Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: The Centers for Medicare and Medicaid Services removed total hip arthroplasty (THA) from the inpatient-only list but continued to classify admissions as inpatient if they include two midnights, complicating care if an outpatient THA requires extended hospitalization. This study evaluates risk factors of patients undergoing outpatient-designated THA with a length of stay (LOS) ≥ 2 days.

Methods: A total of 17,063 THA procedures designated as outpatient in the National Surgical Quality Improvement Program database between 2015 and 2020 were stratified by LOS < 2 days (n = 2,294, 13.4%) and LOS ≥ 2 days (n = 14,765, 86.6%). Demographics, comorbidities, and outcomes were compared by univariate analysis. Multivariable regression analysis identified predictors of LOS ≥ 2 days.

Results: Outpatients with extended LOS were older (mean 65.3 vs. 63.5 years; P < 0.01); were more likely to have body mass index (BMI) > 35 (24.0 vs. 17.8%; P < 0.01); and had higher incidences of smoking (15.1% vs. 10.3%; P < 0.01), diabetes (15.4% vs. 9.9%; P < 0.01), chronic obstructive pulmonary disease (4.4% vs. 2.3%; P < 0.01), and hypertension (57.6% vs. 49.2%; P < 0.01). Patients with LOS ≥ 2 days had a higher incidence of surgical site infection ( P < 0.01), hospital readmission ( P < 0.01), and revision surgery ( P < 0.01) over 30 days. Multivariable analysis demonstrated advanced age, female sex, African American race, Hispanic ethnicity, diabetes, smoking, and hypertension were independent risk factors for LOS ≥ 2 days.

Conclusion: Despite removal from the inpatient-only list, a subset of outpatient THA remains at risk of an extended LOS. This study informs surgeons on the relevant risk factors of extended stay, enabling early inpatient preauthorization.

Proximal humerus fractures account for 2% of fractures in skeletally immature patients. Avulsion fractures of the lesser and greater tuberosity are a rare subset of these injuries. Lack of awareness of these fracture types and subtle radiographic findings can result in delayed diagnosis and treatment. Case reports provide most of the current literature, and thus common injury mechanisms, clinical presentation, and ideal treatment time frame and modality are still undetermined. There are limited data directly comparing outcomes with nonsurgical or surgical management leading to unclear treatment guidelines. Presently, techniques for management of these injuries continue to evolve. Although these injuries represent a subset of pediatric proximal humerus injuries, they must be considered when evaluating a child with atraumatic and traumatic shoulder pain.

For years, anterior cervical diskectomy and fusion has been considered the benchmark for patients with cervical radiculopathy/myelopathy. However, concerns regarding adjacent segment pathology have promoted the popularity of cervical disk arthroplasty (CDA) with its motion-preserving properties. To replicate the natural cervical disk's six degrees of freedom and compressibility in cervical spine implants, designers need to carefully consider the level of constraint for stability and material selection. Recent CDA designs have incorporated strategies to facilitate unrestricted or semirestricted motion, deploying various articulating components and materials with distinct wear and compressibility properties. To optimize outcomes, patient selection considering additional degeneration of the cervical spine is critical. Clinical long-term studies have been reported in industry-funded FDA investigational device exemption and nonindustry-funded data for one-level and two-level CDA. There are limited data available on three-level and four-level CDA. Adverse events such as heterotopic ossification, osteolysis, migration, subsidence, and failure have been described, where analysis from explanted devices yields insight into in vivo wear and impingement performance. CDA has shown short-term cost advantages, such as decreased procedural expenses. Nonetheless, long-term analysis is necessary to assess possible economic tradeoffs. Advancements in designs may lead to improved implant longevity while evidence-based decision making will guide and responsibly manage the rapid advancement in CDA technology.

Introduction: There remains a lack of consensus on the optimal treatment of isolated distal radius fractures in young adults. The primary aim of this study was to identify differences in treatment of isolated distal radius fractures in patients aged 17 to 21 years treated by adult versus pediatric orthopaedic surgeons. The secondary aim was to identify whether there is a variation in utilization of open reduction and internal fixation (ORIF) versus closed reduction and percutaneous pinning when treated surgically by adult versus pediatric orthopaedic surgeons.

Methods: Patients aged 17 to 21 years with isolated distal radius fractures who were treated by adult or pediatric orthopaedic surgeons at 1 of 3 hospitals were identified through retrospective chart review. 72 patients in the pediatric surgeon cohort and 64 patients in the adult surgeon cohort were included. Demographic details were recorded, and radiographs from the initial clinic visit and final follow-up were obtained. Bivariate analysis was used to evaluate for primary and secondary aims.

Results: 40 of 136 patients were treated surgically. Bivariate analysis showed that factors associated with surgical treatment were treatment by an adult orthopaedic surgeon, higher body mass index, radiographic severity, AO classification, intraarticular involvement, distal radial-ulnar joint involvement, and meeting AAOS clinical practice guideline surgical criteria. Factors associated with ORIF compared with closed reduction and percutaneous pinning included treatment by an adult orthopaedic surgeon, older age, higher body mass index, and greater articular step-off.

Discussion: In comparable cohorts of young adult patients with distal radius fractures with similar fracture characteristics, there was notable variation in treatment between adult and pediatric orthopaedic surgeons. Surgical treatment was used more by adult surgeons, and when treated surgically, ORIF was used more by adult surgeons. Variation among surgeons illustrates the persistent lack of consensus on the optimal treatment in this population and highlights the need for additional research on this topic to guide management.

Level of evidence: Level IV.

Introduction: Orthopaedic surgery has been recognized as one of the least diverse surgical specialties. Previous studies have demonstrated that women are heavily underrepresented within orthopaedic surgery. The purpose of this study was to determine whether orthopaedic surgery residency programs with a higher presence of women faculty had a higher proportion of women residents.

Methods: The Fellowship and Residency Electronic Interactive Database was used to identify all orthopaedic surgery residency programs in the United States. Resident and faculty's sex and degree were recorded in addition to faculty administrative title (eg, program director, chair) and academic rank (clinician, professor, etc). Pearson correlation coefficients were used to compare the number of women residents with the number of women faculty.

Results: A total of 192 orthopaedic surgery programs were analyzed. Of the 5,747 faculty members and 4,268 residents identified, 13.1% (n = 752) and 22.6% (n = 963) were women, respectively. The number of women residents markedly correlated with the number of women faculty in leadership positions (r = 0.516, P < 0.001), such as chief or chair. The most significant correlations were among women with the academic role of "professor" (r = 0.575, P < 0.001), "assistant professor" (r = 0.555, P < 0.001), and women who held faculty positions but held no higher academic appointment (r = 0.509, P < 0.001). Program directors and assistant program directors were not found to have significant correlations with the number of women residents.

Conclusion: This study demonstrates a positive correlation between women faculty and residents at orthopaedic surgery residencies. Some academic positions, such as division chief, held more significant associations, whereas other positions, such as professor emeritus, were not held by any women, thereby limiting statistical analysis. Further investigation into minority representation in orthopaedic surgery and initiatives to address the observed disparities is paramount.

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.

Fingertip injuries are among the most common injuries seen in the emergency department. Specific considerations in management include ensuring robust soft-tissue coverage over exposed bone or tendon, maximizing functional length, preserving nail function and appearance, and minimizing chronic pain. Bony injuries are generally managed non-operatively, although select operative indications exist-particularly for jersey finger injuries, unstable fractures, or those with significant translation. Nail bed injuries can be managed with trephination for subungual hematomas or formal nail plate removal with nail bed repair depending on the degree of nail plate or soft-tissue injury. Soft-tissue coverage can be approached in a stepwise manner with secondary intention, grafts, or flaps from the affected digit, adjacent digits, or hand all playing a role. With proper management, most patients can achieve good outcomes.

Foot and ankle arthrodesis surgery is often associated with high rates of nonunion ranging from 8% to 40%. This complication can result in individual patient burden and system burden in the management of these complex patients. Biologic factors contribute greatly to the development of a nonunion, including patient-related modifiable risk factors, metabolic and endocrine factors, systemic disease, previous surgeries, medications, weight loss treatments, and posttraumatic and postsurgical factors. Despite the high nonunion rate, there is a lack of high-level evidence in the identification of high-risk patients, strategies to minimize nonunion, and the management of patients with nonunion. An accepted standard of practice has not been established. This review aims to provide foot and ankle surgeons with (1) a comprehensive review of risk factors for nonunion, (2) a tool to identify high-risk patients using a preoperative patient questionnaire, (3) a clinical practice guide to preoperative and intraoperative testing that aims to improve preoperative counselling and patient optimization, and (4) perioperative strategies to minimize nonunion risk. With the above framework, our goal is to minimize nonunion risk in patients undergoing foot and ankle arthrodesis surgery to improve patient care and outcomes.

Introduction: Symptomatic interlocking screws are common after intramedullary nail fixation of tibia fractures. Low-profile headless interlocking screws recently became available and could potentially reduce the rate of symptomatic screws. The purpose of this study was to compare the rate of symptomatic screws and screw removals between these screw types.

Methods: A retrospective review identified patients with tibia shaft fractures treated with tibia intramedullary nails between August 1, 2018 to September 1, 2023 by 11 surgeons. Low-profile headless interlocking screws became available on June 28, 2021 and were routinely used thereafter. Patients treated with low-profile headless versus standard headed interlocking screws were compared in terms of symptomatic screws, defined as a patient reporting pain or discomfort at the site of a screw head in clinical documentation, symptomatic screw removals, screw failure (breakage or backout), and procedures to promote bone union.

Results: Overall, 79 patients were included in the analysis: 33 patients treated with 144 headless screws and 46 patients treated with 187 standard screws. The median patient age was 35 years, and a majority were male (68.4%, n = 54). The median follow-up length was 8.5 months (interquartile range 5.5 to 8.8 months). The headless screw group, compared with standard screw group, did not differ in age, injury mechanism severity, open fracture classification, tobacco use, American Society of Anesthesiologists classification >2, number of interlocking screws used, or follow-up time (P > 0.05). The headless screw group was less likely to have symptomatic screws (0.0% vs. 23.9%; P = 0.002), less likely to have symptomatic screw removal (0.0% vs. 13.0%; P = 0.03), and had no difference in procedures to promote bone union (10.0% vs. 6.8%; P = 0.68) or screw backout (0.0% vs. 4.4%; P = 0.50).

Discussion: Standard headed interlocking screws were symptomatic in 23.9% of patients and 13.0% underwent symptomatic screw removal. In comparison, no patients treated with low-profile headless interlocking screws had symptomatic screws.

Level of evidence: Level 3, diagnostic.

Background: Hip fractures are among the most morbid acute orthopaedic injuries often due to accompanying patient frailty. The purpose of this study was to determine the reliability of assessing surgical risk after hip fracture through machine learning (ML) algorithms.

Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2011 to 2018 and the American College of Surgeons National Surgical Quality Improvement Program hip fracture-targeted data set was queried from 2016 to 2018 for all patients undergoing surgical fixation for a diagnosis of an acute primary hip fracture. The data set was randomly split into training (80%) and testing (20%) sets. 3 ML algorithms were used to train models in the prediction of extended hospital length of stay (LOS) >13 days, death, readmissions, home discharge, transfusion, and any medical complication. Testing sets were assessed by receiver operating characteristic, positive predictive value (PPV), and negative predictive value (NPV) and were compared with models constructed from legacy comorbidity indices such as American Society of Anesthesiologists (ASA) score, modified Charlson Comorbidity Index, frailty index, and Nottingham Hip Fracture Score.

Results: Following inclusion/exclusion criteria, 95,745 cases were available in the overall data set and 22,344 in the targeted data set. ML models outperformed comorbidity indices for each complication by area under the curve (AUC) analysis (P < 0.01 for each): medical complications (AUC = 0.65, PPV = 67.5, NPV = 71.7), death (AUC = 0.80, PPV = 46.7, NPV = 94.9), extended LOS (AUC = 0.69, PPV = 71.4, NPV = 94.1), transfusion (AUC = 0.79, PPV = 64.2, NPV = 77.4), readmissions (AUC = 0.63, PPV = 0, NPV = 96.8), and home discharge (AUC = 0.74, PPV = 65.9, NPV = 76.7). In comparison, the best performing legacy index for each complication was medical complication (ASA: AUC = 0.60), death (NHFS: AUC = 0.70), extended LOS (ASA: AUC = 0.62), transfusion (ASA: AUC = 0.57), readmissions (CCI: AUC = 0.58), and home discharge (ASA: AUC = 0.61).

Conclusions: ML algorithms offer an improved method to holistically calculate preoperative risk of patient morbidity, mortality, and discharge destination. Through continued validation, risk calculators using these algorithms may inform medical decision making to providers and payers.