Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews最新文献

Introduction: Patients undergoing total shoulder arthroplasty (TSA) may experience postoperative new-onset depression (NOD), which is gaining attention because of its detrimental effect on patient outcomes.

Methods: The PearlDiver Mariner database from 2010 through October 2022 was queried for adult patients undergoing first-time TSA. Exclusion criteria included patients with diagnoses of tumors, trauma, and infections within 30 days before surgery and patients with previous depression or psychiatric risk factors for depression. The incidence of NOD diagnoses within 1 year after surgery was identified. Those with and without NOD were exact matched 1:4 based on age, sex, and Elixhauser Comorbidity Index and compared on multivariate logistic regression to determine whether various 90-day postoperative complications were associated with the development of NOD. After Bonferroni correction, significance was established at P < 0.003. Five-year revision rates were also compared with the log-rank test.

Results: Overall, 144,773 TSA patients meeting inclusion criteria were identified. NOD diagnoses in the year after surgery were identified for 4,321 (3.0%). Those with NOD were more likely to be female and have greater comorbidity burden (P < 0.003 for both). Among matched comparisons, those with NOD had higher odds of experiencing various 90-day complications, visits to the emergency department, hospital readmission, and were more likely to undergo revision TSA within 5 years (P < 0.003).

Conclusions: Postoperative NOD was diagnosed in 3% of patients after TSA. Having NOD was associated with various postoperative complications and higher revision rates. Recognizing predisposing factors for NOD may help target risk mitigation strategies.

Introduction: Septic arthritis presenting as an acutely inflamed knee (AIK) requires prompt diagnosis and treatment to prevent irreversible joint damage and systemic complications. A lack of high-quality diagnostic criteria hinders decision making. A multivariable prediction model developed among nonveterans demonstrated strong performance characteristics. This was converted into the Septic Arthritis Risk Calculator (SARC), providing personalized risk estimates for native knee septic arthritis. The purpose of this study was to externally validate the accuracy and calibration of SARC.

Methods: A retrospective cohort study was conducted for veterans with a native AIK at a Veterans Affairs Medical Center from 2007 to 2022. Demographics, comorbidities, history, physical examination, laboratory and radiographic findings, and confirmation of septic arthritis were collected. Septic arthritis risk was calculated. Discrimination was assessed by receiver operating characteristic analysis. Calibration was assessed via Hosmer-Lemeshow goodness-of-fit and Cox calibration regression (statistical significance for P < 0.05).

Results: The cohort consisted of 241 veterans with 50 cases (20.7%) of septic arthritis. The area under the curve was high (0.89) with 90% of cases correctly classified. The model fit the cohort well, supported by Hosmer-Lemeshow goodness-of-fit (P = 0.43) and Cox calibration regression yielding an estimated slope of 1.0 (95% CI: 0.74 to 1.3) and intercept near zero (-0.51 to 0.51).

Conclusion: SARC was accurate and well calibrated among veterans as in the original nonveteran cohort. We recommend its use in the setting of an AIK. Further research will involve implementation through an online decision support tool for point of care clinical use.

Background: Artificial intelligence (AI) and machine learning are powerful computational approaches that have the capacity to automate and improve medical care delivery in orthopaedic surgery through augmentation of medical devices, from diagnostic modalities to surgical guidance. Existing research has focused on prospective device applications and ongoing clinical trials, but a comprehensive analysis on cleared devices by the FDA is lacking.

Methods: A retrospective analysis was conducted for 70 FDA-cleared AI/machine learning-based medical devices (AIMDs) for orthopaedic surgery indications as of February 2025. These devices were categorized by indicated use, corresponding orthopaedic subspecialty, development history, AI architecture, and commercialization approach. For commercialization approach, active manufacturers were categorized by private or publicly traded status, acquisition history, and headquartered country.

Results: Since the first orthopaedic AIMD clearance in 2017, the 3-year moving average of AIMD clearances increased from 3.0 devices/year from 2017 to 2019 to 16.6 from 2022 to 2024. Alongside this growth, deep learning emerged as the dominant AI technique, comprising 57.3% of AIMDs approved from 2022 to 2024. Spine surgery was the most common orthopaedic subspecialty for devices, representing 42.9% of devices, followed by hip and knee at 20.0%. Surgical planning predominated across orthopaedic subspecialties except in trauma, where devices focused on fracture identification and surgical guidance. 62.2% of orthopaedic AIMDs cleared from 2017 to 2019 lacked any clinical testing, but this rate declined to 19.7% from 2022 to 2024. Overall, 22.8% of orthopaedic AIMDs lacked clinical testing and 68.6% were tested with retrospective data sets. Only 8.6% were validated through a formal, prospective clinical trial.

Conclusion: Although AI represents an exciting and rapidly developing area of innovation in orthopaedic surgery, improved regulatory safeguards and clinical evaluation standards are essential for the evidenced adoption and safe implementation of these promising technologies.

Introduction: Total hip arthroplasty (THA) is a widely performed procedure. Despite its overall success, adverse outcomes have been associated with defined comorbidities. Hypertension (HTN), which affects a notable portion of the adult population, may be one such factor but has not been independently studied in this regard.

Methods: THA patients were abstracted from the 2010 to 2022 M165 Ortho PearlDiver Mariner Database. Adult patients with versus without HTN were matched 1:1 based on age, sex, and Elixhauser Comorbidity Index. Ninety-day adverse outcomes and 5-year implant survival rates were compared for the matched cohorts with multivariable analysis, adjusting for multiple comparisons.

Results: Of 851,605 THA patients identified, HTN was noted for 601,475 (70.6%). After matching, there were 148,946 patients with and the same number without HTN. Patients with HTN were at independently greater odds of most individual adverse outcomes assessed, any adverse events (odds ratio [OR] 2.18), serious adverse events (OR 2.19), minor adverse events (OR 2.26), and readmissions (OR 1.52) (P < 0.001 for each). Furthermore, the 5-year implant survival rate was mildly lower in HTN group (96.5% versus 97.5%, P < 0.001).

Discussion: The current, large-cohort study identified HTN to be diagnosed for more than half of patients undergoing THA. The clear correlation of HTN with many adverse outcomes and mildly (but statistically) lower 5-year implant survival highlights the need for further consideration of this variable. Although there could be other confounding factors that may not have been fully controlled, those with HTN are clearly an "at-risk" group.

Introduction: Total knee arthroplasty (TKA) patients undergo intraarticular (IA) injections before surgery to reduce pain, improve function, and delay surgery. The purpose of this study was to determine the relationship between different types of IA injection exposure and preoperative and postoperative outcomes.

Methods: We reviewed a series of 321 patients who underwent primary TKA from 2016 to 2022, excluding patients with contralateral TKA within 6 months. Patients were categorized by IA injection type-ketorolac, triamcinolone, or no injection-received within 6 months of TKA. Main outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS), and opioid prescriptions received before and 3 months after TKA.

Results: Most of the 321 patients were female (64%) and White (62%). Of the 321 patients who underwent TKA, 113 (35%) received ketorolac, 64 (20%) received triamcinolone, and 144 (45%) received no injections. Significant differences in preoperative KOOS pain and ADL scores (P = 0.021 and P = 0.047) were observed among groups. Triamcinolone was associated with significantly less preoperative pain (P = 0.016) and greater function (P = 0.046) than ketorolac. No significant differences were found between groups in any KOOS subscale at 3 months post-TKA. Opioid prescriptions, refills, and total morphine milligram equivalents did not differ between injection groups.

Conclusion: Triamcinolone IA injections were associated with less pain and greater function before TKA than ketorolac. Future studies should include prospective studies, stratified by severity of knee osteoarthritis, to investigate whether exposure to IA injections has a favorable risk-benefit profile, accounting for osteoarthritis disease progression and heterogeneity.

Bilateral asymmetric hip dislocation is a rare injury with a complex mechanism, and treatment of delayed cases is difficult with unpredictable outcomes. We report a case of a 25-year-old man with bilateral asymmetric hip joint dislocation (right anterior, left posterior) and a Pipkin type II left femoral head fracture. His dislocations were reduced under sedation within 4 hours of the accident, but the surgical fixation of his fracture was delayed for 4 days. Hip dislocation should be reduced within 6 hours of injury. Postreduction CT in high-energy trauma is especially crucial for detecting associated fractures. If closed reduction fails, then open reduction should be conducted to prevent complications such as osteonecrosis, heterotopic ossification, and osteoarthritis.

Background: Polyethylene bearing (PEB) thickness in total knee arthroplasty (TKA) is a critical factor in achieving joint stability and soft-tissue balance. Despite long-standing surgical preference for thinner bearings, the effect of thicker PEBs on patient-reported outcomes (PROs) remains unclear. The purpose of this study was to compare patient-reported and surgical outcomes between patients receiving thicker (≥13 mm) and thinner (<13 mm) PEBs in primary TKA.

Methods: We retrospectively analyzed 2,751 patients who underwent primary TKA for osteoarthritis at a single high-volume orthopaedic hospital between 2020 and 2023. Patients were divided into two groups based on PEB thickness. Outcomes included PROs (Knee Injury and Osteoarthritis Outcome Score for Joint Replacement; Forgotten Joint Score), inpatient pain and mobility, surgical data, and 90-day postoperative complications. Multivariate statistical methods were used for analysis.

Results: PEB thickness was not associated with clinically notable differences in PROs. At 6 and 12 months, Knee Injury and Osteoarthritis Outcome Score for Joint Replacement and pain scores were slightly better in the ≥13-mm group (P < 0.05), but differences were not clinically meaningful. Subgroup analysis showed these differences were notable only in male patients. Forgotten Joint Scores and early complication rates were equivalent between groups.

Discussion: The use of thicker PEBs (≥13 mm) in TKA does not negatively affect PROs or early surgical outcomes and may slightly improve midterm pain and function in male patients. These findings support the selective use of thicker bearings when required for intraoperative balance without compromising patient satisfaction or recovery.

Study design: This was a retrospective study.

Objective: The primary objective of this study was to analyze risk factor for recurrent disk herniation after biportal endoscopic diskectomy.

Method: A total of 237 patients who underwent biportal endoscopic diskectomy for lumbar disk herniation were retrospectively reviewed. After exclusion criteria, the clinical and radiographic data of 160 patients were analyzed. Preoperative and postoperative visual analog score (VAS) and Oswestry Disability Index (ODI), preoperative demographic data, and radiological data were collected to assess for recurrent disk herniation risk factors.

Result: Back VAS, leg VAS, and ODI showed improvement in symptoms at final follow-up (minimum 3 years). Fifteen patients were diagnosis with recurrent disk herniation. All 15 patients were symptom free for 6 months before recurrence of symptoms. Eight of 15 patients improved with conservative treatment, whereas the remaining underwent revision diskectomy by using the biportal endoscopic technique. Diabetes, smoking, and disk type (contained disk herniation) were risk factors of recurrent disk herniation after biportal endoscopic lumbar diskectomy (P < 0.05).

Conclusion: Single-level biportal endoscopic diskectomy showed good clinical outcomes similar to previous studies. Intermediate symptomatic recurrence rate was 9.4%, whereas only 5% required repeat surgery. Risk factors for recurrence was similar to open and tubular techniques. Despite the minimally invasiveness and high visualization capabilities of biportal endoscopy, patients who are diabetic, smoker, or contained disk herniation on MRI should be counseled for higher risk of recurrence.

Introduction: Periprosthetic distal femur fractures (PDFFs) are increasing with rising arthroplasty volumes. An optimal fixation strategy remains debated. This study evaluated outcomes of single lateral locking plate constructs (sLLPs), retrograde intramedullary nails (IMNs), and dual constructs (nail-plate or dual plating).

Methods: A retrospective cohort study was done at a level I trauma center (2012 to 2024). Adults with PDFF (AO/Orthopaedic Trauma Association 33) treated with sLLP, IMN, or dual constructs were included. All patients were assessed for postoperative weight-bearing status, while clinical outcomes required ≥6-month follow-up or earlier documented complications. Outcomes included revision surgery, infection, implant failure, hardware removal, wound dehiscence, and time to weight bearing as tolerated (WBAT).

Results: Of 99 identified patients, 64 met criteria (IMN: n = 20; sLLP: n = 19; dual: n = 25). Mean age was 69.0 years; 75.0% female, 59.4% Black; mean follow-up 391.5 days. Immediate WBAT was ore common in dual (70.7%) and IMN (52.8%) groups than sLLP (9.1%; P < 0.001). Mean time to WBAT was shortest with dual constructs (13.8 days), followed by IMN (26.0) and sLLP (42.8; P = 0.020). On multivariable analysis, sLLP fixation was associated with increased odds of unplanned revision surgery (OR 6.27, 95% confidence interval, 1.29 to 30.50, P = 0.023), while neither IMN (P = 0.157) nor dual constructs (P = 0.071) demonstrated a significant association.

Conclusion: Single lateral locking plate fixation in PDFF was associated with higher odds of unplanned revision surgery. Dual construct patients had the shortest time to postoperative weight bearing and were more frequently permitted WBAT immediately after surgery.

Background: Nonhealing or rupture of the subscapularis after shoulder arthroplasty has been identified as a source of shoulder pain, weakness, and potentially prosthetic instability. Subscapularis-sparing approaches have been developed to mitigate this risk. However, these approaches are rarely used, despite the increasing frequency of shoulder arthroplasty. This review aims to assess the safety and efficacy of subscapularis-sparing approaches for shoulder arthroplasty.

Methods: A PRISMA-compliant review of the English literature in the PubMed/MEDLINE database after January 1, 2014, was conducted to identify clinical studies that reported the use of subscapularis-sparing shoulder arthroplasty in adults. Studies included in relevant systematic reviews were also screened. Baseline demographic data, procedural data including procedure time and blood loss, and treatment characteristics including surgical approach and device used were extracted. Efficacy outcomes included range of motion, functional scores, strength, pain, and implant stability or failure. Safety outcomes included infection, severity of infection, and antibiotic use. Because of the low number of comparative studies, study conclusions were qualitatively compared.

Results: A total of 15 studies (1573 patients) reporting subscapularis-sparing shoulder arthroplasty were identified. Eight studies reported reverse arthroplasty (RSA), whereas seven reported anatomic arthroplasty (TSA), including one reporting hemiarthroplasty. Eight studies directly compared subscapularis-sparing and nonsparing techniques. The comparative studies reported that subscapularis-sparing techniques had comparable outcomes to nonsparing techniques in both TSA and RSA, including range of motion, functional scores, pain, and revision. Findings for subscapularis integrity were similar between studies using TSA and RSA.

Conclusion: Subscapularis-sparing shoulder arthroplasty is a safe and effective technique with comparable patient outcomes to nonsparing techniques. The number of comparative studies is limited, and more randomized controlled trials are needed to confirm these results.