JBJS Open Access最新文献

Background: Rock climbing participation in the United States has grown markedly, yet recent epidemiologic data are limited. This study characterizes national trends, injury patterns, and risk factors for severe injuries among climbers treated in US emergency departments from 2014 to 2023.

Methods: Rock climbing-related injuries were identified in the National Electronic Injury Surveillance System database. Injuries were analyzed by type, body region, mechanism, and demographic group. Weighted logistic regression assessed fracture and hospitalization risk by age and fall height.

Results: From 2014 to 2023, an estimated 47,251 injuries occurred. Fractures (26.8%) were most common, followed by sprains/strains (20.4%), soft tissue (10.2%), and lacerations (8.0%). Lower extremities were most frequently injured (50.6%), followed by upper extremities (26.7%) and torso (14.9%). Falls (58.8%) were the leading mechanism; falls >20 ft carried 52% higher fracture risk (odds ratio = 1.52, [1.41-1.63]). Adults 21 to 45 years accounted for 63.1% of cases. Climbers >45 years had 45% higher fracture odds compared with those 7 to 20 years. Hospitalization occurred in 9% of cases.

Conclusion: Fractures and lower extremity injuries are the most common presentations in US rock climbing Emergency Department visits. Older age and higher fall height were associated with increased severity of the injury.

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

Background: For intercalary defects after resection of pediatric sarcoma, an isolated vascularized free fibular graft (VFFG) offers a living bone option with the potential for durability but is underutilized due to concerns about mechanical sufficiency. By contrast, structural allograft is initially strong but is associated with a high complication profile with or without a composite VFFG (Capanna). Our aim was to compare the complications associated with allograft/VFFG composites to isolated VFFG.

Methods: This is a retrospective comparison of 32 pediatric patients with primary femoral or tibial sarcoma. Reconstructions were categorized into 2 groups: allografts + VFFG (Capanna) (Group 1, n = 9) and "single barrel" isolated VFFG (Group 2, n = 23). Descriptive and inferential statistical analyses were performed.

Results: No significant differences between the 2 groups were observed in age, sex, diagnosis, length of reconstruction, or follow-up (56 months (SD 29) for Group 1 and 53 months (SD 24) for Group 2). Group 1 participants exhibited a higher number of complications including the need for unplanned surgery (mean 2.9) compared with those in Group 2 (mean 1.6, p < 0.01). Disparities in bone healing were notable. At the final follow-up, 46% in Group 1 had achieved full consolidation compared with 96% in Group 2 (p = 0.002). Graft fractures and hardware failures were not different between the groups despite full weight-bearing among all subjects, suggesting mechanical equivalency within the follow-up period. The mean numbers of unplanned surgeries per participant were 4.2 ± SD 4.4 and 2.3 ± SD 2.5 for Groups 1 and 2, respectively (p = 0.149).

Conclusions: Isolated single barrel VFFG reconstructions are structurally sound and had fewer complications and faster union than composite allograft/VFFG composites.

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

Background: Competency-based medical education relies on assessment to evaluate performance and guide learning. This study compared the validity evidence and psychometric performance of the Objective Structured Assessment of Technical Skills (OSATS), adapted for distal radius fracture fixation, with a procedure-specific instrument-the Distal Radius Fracture Assessment of Technical Expertise (DRF-RATE)-for assessing technical performance during volar locking plate (VLP) fixation of distal radius fractures (DRFs).

Methods: First-year orthopaedic residents (n = 12) and practicing trauma or hand surgeons (n = 13) performed standardized VLP fixation on a cadaveric DRF model. Anonymous video recordings were independently assessed by 2 orthopaedic trauma surgeons and 2 hand surgeons using either OSATS or DRF-RATE. Validity evidence was gathered in accordance with the Messick contemporary validity framework.

Results: Internal consistency reliability was good-to-excellent for OSATS (α = 0.82-0.98) and DRF-RATE (α = 0.95). Interrater reliability was weaker for OSATS (r = 0.59-0.69) than for DRF-RATE (r = 0.78), though both demonstrated systematic rater bias. OSATS discriminated between novices and experienced surgeons (p = 0.02), whereas DRF-RATE demonstrated even stronger discrimination (p < 0.001). Contrasting-groups analysis revealed higher misclassification rates with OSATS (21%-40%) than DRF-RATE (11%-13%), indicating superior accuracy for the latter.

Conclusions: The DRF-RATE demonstrated stronger and more comprehensive validity evidence than the modified OSATS, with better reliability, higher discrimination and classification accuracy, and overall superior psychometric performance compared with OSATS. Its procedural granularity and structured design address key limitations of OSATS and support detailed, high-quality formative feedback for distal radius fracture fixation.

Background: This 5-year longitudinal study evaluated changes in occupational radiation exposure and radiation-induced skin injury among orthopaedic surgeons, focusing on the effects of educational campaigns.

Methods: Orthopaedic surgeons at Hirosaki University were surveyed in 2019 and 2024. Self-reported weekly fluoroscopy ("beam-on") time and dermatologist-graded hand skin findings were compared. Educational campaigns (2020-2023) emphasized As Low As Reasonably Achievable principles and personal protective equipment. We hypothesized that repeated education would improve radiation-safety attitude, reduce self-reported fluoroscopy time, and mitigate dermatologic injury.

Results: The proportion of surgeons cautious about radiation increased from 5.8% to 70.9%. The median weekly self-reported fluoroscopy time decreased from 9.5 to 8.0 minutes (p = 0.045). The prevalence of radiation-induced skin injury declined from 34.9% to 25.6%. Inter-rater reliability was excellent (weighted κ = 0.910). Nonspine surgeon status predicted improvement in skin condition.

Conclusions: During the 5-year period in which repeated radiation-safety education was conducted, surgeons demonstrated improved safety attitudes, decreased self-reported fluoroscopy time, and improved dermatologist-graded skin findings. These observations indicate an association between educational activities, self-reported exposure, and skin findings, but do not establish causality because exposure was self-reported and the study lacked a control group.

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

Background: Slipped capital femoral epiphysis (SCFE) is a common pediatric hip disorder primarily managed with transphyseal screw fixation. Opioid pain medication is often used postoperatively, but there is little evidence to guide prescribing practices. The purpose of this study was to describe opioid utilization and prescribing practices for patients after screw fixation of SCFE.

Methods: This was a prospective observational study of patients with SCFE who underwent transphyseal screw fixation. Patients and guardians were contacted on postoperative days 1, 3, and 5 for data collection. Postdischarge analgesic use, pain severity using a parental proxy, and pain control satisfaction were recorded. Patients who underwent surgical osteotomy or open reduction, patients with cognitive disability, or patients who had other injuries impeding accurate pain assessments were excluded.

Results: Of the 34 patients recruited for the study, 91.2% (31/34) of patients were prescribed opioid medications. Of these 31 patients, 4 were lost to follow-up (87% follow-up). In total, 266 opioid doses were prescribed and 28 were used (p < 0.0001). On average, patients were prescribed 9.85 ± 3.8 opioid doses but used an average of 0.77 ± 1.27 opioid doses (p < 0.0001). Sixty percent of patients did not use any of their prescribed opioid medication, and 90% were satisfied with their pain postoperatively. In addition, 90% of prescribed opioid doses went unused. There was no significant difference in pain control between patients who took opioids and those who did not for each postoperative day. Analysis of opioid use distribution demonstrated that a prescription of 3 doses postoperatively would be sufficient for greater than 95% of all patients.

Conclusions: Overprescription of opioids occurs following screw fixation of SCFE, introducing oversupply into the population. Most patients do excellently with minimal opioid use and have low levels of pain. With adequate nonopioid analgesia counseling and use, outpatient opioid prescriptions following screw fixation of SCFE should be limited. If providers elect to prescribe opioids, we recommend prescribing no more than 3 doses following screw fixation of SCFE.

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

Background: Evidence has been mixed about the efficacy of intra-articular hyaluronic acid (HA) for knee osteoarthritis. This has led to conflicting clinical practice guidelines (CPGs) over the years. After the American Academy of Orthopaedic Surgeons (AAOS) issued a strong recommendation against HA in 2013, a claims-based study showed rapid decline in use. More recent endorsements from Osteoarthritis Research Society International (OARSI) in 2019 and the Veterans Affairs and Department of Defense (VA-DoD) in 2020 may have altered this trajectory. This study aimed to gauge contemporary utilization of HA knee injections.

Methods: All patients aged 18 years and older diagnosed with knee osteoarthritis were identified from the 2010Q1-2023Q1 PearlDiver database. The percentage of patients receiving intra-articular HA relative to the number of patients diagnosed for knee osteoarthritis was calculated quarterly. Linear regression analyses were segmented by 2 key CPG inflection points: 2013Q3 AAOS' recommendation against HA injections and the 2019Q4 endorsements. Analyses were also stratified by provider specialty. Statistical significance was set at p < 0.05.

Results: A total of 16,581,526 knee OA patients were identified, among which HA knee injections were performed for 1,886,788 (11.4%). For the post-2013 AAOS CPG period (2013Q3-2019Q3), injection rates decreased (-0.10% per quarter; p < 0.001). However, following OARSI/VA-DoD endorsement (2019Q4-2023Q1), the slope leveled to -0.003% per quarter; p = 0.921. Through the study period, utilization declined for both women and men and both younger and older patients (<50 years old and ≥ 50 years old) (p < 0.001 for all). Utilization declined among orthopaedic surgeons, nonoperative musculoskeletal specialists, and primary care physicians, while utilization increased among pain medicine physicians (p < 0.001 for all).

Conclusions: Intra-articular HA injection use decreased after the 2013 CPG from AAOS but has stabilized after more positive 2019 and 2020 CPGs from OARSI/VA-DoD. Notably, practice patterns are diverging patterns across specialties, suggesting variabilities in use.

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

Background: Diffuse tenosynovial giant cell tumor (DTGCT) is a locally aggressive benign tumor of the synovium. Patients often initially present with pain, stiffness, and swelling of the affected joint with varying levels of severity. Treatment traditionally involved surgical resection exclusively; however, this could be complicated by high disease recurrence rates. New research has introduced several targeted systemic therapies onto the market changing the treatment paradigm and necessitating a multidisciplinary treatment approach in specialized centers to optimize patient outcomes.

Methods: This review synthesizes the current literature on DTGCT including its pathophysiology, classification, diagnosis, and available treatment options. There is a particular focus on the newer systemic therapies available and how these medications may be used in conjunction with surgery to enhance disease control.

Results: DTGCT most commonly affects young to middle-aged adults, with a slight female predominance, and is most frequently found in the knee. Arthroscopic and even open synovectomy can have disease recurrence rates exceeding 50%. Colony stimulating factor 1 (CSF1) receptor inhibitors have proven effective at symptom palliation and reducing tumor burden in approximately 40% of patients. While these medications improve the quality of life for patients with unresectable disease, they may also be effective in the neoadjuvant setting to downstage surgical approaches and possibly improve disease control in otherwise highly morbid cases.

Conclusions: Surgery alone, the traditional standard for DTGCT, is often insufficient due to high recurrence rates. Systemic therapies can restore function and improve quality of life in patients with advanced disease with rare-but potentially serious-adverse effects. Combining surgical resection with neoadjuvant CSF1R inhibition may provide superior outcomes. Further research is needed to refine the role of systemic agents and develop multidisciplinary protocols. Although initial symptoms often lead patients to community providers, optimal care for patients with DTGCT is best delivered at referral centers with dedicated musculoskeletal oncology programs.

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

Background: The prevalence and characterization of specific types of musculoskeletal (MSK) conditions associated with menopausal transition remains unclear and is often underreported. Our objectives were twofold: (1) to systematically review, and conduct meta-analysis whenever appropriate, to compare the prevalence of MSK symptoms across the different stages of menopause and (2) to characterize the specific MSK conditions associated with transition to menopause.

Methods: We searched Medline, EMBASE, CENTRAL, and PubMed from inception to May 2024. Articles were eligible for inclusion if they included perimenopausal women and reported any primary data on MSK symptoms or pathology. The outcomes we aimed to find included muscle and joint pain, back pain, and the prevalence of various MSK conditions. A pairwise meta-analysis was performed using a DerSimonian-Laird random-effects model for all comparative data, and subgroup analyses were used to explore heterogeneity.

Results: After screening 5,556 relevant records, 37 observational studies across 22 countries enrolling 93,021 women were included in the quantitative analysis. Four in 10 women experienced muscle or joint pain during the premenopausal phase (40% [95% confidence interval {CI}: 32%-49%]). Whereas over half of perimenopausal women (57% [95% CI: 48%-65%]) and postmenopausal women (59% [95% CI: 50%-67%]) experienced muscle or joint pain, representing a 1.35-fold increased risk (risk ratio [RR] 1.35, 95% CI: 1.25-1.46, p < 0.001, I² = 88.6%; absolute risk difference 130 more per 1,000 [95% CI: 93-171]) and a 1.40-fold increased risk (RR 1.40, 95% CI: 1.28-1.53, p < 0.001, I² = 95.0%; absolute risk difference 148 more per 1,000 [95% CI: 104-197]) on pairwise comparison with premenopausal women, respectively. Geographic study location nor measurement scale explained the considerable heterogeneity in the pooled analyses. There was underreporting of specific MSK conditions beyond the generic descriptors of muscle and/or joint pain.

Conclusion: Women transitioning to menopause appear to be at increased risk of developing muscle or joint pain. However, as these findings are based on observational studies, specific causes of MSK pain are underreported, and there is significant heterogeneity. Further high-quality research is needed to confirm and clarify this association.

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

Background: Vertebral body tethering (VBT) for adolescent idiopathic scoliosis (AIS) is an alternative to posterior fusion. There are limited prospective, multicenter data available on VBT following US Food and Drug Administration approval. We hypothesize that curve correction on first postoperative standing (first erect, FE) imaging is associated with higher rates of successful correction at final follow-up.

Methods: All qualifying patients with AIS who underwent thoracic and lumbar VBT between 2019 and 2022 were prospectively enrolled from 9 institutions. Radiographic and clinical data were compared preoperatively, at FE, and at final follow-up with minimum of 2 years. Success was defined as major curve magnitude of ≤35° at final follow-up and no fusion surgery.

Results: One hundred twenty-seven patients were enrolled (79.5% female), with mean follow-up 2.4 years. Mean age at surgery was 12.9 ± 1.4 years, most had bone age of Sanders 4 or lower (93/112, 83.0%). In average, 7.6 ± 1.7 levels were tethered. Mean preoperative major curve magnitude was 50 ± 8°, with mean initial correction at FE of 29 ± 8° (% correction, 39 ± 18%). At final follow-up, mean curve magnitude was maintained at 26 ± 11° (% correction, 45 ± 23%) despite 29% of tether breakage. Patients who had mean FE curve magnitude of ≤35° were 88% successful compared with only 60% in those with >35° on FE (p = 0.0021). Patients showed stable sagittal alignment across all timepoints. Scoliosis Research Society-22 scores improved significantly by 2 years (p < 0.0001).

Conclusion: This was the first prospective, multicenter study to assess outcomes of VBT for patients with AIS. VBT shows promise, but optimal results may depend on careful patient selection and surgical technique. FE major curve magnitude of ≤35° was associated with 88% success rate compared with only 60% success for those with poor correction.

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

Background: Blount disease is growth disorder of the proximal tibia, resulting in genu varum, internal rotation, and procurvatum. Three different forms of the condition are described: infantile, or early onset, juvenile onset, and adolescent or late onset. Although several hypotheses exist, the etiology of Blount disease remains unknown. The best-founded hypothesis is the "increased mechanical force hypothesis". In particular, the relation between obesity and Blount disease. Although, most studies supporting this hypothesis are conducted in high income countries. However, unlike in the Western population that was studied to establish this hypothesis, Blount disease is relatively common in African countries and obesity is not.

Methods: This study is a retrospective, case control study in a rural hospital in Ghana (2012-2021). Demographic information, body weight, and age at presentation were collected. The World Health Organization (WHO) weight-for-age growth standard was used. Overweight was defined as a percentile between 85th and 97th. Obese as a percentile between 97th and 99th. Above the 99th percentile was defined as severely obese.

Results: In total 96 patients with infantile Blount disease were included, all of black Ghanaian descent. The mean age of onset of Blount disease in our patients was 1.7 (±0.9) years, and the mean age at presentation was 6.3 (±3.4) years. This was not different between boys (n = 27) and girls (n = 69). The mean weight for age percentile in our population was 56.8th (±35.3th), and 68% was of normal weight, 15% overweight, 8% obese, and 9% severely obese. Our study population had a significant (p < 0.05) higher mean weight percentile compared with the local control group (n = 79, 37.0th ± 26.0th).

Conclusion: Although our study population of patients with infantile Blount was significantly heavier compared with the control group, the mean weight (56.8th ± 35.3th) was well within normal values. Obesity might have a role in the development of infantile Blount disease, but it is shown to be not as an important factor in the Ghanaian population (18% obese) compared with the more extensively studied US population with much higher obesity rates.

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