Journal of the American Academy of Orthopaedic Surgeons最新文献

Objective: There is growing evidence on the relationship between social determinants of health (SDOH) dimensions and utilization and outcomes of joint arthroplasty; however, this literature is not currently guided by a conceptual framework that is specific to this patient population. The purposes of our study were to (1) present a comprehensive evidence-driven conceptual framework of SDOH specific to hip and knee arthroplasty and (2) conduct a narrative systematic review of SDOH literature to assess the extent of SDOH coverage and inform the likely directionality of association between proposed variables and joint arthroplasty outcomes.

Methods: Existing SDOH conceptual frameworks were reviewed to identify all domains relevant to joint arthroplasty. A systematic narrative review of the hip/knee arthroplasty literature was then conducted in PubMed in accordance with PRISMA principles to inform the extent to which SDOH dimensions are covered and the directionality of associations.

Results: The final proposed conceptual framework identified seven dimensions from both Healthy People 2030 and Luong et al. Our narrative review found 25 articles, and most examined about half of the proposed SDOH domains. Only two of 26 studies accounted for all seven domains. The directionality of multivariable associations was reasonably consistent across studies for person-level dimensions but generally not for Healthy People 2030 dimensions.

Conclusion: Our proposed conceptual framework is the first to describe a comprehensive set of SDOH dimensions. Application of the framework to future research will likely lead to a comprehensive assessment of the role of SDOH in potentially influencing a variety of arthroplasty outcomes.

Increased participation in youth sports has led to a corresponding increase in throwing-related injuries among skeletally immature athletes. These injuries often stem from overuse and can in part be attributed to sport specialization leading to year-round sport participation without adequate rest and an increase in volume of practices and games during the season. Injuries that occur in skeletally immature athletes can be unique to this population due to the vulnerability of the open growth plates. Common injuries include Little League shoulder (proximal humeral epiphysiolysis), internal impingement of the shoulder, Little League elbow, medial ulnar collateral ligament injuries, and capitellar osteochondral defects. Diagnosis and management of these injuries requires a high index of suspicion from the treating physician. In addition, prevention strategies and pitching guidelines have been introduced to decrease the burden of injury on this population. Proper treatment, appropriate intervention, and a thorough understanding of injury prevention guidelines can allow these young athletes to undergo a timely recovery and return to sport participation with minimal long-term effect.

Introduction: Durability of surgical treatment is important to patients, providers, and payers. In addition to the obvious effect on clinical outcomes and satisfaction, durability is an important variable when evaluating cost-effectiveness. The purpose of this study was to analyze the prevalence and indications for revision surgery after anterior cervical discectomy and fusion (ACDF).

Methods: A multisurgeon, single-institution database was queried for revision surgery after ACDF from 2014 to 2018 with a minimum follow-up of 4 years (N = 1,652). Demographic data, surgical data, and primary indication for revision surgery were collected by medical record analysis. All statistical analyses were performed using IBM SPSS v28.0 (IBM).

Results: A total of 147 of 1,652 patients (9%) underwent unplanned revision surgery during the study period. The mean patient age was 53.6 years; the mean number of surgical levels was 1.8. The most common indication for revision surgery was nonunion (N = 94, 6%), which occurred at a mean of 33 months postoperatively. The second most common indication was adjacent segment disease (N = 37, 2%), which occurred at a mean of 24 months postoperatively. Patients who had a revision surgery for nonunion had more levels fused (2.06) compared with patients who had no revision surgery (1.65) or had surgery for adjacent segment disease (1.76) ( P < 0.001). Likewise, patients with nonunion had longer surgical time ( P < 0.001) and length of stay ( P = 0.036). Patients who underwent a revision surgery for adjacent segment disease had a higher body mass index (BMI = 33.6) compared with patients without revision surgery (BMI = 30.4) or patients who underwent revision surgery for nonunion (BMI = 31.2) ( P = 0.012). Comorbidities as measured by ASA grade did not differ between groups ( P = 0.633). Smoking status, use of anterior plate, and use of structural allograft did not differ between groups ( P > 0.05). No other differences were found among these groups. Other indications for revision surgery were much less common (<1%) and included evacuation of hematoma (N = 5), repeat decompression (N = 5), infection (N = 2), extension into the thoracic spine (N = 2), and implant reposition (N = 2).

Discussion: ACDF is a relatively durable procedure (91%) as currently indicated and performed in a large multisurgeon spine center. Early revision surgery (<90 days) for hematoma or infection is rare. Late revision surgery (>90 days) for nonunion is more than twice as common as adjacent segment disease and occurred earlier and more commonly when a greater number of levels were fused. These data can help guide clinicians and researchers in future quality improvement initiatives.

Introduction: Pediatric patients with severe neuromuscular scoliosis (NMS) often require posterior spinal fusion (PSF) surgery. Curve magnitude, among other comorbidities, is a risk factor for worse postoperative outcomes, but social determinants of health also have large effects on patient outcomes. Our hypothesis was that lower socioeconomic status (SES), race, and public insurance status independently affect preoperative diagnosis severity for children with NMS.

Methods: We used the area deprivation index (ADI) and insurance type to stratify groups for analysis. Higher ADI indicates higher socioeconomic deprivation. We studied 216 patients with NMS who underwent PSF of >13 levels from 2015 to 2020 at our institution. χ 2 tests for independence α < 0.05, T-tests, analysis of variance, and Pearson correlations were used to analyze clinical variables to determine whether diagnosis severity at presentation depended on ADI, insurance type, or race.

Results: Patients with higher ADI had larger preoperative curves ( P = 0.002) and higher outpatient no-show rates ( P < 0.001) were more likely to be from single caregiver households ( P = 0.031), publicly insured ( P < 0.001), and non-White ( P < 0.001). Publicly insured patients had more comorbidities ( P = 0.029), higher outpatient no-show rates ( P < 0.001), and mean ADI ( P < 0.001) were less likely to seek second opinions ( P < 0.001) and more likely to be from single caregiver households ( P < 0.001). Non-White patients had a higher mean ADI ( P < 0.001) and higher no-show rates ( P < 0.001) were more likely to be publicly insured ( P < 0.001) and presented with more comorbidities ( P = 0.014).

Conclusion: SES has notable effects on patients with NMS, as those with lower SES and public insurance presented with greater preoperative curve magnitudes, more comorbidities, and higher outpatient no-show rates. Greater diagnosis severity at presentation may affect outcomes afforded by surgery and pose a higher risk of postoperative complications. This population at risk should be identified preoperatively and provided education and resources to mitigate the effect of SES on diagnosis severity before PSF for NMS.

Level of evidence: III.

Introduction: Testosterone deficiency (TD) affects a notable portion of the aging male population, leading to muscle loss and reduced bone density. Most men with TD do not receive testosterone replacement therapy (TRT). However, the association of untreated TD on surgical outcomes after total joint arthroplasty (TJA), including total hip arthroplasty (THA) and total knee arthroplasty (TKA), remains unexplored. This study aims to assess whether untreated TD is associated with poorer surgical outcomes in TJA patients without prior TRT.

Methods: This retrospective cohort study used data from the TriNetX US Research Network, a large claims database including over 95 healthcare organizations and 130 million patients. Male patients undergoing THA or TKA were divided into two groups based on testosterone levels (TD: <300 ng/dL; eugonadal/non-TD: ≥300 ng/dL). Those with TRT before or within 2 years after TJA were excluded. Propensity score matching balanced demographics and comorbidities. Outcomes, including thromboembolic events, infections, prosthetic complications, revision, resection, readmission, and mortality, were assessed at 90 days, 1, and 2 years post-TJA.

Results: A total of 133,696 male patients without hormone replacement therapy who underwent THA were analyzed, with 5,400 patients in both TD and eugonadal cohorts after matching. TD patients had a higher risk of deep vein thrombosis and pulmonary embolism at 90 days, 1, and 2 years post-THA compared with their eugonadal counterparts. In the TKA population of 147,203 male patients, 6,658 patients per cohort were matched. TD patients had an increased risk of deep vein thrombosis, aseptic loosening, manipulation, readmission, and revision surgery within two years but lower risk of prosthetic joint infection than eugonadal men.

Conclusion: TD is associated with poorer postoperative outcomes in TJA, with distinct patterns observed in THA and TKA. These findings suggest that hypogonadal status should be considered in the perioperative management of patients undergoing TJA.

Introduction: Although spine surgery careers are influenced by a multitude of professional and personal factors, predictors of career trajectories and future research effect may be identifiable at the spine fellow applicant stage. As such, this study aimed to (1) determine factors predictive of University Hospital [UH] employment and research contributions and (2) compare the application metrics identified as most important to an academic career by spine surgery program directors (PD) to those predictive of career environments from prior spine fellows applications.

Methods: All applications of individuals applying for spine fellowship training between 2017 and 2021 at an academic institution were reviewed. Application metrics pertaining to research achievement, academic achievement, prior and current education, extracurricular involvement, leadership, examination scores, applicant interests, and letter of recommendation (LOR) reputation were extracted. The careers of all prior spine fellow applicants were grouped by the presence or absence of full-time university appointment and research effect (current H-index). A survey sent to spine PDs asked them to rank the importance of application factors to academic careers using analogous metrics to the application review.

Results: A total of 310 applications were reviewed. Residency publications (odds ratio [OR]: 1.09, P = 0.0116), preclinical publications (OR: 1.24, P = 0.0447), and expressed academic interest (OR: 2.25, P = 0.0229) predicted UH appointment. Applicant physician scientist interest (β: 2.41, P < 0.001), LOR writers' reputation (β: 0.05, P < 0.001), and journal reviewer positions (β: 0.80, P < 0.001) predicted current H-index. In the PDs survey, metrics predicting academic trajectory were ranked (descending): research achievements, physician scientist interest, academic interest, leadership positions, LOR writers' reputation, prestige of training, and United States Medical Licensing Examination scores. Research year(s), advanced degrees, and society leadership and membership positions, although theoretically deemed important by PDs, were in actuality minor contributors to the career environments of spine fellow applicants.

Conclusion: Spine fellow academic interest, residency publications, and preclinical publications predicted full-time UH-based careers.

Level of evidence: 3.

Study design: Retrospective Cohort Analysis.

Knee arthrofibrosis (AF) is a debilitating complication after total knee arthroplasty. AF is characterized by formation of fibrotic adhesions, loss of joint mobility, and pain. With osteoarthritis prevalence and associated total knee arthroplasties projected to rise sharply, AF is becoming increasingly prevalent, yet its pathogenesis remains poorly understood and no effective treatments exist. Like other fibrotic diseases, knee AF is a multifactorial disease that exhibits TGFβ1-driven myofibroblast transformation and excessive collagen deposition. However, knee AF also displays unique features, including rapid disease development and the establishment of a highly fibrotic mass rather than fibrotic tissue infiltration. Our integrative research approach uses human patient fibroblasts, multiomics profiling, and in vivo animal models to dissect disease mechanisms and identify therapeutic targets. Our work suggests altered adipogenic cell differentiation in the knee and epigenetic pathways controlling myofibroblastogenesis to be involved in AF development. Anti-inflammatory interventions with ketotifen and celecoxib reduce knee AF in vivo, indicating a contributory role of inflammation as well. Together, our novel findings elucidate causal and mechanistic drivers of AF and define this disease as an adipose-depleted fibrotic disorder driven by aberrant differentiation and epigenetic regulation, suggesting new therapeutic avenues for intervention.

Background: Conversion total hip arthroplasty (cTHA) is commonly used for patients with persistent osteoarthritis or failed fixation following femoral neck fracture (FNF). There are limited data comparing patient-reported outcomes between patients undergoing cTHA after FNF and primary THA (pTHA) patients. This study aimed to compare the time to reach the minimal clinically important difference for improvement (MCID) for the Hip Disability and Osteoarthritis Outcomes Score-Physical Function Short Form, Patient-Reported Outcomes Measurement Information System (PROMIS) Global Physical, and PROMIS Physical Function short form 10a (PF-10a).

Methods: Patients undergoing cTHA for FNF between 2016 and 2022 were identified from an institutional database and propensity score matched 1:4 to pTHA patients by age, sex, body mass index, and Charlson Comorbidity Index. Demographic and MCID achievement rates were compared. To assess the time to achieve MCID, survival curves with and without interval censoring were used.

Results: A total of 258 THAs (52 FNF cTHA and 206 pTHA) were analyzed. All FNFs were managed surgically. The rate of achieving MCID was similar between the FNF cTHA and pTHA cohorts for all three PROMs. For PROMIS PF-10a, FNF cTHA had a markedly longer median time to MCID at 9.8 months (95% confidence interval [CI], 6.5 to 12.1) compared with 4.2 months (95% CI, 3.3 to 6.0) for pTHA ( P < 0.001). Interval censoring revealed that FNF cTHA achieved MCID for PROMIS PF-10a between 5.07 and 5.34 months, whereas pTHA achieved MCID between 1.37 and 1.37 months ( P < 0.001).

Conclusion: The time to achieve MCID was markedly slower for FNF cTHA patients compared with pTHA patients. This delay in achieving MCID should be factored into shared decision-making discussions to enhance preoperative expectation management and patient education. Future research is needed to identify modifiable factors that could improve recovery outcomes for FNF cTHA patients.

First responders, including firefighters, law enforcement, and emergency medical services, represent a unique patient population at high risk of knee injury. High rates of on-scene and training injuries are driven by dynamic and repetitive maneuvers often done under load. Excellent care of first responders starts with an understanding of the patient's occupational demands to provide the treatment and rehabilitation that optimizes their ability to return to high-level activity. By aligning treatment algorithms with real-world job demands and realistic return-to-duty timelines, orthopaedic surgeons can optimize functional outcomes and maintain the operational readiness of these essential public safety professionals. This review discusses the current literature pertaining to knee injuries in first responders.

Introduction: Delays in time to surgery (TTS) for patients with a hip fracture negatively affect patient outcomes, including mortality. Surgery within 24 to 48 hours of admission for a hip fracture markedly reduces these risks; however, attempts at improving TTS after hip fracture have had mixed results. Drivers of delays in TTS across different settings in the United States are not well described. Therefore, the aim of this study was to identify drivers of delays in TTS for patients with a hip fracture from different settings to inform where patient- and context-specific improvements in TTS may be implemented.

Methods: Semistructured interviews were completed using the Consolidated Framework for Implementation Research and Theoretical Domains Framework. Interviews were completed with stakeholders involved in hip fracture care between June 2023 and October 2023. Transcripts were analyzed iteratively through a combined inductive and deductive approach. The data were analyzed to synthesize overarching themes related to drivers of delays of TTS.

Results: A total of 25 stakeholders, 24 orthopaedic surgeons, and 1 nurse practitioner, from 22 different hospital systems across the United States participated in semistructured interviews. Eight themes of drivers of delayed TTS emerged: (1) patient health; (2) structural drivers of health; (3) care coordination; (4) prioritization; (5) improvement climate; (6) availability; (7) incentive structure; and (8) empowerment.

Conclusion: Eight major themes related to drivers in TTS for patients with a hip fracture were identified across hospital systems. These findings inform the process of identifying site-specific drivers of delayed TTS at individual health systems and implementing targeted improvement programs for TTS for patients with a hip fracture.