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

Abstract: In silico clinical trials, particularly when augmented with artificial intelligence methods, represent an innovative approach with much to offer, particularly in the musculoskeletal field. They are a cost-effective, efficient, and ethical means of evaluating treatments and interventions by supplementing and/or augmenting traditional randomized controlled trials (RCTs). While they are not a panacea and should not replace traditional RCTs, their integration into the research process promises to accelerate medical advancements and improve patient outcomes. To accomplish this, a multidisciplinary approach is needed, and collaboration is instrumental. With advances in computing and analytical prowess, and by adhering to the tenets of team science, realization of such a novel integrative approach toward clinical trials may not be far from providing far-reaching contributions to medical research. As such, by harnessing the power of in silico clinical trials, investigators can potentially unlock new possibilities in treatment and intervention for ultimately improving patient care and outcomes.

Background: Value is defined as the ratio of patient outcomes to the cost of care. One method to assess value is through patient-level value analysis (PLVA). To our knowledge, this tool has not previously been implemented in the setting of total hip arthroplasty (THA). The purposes of this study were to perform PLVA for a 1-year episode of care among patients undergoing primary THA and to identify characteristics that affect value in a metropolitan health-care system.

Methods: The patient-reported outcome (PRO) measure database of the institution was queried for all primary THAs from 2018 to 2019. The PRO measure that was utilized was the Hip disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS-JR). Cost was evaluated with use of time-driven activity-based costing (TDABC) for a 1-year episode of care (consisting of the day of surgery, inpatient stay, discharge facility, postoperative appointments, and physical therapy). The primary outcome was the 1-year value quotient, or the ratio of the 1-year change in HOOS-JR to the cost of the episode of care (VHOOS). The value quotient was compared among all included patients and evaluated for variables that may affect the overall value of the episode of care.

Results: In total, 480 patients were included in the analysis. The mean improvement in the HOOS-JR was +34.9 ± 16.1 (95% confidence interval [CI]: 33.5, 36.3). The mean cost was $13,835 ± $3,471 (95% CI: $13,524, $14,146). The largest contributor to cost was implants (39.0%), followed by post-recovery care (i.e., inpatient stay and specialized nursing facilities; 24.1%). Change in the HOOS-JR was poorly correlated with the cost of care (r = -0.06; p = 0.19). THAs performed at an ambulatory surgery center (ASC) with discharge to home demonstrated higher value (VHOOS = 0.42) than THAs performed at a hospital with discharge to a rehabilitation facility (VHOOS = 0.15; analysis of variance F-test, p < 0.01).

Conclusions: Our study found that PROs did not correlate with costs in the setting of primary THA. Implants were the largest cost driver. Surgical setting (an ASC versus a hospital) and discharge destination influenced value as well. PLVA is a value measurement tool that can be utilized to optimize components of the care delivery pathway.

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

Background: Precise measurement of the intraosseous corridor within the superior pubic ramus is essential for the accurate percutaneous placement of a retrograde superior ramus screw (SRS). However, conventional manual measurement methods are often subjective, leading to variations in results among observers. Our goal was to develop an automated and dependable method for determining the retrograde SRS corridor.

Methods: We developed an automated technique that utilized a computed tomography (CT) image-based search algorithm to identify the retrograde SRS corridor with the maximum diameter. We evaluated the reliability of this automated approach in comparison to a manual method using 17 pelves. Subsequently, we used both methods to measure the diameter, length, and orientation of the retrograde SRS corridor in 204 pelves in a Chinese population and assessed the intra- and interobserver agreement of each method by calculating the root-mean-square error (RMSE) and constructing Bland-Altman plots. We determined the screw applicability (percentages of hemipelves that could be treated with specific sizes of screws) for each method. Additionally, we investigated potential factors influencing the corridor, such as sex, age, height, and weight, through regression analysis.

Results: The intra- and interobserver intraclass correlation coefficients (ICCs) for the automated method (0.998 and 0.995) were higher than those for the manual approach (0.925 and 0.918) in the assessment of the corridor diameter. Furthermore, the diameter identified by the automated method was notably larger than the diameter measured with the manual method, with a mean difference and RMSE of 0.9 mm and 1.1 mm, respectively. The automated method revealed a significantly smaller corridor diameter in females than in males (an average of 7.5 and 10.4 mm, respectively). Moreover, use of the automated method allowed 80.6% of the females to be managed with a 4.5-mm screw while a 6.5-mm screw could be utilized in 19.4%, surpassing the capabilities of the manual method. Female sex had the most substantial impact on corridor diameter (β = -0.583).

Conclusions: The automated method exhibited better reliability than the manual method in measuring the retrograde SRS corridor, and showed a larger corridor diameter for screw placement. Females had a significantly smaller corridor diameter than males. Given the intricate nature of the automated approach, which entails utilizing different software and interactive procedures, our current method is not readily applicable for traumatologists. We are working on developing integrated software with the goal of providing a more user-friendly solution for traumatologists in the near future.

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

Background: A dorsal bunion may occur in nonambulatory adolescents with cerebral palsy (CP) and a Gross Motor Function Classification System (GMFCS) level of IV or V. The deformity can cause pain, skin breakdown, and difficulty wearing shoes and braces. A consensus on the biomechanics and surgical management of dorsal bunions in persons with severe CP has not been established.

Methods: This retrospective cohort study included 23 nonambulatory adolescents with CP, GMFCS level IV or V, and symptomatic dorsal bunions requiring surgery. The median age at surgery was 17 years, and the median follow-up was 56 months. Reconstructive surgery included the excision of a 2 to 3-cm segment of the tibialis anterior tendon to correct the elevation of the first metatarsal. The fixed deformity of the first metatarsophalangeal joint was managed with use of corrective arthrodesis and dorsal plate fixation. Clinical and radiographic outcomes were assessed preoperatively and postoperatively at the transition to adult services.

Results: There were significant improvements in the clinical and radiographic outcome measures (p < 0.001). Pain was relieved, and there were no further episodes of skin breakdown. The elevation of the first metatarsal was corrected from a mean of 3° of dorsiflexion to a mean of 19° of plantar flexion. The deformity of the first metatarsophalangeal joint was corrected from a mean of 55° of plantar flexion to a mean of 21° of dorsiflexion. Six patients had complications, all of which were grade I or II according to the modified Clavien-Dindo system.

Conclusions: The surgical reconstruction of a dorsal bunion via soft-tissue rebalancing of the first ray and corrective arthrodesis of the first metatarsophalangeal joint resulted in favorable medium-term clinical and radiographic outcomes in nonambulatory adolescents with CP.

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

Background: Restoration of hand function after traumatic brachial plexus injury (BPI) remains a formidable challenge. Traditional methods such as nerve or free muscle transfers yield suboptimal results. Advancements in myoelectric prostheses, characterized by novel signal acquisition and improved material technology, show promise in restoring functional grasp. This study evaluated the ability of adults with a BPI injury to control an externally powered prosthetic hand using nonintuitive signals, simulating the restoration of grasp with a myoelectric prosthesis. It also assessed the effectiveness of a comprehensive multidisciplinary evaluation in guiding treatment decisions.

Methods: A multidisciplinary brachial plexus team assessed adults with compromised hand function due to BPI. The feasibility of amputation coupled with fitting of a myoelectric prosthesis for grasp reconstruction was evaluated. Participants' ability to control a virtual or model prosthetic hand using surface electromyography (EMG) as well as with contralateral shoulder motion-activated linear transducer signals was tested. The patient's input and injury type, along with the information from the prosthetic evaluation, were used to determine the reconstructive plan. The study also reviewed the number of participants opting for amputation and a myoelectric prosthetic hand for grasp restoration, and a follow-up survey was conducted to assess the impact of the initial evaluation on decision-making.

Results: Of 58 subjects evaluated, 47 (81%) had pan-plexus BPI and 42 (72%) received their initial assessment within 1 year post-injury. Forty-seven patients (81%) could control the virtual or model prosthetic hand using nonintuitive surface EMG signals, and all 58 could control it with contralateral uniscapular motion via a linear transducer and harness. Thirty patients (52%) chose and pursued amputation, and 20 (34%) actively used a myoelectric prosthesis for grasp. The initial evaluation was informative and beneficial for the majority of the patients, especially in demonstrating the functionality of the myoelectric prosthesis.

Conclusions: The study indicates that adults with traumatic BPI can effectively operate a virtual or model myoelectric prosthesis using nonintuitive control signals. The simulation and multidisciplinary evaluation influenced informed treatment choices, with a high percentage of patients continuing to use the myoelectric prostheses post-amputation, highlighting its long-term acceptance and viability.

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

Background: Acupuncture and epidural steroid injection (ESI) are frequently performed in patients with degenerative lumbar disease. The purpose of this study was to explore preoperative acupuncture and ESI as risk factors for postoperative infection after elective lumbar fusion.

Methods: Patients >50 years of age who underwent spinal fusion due to degenerative lumbar disease from 2010 to 2019 were identified by diagnostic and procedural codes using a nationwide database. The incidence of spinal infection within 90 days after surgery was identified. Patients who underwent acupuncture and/or ESI within 90 days prior to spinal surgery were identified using procedural codes. The infection rate was analyzed by dividing patients into 4 groups as follows: patients who underwent neither acupuncture nor ESI (unexposed group), patients who underwent acupuncture only (acupuncture group), patients who underwent ESI only (ESI group), and patients who underwent both acupuncture and ESI (combined group). Cox regression analysis was performed to identify risk factors for postoperative spinal infection.

Results: A total of 207,806 patients were included in this study. The postoperative infection rate among all patients was 4.29%. The infection rates in the unexposed, acupuncture, ESI, and combined groups were 4.17% (4,342 of 104,106 patients), 3.90% (340 of 8,726 patients), 4.48% (3,761 of 83,882 patients), and 4.26% (473 of 11,092 patients), respectively. Increasing age, male sex, and ESI were demonstrated to be risk factors for postoperative spinal infection. ESI was no longer a risk factor when patients who received acupuncture or ESI within 2 weeks of spinal surgery were excluded. Preoperative acupuncture was not associated with postoperative spinal infection.

Conclusions: Acupuncture and ESI performed >2 weeks prior to spinal surgery did not increase the risk of postoperative infection.

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

Background: Despite the use of in-depth peer-review processes, there occasionally are issues with published manuscripts that require retraction. The purpose of the present study was to explore the reasons for the retraction of orthopaedic research articles, with consideration of the journal impact factor and the orthopaedic subspecialty.

Methods: In 2023, a database search was conducted for retracted papers written in the English language in the orthopaedic literature. The initial search yielded 3,147 results. These papers were screened by 3 independent reviewers, and 207 studies were jointly identified as retracted orthopaedic research articles. We collected data regarding the reasons for retraction, the date of publication, the date of retraction, the orthopaedic subspecialty, the impact factor of the journal, the countries of research origin, and the study design.

Results: Of the 207 retracted articles, 104 (50.2%) were clinical science studies and 103 (49.8%) were basic science studies. The reasons for retraction were plagiarism (n = 39), intrinsic errors (n = 33), duplication (n = 30), fraud (n = 25), manipulation of the peer-review process (n = 20), no reason given (n = 18), no approval from an ethics board (n = 17), author's choice (n = 9), data ownership and/or copyright issue (n = 9), and other (n = 7). The journal impact factors ranged from 0.17 to 9.80, with a median of 2.90. The mean time from publication to retraction across all of the studies was 32.1 months (standard deviation = 37.3 months; n = 201).

Conclusions: An analysis of orthopaedic research revealed that the majority of retractions of articles were due to plagiarism, study errors, or duplicated material; retractions occurred internationally and across a wide range of journals.