Orthopedics最新文献

Background: Antiphospholipid syndrome (APS) is a systemic autoimmune condition that predisposes patients to venous thromboembolism (VTE). Although many studies have explored risk factors for VTE after joint reconstructive procedures, the impact of APS is still unclear.

Materials and methods: A retrospective cohort study was conducted using TriNetX, a health care database that includes 442,494 patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Ninety-day postoperative complications and 1- and 2-year surgical complications were compared between patients with and without preexisting APS. Patients underwent propensity score matching in a 1:1 ratio based on relevant comorbidities.

Results: Patients undergoing THA or TKA with APS, compared with those without, had higher rates of deep venous thrombosis (hip: 9.2% vs 6.0%, odds ratio, 1.589, P=.022; knee: 10.5% vs 4.1%, odds ratio, 2.763, P<.001), pulmonary embolism (hip: 6.9% vs 3.6%, odds ratio, 1.992, P=.005; knee: 8.4% vs 3.0%, odds ratio, 2.989, P<.001), and anemia (hip: 24.8% vs 18.6%, odds ratio, 1.447, P=.004; knee: 18.5% vs 13.9%, odds ratio, 1.406, P=.007). Patients undergoing THA with APS also had higher rates of urinary tract infection (5.0% vs 2.8%, odds ratio, 1.842, P=.029) and pneumonia (3.7% vs 1.8%, odds ratio, 2.119, P=.025). APS did not impact rates of surgical complications or revision surgery.

Conclusion: Overall, APS heightens patients' risk for complications after THA and TKA. Specific anticoagulation protocols and preoperative risk stratification should be implemented to reduce the risk of adverse events. [Orthopedics. 2024;47(5):301-307.].

Background: In this study, we tested the null hypothesis that robotic-assisted total hip arthroplasty (THA) vs conventional THA was not associated with (1) the amount of postoperative opioid use and (2) the incidence of new, persistent opioid use.

Materials and methods: We used a large, national administrative database to identify patients 50 years and older undergoing primary robotic or conventional THA. Patients with hip fractures or a history of malignancy, hip infection, or opioid use disorder were excluded. Patients who filled an opioid prescription within 1 year to 30 days preoperatively or who underwent a subsequent procedure within 1 year after THA were excluded. Outcomes included the morphine milligram equivalents (MMEs) filled within the THA perioperative period and the incidence of new, persistent opioid use. Multivariable logistic regression models were used to evaluate associations between robotic-assisted THA and new, persistent opioid use, adjusting for age, sex, insurance plan, region, location of surgery, and comorbidities.

Results: In the postoperative period, robotic-assisted THA, compared with conventional THA, was associated with a lower mean total MMEs filled per patient (452.2 vs 517.1; P<.001) and a lower mean MMEs per patient per day (71.53 vs 74.64; P<.001). Patients undergoing robotic-assisted THA had decreased odds of developing new, persistent opioid use compared with patients undergoing conventional THA (adjusted odds ratio, 0.82 [95% CI, 0.74-0.90]).

Conclusion: Robotic-assisted THA is associated with lower postoperative opioid use and a decreased odds of developing new, persistent opioid use compared with conventional THA. For the purposes of reducing opioid use, our results support the adoption of robotic-assisted THA. [Orthopedics. 2024;47(5):289-294.].

Background: Displaced diaphyseal fractures can be reduced using the push-pull technique, wherein a plate is affixed to the distal fragment of the fracture, a post screw is placed proximal to the plate, and a lamina spreader creates distraction. This study evaluated the load to failure and mechanism of failure of bicortical and unicortical post screws during reduction.

Materials and methods: Four matched pairs of cadaver legs were subjected to a 2-cm oblique osteotomy simulating a displaced, oblique diaphyseal fracture. A 6-hole compression plate was affixed to the distal fragment with 2 unicortical locking screws, and a 12-mm unicortical or 20-mm bicortical screw was inserted as a post screw proximal to the plate. A lamina bone spreader was used to exert a distraction force between the plate and the post screw. A mechanical actuator simulated the distraction procedure until failure. Maximum applied load, displacement, and absorbed energy were recorded and compared across unicortical and bicortical groups by paired t tests.

Results: At maximum load, we found statistically significant differences in displacement (P=.003) and energy absorbed (P=.022) between the two groups. All unicortical screws failed through screw toggle and bone cut-out. Bicortical screws failed through bending, with no visible damage to the bone at the screw site.

Conclusion: When diaphyseal fractures are significantly shortened and require a greater distraction force to achieve reduction, bicortical screws demonstrate a higher mechanical load to failure and increased bone loss from the screw-removal site. A unicortical post screw may be used if minimal distraction is needed. [Orthopedics. 2024;47(5):308-312.].

Background: Periprosthetic fractures around total hip arthroplasty (THA) represent a significant source of morbidity and mortality. The use of tranexamic acid (TXA) in arthroplasty is well described, yet little literature supports its role in periprosthetic femur fractures (PFFs). This study investigated the effect of preoperative TXA administration on transfusion rate and volume, length of stay, and 90-day complication rates in patients undergoing revision THA for PFF.

Materials and methods: All patients undergoing revision THA for PFF (Vancouver B2/B3) at our institution from August 2016 to June 2022 were identified. Routine TXA administration at surgical start was introduced in 2018. Patient demographics, operative time, blood product use, length of stay, and 90-day complications were collected. Patients were divided into those who received TXA preoperatively and those who did not.

Results: A total of 56 patients were included. There was no difference in age, sex, anesthetic type, fracture classification, or preoperative blood values between cohorts. TXA significantly lowered the amount of blood product required (2.3 units vs 3.2 units, P=.023). Preoperative TXA did not independently reduce length of stay; however, blood transfusion was associated with increased length of stay (7 days vs 4.7 days, P=.003). There were no differences in 90-day complications.

Conclusion: Among patients who underwent revision THA for Vancouver B2/B3 PFF, TXA did not affect transfusion rates but did result in the use of fewer blood products without an increase in complications. We support routine use of TXA in this patient population. Future studies should assess earlier administration of TXA in the emergency department or once patients' conditions have been medically optimized. [Orthopedics. 2024;47(5):e261-e267.].

Posterolateral corner and arcuate fractures can cause significant disruption to the stability and kinematics of the knee. This study aimed to determine the biomechanical performance of a novel spiked washer (SW) and intramedullary screw technique compared with a tension slide technique (TST) for the repair of arcuate fractures. Sixteen matched fresh-frozen cadaver knees underwent repair. Each specimen underwent transection of the posterolateral corner and lateral capsule along with a proximal fibula osteotomy to simulate an arcuate fracture. Eight specimens underwent repair with a SW technique and 8 underwent repair with a TST. Each specimen underwent cyclic loading followed by load to failure. Gap formation, ultimate load to failure, energy to failure, and stiffness were assessed. The SW technique had significantly less gap formation and higher load to failure. Furthermore, the SW technique had significantly higher stiffness and energy to failure. A SW and screw technique provided a significantly stronger construct with less gap formation when compared with a TST. [Orthopedics. 2024;47(5):e277-e281.].

Background: Patients undergoing total joint arthroplasty (TJA) may receive unexpected medical bills. Such "surprise" bills may cause financial hardship for patients, which prompted policymakers to pass the No Surprises Act. The purpose of this study was to determine the incidence of surprise bills for patients undergoing TJA and the effect of surprise billing on patient satisfaction.

Materials and methods: This was a retrospective study of patients who underwent a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at a large multi-state institution. Patients completed a questionnaire regarding the incidence of surprise bills after their surgery, details of those bills, and how the bills affected their surgical satisfaction. Independent predictors for receiving a surprise bill were assessed through a multivariate regression analysis.

Results: Twelve percent of participants received at least one surprise bill after their TJA. The most common surprise bill came from the surgical facility (48%), followed by anesthesia (36%). Multivariate logistic regression analysis identified older age and Black race to be independent predictors of surprise billing. Furthermore, surgery occurring after the No Surprises Act bill enforcement on January 1, 2022, was found to increase a patient's likelihood of receiving a surprise bill (P=.039, effect size=0.18). Patients who received a surprise bill reported being significantly less satisfied with their surgery (P=.002, effect size=0.45). Forty-nine percent of patients with a surprise bill felt their billing negatively affected their surgical satisfaction.

Conclusion: Surprise billing continues to occur after TJA and can negatively affect patient satisfaction. Although surgeons may be unable to limit the amount of bills patients receive postoperatively, increased communication and education regarding the perioperative billing process may prove to be beneficial for both patient satisfaction and the physician-patient relationship. [Orthopedics. 2024;47(5):283-288.].

Background: Patient-reported outcome measures (PROMs) were originally developed as research tools; however, there is increasing interest in using PROMs to inform clinical care. Prior work has shown the benefits of implementing PROMs at the point of care, but a patient's health numeracy (their ability to understand and work with numbers) may affect their ability to interpret PROM results.

Materials and methods: We recruited patients presenting to an outpatient orthopedic clinic. Forty-nine patients completed a survey that included demographic information, the short-form General Health Numeracy Test, and accuracy questions about four PROM displays (bar graph, table, line graph, pictograph) that indicated the same PROM results.

Results: Patients with higher health numeracy answered all display accuracy questions correctly (P=.016). Patients who preferred using the table were more likely to answer display accuracy questions incorrectly (odds ratio, 0.013, P=.024). The two most frequently preferred PROM formats were bar graphs and tables, and most patients preferred to learn about their PROM function scores via a combination of displays and verbal discussions.

Conclusion: Patient health numeracy is associated with the ability to correctly interpret visual displays of PROMs. Implementation of PROMs at point of care currently does not account for health numeracy. Efforts to account for health numeracy when using PROMs at point of care may improve the efficacy of using PROMs to improve outcomes in orthopedic surgery. [Orthopedics. 2024;47(5):e255-e260.].

Background: The recent addition of biceps tendon augmentation to partial arthroscopic rotator cuff repair (ARCR) for the treatment of large-to-massive rotator cuff tears is proposed to improve clinical outcomes and reduce re-tears.

Materials and methods: The purpose of this systematic review and meta-analysis (5 studies) was to compare outcomes between partial ARCR with (142 patients) and without (149 patients) biceps augmentation.

Results: Partial ARCR with and without biceps augmentation were comparable in pain, function, and range of motion. However, biceps augmentation vs no augmentation at all during ARCR may lower re-tear rates for irreparable large-to-massive rotator cuff tears (42.9% vs 72.5%, P=.007).

Conclusion: More research is needed to investigate this technique and guide surgical decision-making. [Orthopedics. 2024;47(5):e217-e224.].