JBJS Open Access最新文献

Background: The increasing utilization of magnetic resonance imaging has facilitated the detection of intraspinal abnormalities in congenital scoliosis (CS) caused by hemivertebra. However, the risk of intraspinal abnormalities across different hemivertebra patterns remains unclear. The aim of this study was to compare the prevalence of intraspinal abnormalities between single hemivertebra and multiple hemivertebra and identify key associated risk factors.

Methods: A total of 1,048 patients with CS caused by hemivertebra who received surgical correction were included. The radiographic and clinical data for each patient were collected and analyzed.

Results: Intraspinal abnormalities were present in 16.5% of patients, including syringomyelia (9.2%), lipoma filum terminale (6.0%), low-lying conus medullaris (3.1%), tethered spinal cord (2.9%), diastematomyelia (2.4%), and Chiari malformation (1.9%). Patients with multiple hemivertebra demonstrated a significantly higher intraspinal abnormalities incidence than those with single hemivertebra (24.4% vs. 14.1%, p < 0.001). In single hemivertebra (HV), 51 of 114 patients (44.7%) have intraspinal abnormalities located outside the region of bony HV, while the figure is 26 of 59 (44.1%) in patients with multiple HVs. Multivariate logistic regression showed that female sex [odds ratio (OR) = 1.800, p = 0.001], semisegmented/nonsegmented morphology (OR = 1.499, p = 0.003), and multiple hemivertebra (OR = 1.957, p = 0.001) are the risk factors of intraspinal abnormalities in all cases. Although 12.1% of all patients with intraspinal abnormalities had positive neurological findings, this was not statistically significant compared with those without intraspinal abnormalities (9.0%).

Conclusion: Patients with multiple hemivertebra have a 1.96-fold higher risk of intraspinal abnormalities compared with those with a single hemivertebra. Importantly, intraspinal abnormalities are associated with female sex, multiple hemivertebra, and nonsegmented morphology, but not neurological symptoms, and caution should be paid to the intraspinal abnormalities outside of the bony lesions.

Background: The decision to reconstruct or amputate a limb after high-energy lower extremity trauma is influenced by time-dependent factors including evolution of the extent of injury and complications. The purpose of this study was to introduce a time-dependent classification of limb condition and assess its association with amputation.

Methods: This was a secondary analysis of OUTLET, a multicenter study of participants aged 18 to 60 with a Gustilo-Anderson Type III pilon, talar, calcaneal, IIIB or C ankle fracture, or an open or closed blast/crush foot injury. The primary outcome was amputation within 18 months. The Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) was modified to score the evolving condition of the injured limb postoperatively throughout the treatment course to create a time-dependent OFC (OFC-P). Cox proportional hazards models were fit to estimate the hazard of amputation associated with OFC-P domains over time and compared with models using the baseline OTA-OFC.

Results: 568 participants comprised the study sample, of which 99 underwent amputation. The average age was 38, 33% female, and 68% White. Using the least injured state (score = 1) as the referent, the highest adjusted hazard ratios for amputation were estimated for 2-point changes in the skin (6.1-fold; 95% confidence interval [CI]: 3.1-12.0), muscle (28-fold; 95% CI: 6.8-117), arterial (12.9-fold; 95% CI: 7.1-23.2), and contamination (7.2-fold; 95% CI: 2.9-18.0) domains of the OFC-P. When the relationship of the OFC-P with amputation was allowed to change after 2 weeks from injury, further improvements in model fit were found for skin (p = 0.03) and muscle domains (p = 0.005). The time-dependent models outperformed baseline models, with the largest effect sizes observed within 14 days after injury.

Conclusions: A longitudinal modification of the OTA-OFC is more strongly associated with amputation, especially among skin and muscle domains. Dynamic, quantitative limb viability assessment more accurately reflects clinical practice and patient management but requires prospective validation.

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

Background: Mastery of hip reduction techniques is a critical skill for emergency medicine physicians and orthopaedic surgeons. Resident physicians often face challenges in acquiring necessary hands-on experience with this procedure, with limited or variable exposure in the clinical learning environment. Soft-embalmed cadavers have unique properties that maintain joint range of motion and may provide an innovative model for training hip reduction techniques in a simulated environment. This project sought to assess the feasibility and physical resemblance of soft-embalmed cadavers as a novel hip dislocation-reduction model.

Methods: The model was created using 2 soft-embalmed cadavers. An orthopaedic surgeon conducted a dissection of the femoroacetabular joint to facilitate repeated dislocations and reductions without compromising the model's integrity. This model was tested by a multidisciplinary group of subject matter experts (SMEs) including 6 physicians specializing in emergency medicine, sports medicine, and orthopaedic surgery who performed hip reductions on the cadaveric model. The experts then completed a survey to assess physical resemblance and utility of the cadaveric model for teaching hip reductions.

Results: All SMEs noted near-complete realism regarding the model's anatomy and range of motion. For replicating a hip dislocation, 83% of SMEs stated the model was realistic. While 66% of SMEs stated the cadaver gave a realistic representation of a hip reduction, only 33% reported the cadaver was able to simulate forces of a real patient. Overall, 66% of SMEs expressed a strong inclination to use this model for teaching learners.

Conclusion: In sum, soft-embalmed cadavers are a feasible model for hip reduction training, limited in their ability to simulate forces required for reduction. In the absence of other available simulators, they may provide learning opportunities for training hip reduction and have potential as a training model for other orthopaedic procedures.

Background: Surgeon selection can influence patient satisfaction, outcomes, and access in total joint arthroplasty (TJA). Awareness of patient preferences enables practices to enhance trust, optimize communication, and improve adherence. While referrals and word-of-mouth recommendations often outweigh online marketing, prospective multicenter research exploring how patients choose their TJA surgeon is limited. The aim of this study was to identify key decision-making factors and how they vary by demographics.

Methods: This prospective, multicenter cross-sectional survey study included patients undergoing elective total joint arthroplasty at 4 high-volume institutions from January 2024 to 2025. Participants completed a survey on surgeon selection, including how they first heard of the surgeon, number of visits before deciding on surgery, and whether other surgeons were consulted. Patients rated 10 factors (1-10 scale) and selected the top 3 most important ones from a list of 7 factors.

Results: Among 808 participants, most selected their surgeon through referrals (44.9%) or word-of-mouth recommendations (18.7%); only 8.4% cited online advertisements. Female patients rated surgeon gender (p = 0.010), ease of communication (p = 0.036), and time spent (P = 0.008) as more important than male patients. Minority patients prioritized gender (p = 0.003), race (p < 0.001), bedside manners (p = 0.013), time spent (p = 0.045), and implant type used (p = 0.004) more than White patients. Patients with a median household income between $30,000 and $70,000 rated insurance acceptance higher than those with household income higher than $300,000 (p = 0.007).

Conclusions: Patients choose their arthroplasty surgeon primarily by way of referrals and word-of-mouth recommendations, underscoring the importance of trust. Female and minority patients value surgeon gender, race, and interpersonal skills, supporting culturally responsive care. Strengthening primary care physician engagement and community outreach may improve trust and promote equitable access.

Background: Muscle rebalancing improves shoulder internal rotation contracture due to brachial plexus birth injury but is less effective for correcting marked glenohumeral dysplasia. For severe cases, combining glenoid anteversion osteotomy (GAO) with subscapularis lengthening and tendon transfers is an alternative to external rotation osteotomy of the humerus. We asked how the addition of glenoid osteotomy affects shoulder motion.

Methods: We defined 2 groups who underwent very similar procedures with the exception of GAO: GAO group-combined GAO, subscapularis slide, and tendon transfers for severe glenohumeral dysplasia, and non-GAO group-subscapularis slide and tendon transfers without GAO for cases of milder dysplasia. We compared active and passive rotation, Active Movement Scale (AMS) and Mallet scores.

Results: We compared 86 children in the GAO group with 74 children in the non-GAO group with median follow-ups of 58 (IQR1-3:22-101) and 46 (IQR1-3: 24-72) months, respectively. Preoperatively, the children in the GAO group were older (median 79 (range 14-210) months vs. 34 (range 6-204) months) and exhibited a relatively severe distribution of glenohumeral dysplasia than those in the non-GAO group, as expected. The extent of active external rotation (ER) in adduction improved postoperatively in the GAO group by 65° (p < 0.05), and in the non- GAO group by 84° (p < 0.05). Despite loss of the mean end range of internal rotation by 31° and 27°, the total arc of rotation increased by 34° and 57° in the GAO and Non-GAO groups, respectively. At final follow-up, active ER at 90° abduction (p = 0.14), passive ER (p = 0.17), total arc of rotation (p = 0.11), AMS ER (p = 0.45), Mallet global ER (p = 0.9), and Mallet composite (p = 0.9) scores were similar between the groups, irrespective of the glenoid osteotomy.

Conclusion: The 2 approaches compared here resulted in similar functional outcomes despite different initial severities of glenohumeral dysplasia. Addition of GAO for severe cases does not obviate improved motion.

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

Background: Geographic access to orthopaedic surgery remains limited in nonmetropolitan regions, where over half of US counties lack an orthopaedic surgeon. Osteopathic physicians (DOs) are nearly twice as likely as allopathic physicians (MDs) to practice in these areas, making them a key component of the rural surgical workforce. However, their representation in orthopaedic training has declined since the ACGME-AOA merger.

Methods: This cross-sectional national study used 2022 Area Health Resource Files, National Residency Matching Program Match data (2020-2024), and USDA Rural-Urban Continuum Codes (RUCC) to evaluate workforce distribution and match outcomes. Statistical analysis included chi-square testing and odds ratios to assess nonmetropolitan representation by degree and state.

Results: Of 30,243 orthopaedic surgeons, 92.9% practiced in metropolitan counties and 7.1% in nonmetropolitan areas. Among DOs, 12.5% practiced in nonmetropolitan regions compared with 6.9% of MDs (OR = 1.92; 95% CI: 1.67-2.19). Eleven states showed significantly higher odds of DOs practicing in nonmetropolitan counties, 9 of these states with longstanding in-state osteopathic schools. From 2010 to 2022, DO presence in nonmetropolitan areas increased by 59%, nearly double the rate of MDs. Despite these contributions, DO match rates in orthopaedic surgery declined from 63.3% to 45.7% between 2020 and 2024, widening the DO-MD gap.

Conclusions: DOs play an important role in orthopaedic coverage, as a percentage of their total, in nonmetropolitan communities. Declining match rates raise concerns about the sustainability of this workforce, particularly in states where DOs help maintain surgical access. Structural reforms in training pathways and residency selection may help preserve geographic workforce diversity.

Clinical relevance: Targeted strategies, such as rural training programs, holistic applicant evaluation, and state-specific recruitment efforts, may strengthen access to musculoskeletal care in underserved regions and support a more equitable orthopaedic workforce.

Background: Adult spinal deformity (ASD) is a 3-dimensional deformity that may compromise spinal stability. We hypothesized that this instability increases the risk of spinal fractures in patients with ASD.

Methods: This observational, cross-sectional cohort study was conducted at a single university hospital. All patients aged 40 years or older who underwent DEXA scans over a 3-year period were included. Clinical and radiological data were analyzed using SPSS software.

Results: A total of 7,075 patients (6,476 females, 599 males) were included. The mean age was 60.7 ± 10.7 years, and the mean T-score was -1.11 ± 1.38. Among these, 970 (13.7%) were osteoporotic and 645 (9.1%) had scoliosis. Spinal fractures were identified in 202 patients (2.9%) of whom 67 (33.1%) had scoliosis. Approximately 75% of these fractures occurred above the apex of the scoliotic curve, and 16% occurred at the apex itself. Multivariate analysis identified several independent risk factors for spinal fracture: increasing age (odds ratio [OR] = 1.12, 95% confidence interval [CI]: 1.09-1.15, p = 0.00), Chinese ethnicity (OR = 2.64, 95% CI: 1.07-6.55, p = 0.036), osteoporosis (OR = 1.68, 95% CI: 1.33-2.12, p < 0.001), and scoliosis (OR = 5.37, 95% CI: 3.96-7.28, p < 0.001). Subgroup analysis showed a progressive increase in fracture risk with greater Cobb angles: 10° to 20° (OR = 4.78, p < 0.01), 21° to 30° (OR = 4.95, p = 0.005), and >30° (OR = 6.14, p = 0.043). The risk increased to 31.3 times when the patient was female, osteoporotic, and had a Cobb angle ≥30° (OR = 31.3, 95% CI: 18.1-44.7, p = 0.05).

Conclusion: To the best of the author's knowledge, this is the first large study to describe lumbar scoliosis as an independent risk factor for spinal fracture. Although patient's age, race, and sex may be risk factors for the development of spinal fractures, the presence of lumbar scoliosis significantly increases the risk, especially in patients with osteoporosis. The risk of developing spinal fracture increases to 31.3 times if the patient is female, has osteoporosis, and Cobb angle ≥30°. This study serves to alert the physician that elderly osteoporotic patients with thoracolumbar/lumbar scoliosis are at higher risk of developing spinal fractures, and careful follow-up with aggressive treatment of osteoporosis may be required.

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

Clinical relevance: Elderly female osteoporotic patients with thoracolumbar/lumbar scoliosis are at higher risk of developing spinal fractures. Careful follow-up with aggressive treatment of osteoporosis may be required.

[This corrects the article DOI: 10.2106/JBJS.OA.25.00150.].

Background: Nerve injuries (NI) after pediatric supracondylar humeral fractures (SHF) are commonly reported as neurapraxic, with most studies focusing on motor recovery alone. This study aimed to analyze both sensory and motor outcomes of NI in SHF to identify patterns of recovery and predictors of prolonged nerve recovery.

Methods: A 4-year retrospective cohort study of children 0 to 12 years with NI after SHF was performed. Patterns of nerve recovery and outcomes of spontaneous recovery were analyzed descriptively. Predictors of prolonged nerve recovery (>4 months) were explored using multivariable logistic regression.

Results: Of 1,137 children with SHF, 93 (52% male; mean age 7.2 ± 2.1 years) presented with traumatic NI. The median nerve was most frequently injured (62.4%, n = 58), followed by the radial (29.0%, n = 27) and ulnar nerves (8.6%, n = 8). All children had both sensory and motor deficits; there were no motor-only injuries. Complete spontaneous recovery occurred in 90 children, with 64% (n = 56) taking more than 4 months to recover. Two patients (2.2%) had neurotmetic injuries necessitating nerve grafting. Radial NI showed faster recovery, with 69.2% (n = 18) resolving within 4 months, compared with 20.6% (n = 12) and 25% (n = 2) of median and ulnar NI, respectively.

Conclusions: Traumatic NI after pediatric SHF achieve full spontaneous recovery in most cases, but the majority take longer than 4 months to recover. Radial NI recover more rapidly (<4 months) than median or ulnar NI. Factors such as time to surgery, presence of a pink-pulseless limb, and multidirectional instability did not predict prolonged recovery in extension-type SHF.

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