JBJS Open Access最新文献

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.

» Video-based coaching (VBC) is an educational technique that integrates real-time recordings of resident-performed procedures that are later analyzed by an expert coach, providing an opportunity for objective feedback. » Head-mounted point-of-view cameras provide a clear visual recording of the surgical field from the surgeon's perspective. Pilot studies using primarily head-mounted cameras showed that the VBC approach demonstrates a potential improvement in residents' technical skills. » VBC can promote the development of nontechnical skills, such as cognitive awareness and critical thinking. This may enhance residents' self-confidence, influencing their ability to perform the same procedures in the future. » This scoping review performs a comprehensive evaluation of existing literature on VBC within surgical education to determine its importance, effectiveness, and application to orthopaedic surgery residency training. » While traditional intraoperative exposure remains a critical component of orthopaedic resident training, VBC offers a promising and valuable supplementary educational resource.

Background: The role of research personnel (e.g., research assistants, research coordinators, research managers, etc.) is critical to the success of clinical trials in orthopaedic surgery. Retention of research personnel is a challenge faced by many academic surgical researchers. Limited investigation has been conducted to identify and quantify factors that lead to low retention rates, especially in the field of orthopaedic surgery clinical research.

Methods: We developed an electronic survey, containing the validated Job Satisfaction Survey (JSS), to evaluate job satisfaction, career path, and educational pathways in the context of long-term retention of research personnel working in orthopaedic surgery. We distributed the anonymized survey to research personnel who currently or had previously participated in at least 1 orthopaedic trauma clinical trial coordinated by a university-affiliated surgical methods center.

Results: Seventy-two research personnel working on clinical orthopaedic studies completed the survey (43%). Using the JSS, overall respondent scores (mean 143.8, SD 26.6) fell on the border of the ambivalent and satisfaction categories. The lowest mean scores, representing dissatisfaction (scores <12), were seen within the promotion (11.4, SD 4.9) and pay (11.9, SD 5.1) subscales. Higher pay was the most common factor that would increase respondents' satisfaction in their current position (72%). Almost half (46%) expressed funding being a barrier to accessing continuing education, and 54% were unsure or considered clinical research in orthopaedic trauma a temporary position. Four main themes arose from the qualitative portion of the survey: (1) appreciation and involvement, (2) institutional barriers, (3) training, and (4) support from the principal investigator.

Conclusions: Research personnel in clinical orthopaedic trauma surgery are a highly motivated group with job satisfaction bordering ambivalence into satisfaction. Despite the desire to grow in their positions, pay and inadequate funding to support continuing education opportunities are barriers. The qualitative findings provide additional insights into how job satisfaction and retention can be improved among clinical research personnel in orthopaedic trauma surgery.

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

Background: Rapidly progressive idiopathic arthritis (RPIA) of the hip is a rare, poorly understood, destructive hip disease. Etiologies are understudied; however, recent literature suggests a causal relationship between intra-articular corticosteroid hip injections and the development of RPIA. This study's primary objective was to identify the prevalence of RPIA following methylprednisolone intra-articular hip injections (IAHI) and assess these cases' baseline characteristics.

Methods: Patients who received at least 1 fluoroscopy-guided methylprednisolone IAHI into a native hip between January 2010 and December 2019, had available preinjection and postinjection images, and met inclusion criteria were enrolled. Demographic variables, injection dose and laterality, and number of injections per hip were collected from electronic medical records. Postinjection RPIA was determined through imaging review.

Results: The total was 1,402 unique hips. The mean age at the time of first injection was 63 (SD = 12.65), and 54% (n = 752) of patients were female. Review of preinjection and postinjection imaging revealed 31 cases of RPIA, thus 2.2% overall prevalence. The mean number of methylprednisolone injections per hip was 1.67 (SD = 1.72), with a mean cumulative dose of 74.91 mg (SD = 84.58). Conditional logistic regression showed each 100 mg increase in cumulative dose was associated with an odds ratio of 0.90 (95% confidence interval 0.59-1.37; p = 0.62). Thus, increasing dose was not significantly associated with the risk of RPIA.

Conclusion: To our knowledge, this is the first study to exclusively analyze methylprednisolone IAHI, which found a lower prevalence of postinjection RPIA than most previous studies. Importantly, cumulative methylprednisolone dose was not significantly associated with an increased risk of RPIA, suggesting that repeat dosing within the studied ranges is unlikely to substantially increase the risk of this complication.

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

» Nutritional optimization is essential for improving orthopedic surgical outcomes by addressing the hypermetabolic state and supporting tissue regeneration. » Evidence-based preoperative interventions, including tailored carbohydrate, protein, omega-3 fatty acids, and micronutrient intake, support muscle preservation and enhance recovery. » Integrating dietitians into surgical care improves nutritional screening and personalized dietary plans, optimizing outcomes for high-risk patients.

Background: Civilian fractures resulting from firearm injuries are a challenging clinical entity associated with a high risk of infection. This study aims to characterize rates, associated risk factors, and pathogen profile of infections after low-energy civilian firearm fractures.

Methods: This study included 1,508 adults with low-velocity firearm fractures at a Level I trauma center (2018-2022). Demographic, injury, and clinical data were collected with infection status determining stratification. Outcomes of interest in the infection cohort included pathogen, timing of antibiotics, and clinical course.

Results: Of 1,508 patients, 140 patients (9.3%) developed an infection. Factors significantly associated with infection included age, male gender, lower extremity fracture, vascular injury, compartment syndrome, visceral injury, retained foreign body, and operative intervention. Polymicrobial infections were found in 67 patients (68%), and the mean time from injury to positive culture was 70.8 ± 129.2 days.

Conclusion: Infections after firearm fractures are a challenging complication with a predominance of methicillin-resistant Staphylococcus aureus, multidrug resistant Gram-negative organisms, and rare pathogens typically seen in immunocompromised individuals. Our study emphasizes need for further study regarding efficacy of prophylactic antibiotics and suggests utility in targeted treatment for atypical organisms.

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

Background: Patient portal (PP) usage enhances patient engagement, quality of care, and clinical outcomes. However, effective utilization requires digital literacy and internet access, resulting in disparities, particularly among older, non-White, uninsured, or publicly insured patients. While prior studies have examined PP use in specific orthopaedic subspecialties, comprehensive analyses are limited. The aim of this study was to identify social determinants of health of interest (SDOH) associated with PP utilization across orthopaedic subspecialties and to assess its association with outcomes.

Methods: A retrospective cohort study of adult patients who underwent orthopaedic procedures was conducted between January 2021 and December 2022. The study included 33,143 encounters involving 28,028 patients. PP utilization was defined as activating and using the PP at least once. SDOH assessed included age, sex, race, ethnicity, language, domestic partnership status, employment status, insurance, and urbanicity. Clinical outcomes included hospital length of stay, 30-day return to the emergency department (ED), 30-day readmission, and discharge disposition. Univariable and multivariable models evaluated associations between SDOH and PP use, while mixed-effects models assessed the association between PP utilization and outcomes.

Results: PP utilization varied across subspecialties, with the highest rates in sports medicine (93.9%) and hip preservation (92.6%) and the lowest in trauma (71.7%). Lower odds of PP use were observed among patients older than 65 years, male, non-White, non-English speaking, single, unemployed, uninsured or publicly insured, and those living in rural areas. A decrease of 1 SDOH was associated with a 2.21-fold increase in PP use (odds ratio [OR]): 2.21; 95% confidence interval [CI]: 2.14-2.29; p < 0.001). Nonusers had higher odds of 30-day ED return (OR: 1.73; 95% CI: 1.51-1.99), 30-day readmission (OR: 2.49; 95% CI: 2.12-2.93), nonhome discharge (OR: 4.63, 95% CI: 3.76-5.70), and experienced longer hospital stays (Rate Ratio: 1.61; 95% CI: 1.52-1.70).

Conclusions: PP utilization in orthopaedic surgery is associated with social determinants of health and varies by subspecialty. PP nonusage is associated with worse clinical outcomes, highlighting the need for targeted interventions to improve PP adoption among at-risk populations and reduce disparities in orthopaedic care.

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

Background: Scoliosis has various etiologies, ranging from idiopathic, congenital, to those with spinal cord abnormalities. Advanced imaging is not always feasible and limited by cost, low-yield, and anesthesia risks in children. Given artificial intelligence's potential, we hypothesize that a deep learning (DL)-based image classifier will demonstrate superior performance in radiographic classification of scoliosis etiology compared witht experienced spine surgeons based on spine radiographs.

Methods: One thousand thirty-six pediatric patients from single institution with scoliosis diagnosis and paired anterior-posterior - lateral images were included. Patients were manually classified based on their scoliosis etiology from chart review, including previous spine imaging studies when available. Categories included idiopathic, congenital, and spinal cord pathology. Images were randomized and assigned for training, validation, and testing. A DL-classifier using EfficientNet B4 architecture was trained on the radiographs. Accuracy and positive predictive value as defined by precision, recall, and F1-score were calculated to assess final performance metrics.

Results: The trained classifier performed well at identifying correct etiologies, with F1-Score (harmonic mean of precision-recall) of 0.97. Model precision was 0.99 for adolescent idiopathic scoliosis, 0.89 for congenital, and 0.78 for spinal cord pathology. Performance was higher on more common classes, with lower performance observed in class with fewer images. The algorithm has highest overall precision (0.96), recall (0.96), and F1 (0.96), while Surgeons 1 and 2 have lower accuracies (precision 0.80, recall 0.79, and F1 0.79 and precision 0.76, recall 0.67, and F10.71, respectively). There was no clear pattern identified regarding the surgeons' errors and poor agreement on which X-rays corresponded to underlying spinal cord pathology.

Conclusion: A DL-convolutional-neural-network classifier has been trained to high degree of accuracy to distinguish between 3 scoliosis etiologies on pediatric spine radiographs. This model could provide a novel tool to clinicians to decide when to refer for axial imaging. It had superior diagnostic performance compared with experienced spine surgeons. After further validation and refinement, a clinician could put a patient's X-rays into the predictive tool for analysis and use the results to discuss with the family the risk of finding spinal cord pathology, helping them determine together the best timing for an MRI.

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