JBJS Reviews最新文献

» Medicare reimbursement: Physician payments have declined 29% since 2001, straining practice sustainability. Proposed legislation (H.R. 2474) could align payments with inflation, although concerns persist about its fiscal impact on Medicare.» Medicare advantage: These plans provide benefits such as cost caps and premium-free options for patients, but increase administrative burdens, delay care, and restrict provider networks for physicians.» Prior authorization: Intended to ensure appropriate care and control costs, prior authorization frequently delays treatment, raises administrative workloads, and contributes to physician burnout. Proposed reforms aim to balance efficiency and oversight.» Noncompete clauses: Advocates argue noncompete clauses protect healthcare investments, but critics highlight their role in limiting physician mobility, disrupting patient care, and reducing competition. Legal challenges to a federal ban add uncertainty.» Physician-owned hospitals: Supporters emphasize physician-owned hospitals' high-quality care and competitive benefits, whereas detractors warn of risks such as conflicts of interest, inequities in patient access, and strain on community hospitals.» Advancing nonopioid pain management: Nonopioid strategies reduce dependency risks and improve recovery but may require additional resources and upfront costs. Policies such as the Non-Opioids Prevent Addiction in the Nation Act aim to incentivize their use.

» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.

» Osteotomy is an effective treatment strategy for young, active patients with symptomatic valgus malalignment of the knee that has been unresponsive to conservative management.» Osteotomies are also indicated to support joint preservation procedures, such as lateral meniscus allograft transplantation and/or cartilage restoration to the lateral compartment, in the valgus malaligned patient, even if the malalignment is subtle.» Techniques to correct valgus include lateral opening wedge distal femoral osteotomy (LOWDFO), medial closing wedge distal femoral osteotomy (MCWDFO), lateral opening wedge high tibial osteotomy (LOWHTO), or medial closing wedge high tibial osteotomy (MCWHTO). The specific technique chosen depends on surgeon preference, concomitant procedures, and deformity location (femoral, tibial, or both).» Each approach comes with its own advantages and disadvantages. LOWDFO offers easier correction for larger deformities but has a higher risk of nonunion, while MCWDFO facilitates faster time to union but is more technically demanding. For those with a tibial-based deformity, LOWHTO carries a higher risk of nonunion, MCWHTO may lead to medial collateral ligament laxity or patella baja, and both may cause alterations of the tibial slope and may be limited as an isolated procedure in severe deformity correction.» Irrespective of the surgical approach, the outcomes of these procedures are generally favorable, improving patient-reported outcomes and potentially delaying the need for total knee arthroplasty. However, it is crucial to carefully select the appropriate procedure based on the patient's anatomy and the specificities of their valgus deformity to ensure the best possible results.

Background: Cauda equina syndrome (CES) is a rare but life-altering disease resulting from compression of the nerve roots at the spinal cord's terminus. CES typically presents with low back pain, sciatica, sensorimotor deficits, and bowel and bladder dysfunction. Owing to its rarity, the condition is often missed, leading to significant morbidity and potential legal implications for physicians.

Methods: This review synthesizes the current literature on CES, including its epidemiology, pathophysiology, classifications, and management strategies. Emphasis is placed on the diagnosis and treatment of CES as well as the legal implications of CES for spine surgeons.

Results: The literature reveals variability in the reported prevalence of CES, with incidence rates ranging from 0.34 to 7 per 100,000 individuals annually. The timing of decompression remains debated. Some studies report no significant difference in outcomes between decompression within 24 hours vs. 48 hours, while others emphasize the importance of immediate intervention. Legal cases related to CES frequently involve delayed diagnosis, with significant ramifications for physicians.

Conclusions: Surgical decompression remains the definitive treatment of CES, though the timing of surgery requires careful consideration to balance the urgency of intervention with the risks of complications. Further research is needed to explore strategies that would allow for improvement in identifying and treating patients with CES in a timely manner.

Level of evidence: Level V. See Instructions for Authors for a complete description of levels of evidence.

Background: Since its inception, activity level and bone quality have been essential considerations for patients undergoing hip resurfacing arthroplasty (HRA). Moreover, younger patients tend to experience fewer complications, lower revision rates, and better outcomes after any surgery. This study aims to compare the clinical outcomes, complication rates, and survivorship rates between younger and older patients undergoing HRA, providing insights into whether active older patients with appropriate bone quality can still achieve significant benefits from HRA.

Methods: A literature search was conducted using PubMed, Embase, and Scopus databases. Articles were screened by title and abstract, followed by full-text review. A meta-analysis was performed using a random effects model to compare UCLA scores and odds of prosthesis survivorship between younger (<50 years of age) and older (>50 years of age) patients in studies comparing both age groups. Statistical significance was defined as a 95% confidence interval that does not include 1. In addition, the average complication and prosthesis survivorship rates were calculated and compared between younger and older hips using both comparative and noncomparative studies.

Results: From an initial pool of 1,286 articles, 31 met inclusion criteria, encompassing 22,691 patients. Analysis revealed a pooled mean age of 33.65 years for the younger cohort and 63 years for the older cohort, and a complication rate of 5.37% in younger compared with 3.83% in older hips. The difference in postoperative UCLA scores was deemed statistically insignificant based on meta-analysis. However, the difference in mean survivorship rates was found to be statistically significant at 86% for younger and 94.9% for older patients through univariate analysis and meta-analysis.

Conclusion: There is no significant difference in postoperative outcomes between younger and older patients undergoing HRA. In fact, older patients seem to experience higher prosthesis survivorship rates compared with younger cohorts. Older patients who are active and possess good bone quality can achieve outcomes comparable to their younger counterparts, indicating that HRA may be viable for a broader age range than previously considered.

Level of evidence: Level III, systematic review of Level II, III, and IV studies. See Instructions for Authors for a complete description of levels of evidence.

» Ossification of the posterior longitudinal ligament (OPLL) is a hyperostotic condition that results in ectopic bone formation and calcification of the posterior longitudinal ligament.» OPLL can present in any race/ethnicity but historically has been reported in the East Asian population.» OPLL predisposes patients to spinal cord injury in the setting of minor trauma.» Asymptomatic patients typically can be managed nonoperatively. Surgical treatment is reserved for patients presenting with myelopathy and worsening radiculopathy that has not responded to conservative treatment.» The decision to use anterior, posterior, or combined anterior-posterior approaches should be an individualized decision that considers the degree of OPLL pathology, K-line imaging findings, and other patient-specific risk factors.

» Although spine surgery is effective in reducing pain and improving functional status, it is associated with unacceptably high rates of complications, thus necessitating comprehensive preoperative patient optimization.» Numerous risk factors that can impact long-term surgical outcomes have been identified, including malnutrition, cardiovascular disease, osteoporosis, substance use, and more.» Preoperative screening and personalized, evidence-based interventions to manage medical comorbidities and optimize medications can enhance clinical outcomes and improve patient satisfaction following spine surgery.» Multidisciplinary team-based approaches, such as enhanced recovery after surgery protocols and multidisciplinary conferences, can further facilitate coordinated care from across specialties and reduce overall hospital length of stay.

Background: Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs.

Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design.

Results: Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery.

Conclusion: Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs.

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

» Lumbar spine pathology is a known cause of referred pain to the lower extremities and should be investigated as a possible source of knee pain, especially with patients in their sixth decade.» While primary knee pathology is common, spinal pathology should always be considered in older patients presenting with knee pain, especially in atraumatic cases where knee imaging does not correlate with complaints or examination findings.» Lumbar (L) 3-4 pathology is most commonly affected in referred knee pain, with the 2 most common pathologies being spinal stenosis and disc herniation.» If knee radiographs do not demonstrate major pathology that correlates with a patient's history and examination, a thorough spine examination should then be performed with attention paid to patellar tendon reflex, quadriceps muscle strength, and any loss of sensation, as these can be hallmarks of L3-4 pathology.

» Anemia is a common comorbidity in orthopaedic trauma patients with important clinical consequences, significantly negatively affecting a patient's course following orthopaedic trauma.» Anemia remains relatively understudied in the orthopaedic trauma population with a large amount of current literature focused solely on geriatric hip fracture patients.» Greater investigation into alternatives to blood transfusions such as iron therapy or cell salvaging for treatment of anemia in the orthopaedic trauma population is needed.