Journal of the American Academy of Orthopaedic Surgeons最新文献

Golf is a popular sport with an estimated 60 million participants worldwide. The sport remains popular among older adults, including those with a total hip arthroplasty (THA) or total knee arthroplasty (TKA) because of the low-moderate intensity of the activity. Accordingly, golfers who are contemplating undergoing THA or TKA are interested in the rate of return to play, outcomes, and limitations after surgery. The factors affecting return to golf are numerous, including patient-specific factors and biomechanical changes in the hip and knee affecting the golf swing. Specifically, younger age, male sex, and lower body mass index are independent predictors of return to golf. Furthermore, changes in leg length, alignment, and implant type/position can also affect function and play. Despite these factors, golfing patients routinely demonstrate successful return to their sport with less pain and improved mobility after THA and TKA. A comprehensive preoperative evaluation, expectation setting to return to any recreational activity, patient-specific surgical planning, and a functional rehabilitation program can provide optimal outcomes in those wishing to return to golf after total joint arthroplasty.

The decision making surrounding return to play after anterior cruciate ligament (ACL) injuries is complex and multifactorial. A successful return to play is dependent on several factors, including the stability of the knee, patient-reported symptoms, and adequacy of rehabilitation of the injured knee. The American Academy of Orthopaedic Surgeons has developed an appropriate use criteria (AUC) to determine the appropriateness of return to play following an ACL injury. The purpose of this AUC was to determine the appropriateness of clinical practice guideline recommendations for the ACL-injured patient population. This article will highlight the use of the AUC in return-to-play decision making through a case-based approach.

Introduction: The primary objective of this meta-analysis was to evaluate and compare the functional outcomes, postoperative reinfection rates, and complication rates in patients undergoing one-stage versus two-stage surgical revision for periprosthetic hip infection.

Methods: The study population included adult patients who had undergone revision hip arthroplasty. Comparative studies have compared two-stage and one-stage revision strategies. Searches were conducted using the major databases. Review Manager software was used to estimate the effects. A sensitivity analysis was also conducted.

Results: Nine cohort studies including 2,502 hips were included. The success rate did not show significant differences between the groups (odds ratio [OR] 0.42, 95% confidence interval 0.05 to 3.37). No difference was noted in reinfection (OR 0.81, 95% CI 0.56-1.19). Life quality per Harris Hip Score was higher for one-stage revision strategies (mean difference [MD] 9.00, 95% CI 2.23-15.78). No differences were noted in mortality, aseptic loosening, or revision rates. Age (MD 2.32, 95% CI 1.34-3.29) and body mass index (BMI) (MD 1.88, 95% CI 0.38-3.38) were lower in the two-stage group. Sinus tract presence was higher in the one-stage group (OR 1.44, 95% CI 1.05-1.95). Paprosky I acetabulum was higher in the one-stage group, and Paprosky III was higher in the two-stage group.

Conclusions: The results did not demonstrate notable clinical differences between one-stage and two-stage hip arthroplasties, regardless of the treated microorganism. However, the quality of life may be somewhat better in the one-stage group. Age, body mass index, and Paprosky classification are factors that influence procedure selection.

Background: The utilization of total shoulder arthroplasty (TSA) in an aging population continues to rise, but the perioperative risk profile of TSA in the very elderly is not well-described. The objective of this study was to quantify the risk profile of 30-day perioperative adverse events after TSA in octogenarians and nonagenarians using a large national database over a recent 10-year period.

Methods: The National Surgical Quality Improvement Program database was queried for TSA from 2011 to 2020. Patients were stratified into three age groups: (1) age < 80 years, (2) 80 years ≤ age < 90 years ("octogenarians" in this study), and (3) age ≥ 90 years ("nonagenarians" in this study). The primary outcome was 30-day complication, and secondary outcome variables included 30-day readmission, revision surgery, and mortality. Multivariable logistic regression analyses adjusted for relevant comorbidities were done.

Results: The cohort included 33,089 patients who underwent TSA, including 28,543 patients younger than 80 years, 4,334 octogenarians, and 212 nonagenarians. Complication rates were 4% in patients younger than 80 years, 8% in octogenarians, and 16% in nonagenarians. Readmission rates were 3% in patients younger than 80 years, 4% in octogenarians, and 7% in nonagenarians. Mortality rates were 0.1% in patients younger than 80 years, 0.4% in octogenarians, and 2% in nonagenarians. Revision surgery was not markedly different among age groups. In the adjusted multivariable logistic regression analysis, compared with patients younger than 80 years, octogenarians had 1.9-times higher odds of complications and 1.5-times higher odds of readmission, and nonagenarians had 7.1-times higher odds of complications and 2.2-times higher odds of readmission.

Discussion: Our findings are germane to preoperative counseling in very elderly patients considering TSA, to balance potential improvements in quality of remaining life years against the risk of adverse events.

Level of evidence: Level IV Prognostic.

As anatomic shoulder arthroplasty continues to increase in popularity, there will be a similar need for revising these implants to reverse total shoulder arthroplasty. To address this problem, convertible glenoid and humeral components have been developed to facilitate a less complicated, less traumatic, and bone-preserving procedure. However, convertible glenoids have a historically higher failure rate due to loosening and joint overstuffing when used for anatomic shoulder arthroplasty, and convertible humeral stems can be problematic at the time of revision and often need to be removed because of stem malposition. Despite these issues, there have been recent advances with the humeral and glenoid components which continue to make these implant options appealing and relevant. At the same time, there is a trend toward stemless arthroplasty which makes a convertible humeral stem less important due to the ease of revision from a stemless component to a stemmed reverse shoulder arthroplasty.

Intermediate length (235 to 240 mm) cephalomedullary nails have been introduced as alternatives to the classic short and long cephalomedullary nails for the management of different types of proximal femur fractures. Recently, they have gained popularity among many surgeons because of the ease of distal locking screw insertion compared with long nails and the additional diaphyseal fit they provide compared with short nails. Despite their increasing popularity, the literature offers limited guidance on their ideal indications, with few studies comparing their outcomes with those of short and long nails. In this review, we aim to explore the potential indications for intermediate length cephalomedullary nails and examine the existing literature on their outcomes in the treatment of proximal femur fractures, highlighting the comparative studies.

Introduction: Skeletal metastases increase the risk of pathologic fractures, causing functional impairment and pain. Predicting morbidity in patients undergoing surgical fixation for these fractures is challenging due to the complexity of metastatic disease. The Pathologic Fracture Mortality Index (PFMI) was developed to predict 30-day postoperative morbidity in long bone fractures caused by metastases. External validation is necessary for clinical use. This study aims to evaluate the following: (1) How well does the PFMI predict 30-day medical, surgical, utilization, and all-cause morbidity after pathologic fracture fixation in an external cohort of patients with long bone metastases? (2) How does the performance of the PFMI compare to established predictive indices including the American Society of Anesthesiologists (ASA) classification score, the modified 5-Item Frailty Index (mF-I5), and the modified Charlson Comorbidity Index (mCCI)?

Methods: We analyzed 978 patients who underwent internal fixation for pathologic fractures at two urban tertiary centers. The area under the receiver operating characteristic curve (AUC) was calculated for each predictive index to assess their accuracy in predicting 30-day morbidity across medical, surgical, utilization, and all-cause categories.

Results: All four predictive indices demonstrated suboptimal performance, with AUC values ranging from 0.51-0.62, 0.45-0.51, 0.51-0.62, and 0.50-0.57 for medical, surgical, utilization, and all-cause morbidity, respectively. The PFMI outperformed the ASA (P < 0.001), mF-I5 (P = 0.018), and mCCI (P = 0.034) in predicting utilization morbidity. It also better predicted medical (P = 0.021) and all-cause (P = 0.009) morbidity than ASA but did not outperform mF-I5 or mCCI in these areas. The PFMI did not surpass any indices in surgical morbidity.

Conclusion: None of the indices reached the ideal AUC of 0.80 for any morbidity type, emphasizing the need for refinement. Updating these tools with contemporary data and exploring new prognostic factors is critical to improve morbidity risk stratification in metastatic bone disease.

The Patient-Reported Outcomes Measurement Information System (PROMIS) is a collection of patient-reported outcome measures assessing physical, mental, and social health that are relevant across a variety of conditions. The use of PROMIS measures in capturing important symptoms and functions has increased over time, yet detail on more recent use of PROMIS measures in orthopaedics and its specialties has been lacking. The goal of this scoping review is to characterize and quantify the use of PROMIS measures in orthopaedic populations across published studies from 2018 through 2022 to inform opportunities for expansion of PROMIS across orthopaedics in research and clinical practice. We identified 699 published studies with 1,835 PROMIS measures. Publications were distributed across orthopaedic subspecialties, including 27% (185 studies) in spine patient populations, 21% (143 studies) in hand/shoulder/elbow, 11% (80 studies) in arthroplasty, 9% (65 studies) in foot/ankle, and 9% (65 studies) in sports medicine. The most commonly used PROMIS measures across all orthopaedic publications assessed physical function (63%), pain interference (55%), and depression (30%). We observed an overall increase in orthopaedic publications using and reporting on PROMIS measures. PROMIS measures are efficient, and precise tools and their use is expected to continue to increase across medical and surgical specialties.

Background: Declining reimbursement rates can lead to decreased access and utilization of common orthopaedic surgeries for patients on Medicare, which is a particularly vulnerable population for musculoskeletal injuries.

Methods: Using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool from 2016 to 2024 and utilization data for Medicare and part B beneficiaries from 2016 to 2022, we analyzed reimbursement and utilization trends. Simple linear regressions were executed to measure the annual trends, and Wilcoxon matched-pairs signed rank test were used to analyze the statistical significance of price and utilization changes.

Results: Between 2016 and 2024, mean reimbursements for all evaluated orthopaedic surgeries decreased 26.2% with a -3.34% compound annual growth rate, from $1,558 to $1,150 ( P < 0.0001). Comparatively, reimbursement rates for evaluation and management (E/M) services fell by 15.82% or a -1.91% compound annual growth rate, from $102.3 to $86.12 ( P < 0.0021). The federal utilization of all orthopaedic surgeries fell from 2016 to 2022 ( P < 0.0001), although no significant changes were seen for E/M services ( P = 0.9102).

Conclusion: We observe that Medicare reimbursement rates for orthopaedic surgeries from 2016 to 2024 have fallen consistently with a large drop in utilization, especially during the Covid-19 pandemic. Reimbursements for E/M services have fallen at attenuated rates with minimal changes in utilization. This demonstrates the supportive role that declining reimbursement rates may play in utilization and accessibility of orthopaedic surgery.