cases performed after hours and the wait times from consultation to surgery. A post hoc analysis examined total hospital costs. Multivariable logistic regression was used to estimate associations with binary outcomes, and multivariable negative binomial regression was used to estimate associations with continuous outcomes. Other outcomes, including caseload, surgical complications, and revision surgeries, were assessed using univariate analysis.

Results: After DTOR implementation, after-hours cases decreased from 18% (109 of 599) to 8% (45 of 541). Adjusting for covariates, DTOR implementation was associated with fewer emergency hand surgeries being performed after hours (odds ratio, 0.47 [95% confidence interval (CI), 0.23 to 0.95]; p = 0.03). The median wait times were similar before and after DTOR implementation: 6 days before implementation and 8 days after it (rate ratio, 1.03 [95% CI, 0.91 to 1.16]; p = 0.64). DTOR implementation was associated with a 19% adjusted reduction in total hospital costs: in Canadian dollars, $2,578.66 before DTOR implementation and $2,220.98 after it (rate ratio, 0.81 [95% CI, 0.78 to 0.84]; p < 0.001). The hand trauma caseload was similar (p = 0.09) before and after DTOR implementation. Complications became less frequent after DTOR implementation (reduced from 5% to 2%; p = 0.03), whereas revision rates did not change (10% and 11%; p = 0.70).

Conclusions: DTOR implementation was associated with fewer after-hours surgeries, lower complication rates, and meaningful hospital cost savings, without increasing wait times or revision rates. These findings support integrating DTORs to improve operational efficiency and patient outcomes in hand trauma care.

Level of evidence: Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

➢ The incidence of vertebral compression fractures is increasing, particularly in elderly populations and postmenopausal women, in whom low bone mineral density is a key underlying factor.➢ Conservative management remains the first-line treatment option due to its high success rate and avoidance of surgical complications. When surgical intervention is necessary, cement augmentation via kyphoplasty and via vertebroplasty remain the most common options.➢ Kyphoplasty may be favored over vertebroplasty, especially in patients with severe preoperative kyphotic deformities, as kyphoplasty has a lower risk of adjacent vertebral fractures and demonstrates a greater reduction of the kyphotic deformity.➢ Consideration of restoring proper local spinal alignment is essential in preventing adjacent vertebral fractures and maintaining long-term spinal stability.

Background: More than 1 million total knee arthroplasties (TKAs) are performed annually in the United States to reduce knee pain, restore physical function, and enhance quality of life. However, nearly 1 in 5 patients are not satisfied after 1 year. We aimed to compare patient satisfaction with the U.S. Centers for Medicare & Medicaid Services (CMS) definition of success in TKA.

Methods: We studied a multicenter cohort of patients undergoing primary unilateral TKA, comparing patient satisfaction with CMS-defined surgery success, which is a minimum 20-point improvement in the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR, scored 0 to 100) at 1 year. We cross-classified surgeries by satisfaction and success and used multivariable logistic regression to identify factors associated with satisfied patients being deemed as having undergone surgeries that failed.

Results: We studied 8,444 patients with a mean age of 68 years (with patients grouped by age: 30 to 64 years and 65 to 95 years). Of the patients, 67% were women and 60% were obese. With regard to the patients' race and/or ethnicity, 81% were White, 17% were Black, 1% were Asian, 0.6% were Native American or Alaskan Native, and 0.3% were native Hawaiian or other Pacific Islander. Although 84% of all patients reported satisfaction with the surgery, only 64% of surgeries were deemed successful. Among satisfied patients, only 71% underwent a surgery that was deemed to be successful, and discordance depended strongly on their baseline score. For satisfied patients with the worst baseline status (KOOS JR of <40), the CMS deemed the surgeries to be successful 91% of the time. In contrast, for satisfied patients with better baseline status (KOOS JR of ≥60), the CMS determined that only 39% of the surgeries were successful. Surgical failure in satisfied patients was also associated with younger age, back pain, contralateral knee pain, lower health literacy, diabetes, and poorer mental health. Including the baseline KOOS JR in the model significantly increased predictive accuracy (the area under the receiver operating characteristic curve rose from 0.58 to 0.79).

Conclusions: We found substantial discordance between patients' satisfaction with the procedure and how the CMS currently assesses TKA success. A graded success metric, risk-adjusted for patients' baseline status, would align better with satisfaction. It is also worth exploring whether adding a few questions on joint-specific pain and function could better capture meaningful changes in patients whose high baseline status leaves little room for improvement on the KOOS JR.

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

Background: The trapezius is recognized as a dynamic stabilizer of the acromioclavicular (AC) joint. This function has drawn attention in the treatment of AC joint dislocation. We aimed to clarify the anatomy of the aponeurosis of the trapezius insertion about the AC joint. We hypothesized that the trapezius aponeurosis would exhibit distinctive characteristics in 3 regions: the acromial, AC-joint, and clavicular insertions.

Methods: We analyzed 21 cadaveric shoulder girdle specimens from 13 donors of Japanese ethnicity (4 male and 9 female; mean age [and standard deviation], 86 ± 7.9 years [range, 72 to 97 years]). Fifteen specimens were analyzed macroscopically and 5 histologically. One specimen was excluded because of osteoarthritis. Macroscopic examination included aponeurosis length measurement and fiber orientation analysis.

Results: The trapezius aponeurosis inserted on the medial edge of the acromion, the posterior end of the AC joint, and the posterior edge of the lateral clavicle. The mean aponeurosis length was longest at the acromial insertion (mean, 28.9 ± 5.4 mm), followed by the AC-joint insertion (20.3 ± 7.7 mm), and shortest at the clavicular insertion (7.2 ± 3.2 mm) (p < 0.001). The trapezius aponeurosis was found to extend to the surface of the acromion and AC joint, connecting these structures to the deltoid origin. The coherency value, which reflects the regularity of fiber orientation, was higher on the osseous surface of the acromial insertion (median [interquartile range], 0.36 [0.26 to 0.55]) and the AC-joint insertion (0.37 [0.23 to 0.44]) than at the clavicular insertion (0.22 [0.18 to 0.30]). Histological observation showed that the aponeurosis was inserted via fibrocartilage only at the acromial insertion, just posterior to the AC joint. The aponeurosis at the AC-joint insertion was thicker than that at the clavicular insertion.

Conclusions: The trapezius aponeurosis at the acromial and AC-joint insertions formed a contiguous complex with the origin of the deltoid tendon and with the superior AC-joint capsule.

Clinical relevance: The trapezius aponeurosis at the acromial insertion, just posterior to the AC joint, may be critical for the dynamic stability of the joint.

Background: Patients undergoing total joint arthroplasty (TJA) who are on long-term use of clopidogrel for atherothrombotic prophylaxis often continue this drug as venous thromboembolism (VTE) chemoprophylaxis following primary total knee (TKA) and total hip arthroplasty (THA). We sought to assess the 90-day bleeding and thromboembolic risk profiles of patients receiving clopidogrel monotherapy for postoperative VTE chemoprophylaxis compared with those receiving aspirin following TJA.

Methods: Utilizing a national, all-payer health-care database that captures approximately 25% of all inpatient procedures in the U.S., we identified all adult patients who underwent primary elective TKA or THA between 2016 and 2021. Patients who received clopidogrel monotherapy for postoperative VTE chemoprophylaxis were propensity-score matched in an approximately 1:7 ratio to patients who received aspirin monotherapy on the basis of age, sex, procedure type, perioperative tranexamic acid administration, and known indications for clopidogrel administration. Primary outcomes included the 90-day risks of bleeding and thromboembolic complications.

Results: A total of 21,273 patients who received aspirin were matched to 3,078 patients who received clopidogrel. After matching, there were no significant differences between the 2 cohorts with respect to patient demographics, comorbidities, rates of tranexamic acid administration, and hospital characteristics. After accounting for potential confounding variables, patients who received clopidogrel were at an increased risk for postoperative blood transfusion (adjusted odds ratio [aOR]: 1.69; 95% confidence interval [CI]: 1.30 to 2.21; p < 0.001) and acute anemia (aOR: 1.13; 95% CI: 1.03 to 1.26; p = 0.015) relative to patients receiving aspirin. No significant differences between the cohorts in the risk of deep vein thrombosis, pulmonary embolism, stroke, myocardial infarction, hematoma, or hemorrhage were found.

Conclusions: Patients who received clopidogrel monotherapy for postoperative VTE chemoprophylaxis had an increased risk of postoperative bleeding complications but a similar risk of thromboembolic complications following TJA compared with patients who received aspirin. These findings suggest that the decision to resume clopidogrel for postoperative thromboprophylaxis should balance the potent antiplatelet activity with the risk of bleeding complications in high-risk cardiovascular patients.

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

Background: Unacceptable pain relief after hemiarthroplasty (HA) has limited its utilization for shoulder replacement. The material properties of pyrolytic carbon-graphite composites may result in less abrasion compared with metal bearing surfaces, theoretically decreasing glenoid-sided pain and erosion. This prospective, single-arm, multicenter study was performed to evaluate the short-term clinical outcomes and implant survivorship of pyrocarbon HA.

Methods: The enrollment of 157 patients occurred at 18 sites between December 2015 and April 2017 as part of an Investigational Device Exemption protocol. The Constant score, American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, patient satisfaction, EuroQol-5 Dimensions (EQ-5D) score, and active range of motion were evaluated. A historical control cohort treated with cobalt-chromium HA was identified through a propensity score subclassification analysis. The pyrocarbon HA and cobalt-chromium HA cohorts were compared on the basis of a Composite Clinical Success (CCS) rate, defined as a ≥17-point change in the Constant score without revision or a device-related adverse event.

Results: Of the 157 patients enrolled, 144 had short-term follow-up (mean, 24.4 ± 1.2 months), 10 were lost to follow-up, and 3 underwent revision prior to 24 months due to pain or low-grade infection. The mean patient age was 52.4 ± 10.9 years (range, 19 to 73 years). There were significant improvements in all active range-of-motion and patient-reported outcomes. The outcomes of the pyrocarbon HA cohort (n = 157) were compared with those of the cobalt-chromium HA group (n = 169) eligible for a minimum 24-month follow-up, in which multiple imputation was employed to address missing data. The CCS was 82.7% for the pyrocarbon HA group and 66.8% for the cobalt-chromium HA group (p < 0.001).

Conclusions: Pyrocarbon HA demonstrated favorable results at a short-term follow-up and improved outcomes compared with the propensity score subclassification-derived cobalt-chromium HA cohort.

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

Background: The Lenke classification for adolescent idiopathic scoliosis (AIS) has interobserver variability due to subjective clinical assessment. We developed and validated a fully automated deep learning system for precise Lenke classification using spinal radiographs.

Methods: This retrospective study included 650 individuals (mean age, 13.75 ± 2.23 years; 433 female, 217 male; 618 Han Chinese, 32 Tibetan), comprising 183 healthy controls and 467 patients with AIS (aged 10 to 18 years; 25° ≤ Cobb angle < 90°) with full-spine radiographs. A multistage deep learning system consisting of (1) Swin-Unet segmentation of vertebrae (C7-S1) for automated Cobb angle measurement, (2) DeepLabv3+ localization of lumbar pedicles (L1-L5) to determine modifiers via the centroid-to-CSVL (central sacral vertebral line) distance, and (3) a fusion module integrating features to curve types and lumbar (A/B/C) and sagittal thoracic (-/N/+) modifiers was designed to perform end-to-end Lenke classification automatically. Validation used an independent test set.

Results: The system achieved 95.6% overall accuracy in Lenke classification and had a macro-averaged F1 score of 0.862. Vertebral segmentation attained Dice coefficients of 0.917 (anteroposterior) and 0.942 (lateral). Cobb angle measurements showed excellent agreement with those of experts (intraclass correlation coefficient, 0.969 to 0.976 for thoracic or thoracolumbar/lumbar curves). Modifier assignment achieved F1 scores of 0.912 (lumbar A/B/C) and 0.928 (sagittal -/N/+), exceeding clinical acceptability thresholds.

Conclusions: The fully automated system was able to perform rapid, objective, interpretable, and clinically reliable classification of the Lenke type directly from radiographs, with performance comparable with that of expert assessment. It demonstrates potential for standardizing AIS surgical planning, reducing diagnostic variability, and improving surgical workflow efficiency.

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