Journal of the American Academy of Orthopaedic Surgeons最新文献

Orthopaedic surgery is widely perceived as one of the most demanding medical specialties, with long work hours, heavy surgical volumes, and extensive administrative responsibilities often leaving little room for personal needs. This environment has perpetuated a myth that work-life balance is incompatible with professional excellence. Consequently, burnout, manifested by emotional exhaustion, depersonalization, and a diminished sense of accomplishment, has become pervasive among both residents and attending surgeons. Despite a growing awareness of burnout's effect, many existing interventions fall short because they focus on surface-level solutions, such as mandatory wellness seminars, rather than addressing the systemic and cultural elements that sustain chronic stress. This narrative review critically examines the misconceptions that deter surgeons from pursuing healthier work-life integration. It also illustrates how deeply ingrained beliefs, such as equating balance with reduced commitment, hinder meaningful progress. Drawing on experiences from diverse orthopaedic models, the review highlights successful strategies that include redesigning clinical workflows to reduce after-hour documentation, fostering mentorship networks that address trainees' individual needs, and implementing flexible scheduling policies to ensure adequate rest and recovery. These strategies move beyond quick fixes to target the root causes of burnout, offering a blueprint for cultivating a sustainable culture of well-being within orthopaedics.

Background: There are more than 100 million obese American individuals, with number expected to rise. Lumbar stenosis is a neurodegenerative disease causing narrowing of the spinal canal. Little is known about the role of obesity in the pathophysiology of spinal stenosis. Therefore, the purpose of this study was to analyze patient body mass index (BMI) and radiologic measurements of (1) spinal canal width; (2) thickness of ligamentum flavum and (3) spinal canal cross-sectional area at spinal levels of L2-3, L3-4, and L4-5, respectively, to determine whether there exists a correlation between obesity and the development of lumbar spinal stenosis.

Methods: Hospital data from January 1, 2016, to December 31, 2021, were used to identify patients who underwent a lumbar MRI to determine the development of radiological lumbar spinal stenosis. Patients older than 17 years and whose BMI's ranged from <20 to >40, who had complete lumbar MRIs, with no preexisting bony pathology, neoplasm, or previous lumbar surgery were included in this study. We assessed the thickness of the ligamentum flavum, width of the spinal canal, and the cross-sectional area of spinal canal at the level of the facet joint. Linear regression models were performed on each assessed variable at each spinal level measured.

Results: A significant negative association was found between BMI and spinal canal width at all levels measured (L2-3: B = -0.31, P < 0.001; L3-4: B = -0.29, P < 0.001; L4-5: B = -0.27, P < 0.001). No significant association was found between BMI and thickness of the ligamentum flavum ( P = 0.94 at L2-3; P = 0.70 at L3-4; P = 0.62 at L4-5). Furthermore, no significant association was found between BMI and cross-sectional area of the spinal canal ( P = 0.43 at L2-3; P = 0.55 at L3-4; P = 0.22 at L4-5).

Conclusion: This study found that patients with elevated BMI have decreased lumbar spinal canal width and provides new insight into the role of obesity in neurodegenerative diseases.

Levels of evidence: III.

The posterior cruciate ligament (PCL) is crucial for normal knee kinematics and stability. An improved understanding of the long-term consequences of PCL injuries has led to greater focus on accurate injury diagnosis and improvements in surgical instrumentation and techniques. However, controversy remains regarding indications for surgical versus nonsurgical management, as well as optimal surgical techniques such as PCL repair versus reconstruction, single-bundle versus double-bundle reconstruction, transtibial versus tibial inlay fixation, and graft choice. Recognition of concomitant injuries and posterior tibial slope, as well as considerations in pediatric patients, warrants additional attention to ensure satisfactory outcomes. The purpose of this review was to evaluate the current state of the literature on PCL injuries and variables associated with injury decision making based on reported outcomes.

Introduction: Clinical guidelines rely heavily on expert opinions and institution protocols to provide recommendations for administration of systemic antibiotic prophylaxis for open extremity fractures to prevent fracture-related infections. The purpose of this study was to determine evidence-based (1) durations; (2) types; (3) dosing regimens of systemic perioperative antibiotic prophylaxis following Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity open fractures, and isolated lower extremity open fractures to prevent fracture-related infections.

Methods: Guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and the GRADE approach were implemented to structure and synthesize this study. Five databases (PubMed, Cochrane Library, Web of Science, Scopus, CINAHL) were systematically and independently searched for randomized controlled trials (RCTs) meeting eligibility criteria. Included patients had open extremity fractures and were treated with prophylactic systemic antibiotics administered perioperatively (preoperative, intraoperative, postoperative). Meta-analyses were done of the data.

Results: Twenty-one (n = 21) RCTs met eligibility criteria (Gustilo-Anderson type I = 6, Gustilo-Anderson type II = 4, Gustilo-Anderson type I/II = 12, Gustilo-Anderson type III = 4, Gustilo-Anderson type I/II/III = 21). Summary tables were generated to provide evidence-based durations and types of systemic antibiotic prophylaxis after Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity (hand) open fractures, and isolated lower extremity open fractures.

Discussion: Although data were derived primarily from older studies, we summarized the strongest available evidence from RCTs for antibiotic prophylaxis following Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity open fractures, and isolated lower extremity open fractures.

Introduction: Cervical disk arthroplasty (CDA) has emerged as a motion-preserving alternative to anterior cervical diskectomy and fusion, offering the potential to reduce adjacent segment degeneration while maintaining cervical spine mobility. Although previous studies have highlighted the increasing adoption of CDA, trends within the broader Medicare population, including those enrolled in Medicare Advantage (MA), remain less defined. This study retrospectively analyzed Medicare Part B National Summary data from 2009 to 2022 to assess historical utilization patterns of single-level and multilevel CDA and applied statistical modeling to project future procedure volumes through 2040.

Methods: Medicare Part B National Summary data from 2009 to 2022 were analyzed to quantify single-level and multilevel CDA procedure volumes. Data adjustments accounted for MA enrollment using established correction factors. Forecasting models-including log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average-were applied to project utilization trends. Model performance was assessed using mean absolute error and root mean square error. The Poisson regression model was selected for final projections due to its optimal balance of predictive accuracy and stability.

Results: From 2009 to 2022, single-level CDA volume increased by 1,454% (108 to 1,679 cases), while multilevel CDA volume grew by 609.5% from 2015 to 2022 (147 to 1,042 cases). Forecasting projected a 23.5% annual growth rate for single-level CDA and 24.4% for multilevel CDA through 2040. By 2040, single-level CDA is expected to reach 96,430 procedures annually (95% confidence interval, 95,822 to 97,039), while multilevel CDA will reach 63,362 procedures (95% confidence interval, 62,869 to 63,856).

Conclusion: CDA utilization among all Medicare beneficiaries, including those enrolled in MA, has grown substantially and is projected to continue increasing through 2040. These trends reflect rising demand for motion-preserving cervical spine procedures and highlight the importance of healthcare planning, surgeon training, and equitable reimbursement policies to accommodate future growth.

Introduction: Nonsurgical management is the standard of care for most distal radius fractures involving the epiphyseal plate. However, because of the lack of remodeling potential in adolescents, nonanatomic reduction can result in a symptomatic malunion necessitating late complex surgical correction. Guidelines outlining optimal management strategies for SH2 distal radius fractures in the adolescent population are needed.

Methods: This study is a retrospective review of isolated SH2 distal radius fractures from two, large, regional, referral pediatric ACS trauma level 1 hospitals between 2017 and 2020 in patients aged 9 to 18 years. Patients were identified by Current Procedural Terminology coding associated with their fracture management. Demographics, timing and type of treatment, and fracture displacement at relevant time points were recorded. Bivariate analysis was used to identify predictors of decision for acute surgery and/or correlates with the need for malunion correction. A Classification and Regression Tree model was fit to identify predictors of surgeon decision making for acute surgical intervention.

Results: Sixty (11%) of 556 patients underwent acute surgical intervention following closed reduction. Seventeen cases (3%) were done to correct late malunion. A Classification and Regression Tree model correctly classified the decision for acute surgery in 77% of patients using sagittal translation post reduction of ≥35% followed by age at injury of ≥12 years. The decision for acute surgery included older patients (median age 13.8 vs. 12.6 years, P < 0.001), with greater coronal (11.6% vs. 0%, P < 0.001) translation, sagittal (30% vs. 0%, P < 0.001) translation and increased dorsal tilt (5.2° vs. 0°, P < 0.001).

Conclusion: Decision for acute surgical intervention of SH2 distal radius fractures is done most often with persistent deformity of sagittal translation ≥35% in patients ≥12 years following closed reduction at the time of injury. Additional parameters are identified as associated with the decision for acute surgery and progression to symptomatic malunion.

The use of total elbow arthroplasty (TEA) is projected to increase by more than 50% between 2020 and 2045. An aging population, contemporary prosthetic designs, and broadened indications are factors associated with this predicted increase. Although TEA can reliably improve pain and function, overall complication rates remain relatively high compared with other arthroplasties, making technical competence of utmost importance. Careful patient selection, preoperative optimization, and thorough counselling on the complication profile and the potential for mechanical failure following TEA are essential. Although debated, surgical exposure to perform TEA should be tailored to the underlying diagnosis and elbow features. Contemporary exposures, including the paraolecranon and the "diamond pop-up," have been popularized only recently. Understanding the nuances of adequate implant positioning, soft-tissue balancing, and good cementation technique can decrease implant interface stresses, impingement, and rotational instability, which have a direct effect on subsequent mechanical failure. The continued success of TEA will depend on advances in surgical planning and technique as well as implant design and materials to improve longevity and allow use with minimal restrictions.

The predictability of outcomes with reverse shoulder arthroplasty (RSA), compared with hemiarthroplasty or open reduction and internal fixation, has led to its increased use in treating displaced three- and four-part proximal humerus fractures (PHFs) in patients older than 65 years. Although RSA was initially designed to restore humeral elevation in the absence of a functional rotator cuff, studies have shown improved patient-reported outcomes and range of motion in patients who achieve tuberosity union following surgery. Despite numerous advancements in implant design over the past decade, optimal strategies to maximize outcomes in PHFs remain debated. This article reviews indications, intraoperative decision making, implant selection, and surgical techniques to optimize outcomes for patients undergoing RSA for PHFs.

There are numerous approaches to reconstruction of skeletal defects after surgical resection of benign and malignant tumors of bone. Limb-salvage surgery can be successfully performed in more than 90% of patients with aggressive bone neoplasms. Endoprosthetic arthroplasties, bulk allografts, and composite reconstructions successfully restore limb stability and demonstrate encouraging early functional outcomes but are limited in the long term by rates of failure that increase over time and increase the rate of secondary amputation. Biological reconstructions with viable bone autograft can provide more durable long-term reconstructions, as well as growing reconstructions in the pediatric population at the expense of high short-term complication rates and donor-site morbidity. Such reconstructions can take up to a year for successful and stable union. Nonvascularized autograft, pedicled bone transfer, and free vascularized bone transfer are available biologic options for addressing postresection bone defects. Ultimately, the manner of skeletal reconstruction depends on the location and size of the defect, the anticipated growth and functional needs of the patient, and the weighed risks of each procedure as tolerated by the patient.

Introduction: Multiple long bone lower extremity fractures repaired with intramedullary nail (IMN) fixation have been associated with notable cardiopulmonary burden and may result in mortality. These patients are at an increased risk for fat embolism syndrome, pulmonary embolism, acute respiratory distress syndrome (ARDS), and pneumonia. Minimal data exist regarding the risk of simultaneous versus staged fixation of multiple long bone fractures that include both tibial and femoral injuries. We aimed to compare the cardiopulmonary outcomes after simultaneous versus staged IMN fixation.

Methods: The American College of Surgeons' Trauma Quality Improvement Program database was queried to identify patients who sustained multiple long bone lower extremity fractures between January 2016 and December 2019. Patients were split into two cohorts: simultaneous fixation (fixation of all fractures in the same operation/calendar day) and staged fixation (two or more operations each >24 hours apart).

Results: In total, 202,777 records of patients with tibial and/or femoral fractures were identified in the Trauma Quality Improvement Program database; 3,202 patients met the inclusion criteria. In total, 75.9% underwent simultaneous IMN fixation of two or more long bones, and 24.1% received staged fixation. The groups were similar across multiple variables; however, the staged fixation group was older (42 vs. 37, P < 0.0001) and had a significantly higher rate of ventilator associated pneumonia, ARDS, and acute kidney injury. The staged group had a longer time to surgery (16 vs. 39.5 hours, P < 0.0001) and hospital length of stay (17 vs. 11 days, P < 0.0001).

Conclusion: After propensity score matching, simultaneous fixation of multiple long bone lower extremity fractures was not associated with increased cardiopulmonary events, including ARDS, ventilator associated pneumonia, and acute kidney injury. Given these findings, simultaneous IMN fixation should be considered because it was not associated with an increased risk of cardiopulmonary complications in the high-risk patient.