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

Sciatic nerve palsy because of tourniquet use in the pediatric population is rare. Here, we present a case of a 13-year-old girl with sciatic nerve palsy caused by tourniquet use after knee meniscal surgery. On the day after the operation, incomplete tibial and complete peroneal nerve palsy was observed. First, a sciatic nerve palsy caused by the tourniquet use and an iatrogenic common peroneal nerve injury caused by the meniscal suture device of lateral menisci was considered. However, the possibility of the iatrogenic common peroneal nerve injury was ruled out based on the examination findings. As a result, we diagnosed the sciatic nerve palsy caused by tourniquet use. The sciatic nerve palsy gradually improved within a week. Finally, the palsy completely recovered at 8 weeks postoperatively.

Introduction: Muller-Weiss disease (MWD) involves the idiopathic collapse and fragmentation of the navicular bone. Patients present with pain and deformity. Pediatric cases are rare, and it is distinct from Kohler disease. Surgical management can include internal fixation of the navicular, calcaneal lengthening osteotomy, and arthrodesis.

Clinical presentation: A healthy 10-year-old boy with a family history of MWD presented with midfoot pain and toe walking. He had hindfoot equinization, pes planus deformity, and forefoot abduction. Imaging revealed a comma-shaped navicular with lateral collapse and fragmentation. He had a short lateral calcaneal column relative to the talus. Following unsuccessful nonsurgical management, he underwent internal fixation of the navicular, calcaneal lengthening osteotomy, and sliding tendoachilles lengthening. Following recovery, he was pain-free with radiographic union of the navicular fragment.

Discussion: We propose he developed MWD through mechanical compression of the lateral navicular, resulting from a short lateral calcaneal column relative to the talus. Our poor understanding of MWD creates challenges in its diagnosis and management. Although rare in children, it is not exclusively a disease of adulthood. Early recognition may allow correction of underlying deformity to prevent progressive fragmentation and degenerative deformity.

Management of acute blood loss anemia in patients who are Jehovah's witness with orthopaedic trauma injuries remains a moral dilemma and medical challenge. There are varying patient beliefs as to what is considered acceptable in the setting of acute blood loss anemia within the Jehovah's Witness community. Advancements have been made in pharmacologic options (iron replacement, erythropoiesis-stimulating agents, tranexamic acid, clotting factors, artificial oxygen carriers) since the time of the religion's blood ban, as well as procedural interventions (interventional radiology, red blood cell salvage). There is minimal published evidence of the acute management of orthopaedic trauma injuries with acute blood loss anemia requiring ongoing orthopaedic surgeries in the Jehovah's Witness population. Management options can be extrapolated from other surgical fields and orthopaedic case reports to create a systematic approach to treatment. Management of patients who refuse blood products with acute blood loss anemia requires a multidisciplinary approach and strict clarification of the patient's beliefs. The goals of this article are to clarify Jehovah's Witness beliefs regarding blood transfusions, review management options available in the orthopaedic trauma setting, and propose a treatment algorithm.

Introduction: Understanding the impact of space flight on orthopaedic health is crucial for optimization of astronaut health, space flight safety, and chance of mission success. This study sought to assess the rate and degree of bone mineral density (BMD) recovery across various anatomic regions on return to Earth, and further how the length of space flight and astronaut age affect BMD recovery.

Methods: A retrospective cohort study was performed to quantify the changes in BMD and fracture risk after return to Earth. The Lifetime Surveillance of Astronaut Health epidemiology database at National Aeronautics and Space Administration provided preflight and postflight dual-energy radiograph absorptiometry data and Fracture Risk Assessment Tool scores for 94 astronauts. BMD loss and rate of recovery post-space flight was recorded and analyzed. Subanalyses were performed assessing effect of astronaut age and mission duration on BMD recovery and fracture risk.

Results: In the hip and the spine, losses in BMD occurred that do not recover to preflight BMD levels by 1 year postflight. Astronauts who spent greater than 6 months in space flight recovered slower and more incompletely at the spine (P = 0.011), hip (P = 0.018), and femur (P = 0.049) compared with those who spent less than 6 months in space flight. No notable difference was observed in the risk of 10-year osteoporotic hip fracture based on duration of space flight or astronaut age.

Conclusion: Increasing time in space flight leads to larger losses in BMD and slower BMD rate of return. At 1 year postflight, preflight BMD levels at the hip and spine are only achieved by 34.0% and 46.8% of astronauts, respectively.

Background: Understanding the outcomes of humeral shaft fracture treatment using open reduction and internal fixation (ORIF) or intramedullary nailing (IMN) is essential for optimizing patient management strategies. The aim of this study was to identify the outcomes following plate fixation versus IMN in humeral shaft fractures.

Methods: A retrospective cohort study was conducted using electronic medical records from January 2005 to March 2023. A propensity score match was performed based on demographic variables and comorbidities. The primary outcome measured was nonunion. Secondary outcomes included malunion, radial nerve palsy, surgical site infections, wound dehiscence, and revision surgery rates.

Results: Following propensity matching, the study analyzed 6592 patients equally distributed between the ORIF and IMN cohorts. The risk of nonunion was significantly higher with ORIF versus IMN, {risk ratio (RR) = 1.70 (95% confidence interval [CI], 1.52-1.91; P < 0.001)}. Radial nerve palsy was more common with ORIF versus IMN (RR = 2.37 [95% CI, 2.22-2.53; P < 0.001]). Deep infections were more frequent with ORIF versus IMN (RR = 1.56 [95% CI, 1.38-1.78; P = 0.006]). No significant differences were observed for malunion (P = 0.742), total surgical site infections (P = 0.841), or revision surgery (P = 0.216). Wound dehiscence was greater in the ORIF group (RR = 1.54, [95% CI, 1.34-1.76; P = 0.014]).

Conclusion: The findings indicate that IMN is associated with a lower risk of nonunion and radial nerve palsy compared with ORIF with plate fixation in the treatment of humeral shaft fractures. These insights can guide clinicians in making informed decisions regarding surgical intervention, highlighting the importance of individualized treatment planning to mitigate complication risks.

Background: Given the high variability in patient presentation, notable challenges exist in determining patient candidacy for anatomic total shoulder arthroplasty (aTSA). The purpose of this study was to use a modified version of prior scenario-based appropriateness use criteria to evaluate the prevalence of inappropriate, appropriate, and inconclusive aTSA.

Methods: Patients undergoing primary aTSA were evaluated for preoperative outcome scores and baseline demographic information from a multicenter database. Using a validated appropriateness use criteria algorithm, these patients were grouped "inappropriate," "inconclusive," or "appropriate."

Results: Seven hundred seventy-four patients who underwent aTSA were included. "Appropriate" patients comprised 23.9% of the cohort, while 17.8% were "inappropriate," and 58.3% were "inconclusive." Compared with the inconclusive and inappropriate groups, the "appropriate" patients were found to have markedly worse preoperative pain and functional outcomes scores. No notable difference was observed between the number of patients who received intra-articular injections, number of injections received, and analgesic use across the groups.

Conclusions: The large proportion of "inconclusive" patients suggests a lack of consensus regarding aTSA versus reverse TSA candidacy and may be secondary to factors such as worse glenoid morphology and/or prior rotator cuff repair, which are subjects of current debate in determining appropriateness for reverse TSA versus aTSA. Although no definitive conclusions can be made regarding if this algorithm ultimately improves patient outcomes, this study seeks to only help streamline patient evaluation based on American Shoulder and Elbow Surgeons high-volume surgeons' opinion and highlight the large variation in the indications for aTSA in real-world surgical cases.

Background: Anterior cruciate ligament (ACL) reconstruction is a common surgery, following which pain control medications are often prescribed. In recent years, efforts have been made to minimize opioids and other nonnarcotic medications as multimodal regimens evolve following such surgeries.

Methods: Opioid-naïve ACL reconstruction patients were identified from the PearlDiver M165Ortho data set. Those with a history of substance abuse were excluded. Prescriptions of pain management medications were evaluated in the 90 days following surgery per 1000 ACL reconstructions and grouped into the following categories: opioids, benzodiazepines, NSAIDs, serotonin norepinephrine reuptake inhibitor/tricyclic antidepressant/antiepileptic, tramadol, gabapentinoid, and nonbenzodiazepine muscle relaxant.Trends for annual prescriptions and morphine milligram equivalents were defined. Multivariable analysis was performed to determine factors independently associated with narcotic prescriptions.

Results: A total of 101,331 ACL reconstruction patients met study inclusion criteria. In the 90 days following surgery, opioid prescriptions decreased from 402.7 per 1,000 ACL reconstructions in 2010 to 153.5 in 2021 (-61.9%). Prescriptions of other pain management drugs on aggregate decreased from 298.0 in 2010 to 129.8 in 2021 (-56.4%). Among patients who received opioids in the 90 days postoperatively, morphine milligram equivalents prescribed per 1000 ACL reconstructions decreased from 277,941 in 2010 to 39,640 in 2021 (-85.7%).On multivariate analysis, the strongest predictors of postoperative opioid prescriptions were younger age (odds ratio [OR] 1.30 per decade decrease, P < 0.0001), male sex (relative to female, OR 1.39, P < 0.0001), patient comorbidity (per two-point decrease in Elixhauser Comorbidity Index, OR 1.25, P < 0.0001), and region of the country where surgery was performed (relative to west, Northeast OR 1.20, South OR 1.22, Midwest OR 1.41, P = 0.0006, P = 0.0026, P = 0.0002, respectively). Neither having the use of regional nerve blocks nor having multiple concomittent knee procedures affected postoperative opioid prescriptions.

Conclusion: Fewer prescriptions of both narcotic and nonnarcotic medications following ACL reconstruction had been written over the years from 2010 to 2021, likely in favor of nonprescription over-the-counter analgesics including NSAIDs and acetaminophen. There may be opportunities to further reduce opioid prescribing following ACL reconstruction, particularly among patients receiving regional nerve blocks or those undergoing isolated ACL reconstruction.

Introduction: Due to the high risk of complications, the body mass index (BMI) has been a commonly used cutoff metric for joint replacement surgery. However, the percentage of these complications that are treatable has been minimally reported on. This study seeks to quantify the type and incidence of complications that were treated and resolved within 90 days.

Methods: The demographics, comorbidities, perioperative variables, and complications were reviewed for 700 patients with BMI >40. 475 patients underwent total knee replacement (TKAs) and 225 underwent total hip replacement (THAs). Univariable and multivariable hierarchically generalized linear mixed models (GLMMs) were utilized to control for relevant covariates.

Results: 211 of the total 700 patients had at least one complication. 205 procedures resulted in a medical complication (29.3%), 105 surgeries resulted in a surgical complication (15.0%), 97 procedures required reoperation (13.9%), and 104 procedures required readmission (14.9%). 149 of the 211 (70.7%) complications were treatable. Among hip replacements on patients with a BMI >40, BMI did not demonstrate a significant overall effect on any unadjusted (p=0.94) complication rate or adjusted analysis (p=0.66). Among knee replacements on patients with a BMI > 40, BMI did not demonstrate a significant overall effect on any unadjusted complication rate (p=0.95) or adjusted analyses (p=0.66). BMI stratification was performed (40-44.99, 45-49.99, and > 50), and no appreciable difference in complications, treatable or non-treatable, were observed.

Conclusions: Although high complication rates were observed in this population rate with significant preoperative morbidities, the majority were treatable.

Purpose: This study sought to assess clinical outcomes following medial opening wedge high tibial osteotomy (MOWHTO) in patients with symptomatic varus knee malalignment and medial compartment grade 4 chondromalacia.

Methods: This retrospective study included patients who underwent MOWHTO between 2015 and 2023. The sample consists of 28 knees in 26 patients, all diagnosed with symptomatic varus knee malalignment and medial compartment grade 4 chondromalacia. Preoperative and postoperative knee range of motion was assessed, and patient evaluations were performed using the Lysholm Knee Score (LKS), Oxford Knee Score, and Visual Analog Scale (VAS). Lower extremity radiographs were taken to assess Kellgren-Lawrence grade (K-L) and Target Correction Angle.

Results: The mean sample age was 50.3 years, with an average follow-up of 56.0 months. All varus deformities were successfully corrected. The mean LKS increased from 33.6 to 79.6 and Oxford Knee Score from 19.0 to 37.6. Pain, assessed using the VAS, decreased from 8.5 to 1.6. All outcome and pain scores demonstrated significant improvement (P < 0.001). In addition, 96% and 92% of patients exceeded the minimal clinically important difference threshold for the LKS and VAS, respectively. One patient required conversion to total knee arthroplasty, yielding a 98.1% procedure survival rate at 64 months. Complications included two hardware removals due to stress shielding and one wound dehiscence.

Conclusion: MOWHTO demonstrated notable improvements in function and pain, with high survival and minimal complications. These results support its use as a viable joint-preserving treatment option for medial compartment varus overload in knees with advanced chondral damage.

Purpose: To analyze if earlier orthopaedic evaluation (within 100 days of injury) is associated with a greater full duty return to work for shoulder arthroscopy patients with active workers' compensation (WC) claims.

Methods: This was a retrospective chart review of all patients with an active WC claim treated with arthroscopic shoulder surgery at a community hospital between 2011 and 2018 and for 2 years postoperatively. The WC patients were divided into two groups: early orthopaedic evaluation (evaluated within 100 days of injury) and delayed orthopaedic evaluation (evaluated greater than 100 days after injury). Outcomes evaluated were rate and time until full duty return to work.

Results: Final inclusion yielded 59 patients (36 early orthopaedic evaluation and 23 late orthopaedic evaluation). There was a higher rate of return to full duty in early versus late orthopaedic evaluation, 26 of 36 (72%) versus eight of 23 (35%), respectively (P = 0.005). A strong correlation was identified between time until orthopaedic evaluation and time to return to full duty after injury (r = 0.519, P = 0.002). Late orthopaedic evaluation was associated with a 4.89 times increased odds of not returning to full duty (odds ratio = 4.89, 95% confidence interval = [1.6 to 14.9]).

Conclusion: Earlier Orthopaedic Surgeon evaluation of WC patients with shoulder injuries was associated with a higher return to full duty after shoulder arthroscopic surgery.