Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Understanding the reliability of outcomes in randomized controlled trials (RCTs) is crucial, as standard metrics, such as P-value do not fully capture result fragility. This led to the adoption of specific indices: the fragility index (FI), which measures the strength of trial through significant results by calculating the minimum number of patient status changes from nonevent to event required to make the results statistically insignificant; reverse fragility index (RFI), used for insignificant results; and continuous fragility index (CFI), which acts similar to FI for significant continuous outcomes. The objective is to assess the robustness of orthopaedics RCTs using these indices across leading orthopaedic journals.

Methods: A systematic review of RCTs published between 2019 and 2023 in the top five general orthopaedic journals, identified through Scientific Journal Rankings, was done. Data extraction focused on FI, RFI, and CFI and related measures for 160 RCTs. The indices were calculated using established methodologies, with sample size adjustments.

Results: 22 RCTs had statistically significant dichotomous primary outcomes and 17 studies had notable dichotomous secondary outcomes. Twenty-nine had negligible (insignificant) dichotomous primary outcomes, and 92 reported notable continuous outcomes. Only one RCT reported a FI in the article. The median FI was 5 with a median sample size of 142 for dichotomous outcomes. The median RFI was 3 with a median sample size of 100 for negligible outcomes, and the median CFI was 13 with a median sample size of 86.5 for continuous outcomes, showing dichotomous outcomes to be more fragile than continuous ones.

Discussion: Continuous outcomes are less fragile than dichotomous outcomes, with negligible dichotomous outcomes being particularly more fragile. This fragility stems from small sample sizes and limited outcome events. Using these indices, especially when considering patient loss to follow-up, can improve the reliability of findings.

Level of evidence: I.

Background: Lumbar diskectomy is a common procedure, following which a brief course of narcotics is often prescribed. Nonetheless, increasing attention has been given to such prescribing patterns to limit adverse effects and the potential for abuse. This study investigated prescribing patterns of opioid within 90 days following lumbar diskectomy.

Methods: Patients undergoing single-level lumbar laminotomy/diskectomy from 2011 to 2021 were identified in the PearlDiver Mariner161 database. Exclusion criteria included the following: additional same-day spine procedures, age less than 18 years, same-day diagnosis of neoplasm, trauma, or infection, prior diagnosis of chronic pain, records active for less than 90 days following surgery, and filled opioid prescription between 7 and 30 days before the surgery. Predictors associated with receiving opioid prescriptions and excess prescribed morphine milligram equivalents (MMEs) were assessed with multivariable regression analyses. Prescribing patterns over the years were then analyzed with simple linear regression and compared for 2011 and 2021.

Results: A total of 271,631 patients met the inclusion criteria. Opioids were prescribed for 195,835 (72.1%) and were independently associated with lower age, female sex, higher Elixhauser Comorbidity Index, and geographic region (P < 0.0001 for each). Greater MMEs were independently prescribed to those who were younger, had higher Elixhauser Comorbidity Index, and lived in specific geographic regions (P < 0.0001 for each). The proportion of patients receiving opioid prescriptions slightly increased over time (69.0% in 2011 to 71.0% in 2021), whereas a decrease was observed in median MMEs prescribed (428.9 in 2011 to 225.0 in 2021, P < 0.0001) and mean number of prescriptions filled (3.3 in 2011 and 2.3 in 2021, P < 0.0001).

Conclusion: Following lumbar diskectomy, this study found clinical and nonclinical factors to be associated with prescribing opioids and prescribed MME. The decreased MME prescribed over the years was encouraging and the decreased number of prescriptions filled suggests that patients are not needing to return for more prescriptions than prior.

Objective: To evaluate whether functional, clinical, and self-reported tests reflect lumbar spinal stenosis patients' decisions to undergo or defer surgery.

Methods: Among 108 participants, 77 chose surgery (SG), and 31 opted to wait and see (WaSG) whether they got better spontaneously. Both groups were assessed at baseline (t0) and 3 months (t1), with additional self-reported measures at 6 (t2) and 12 months (t3). Key outcomes included corridor walk distance, chair sit-to-stand repetitions, grip strength, and various pain and disability indices.

Results: At baseline, SG reported higher leg pain (NPRS-leg: Δ = 1.66, P = 0.002) and poorer functional outcomes across multiple tests. By t1, both groups improved in disability, but SG showed greater reductions in the Oswestry Disability Index (Δ = 7.85, P = 0.001) and sustained improvements in leg pain at subsequent assessments. WaSG consistently engaged in more walking (mean Δ = 123.5 minutes, P < 0.001). Regression analyses indicated that surgery status, flexibility, and strength significantly predicted improvements in disability (adjusted R² = 0.296). Logistic regression identified predictors for surgery choice, including biological sex, leg pain intensity, walking performance, and weekly walking hours.

Conclusion: Functional status, self-reported disability, and fear-avoidance beliefs in lumbar spinal stenosis patients reflect their subjective decision regarding surgery and highlight the importance of baseline leg pain, calf strength, walking-related parameters, and physical function in recovery.

Study design: Observational prospective cohort.

Introduction: Cervical fusion surgeries are commonly performed to stabilize the spine and relieve pain from various conditions. Recent increases in nontobacco nicotine product use, such as electronic cigarettes, present new challenges because of their unknown effects on spinal fusion outcomes. Our study aims to explore the effect of nontobacco nicotine dependence (NTND) on the success of cervical spinal fusions.

Methods: We analyzed TriNetX database data for patients undergoing primary anterior cervical diskectomy and fusion, identified by specific Current Procedural Terminology codes, and categorized into cohorts based on a preoperative diagnosis of nicotine dependence, excluding those with tobacco use or dependence. Propensity matching in the ratio of 1:1 was done to control for demographics and body mass index. We analyzed 90-day medical and 2-year implant complications using chi-squared exact tests and univariate regressions within the matched cohorts.

Results: The NTND and control cohorts comprised 5,331 and 43,033 patients, respectively. Five thousand two hundred thirty-two matched pairs of patients were included from each cohort as shown in Table 1. Our results indicate notable disparities in complications within 90 days postoperation between the cohorts. The NTND cohort had higher risks for opioid use (85.6% vs. 80.3%, P < 0.001), emergency department visits (13.0% vs. 8.40%, P < 0.001), opioid abuse (0.4% vs. 0.2%, P < 0.001), inpatient hospitalizations (20.0% vs. 17.4%, P < 0.001), and sepsis (1.40% vs. 0.80%, P = 0.01). At the 2-year follow-up, increases were observed in pseudarthrosis (14.0% vs. 9.60%, P < 0.001), adjacent segment disease (3.70% vs. 2.20%, P < 0.001), dysphagia (8.90% vs. 6.3%, P = 0.001), and revision surgery (2.00% vs. 1.40%, P = 0.02).

Conclusion: This study highlights notable postoperative complications in patients with NTND undergoing cervical spinal fusion.

Introduction: Patient-reported outcomes in children can be assessed using self-report or caregiver proxy-report; however, self-reported and proxy-reported outcomes often vary between respondents, a phenomenon called cross-informant variance. This phenomenon has not been studied in pediatric fracture care. This study compares self-reported and proxy-reported patient-reported outcomes in children being treated for upper extremity fractures.

Methods: Children aged 8 to 17 with upper extremity fractures completed pediatric self-report questionnaires and their caregivers completed parent proxy-report questionnaires composed of items from three Patient-Reported Outcomes Measurement Information System (PROMIS) domains (Physical Function-Upper Extremity, Psychological Stress Experiences, and Pain-Interference). Mean patient and caregiver T-scores for each domain were compared using paired T-tests. Correlation between scores was assessed using scatterplots and Pearson correlation coefficient. Agreement between child and caregiver T-scores was assessed using Bland-Altman plots.

Results: One hundred child-caregiver dyads were included. Patients' mean age was 12.3 years, and 68% were male. Statistically significant differences were found between mean patient and caregiver T-scores in all PROMIS domains. Caregivers overestimated patient pain and psychological stress and underestimated upper extremity function. However, only the disagreement in the Pain-Interference domain met the threshold of clinical significance, a difference of three or more T-score points. Bland-Altman analysis revealed proportional bias in the Psychological Stress Experiences and Pain-Interference domains. With higher T-scores, caregivers tended to overestimate psychological stress to a greater extent but tended toward agreement with their children for pain.

Discussion: This study identified cross-informant variance between children and caretakers in the setting of pediatric upper extremity fractures. Although notable differences were observed in all PROMIS domains included, only one met the level of clinical significance, suggesting that not all domains are equally susceptible to child-caretaker disagreement. As patient-reported outcomes become more used in pediatric settings, the possibility of cross-informant variance must be considered when choosing to use self-report or proxy-report instruments.

Level of evidence: Level III.

Introduction: The importance of web resources for educating orthopaedic trauma patients is well recognized. Yet these resources often exceed the sixth-grade reading level and are too complex for most patients to understand. This study examines the readability of the American Academy of Orthopaedic Surgeons' (AAOS) pediatric trauma-related educational content compared with similar materials from the Pediatric Orthopaedic Society of North America (POSNA).

Methods: Eleven AAOS (https://www.orthoinfo.org/) and nine POSNA (https://orthokids.org) pediatric trauma education articles were included. Articles' readability was assessed by two independent examiners using (1) the Flesch-Kincaid Grade Level (FKGL) and the Flesch Reading Ease (FRE) algorithms. The FKGL mean was compared with the sixth-grade level and the average American reading level using a one-sample t-test. A two-sample t-test evaluated the differences in readability between the AAOS and POSNA materials.

Results: A total of 15 unique articles were included. Excellent agreement (>90%) was noted between reviewers for FKGL and FRE. The average (SD) FKGL for AAOS and POSNA articles were 8.5 (0.8) and 9.0 (1.5), respectively, and the FRE scores were 61.2 (3.8) for AAOS and 61.7 (7.7) for POSNA. Only one AAOS article met the sixth-grade reading level. The average readability levels of the AAOS and POSNA articles were markedly higher than the recommended sixth-grade level (P < 0.001). No notable difference was found in FKGL (P = 0.47) or FRE (P = 0.89) when comparing AAOS and POSNA articles.

Discussion: This study indicates that the readability of the AAOS pediatric trauma and POSNA trauma-related articles is well above that which is recommended for the general public, and this has remained so for more than a decade. Both POSNA and AAOS trauma education materials have high readability levels, potentially hindering patient understanding. Improving the readability of these widely used trauma education resources is overdue and will likely improve patient comprehension.

Background: Lumbar microdiscectomy remains the most commonly performed surgical procedure for symptomatic lumbar disk herniation (LDH). Despite advances in surgical techniques, recurrent LDH (rLDH) ranges from 5% to 24%, representing the most common cause of surgical failure and revision surgery. Optimal treatment of reherniation remains controversial. In addition, no previously reported large database studies capture the rLDH rate in patients who did not undergo revision surgery. The purpose of this study was to determine the recurrence and revision surgery rate, time to revision surgery, and type of revision procedures performed after single-level diskectomy for LDH.

Methods: Using the Military Health System Data Repository, we retrospectively identified patients who underwent single-level microdiscectomy between October 2012 and December 2016. Electronic health records were reviewed to determine demographic data, rLDH rate, revision surgery rate, and type of revision surgery. Rates of subsequent procedures involving instrumented fusion and complications were recorded.

Results: Three thousand three hundred eighty-eight single-level microdiscectomies were included in the study. The same-level rLDH rate was 22.8%. A total of 396 revision surgeries (11.7%) were performed, with 274 revision microdiscectomies (69.2%) and 122 fusions (30.8%). Thirty-eight patients required additional surgical treatment. Overall, 138 patients (4.1%) progressed to lumbar arthrodesis after single-level microdiscectomy. Of those requiring more than one revision, 16 (42.1%) required an arthrodesis. All-cause complication during the index microdiscectomy was associated with greater reherniation risk (odds ratio 2.1, P < 0.001).

Conclusion: This retrospective study demonstrates a same-level recurrence rate of 22.8% with an 11.7% revision surgery rate. Within this group, 9.6% would require two or more revision surgeries and 42.1% of these revision microdiscectomy patients would ultimately undergo a lumbar arthrodesis at the same level as the initial disk herniation. Our findings characterize the lumbar disk reherniation population in the military health system, with major implications for the prognosis and treatment strategy of these commonly treated injuries.

Introduction: Complete blood count-based ratios (CBRs), including neutrophil-lymphocyte ratio (NLR), monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) are biomarkers associated with the proinflammatory surgical stress response. This study sought to determine whether preoperative CBRs are associated with postoperative complications, protracted hospital length of stay (LOS), and mortality after total joint arthroplasty, as well as establish threshold values for these outcomes for use in future investigations.

Methods: The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary elective total hip arthroplasty or total knee arthroplasty (TKA). Approximate cut-point values for CBRs were identified by bootstrap simulation using the Youden index. Multivariable adjusted restricted cubic spline models using the predicted cut-point value as the threshold for odds of outcomes were created to identify a final threshold value associated with increased adjusted odds ratio (aOR) of study outcomes.

Results: A total of 32,868 total joint arthroplasties (THA: 12,807, TKA: 20,061) were identified. All measures predicted odds of aggregate postoperative complications (THA: NLR TV: 4.60 [aOR = 2.35], PLR TV: 163.4 [aOR = 1.32], MLR TV: 0.40 [aOR = 2.02], SII TV: 977.00 [aOR = 1.54]; TKA: NLR TV: 3.7 [aOR = 1.69], MLR TV: 0.41 [aOR = 1.62], PLR TV: 205.10 [aOR = 1.43], SII TV: 1,013.10 [aOR = 1.62]; all P < 0.05). A MLR > 0.40 [aOR = 1.54] P < 0.001) was associated with LOS ≥3 days after total hip arthroplasty while an NLR > 13.1 [aOR = 1.38] and an MLR > 0.41[aOR = 1.29] were associated with LOS ≥3 days after total knee arthroplasty (both P < 0.001). No association between inflammatory markers and inpatient mortality was observed.

Conclusion: Given CBRs' ability to both predict outcomes and identify patients with a proinflammatory phenotype, the findings of this study provide a framework for future investigations aimed at identifying and treating high-risk patients with immune-modulating therapies. Continued work to validate these findings by applying TVs to interventional clinical trials is needed before wide clinical adoption.

Introduction: Adequate pain control and early mobilization are critical in the postoperative period after periacetabular osteotomy (PAO). Regional anesthesia can reduce postoperative pain, but certain techniques can increase the risk of postoperative motor block and delayed functional recovery. Continuous lumbar epidurals can provide excellent analgesia but also create challenges with early ambulation. Recently, suprainguinal fascia iliaca (SIFI) single-shot blocks have been shown to provide effective analgesia in PAO patients. The goal of this study was to compare opioid use, time to achieve inpatient physical therapy (PT) goals, and length of stay (LOS) between a cohort of patients receiving SIFI blocks and a cohort of patients receiving epidural analgesia (EA).

Methods: This retrospective single-surgeon comparative cohort study included all patients who underwent a PAO between 2012 and 2022. Regional anesthetic technique (SIFI vs EA), length of hospital stay, intraoperative and postoperative opioid use, pain scores, and time to achievement of PT milestones before discharge were recorded. Patients were excluded if they had any preexisting neuromuscular syndrome or neurosensory deficit. All opioid use was converted to morphine-milligram equivalents using standard conversions.

Results: Two hundred four surgeries were done over the study period; 164 patients received EA, and 40 received a SIFI block. The average age of our cohort was 19.5 years (±6 yrs). The SIFI cohort had a significantly shorter mean LOS than the EA cohort (2.9 vs 4.1 days, P < 0.001). Patients in the SIFI cohort achieved all PT ambulation goals significantly sooner than the lumbar epidural group ( P < 0.001), with lower total opioid use on each postoperative day. No notable differences were observed in sex, race, BMI, or pain scores at inpatient PT visits before discharge.

Conclusion: After PAO surgery, the SIFI block is associated with shorter hospital LOS, reduced postoperative opioid use, and earlier mobilization when compared with those who were managed with an epidural.

Background: Revision total joint arthroplasty (rTJA) is a resource-intensive procedure addressing failed primary total joint hip (total hip arthroplasty [THA]) and knee arthroplasty (total knee arthroplasty [TKA]). Despite predictions of increased demand, reimbursement for rTJA has not kept pace with increasing costs and may be insufficient compared with primary procedures. The study aimed to highlight the diminishing surgeon reimbursement between primary and revision THA (rTHA) and TKA.

Methods: This study is a retrospective analysis of billing data for primary and rTHA and TKA procedures from a single institution between 2019 and 2022. Insurance claims and charges data were provided by a local affiliate of a major national carrier which includes Medicare Advantage (MA) and commercial patients. Using insurance data, the study evaluates the total surgery costs for primary and rTHA and TKA and the individual charges that make up the total surgery cost.

Results: Nine hundred five patients insured by the same carrier, who underwent a primary or rTJA, were identified. Irrespective of MA or commercial insurance, the average surgery cost for a primary THA was $26,043, compared with $53,456 for rTHA. Surgeon reimbursement for primary THA was 20% ($5,323) of the total surgery cost. Despite the doubled surgery cost for rTHA, surgeon reimbursement was 10% ($5,257) of the total surgery cost. Primary TKA surgery costs were $24,489, while revision costs were $43,074. Surgeon reimbursement for primary TKA was 20% ($4,918) of the total surgery cost, while reimbursement for revision TKA was 13% ($5,560). MA reimbursement was markedly lower than commercial reimbursement for primary and revision cases.

Conclusion: Despite the higher total costs for rTJA, surgeon reimbursement is disproportionately diminished. The findings highlight the lack of incentive for revision cases. Surgeon reimbursement from MA and commercially insured patients for rTJA remains inadequate. This may limit patient access-to-care, leading to suboptimal outcomes and increased healthcare utilization.