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

Background: Total joint arthroplasty (TJA) is increasingly being performed as an outpatient (i.e., same-day discharge) procedure. Postoperatively, orthostatic hypotension or pain-related tachycardia can lead to concerns regarding the hemoglobin (Hgb) level of the patient prior to discharge. The purpose of this study was to prospectively assess the reliability and accuracy of, and patient and nurse satisfaction with, postoperative noninvasive hemoglobin (nHgb) monitoring compared with an invasive serum hemoglobin (iHgb) laboratory draw in the outpatient TJA setting.

Methods: We prospectively enrolled 200 patients undergoing outpatient unilateral TJA, of whom 157 were ultimately included in our analysis (94 hips, 63 knees). Postoperatively, both nHgb and iHgb values were obtained at a mean of 36 minutes apart. Surveys were completed by patients and nurses. The strength of the agreement between the 2 Hgb monitoring methods was evaluated with use of the Bland-Altman 95% limits of agreement, concordance correlation coefficient (CCC), and intraclass correlation coefficient (ICC). Receiver operating characteristic curve analyses were performed to investigate the ability of nHgb monitoring to predict an iHgb of <11.2 g/dL (the 5th-percentile iHgb value).

Results: The mean preoperative iHgb was 14.2 ± 1.1 g/dL. The mean postoperative iHgb and nHgb values were 13.3 ± 1.5 and 13.3 ± 1.2 g/dL, respectively. The Bland-Altman 95% limits of agreement were -3.2 and +3.1 g/dL, indicating that 95% of patients' iHgb values are expected to fall between these limits relative to the nHgb value of the patient. The CCC and ICC were both 0.33. An nHgb cutoff value of <12.7 g/dL had 100% sensitivity and 67% specificity for detecting an iHgb of <11.2 g/dL. Patients reported less pain with the nHgb test than with the iHgb test (mean pain score, 0.0 versus 1.8; p < 0.001), and 97% of patients preferred the nHgb test. Following the nHgb test, 73% of responding patients and 83% of responding nurses were "somewhat more reassured" to "significantly more reassured" about same-day discharge.

Conclusions: Routine nHgb testing can rapidly screen patients undergoing outpatient TJA for acute anemia prior to discharge. With an nHgb of <12.7 g/dL, there was perfect sensitivity and 67% specificity for detecting an iHgb of <11.2 g/dL. Most patients and nurses felt more reassured about same-day discharge after nHgb monitoring.

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

Background: Previous research has underscored the benefits of geriatrician consultation in improving outcomes for older patients undergoing hip fracture repair, highlighting enhanced functional outcomes and reduced morbidity. However, the impact of geriatrician care in outcomes for patients undergoing elective total joint arthroplasty (TJA) has yet to be described. We aimed to determine whether preoperative or postoperative geriatrician involvement was associated with differences in the length of hospital stay and emergency department (ED) visits after TJA.

Methods: This retrospective cohort study screened the medical records of patients ≥65 years of age undergoing primary elective TJA in a network of tertiary hospitals. Geriatrician consultations occurring within a period spanning 90 days before to 90 days after TJA were recorded. Bivariate analysis and multivariable regression models were used to assess the relationship between receiving these consultations and changes in the length of stay and ED visits.

Results: A total of 16,076 patients undergoing primary TJA were included. Of these surgical procedures, 9,677 (60.2%) were total knee arthroplasties and 6,087 (37.9%) were total hip arthroplasties; 1,416 (8.8%) of cases had geriatrician visits. Patients had lower odds of requiring postoperative ED visits when they had at least 1 geriatrician appointment within the week preceding an arthroplasty (odds ratio [OR], 0.97 [95% confidence interval (CI), 0.68 to 0.99]; p = 0.005). This effect was most notable for 65-year-old patients (OR, 0.66 [95% CI, 0.45 to 0.98]).

Conclusion: This study reports promising evidence supporting the benefits of perioperative geriatrician visits on TJA outcomes. Preoperative visits were shown to be associated with decreased odds of ED visits after TJA in patients for up to 90 days postoperatively. Thus, geriatrician involvement in elective TJAs has the potential to improve outcomes and reduce morbidity and costs for patients and reduce costs for surgeons and institutions.

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

Background: Patient-reported outcome measures (PROMs) are used to evaluate the impact of musculoskeletal conditions and their treatment on patients' quality of life, but they have limitations, such as high responder burden and floor and ceiling effects. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed to address these issues but needs to be further evaluated in comparison with legacy PROMs. The goals of this study were to evaluate the floor and ceiling effects of, the correlations between, and the predictive ability of PROMIS scores compared with traditional legacy measures at 10-year follow-up in a cohort who underwent revision anterior cruciate ligament (ACL) reconstruction.

Methods: A total of 203 patients (88.7% White; 51.7% female) who underwent revision ACL reconstruction completed the PROMIS via computer adaptive tests as well as legacy PROMs at the cross-sectional, 10-year follow-up of the longitudinal MARS cohort study (MARS cohort n = 1,234). Floor and ceiling effects and Spearman rho correlations between PROMIS and legacy measures are reported. Linear regression with quadratic terms were used to develop and evaluate conversion equations to predict legacy scores from the PROMIS.

Results: No floor or ceiling effects were reported for the PROMIS Physical Function (PF) domain, whereas a floor effect was found for 37.9% of the participants for the PROMIS Pain Interference (PI) domain, and a ceiling effect was found for 34.0% of the participants for the PROMIS Physical Mobility (PM) domain. PROMIS domains correlated moderately with the International Knee Documentation Committee total subjective score (absolute value of rho [|ρ|] = 0.68 to 0.74), fairly to moderately with the Knee injury and Osteoarthritis Outcome Score and Western Ontario and McMaster Universities Osteoarthritis Index scores (|ρ| = 0.52 to 0.67), and fairly with the Marx Activity Rating Scale (|ρ| = 0.35 to 0.44). None of the legacy-measure scores were accurately predicted by the PROMIS scores.

Conclusions: The PROMIS PF domain has value in assessing patients 10 years after revision ACL reconstruction. Because of floor and ceiling effects, using the PI and PM domains may not allow for precision when measuring long-term changes in pain and mobility. Although the PROMIS measures correlated with the legacy measures, with effect sizes ranging from fair to moderate, the legacy scores were not accurately predicted by the PROMIS. The results suggest that knee-specific legacy measures should not be eliminated from long-term follow-up when the goal is to capture the specific knee-related information that they provide.

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

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.