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

A 71-year-old woman presented with acute onset left knee pain and decreased range of motion (ROM) 1.5 years after total knee arthroplasty (TKA) at an outside institution. She underwent arthroscopic lysis of adhesions and manipulation under anesthesia. Intraoperatively, a displaced bucket-handle tear of the lateral meniscus was encountered and excised. At 12-month follow-up, clinical outcomes and ROM were markedly improved. The persistence of meniscus tissue after TKA is rare and should be considered as a possibility for pain and decreased ROM after TKA. This case highlights the value of meticulous removal of meniscus tissue during primary arthroplasty.

Introduction: Modular dual mobility designs (MDM) are designed to reduce the risk of postoperative dislocations following primary total hip arthroplasty (THA). This study investigated both the usage and outcomes (ie, patient-reported outcomes and complications) associated with MDM hips compared with conventional implant designs.

Methods: Patients who underwent a THA at a single, tertiary, orthopaedic specialty hospital between January 2019 and June 2022 were included. Primary outcomes of interest were compared between MDM and conventional hip designs and included complication rates, dislocation rates, clinical outcomes, and the hip disability and osteoarthritis outcome score for joint replacement (HOOS, JR).

Results: A total of 2869 patients (88% conventional THA) were included in this study. Modular dual mobility hip utilization increased 117% during the study period. Patients in the MDM group were often older females (P < 0.001) with concomitant lumbar pathology (P = 0.034). None of the MDM hips dislocated in the first 30 days post THA compared with 0.4% of the conventional hips. Despite markedly lower hip disability and osteoarthritis outcome score for joint replacement scores in the MDM group, the number of patients reaching the minimally clinically important difference was similar (P = 0.915).

Conclusion: MDM patients experience lower rates of dislocation compared with those receiving conventional implants. Despite worse clinical outcomes and increased all-cause emergency department utilization in the MDM group, multivariate regression suggests that these outcomes were associated with the implant being used in an older, sicker population instead of the implant itself. The results suggest similar overall outcomes and a lower dislocation rate for patients who received an MDM hip.

Background: The American Orthopaedic Association initiated the "Own the Bone" program in 2009 to promote a more active involvement of orthopaedic surgeons in managing osteoporosis after fragility fractures. This study investigates the effectiveness of the program by examining the changes in yearly DEXA scan rates and diphosphonate prescriptions since the program's inception.

Methods: Patients aged 50 to 85 years who sustained a femoral neck fracture requiring surgery from 2010 to 2019 were tracked using the PearlDiver database. The study examined annual DEXA scans within 1 year of fracture and diphosphonate treatment within 6 weeks and 1 year. Age, sex, obesity, tobacco, and alcohol use were also analyzed.

Results: In total, 201,499 patients met inclusion criteria (67.0% female). Younger, predominantly female patients more often underwent DEXA scans within 1 year of fracture. Tobacco users, alcohol abusers, and obese patients were also more likely to receive scans. Annual DEXA scan rates from 2010 to 2019 ranged narrowly from 4.66% in 2012 to 5.82% in 2010, ending at 4.87% in 2019. Diphosphonate prescriptions within 1-year postfracture dropped from 5.12% in 2010 to 2.98% in 2019, with early (≤6 weeks) treatment falling from 1.07% to 0.66%, showing no sustained increase over time. Those prescribed bisphosphonates were younger, more likely female, obese, and tobacco users.

Conclusion: The Own the Bone program has not successfully modified orthopaedic surgeons' approaches to managing osteoporosis. This stagnation in practice change could be due to a lack of sufficient incentives or a limited knowledge base that prevents surgeons from providing thorough osteoporosis counseling postfracture.

Introduction: The aim of this study was to evaluate the effect of obesity on clinical outcomes and complications in patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA) based on body mass index criteria.

Methods: Between 2013 and 2020, SBTKA was performed on 795 patients with a mean age of 72 years. After applying exclusion criteria, 776 patients were included in the study. Patients, followed up for an average of 48 months, were categorized by body mass index into two groups: <30 kg/m2 (group I: nonobese) and 30 to 39.9 kg/m2 (group II: obese). Group I consisted of 347 patients while group II included 429 patients. The groups were compared using univariate and multivariate logistic regression analyses for parameters such as length of hospital stay, mobilization time, surgical time, clinical and functional outcomes, prosthetic infection, aseptic loosening, early complications, and wound healing problems.

Results: Statistically, there was no significant difference between the groups regarding the incidence of deep vein thrombosis, acute kidney injury, or pulmonary embolism. Statistical analysis revealed that the risk of complications such as aseptic loosening, septic loosening, and medial retinaculum detachment was lower in group I compared with group II. However, univariate and multivariate logistic regression analyses demonstrated no significant differences in overall complications or clinical outcomes between the groups. The only parameters showing significant differences were surgical time, mobilization time, and length of hospital stay.

Conclusion: We conclude that, when existing comorbidities are taken into account, SBTKA can be safely and successfully performed in obese patients, comparable to nonobese patients.

Introduction: Accurate treatment of elbow rheumatoid arthritis (RA) requires understanding the joint destruction pattern. However, comprehensive bone-deformation patterns remain unclear. Thus, we aimed to quantitatively evaluate three-dimensional (3D) deformity in RA elbows compared with normal elbows.

Methods: The authors created 3D CT models of the distal humerus, proximal ulna, and radial head for 26 elbows with RA (Larsen classification IV) and 26 normal elbows. These models were superimposed onto one reference bone, selected from normal elbows. The intermodel distance was measured at categorized anatomical regions of the individual bones, and the measurements were compared between the RA and normal elbows. Correlation between clinical outcomes, including range of motion and 3D deformities, were also assessed in the RA group.

Results: RA elbows exhibited notable bone destruction in both the anterior-inferior region of the distal humerus (7.9 to 9.9 mm vs. 9.5 to 12.6 mm) and the trochlear notch (16.7 to 20.1 mm vs. 11.3 to 15.4 mm) compared with normal elbows, with all differences being statistically significant (P < 0.05). The radial head in RA elbow was shortened (2.24 ± 1.97 mm vs. -0.18 ± 0.59 mm; P < 0.05), with osteophyte formation, particularly on the lateral side (P < 0.05). Humeroulnar joint deformity correlated with flexion-extension limitation (R = 0.42 to 0.74), and the radial head correlated with forearm supination limitation (R = 0.57 to 0.58).

Conclusion: Bone destruction was shown in the anterior-inferior region of the distal humerus and trochlear notch, and the radial head was shortened with osteophyte formation, resulting in a proximal shift of the forearm bones and impaired motion. This provides valuable insights into RA elbow pathology and contributes to advancements in treatment.

Introduction: Evaluating demographic trends in orthopaedic surgery fellowships is crucial to understanding the field's growth. Existing literature often focuses on diversity in orthopaedic leadership or specific subspecialties. The purpose of this study was to evaluate 10-year demographic trends (2012 to 2022) in Accreditation Council for Graduate Medical Education-accredited orthopaedic fellowships and identify regional demographic disparities from 2023 to 2024 to highlight recent demographic shifts.

Methods: Data from 2012 to 2022 were collected from the Fellowship and Residency Electronic Interactive Database and Accreditation Council for Graduate Medical Education census for each subspecialty: total programs, fellow/faculty sex, race/ethnicity, program-specific data (location, fellows' full names). Sex was classified using pronouns on biographical webpages. Statistical analyses assessed fluctuations across all years.

Results: The total annual proportion of female fellows ranged from 13.4% (68/508) to 19.1% (101/529), average annual increase: +1.86%. The average annual proportion of female foot and ankle fellows increased most (35.86%), ranging from 6.3% to 37.5%; the average proportion of female pediatric fellows decreased most (-1.48%), ranging from 22.9% to 51.2%. Adult reconstruction had the lowest female fellow proportion (5.7%); pediatrics had the highest (37.2%). Hispanic/Latino fellows increased most (+124.9%); Black/African American fellows decreased most (-16.1%). The South had the lowest female representation (fellows: 13.3%, faculty: 12.2%), the Northeast had the highest proportion of female fellows (32.9%), and the West had the most female faculty (19.6%).

Conclusions: This study found a slight increase in female representation in orthopaedic fellowships, although notable gender disparities persist, particularly in adult reconstruction and the South. This highlights the need for continued efforts to enhance diversity, focusing on specific disparities across regions and subspecialties.

Study design: Cross-sectional study: database/website evaluation.

Level of evidence: III.

Background: A critical decision in total hip arthroplasty implant selection is the choice of femoral offset. Femoral offset lateralizes the femoral shaft, tensioning the abductor mechanism providing stability and reducing joint reactive forces. Variations in offset may affect hip biomechanics, potentially influencing the risk of periprosthetic fractures. This study aimed to evaluate the forces required for implant failure and fracture in two femoral stems with different neck angles.

Methods: Twenty osteoporotic composite femurs were prepared and implanted with either a Stryker Accolade II stem with 132° (standard offset) or 127° neck angle (high offset). Femurs were subjected to an axial load using a biaxial servohydroaulic testing machine until failure. Maximum load to failure was recorded. Finite element analysis was conducted to assess stress and strain distributions with the femurs for both implant types.

Results: Femurs with a 132° neck angle exhibited significantly higher mean load to failure compared with those with a 127° neck angle (3,537.8 ± 627.9 vs. 2,947.6 ± 507.6 N, P = 0.032). Finite element analysis revealed that maximum stress in femurs with a high offset implant was 9.5% higher than the standard offset (135.9 vs. 124.1 N/m2) and maximum strain was 25.1% higher in the high offset stem compared with the standard offset (1.580e-8 vs. 1.263e-8).

Conclusion: Higher femoral stem offset decreases the ultimate load to failure of the femur. Although high offset stems offer benefits in hip stability and abductor lever arm enhancement, their potential to increase fracture risk must be further explored.

Introduction: Total hip arthroplasty (THA) in ankylosing spondylitis (AS) patients are at risk of postoperative complications and dislocation. Functional cup positioning was introduced to address the effect of pelvic malrotation. Our study aims to investigate the long-term survivorship of THA in Asian AS patients.

Methods: This is a retrospective study involving Asian AS patients with primary THA between 1970 and 2014. A total of 116 hips in 77 patients were included, with at least 10-year follow-up (mean 20.7 years). Primary outcomes were revision-free and dislocation-free survival of THA up to 30 years. Survival between different fixation methods were compared. Secondary outcomes include postoperative complications, re-revision, and radiographic changes.

Results: Mean revision-free survival after primary THA was 23.0 years (95% confidence interval [CI], 21.1 to 24.9), most commonly due to aseptic loosening (54.3%). Overall, 10-year dislocation-free survival was excellent at 99.1% (95% CI, 97.4 to 100.0). Differences between cemented, noncemented, and hybrid THAs were not notable (log-rank test; P = 0.220). Cemented cups (hazard ratio [HR] 17.4; 95% CI, 2.5 to 122.2) and stems (HR 6.9; 95% CI, 1.6 to 30.7) had increased risk of revision due to loosening compared with noncemented THAs.

Conclusion: Primary THA in AS patients demonstrated favorable survival at 10 years but poor long-term survival. Functional cup positioning demonstrated excellent results in terms of minimizing dislocation. Cemented implants had greater risk of aseptic loosening in long term, but differences were minimal considering all-cause revision.

Introduction: Geriatric femoral neck fractures are common and typically managed with hemiarthroplasty (HA), total hip arthroplasty (THA), or percutaneous pinning (PP) by an on-call physician. The current study assessed if perioperative or longer-term outcomes correlated with orthopaedic surgeon subspecialty.

Methods: The 2016 to 2022 PearlDiver M161 Ortho administrative data set was used to identify patients >65 years who underwent HA, THA, or PP for femoral neck fracture. The subspecialty of the treating surgeon was defined as arthroplasty, trauma, or nonarthroplasty/nontrauma. Exclusion criteria included polytrauma and concurrent neoplasms/infections. For each surgery type, 90-day perioperative adverse events were assessed between surgeon cohorts using multivariate logistic regression. Five-year revisions/dislocations were also assessed.

Results: Overall, 150,728 surgeries were identified (140,850 by nontrauma/nonarthroplasty surgeons, 5,013 arthroplasty, and 4,865 trauma). Arthroplasty surgeons performed THA at higher rates than trauma or nonarthroplasty/nontrauma surgeons (28.1% versus 7.7% and 12.8%, respectively, P < 0.001). Ninety-day outcomes were more similar than different across surgeon specialties. For HA, 5-year dislocation rates were statistically different but within 1% between cohorts (nonarthroplasty/nontrauma 97.5%, arthroplasty 96.8%, trauma 97.8%). Five-year revision rates were also within 1% between the cohorts (nonarthroplasty/nontrauma 98.2%, arthroplasty 97.2%, trauma 97.8%). For THA, 5-year dislocation rates were not statistically different (nonarthroplasty/nontrauma 95.7%, arthroplasty 96.3%, trauma 96.9%), nor were five-year revision rates (nonarthroplasty/nontrauma 93.9%, arthroplasty 93.8%, trauma 95.0%). For PP, 5-year revision rates were not statistically different (nonarthroplasty/nontrauma 93.8%, arthroplasty 95.1%, trauma 95.2%).

Conclusion: Femoral neck fractures were predominantly treated by nonarthroplasty/nontrauma surgeons. Nonetheless, 90-day adverse outcomes and five-year rates of revision/dislocation were clinically quite similar. This can provide confidence that those who self-select to treat geriatric femoral neck fractures are performing comparably regardless of subspecialty.

Hamstring injuries are a common injury sustained by athletes with most injuries occurring as strain injuries within the muscle belly or at the proximal musculotendinous junction. Distal hamstring pathology is relatively uncommon but comprises a collection of both acute and chronic diagnoses that can manifest with symptoms either on the medial or lateral side of the knee based on which hamstring tendons are involved. Pes anserinus bursitis is the most common of these distal hamstring pathologies with other chronic diagnoses, including snapping medial hamstrings or snapping biceps femoris. Acute biceps femoris ruptures can occur in an isolated fashion but most often occur in the setting of concomitant posterolateral corner injury as a result of high-energy trauma. Isolated semitendinosus ruptures can occur with lower-energy acute events, commonly with track and field events. Most distal hamstring pathology can be treated without surgery and do well with conservative treatment. However, acute avulsion injuries often require surgical intervention, as can chronic problems that do not adequately respond to prolonged conservative treatment. Treatment algorithms for distal hamstring injuries are less well-developed than more proximal injuries owing to their lower incidence. This review focuses on distal hamstring injuries, the state of current literature, and treatment strategies.