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

Introduction: To solve barriers to simulation-based training of residents, we have developed a three-dimensional (3D) printed anatomic shoulder simulator that is low cost and deployable worldwide. The purpose of our study was to evaluate the educational and construct validity of a novel 3D-printed shoulder simulator (3DP) for arthroscopy of the shoulder and compare it to a commercially available shoulder simulator (control).

Methods: In this institutional review board-approved randomized controlled trial, 20 participants were divided into four groups: five senior medical students and five expert surgeons for each simulator. Participants completed four arthroscopic tasks, which were videorecorded and assessed using the Arthroscopic Surgery Skill Evaluation Tool (ASSET) and time to task completion. Pre- and posttask anatomy tests were also administered.

Results: The expert surgeon group was faster to complete arthroscopic tasks than the medical student group for both the control (P = 0.003) and 3DP (P = 0.046). The ASSET scores were markedly higher for expert surgeons versus medical students on the 3DP (P = 0.017), with no difference on the control (P = 0.533). After task completion, medical students improved scores on an anatomy test from an average of 52% to a 76% on the control and from 52% to 84% on the 3DP.

Conclusion: The 3D printed arthroscopic shoulder simulator demonstrated construct validity based on time and ASSET scores, while also demonstrating educational value. The commercially available shoulder simulator demonstrated construct validity based on time; however, it was not able to differentiate skill level based on arthroscopic skills assessment.

Background: Bioinductive collagen implants (BCIs) have been growing in popularity for use in rotator cuff repair (RCR) over the past several years, but recent literature has raised concerns about the implants contributing to postoperative stiffness. The purpose of this study was to investigate the incidence of stiffness over a decade of experience with the BCI.

Methods: A retrospective review was conducted of all cases of RCR using a BCI performed between September 2014 and December 2023. The primary outcome measure was postoperative range of motion, with significant stiffness defined by parameters in the existing literature. The secondary outcome measure was any revision procedure for stiffness.

Results: After application of inclusion and exclusion criteria to 522 cases of RCR, there were 432 cases (390 individual patients) available for outcome analysis with an average follow-up of 34.9 months (range, 6 months to 9.25 years). There were only 12 cases (2.8%) of significant postoperative stiffness. All of them required additional operative intervention for stiffness, and all but two patients had at least one risk factor for stiffness. Stiffness rates were 4 of 291 (1.4%) for full-thickness tears and 8 of 141 (5.7%) for partial-thickness tears (P = 0.0149).

Conclusion: This study, the largest single cohort to date analyzing BCIs in RCR, found a low incidence of significant postoperative stiffness in cases associated with the use of the implant. Stiffness rates were markedly higher for repairs of partial-thickness tears. To further improve understanding of postoperative stiffness after RCR with BCI, better definitions and prospective comparative studies across larger groups are needed.

Level of evidence: Level IV, retrospective cohort with no comparison group.

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.