Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Pediatric patients with proximal both bone forearm fractures appear to be at risk of refracture. We evaluated if initial treatment strategy and increasing volar angulation of the radius is associated with an increased need for rereduction or refracture.

Methods: We performed a retrospective review of medical records of patients treated for a proximal both bone forearm fractures at a regional level one pediatric hospital. Skeletally immature patients with open physes and a proximal one-third fracture of the radius with associated ulna fracture were included. Patients with less than 4 weeks of follow-up, single-bone fracture, inadequate radiographs, or midshaft, distal, and Monteggia fractures were excluded. We did a Fisher exact test to evaluate the association of initial management strategy with refractures. A t -test compared volar angulation of the radius between refracture and no refracture groups. A logistic regression model evaluated the odds of refracture given volar angulation deformity of the radius during follow-up.

Results: We identified 147 patients with a mean age of 7.9 years (SD: 3.3), approximately 55% were male. Mean follow-up was 150 days. Initial management maintained a reduction in 79.6% of cases with 20.4% of cases requiring additional treatment through cast-wedging, closed rereduction, or surgical intervention. Overall, 15 refractures (10.2%) occurred. Initial management strategies, splinting/casting in situ, closed reduction and casting, or surgical intervention, were not associated with risk of refracture. Mean volar angulation of the radius was highest among refractures at third the follow-up visit (mean: 6 weeks; 15.8° vs 6.9°; P = 0.0039) among nonsurgically treated patients. Every 1° increase in volar angulation deformity of the radius at the third follow-up visit was associated with a 1.12 times higher odds of refracture (OR, 1.12; 95% confidence interval [CI], 1.02 to 1.23; P = 0.013).

Conclusions: Increasing volar angulation of the radius at union was markedly predictive of future refracture risk. Refracture risk was not associated with initial treatment strategy. Surgeons should consider a volar angulation cutoff of less than 10° for nonsurgical management of the radius.

Level of evidence: Therapeutic IV.

Orthobiologics represents a growing field of potential orthopaedic therapy. However, the current level of evidence supporting or refuting the use of many biologic agents in clinical practice is sparse and of low quality. The American Academy of Orthopaedic Surgeons and members of the Biologic Association recently convened a symposium dedicated to outlining processes with the goal of accumulating real-world evidence in support of the scientific validity and efficacy of orthobiologic agents. The results of this meeting as well as subsequent ongoing work comprise the American Academy of Orthopaedic Surgeons recommendations for the establishment of registries and biorepositories to assess the value of these treatments moving forward.

Background: Lower extremity injuries are common in youth soccer players. The Fédération Internationale de Football Association (FIFA) 11+ Kids program is a neuromuscular training program designed to improve physical performance and reduce injury risk in youth soccer athletes; however, it has not been evaluated in female youth athletes who are at elevated risk for injury compared with their male counterparts. The purpose of this pilot study was to explore the impact of the FIFA 11+ Kids program on strength, balance, and agility in youth female soccer players aged 8 to 11 years. We hypothesized that all measures would improve in the intervention group compared with age-matched controls.

Methods: Twenty-six female soccer players from local competitive soccer clubs (age: 8 to 11 years) were randomized into the FIFA 11+ Kids (n = 14) and CONTROL (n = 12) groups. The FIFA 11+ Kids group completed training twice a week for 8 weeks. Both groups received pre- and postintervention assessments for strength (gluteus medius [glute]; quadriceps [quad]), dynamic balance (Y-balance test [YBT]), hopping, kinetic-jump-testing, and agility. A 2 × 2 analysis of covariance repeated on time and covaried on baseline values was used to compare measures within group and between the groups. Correlation analysis evaluated the relationship between age and baseline test performance. Type I error was set at ∝ = 0.05.

Results: Glute:quad strength ratio increased in the FIFA 11+ Kids group compared with CONTROL ( P = 0.006) and baseline ( P = 0.001). Postintervention YBT posteromedial and posterolateral reach increased compared with the control group ( P < 0.05), whereas posteromedial reach also increased compared with baseline ( P = 0.021). Age correlated with quad strength (r = 0.649, P < 0.001), cross hop distance (r = 0.463, P = 0.017), pro-agility time (r = -0.569, P = 0.002), 6-m hop time (r = -0.547, P = 0.004), and three kinetic jump testing measures (r = 0.451 to 0.515, P < 0.01). Age did not correlate with YBT outcomes.

Conclusion: The FIFA 11+ Kids program may improve components of strength and dynamic balance in youth female soccer players, indicating the value of including it in regular training for this population.

Level of evidence: Level II, Randomized Pilot Study.

Background: Periacetabular osteotomy (PAO) is a common procedure for the treatment of symptomatic acetabular dysplasia in adolescent patients. Despite concerns regarding surgical outcomes and complications in patients with hypermobility spectrum disorders (HSD), the outcomes of PAO in such patients are not well documented.

Methods: We conducted a retrospective cohort review of patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Radiographic parameters including the lateral center edge angle of Wiberg (LCEA), medial center edge angle (MCEA), anterior wall index (AWI), posterior wall index (PWI), and Tönnis angle were measured. Patient-reported outcomes (PROs) were also collected.

Results: The mean duration of follow-up of non-HSD and HSD patients was 2.86 ± 0.73 years and 3.00 ± 1.11 years, respectively. No significant differences were found in mean age ( P = 0.289), sex, body mass index ( P = 0.125), laterality ( P = 0.192), or the duration of follow-up ( P = 0.636). Postoperatively, LCEA and AWI in patients with HSD were higher than those in non-HSD patients ( P = 0.002, P = 0.007, respectively). No notable differences were observed in Modified Harris Hip Score, Nonarthritic Hip Score, International Hip Outcome Tool, Hip Dysfunction and Osteoarthritis Outcome Score, or mean changes in PROs between the non-HSD and HSD groups at preoperative, 1-year postoperative, and most recent follow-up timepoints. However, patient-reported satisfaction with surgery in the HSD group (9.39 ± 1.04) was significantly higher than the non-HSD group (8.35 ± 1.95; P = 0.047).

Conclusion: Patients with HSD exhibited similar outcomes to patients without HSD after PAO for symptomatic acetabular dysplasia. Postoperative AWI and LCEA were markedly greater in patients with HSD consistent with our technical bias toward increased correction in such hips, suggesting greater anterolateral coverage of the femoral head after PAO may be a promising strategy to achieve improved outcomes in patients with HSD.

Introduction: Existing literature lacks clarity on how geography may affect gender disparities among pediatric orthopaedic surgeons. This study compares the academic productivity of pediatric orthopaedic attendings based on their sex and region.

Methods: Faculty lists from the 45 Pediatric Orthopaedic Society of North America fellowship programs were accessed in February 2024. Data on sex, training history, fellowship director status, institution, publication counts, and H-indices were collected from program websites and Scopus. The attending publication rate was calculated by dividing the total number of publications completed as an attending by the number of years in practice. Results were displayed using (mean ± SD). Categorical variables were analyzed using Pearson chi square. Mann-Whitney U and one-way analysis of variance were used for nonparametric and parametric data, respectively. Analyses were done using GraphPad Prism 10, with significance set at P < 0.05.

Results: Four hundred one pediatric orthopaedic surgeons (302 male, 99 female) from 45 fellowship programs were analyzed. Female surgeons had fewer publications, lower H-indices, and lower publication rates than male surgeons. In the Northeast, male attendings had higher publication counts, rates, and H-indices. Men also had higher H-indices than women in the Midwest and Southwest. Among male pediatric orthopaedic attendings, those in the Northeast exhibited the highest publication counts, rates, and H-indices. However, no regional differences were observed among female pediatric orthopaedic surgeons.

Conclusion: Notable gender disparities persist among pediatric orthopaedic surgeons in the United States, reflecting systemic barriers that limit women's research opportunities. Male faculty outnumber female faculty across fellowship programs and have higher publication counts, rates, and H-indices. Regional differences were most notable in the Northeast, where male attendings had markedly higher publication counts, rates, and H-indices. H-index disparities were also present in the Midwest and Southwest. Targeted strategies are needed to improve research access and support for women trainees and faculty.

Introduction: Pediatric olecranon fractures are uncommon periarticular injuries with unclear treatment guidelines for varying magnitudes of intra-articular displacement. Similar to other pediatric elbow fractures, minimally displaced fractures are treated nonsurgically, and potential for further displacement following nonsurgical treatment exists. This study assesses the incidence and risk factors for further displacement after nonsurgical treatment of minimally displaced pediatric olecranon fractures.

Methods: A retrospective review was conducted on patients aged 0 to 15 years with isolated olecranon fractures treated nonsurgically at a single institution. Radiographic measurements of intra-articular and nonarticular displacement on lateral views were collected with follow-up imaging done until confirmed radiographic union. Patients with more than 1-mm change in displacement on the articular side during treatment were identified. Fractures were classified at specified locations, including zone 1 (proximal 1/3), zone 2 (middle 1/3), and zone 3 (distal 1/3).

Results: A total of 64 patients met inclusion criteria, 42 (65.6%) were males, and the average age at injury was 8.25 years. Casting without closed reduction was the definitive treatment method in 59 patients (92.2%). Of the fractures observed, 30 (46.9%) occurred in zone 1, followed by 23 patients (35.9%) in zone 2 and 11 patients (17.2%) in zone 3. Interval displacement was seen in 14 patients at follow-up visits (21.9%) with greater body mass index observed in the redisplacement group ( P = 0.053). Change in management was required in two patients (3.1%). Displacement of ≥1 mm at initial evaluation did not affect the rate of subsequent displacement at follow-up visit ( P = 0.571). Neither fracture zone nor fracture configuration were statistically significant for change in fracture displacement.

Conclusion: Further displacement was observed in 20% of minimally displaced olecranon fractures regardless of the zone and magnitude of initial displacement with a small percentage leading to a change in the management. Close radiographic follow-up for nonsurgically treated olecranon fractures is recommended.

Background: Fibular hemimelia (FH) is a rare congenital condition characterized by longitudinal lower limb deficiency with fibular hypoplasia or aplasia commonly associated with femoral and tibial shortening resulting in leg length discrepancy (LLD). Femoral distraction osteogenesis represents a well-established reconstructive approach in patients with LLD exceeding 2 cm.

Methods: Twenty-three patients with FH were treated with antegrade femoral distraction osteogenesis between 2018 and 2021 using magnetically controlled motorized intramedullary lengthening nails (Precice P2 or Stryde, NuVasive/Globus Medical). The primary end points included accuracy, precision, reliability, distraction and consolidation index, and the complication profile. Radiographic and clinical outcomes were assessed over a median follow-up period of 39 (interquartile range [IQR], 26 to 52) months.

Results: The median preoperative LLD of 45 (IQR, 39 to 53) mm was reduced to 9 (IQR, 4 to 13) mm (P < 0.001) following a median distraction length of 40 (IQR, 34 to 44) mm. Planned lengthening was achieved with an accuracy of 91% ± 8% and a precision of 91%. The mean distraction index was 0.8 ± 0.2 mm/d, and a consolidation index of 36 ± 15 d/cm. At least one complication was observed in 70% of cases, including transient or persistent knee stiffness (39%) and pain (39%). Unplanned additional surgery related to complications was conducted in 17% of patients and all complications were successfully treated without permanent sequelae. The reliability of the treatment was 96%. No significant correlation was observed between distraction length and complications or revision surgery.

Conclusion: Femoral distraction osteogenesis using magnetically driven intramedullary lengthening nails represents a precise and reliable treatment for LLD in FH. Despite favorable radiographic outcomes and high distraction accuracy, the notable complication rate underscores the necessity of rigorous patient selection and structured postoperative management.

Introduction: Psychiatric disorders are known risk factors for complex regional pain syndrome (CRPS), but little is known about psychiatric outcomes after CRPS type I. This study investigates the development of psychiatric conditions after CRPS type I diagnosis in patients with surgically treated long-bone fractures.

Methods: A retrospective, propensity-matched cohort study was conducted using the TriNetX US Collaborative Network. Adults with surgically treated long-bone fractures from 2014 to 2023 were included. Patients with prior psychiatric diagnoses or selective serotonin reuptake inhibitor use were excluded. Those diagnosed with CRPS type I within 1 year were matched 1:1 to control subjects without CRPS. Psychiatric outcomes were assessed over 2 years.

Results: Among 2,540 matched pairs, patients with CRPS had higher risks of anxiety (39% vs. 23%, RR 1.7), mood disorders (35% vs. 22%, RR 1.6), insomnia (24% vs. 13%, RR 1.8), and substance use disorders (33% vs. 24%, RR 1.4). No notable differences were found in psychosis or suicide attempts.

Conclusion: CRPS type I is linked to increased psychiatric morbidity, highlighting the need for proactive mental health screening and care. KEY WORDS: CRPS, Long-bone fracture, Psychiatric sequelae.

Level of evidence: Level III.

Purpose: The primary aim of this study was to identify and characterize medical malpractice lawsuits pertaining to pediatric orthopaedic surgery.

Methods: The Westlaw research database was queried for all jury verdicts and settlements pertaining to pediatric orthopaedic medical malpractice from 1980 to 2024. Cases were only included if the primary basis of litigation rested on a malpractice claim related to pediatric orthopaedic surgery and were levied against an orthopaedic surgeon. Data collected included date and state of case filing, patient (plaintiff) and surgeon (defendant) demographics, jury verdict, monetary awards, alleged negligence, and patient complications.

Results: Of 5,031 cases screened for inclusion, a total of 100 cases met the inclusion and exclusion criteria and were subsequently included in the final analysis. Plaintiff favorable outcomes were more commonly seen than a defendant verdict (56% vs. 44%). Patients most commonly presented for fracture management (62%), and most commonly underwent casting (30%). Alleged failure to diagnose was the most frequent basis of litigation (30%) and was predictive of a plaintiff outcome. The most frequent complication was the presence of permanent deformity (22%). A pediatric orthopaedic surgeon was the primary defendant in 59% of cases and was more commonly named following closed reduction and percutaneous pinning. Adult orthopaedic surgeons (41%) were more commonly named following fracture casting.

Conclusion: The majority of medical malpractice cases in pediatric orthopaedic surgery result in plaintiff-favorable outcomes. Pediatric orthopaedic medical malpractice cases most often arise in the setting of fracture care and allegations of missed diagnoses. Patients pursuing litigation most frequently sustain permanent deformity as a result of the alleged negligence. Both pediatric and adult orthopaedic surgeons primarily face litigation following call-related fracture cases.

Background: Unplanned returns to the emergency department (RTED) and hospital readmissions after surgery are notable burdens on the healthcare system and markers of potential gaps in patient care. The objective of this study was to identify the risk factors associated with RTED and unplanned readmissions after pediatric orthopaedic surgery.

Methods: A retrospective cohort study was conducted between 2017 and 2023 and included patients younger than 18 who underwent orthopaedic surgery at a single, large academic institution. Patient data included current procedural terminology code, demographics, body mass index, insurance, language, and case complexity proxied by work relative value units. Procedural categories were defined by Accreditation Council for Graduate Medical Education case log guidelines for pediatric orthopaedics using current procedural terminology codes. The primary outcomes were RTED and hospital readmission within 7, 30, and 90 days of the index procedure. Univariable and multivariable logistic regression analyses were done to identify notable predictors for each outcome.

Results: In total, 3,044 pediatric patients were included. In multivariable analysis, patients with Medicaid insurance had a higher odd of RTED at 30 days (odds ratio [OR] 2.26, P = 0.007) and 90 days (OR 2.39, P < 0.001), and a higher odd of readmission at 90 days (OR 3.82, P = 0.002). Hispanic ethnicity was associated with 90-day RTED (OR 1.54, P = 0.023). Black or African American race was associated with 7-day (OR 9.24, P = 0.012) and 30-day (OR 4.00, P = 0.013) readmission. After controlling for demographic variables, operations for infection (OR 15.3, P = 0.002) and soft tissue reconstruction (OR 5.45, P = 0.046) were associated with 7-day RTED. Spine deformity surgery was associated with 30-day (OR 12.0, P = 0.006) and 90-day (OR 5.19, P = 0.031) readmission.

Conclusion: Medicaid insurance status and the type of surgical procedure (infection, spine deformity, or soft tissue reconstruction) may represent high-risk populations for postoperative RTED and readmission. These findings underscore the need for enhanced postoperative patient support programs to mitigate adverse outcomes.