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

Introduction: This retrospective and systematic review examines wound closure rates across the fasciotomy approach and wound management technique for lower leg compartment syndrome.

Methods: A retrospective review was done for adult patients treated with lower leg fasciotomy at one level 1 center from 2012 to 2022 by the CPT code. Patient data were collected, including time to fasciotomy closure and techniques used. P < 0.05 was considered significant. A systematic review was done for studies reporting time to wound closure or rates of skin grafting in the setting of fasciotomy by the surgical approach for lower leg acute compartment syndrome in accordance with the PRISMA guidelines.

Results: Of 101 patients, mean time to closure was 9.83 ± 10.16 days. Time to closure was shorter for single-incision (7.00 ± 6.45 days) versus dual-incision fasciotomy (10.31 ± 10.60 days), although insignificantly. Wound management at the time of fasciotomy included VAC (n = 34, time to closure 9.29 ± 10.34 days), shoelace technique (n = 12, 7.36 ± 3.75 days), and packing (n = 37, 10.94 ± 10.56 days). 38.2% treated with VAC, 16.7% shoelace technique, and 67.6% packing required skin grafting (P = 0.043). No specific patient factors were associated with time to closure, or with early versus late closure, defined by median time to closure (6 days). Median was reported here, given the skew of our data, and is therefore more reflective of the central trend of our data. Skin grafting (30.2% versus 69.8%, P = 0.026), increasing LOS (9.25 ± 4.66 days versus 13.64 ± 8.68 days, P = 0.003), and ISS (7.20 ± 4.84 versus 10.79 ± 9.76, P = 0.028) were associated with delayed closure. ISS was the only factor significantly associated with delayed closure on multivariate analysis (P = 0.05). Table 5 outlines the 25 articles included for the systematic review.

Conclusion: Our analysis revealed trends toward increasing time to closure in dual-incision versus single-incision fasciotomy for lower leg compartment syndrome. Wound management markedly favored the wound vac or shoelace technique, corroborated by the results of our systematic review.

Background: This study analyzed the indications, 90-day, and 10-year complication rates among young patients aged 15 to 45 years treated with contemporary total hip arthroplasty (THA) implants.

Methods: Primary or conversion THA patients aged 15 to 45 years were identified from the PearlDiver M165Ortho data set. Surgical indications were categorized by International Classification of Disease codes into the following groups: primary osteoarthritis (OA), osteonecrosis, structural deformities (SD), posttraumatic OA (PTOA), and rheumatoid arthritis (RA). Demographics of THA patients stratified by indication were determined. Ninety-day adverse events and readmissions, 10-year periprosthetic fractures, dislocations, and revisions were determined for each group. Multivariable analysis identified independent predictors of adverse outcomes and 10-year Kaplan-Meier survival to revision analysis was done.

Results: A total of 46,021 THA patients aged 15 to 45 years were identified. The primary surgical indication was OA in 27,805 (60.4%), osteonecrosis in 11,251 (24.4%), SD in 3873 (8.4%), PTOA in 1778 (3.9%), and RA in 1314 (2.9%). Ninety-day adverse events were below 15% and similar across indications. Ninety-day readmissions were highest for the RA group 16.4%. The incidence of 10-year periprosthetic fractures, dislocations, and revisions were highest for PTOA patients at 2.64% and 5.79%, 5.20%, respectively. On multivariable analysis, predictors of 90-day adverse events were younger age, female sex, and PTOA as the indication for surgery (relative to OA). Younger age also strongly predicted 90-day readmissions. Predictors of 10-year periprosthetic fractures included PTOA or SD (relative to OA), and dislocation or revision included PTOA and female sex (relative to male). Younger age was a protective factor against 10-year dislocations and revisions. Although implant survival was different by Kaplan-Meier analysis out to 10 years (P = 0.02), the indication groups were clinically similar, ranging from 93.9% to 94.6%.

Conclusions: Among young THA patients, postoperative complication rates varied by indication; however, long-term implant survival is reassuring regardless of surgical indication-with 10-year survival at approximately 94% for all groups analyzed.

Background: Tranexamic acid (TXA) is often used to reduce the amount of blood lost during total joint arthroplasty (TJA) and decrease the incidence of postoperative transfusion. Despite its extensive use, the ideal dosing regimen is still widely debated. The primary aims of this study were to compare single-dose and two-dose regimens on postoperative hemoglobin levels, transfusion rates, and 30-day complication rates in patients who underwent revision TJA.

Methods: This retrospective study included patients who underwent revision total knee arthroplasty or revision total hip arthroplasty between April 2014 and November 2020 at a single academic institution. Patients were divided into two groups: One group received a 1 g bolus of intravenous TXA just before incision and another intravenous 1 g bolus during wound closure (n = 151), and the second group received a single, 1-g, intravenous bolus of TXA just before incision (n = 189).

Results: No notable statistical differences were found between the two cohorts when evaluating postoperative hemoglobin levels (b = -0.18, 95% confidence interval [CI]: -0.39 to 0.03; P = 0.09), transfusion rates (odds ratio [OR] = 0.74, 95% CI: 0.39 to 1.38; P = 0.34), length of hospital stay (rate ratio = 0.95, 95% CI: 0.84 to 1.08; P = 0.43), and 30-day postoperative complication rates (OR = 1.30, 95% CI: 0.54 to 3.15; P = 0.56) even after controlling for patient characteristics and surgical factors.

Conclusion: In this study, no association was found between a single dose of perioperative TXA during revision TJA and increased rates of post-operative complications when compared with two-doses, suggesting comparable efficacy.

Background: Total knee arthroplasty (TKA) in younger patients is relatively uncommon.

Methods: The PearlDiver M165Ortho data set was used to identify TKA patients aged 15 to 45 years. Primary diagnoses associated with surgery were categorized into the following groups: primary osteoarthritis (OA), posttraumatic arthritis (PTOA), rheumatoid arthritis (RA), and osteonecrosis. Ninety-day adverse events and readmissions and 10-year periprosthetic fractures, loosening, stiffness, revisions, and prosthetic joint infection (PJI) were determined. Independent predictors of adverse outcomes were identified by using multivariable analysis, and Kaplan-Meier survival analysis for 10-year revisions was performed.

Results: A total of 26,566 TKA patients aged 15 to 45 years were identified. Among this cohort, the diagnosis associated with surgery was OA for 22,900 (86.2%), PTOA for 1648 (6.2%), RA for 1438 (5.4%), and osteonecrosis for 580 (2.2%). For the entire study cohort, 90-day adverse events were noted for 11.1% and readmissions for 7.4%. The 10-year periprosthetic fracture rate was 0.2%, aseptic loosening rate was 3.6%, stiffness rate was 26.9%, revision rate was 7.9%, and PJI rate was 5.7%. Diagnosis associated with surgery was not predictive of 90-day outcomes or 10-year adverse periprosthetic fracture, aseptic loosening, stiffness, or revisions. On Kaplan-Meier analysis, survival was clinically similar across all diagnosis groups, ranging from 86.2% to 89.7% at 10 years.

Conclusion: Young TKA patients experience relatively low 90-day adverse events and readmissions and long-term complications regardless of diagnosis associated with surgery. Implant survival is similarly to what is observed in older TKA.

Introduction: Total hip arthroplasty (THA) is a commonly performed orthopaedic procedure, yet the correlation of patient sex with outcomes has been inadequately explored. Previous studies have been limited by population/database constraints. Thus, 90-day adverse event and 5-year outcome differences were assessed in a large national database.

Methods: Patients undergoing THA from the 2010 to 2022 M165 Ortho PearlDiver Mariner Database were identified. Male and female patients were matched 1:1 based on age and Elixhauser Comorbidity Index. Ninety-day adverse events were assessed and compared with multivariable analysis adjusting for multiple comparisons. Five-year survival to revision, dislocation, and periprosthetic fracture was assessed by Kaplan-Meier analysis.

Results: Of 780,745 THA patients, 333,974 (42.7%) were male and 446,771 (57.3%) were female. After matching, there were 327,978 male and 327,978 female patients. At 90 days, female patients had greater odds of any adverse events (odds ratio [OR], 1.36), serious adverse events (OR, 1.76), minor adverse events (OR, 1.43), and readmissions (OR, 1.25; P < 0.001). Female patients had higher rates of surgical site infection, deep vein thrombosis, urinary tract infection, and wound dehiscence but lower rates of cardiac events, pneumonia, and acute kidney injury. At 5 years, female patients had higher rates of revision (1.8% vs. 1.4%, P < 0.001), fracture (1.2% vs. 0.7%, P < 0.001), and dislocation (1.8% vs. 1.2%, P < 0.001).

Conclusion: This study identified notable sex-based differences in THA outcomes. Female patients had greater odds of perioperative complications and 5-year adverse events. These findings may inform patient counseling, surgical planning, and care pathways.

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.