Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Healthcare access varies dramatically across the United States, with rural and underserved populations facing notable barriers to timely, specialized care. The proximity of physician training affects the overall workforce distribution; however, this trend has not been assessed within orthopaedic surgery. This study investigates the impact birthplace and training location have on future practice location among US orthopaedic surgeons and characterizes the per-capita workforce distribution.

Methods: Eight thousand, six hundred seventy-six orthopaedic surgeons who completed residency training between 2004 and 2017 were identified from the American Medical Association Physician Masterfile. Demographic and practice data were extracted, including birthplace, medical school, residency and attending practice as of January 1, 2023. Locations were stratified by state and census division.

Results: The cohort represented 94.84% of orthopaedic surgeons trained nationally during the study period. Attendings returning to their state of birth, medical school, or residency to practice were 21.7%, 31.8%, and 33.9%, respectively, with pronounced state-level variability (birthplace: 2.50% to 47.95%; medical school: 3.94% to 61.8%; residency: 11.71% to 63.95%). Indiana (pop:6,880,131) trained the fewest residents per capita (1:1.15 million), whereas neighboring Ohio (pop:11,824,034) ranked fifth nationally (1:191,000). Univariate logistic regression revealed notable associations (P < 0.01) between practice location by census division at all career stages. Attending distribution per capita showed strong correlations by state (R2 = 0.98) and census division (R2 = 0.99), whereas birthplace (R2 = 0.71), medical school (R2 = 0.53), and residency (R2 = 0.63) showed moderate association.

Discussion: This study demonstrates that birthplace and training location are strongly associated with practice location for US orthopaedic surgeons. Despite variation in trainee numbers by state, the distribution of practicing surgeons normalizes relative to state population, likely driven by economic incentives, local workforce demands, and market conditions. Given the strong statistical association for surgeons to practice near their training location, aligning local programs with underserved or high-need areas may offer a potential solution to reduce regional disparities and improve access to orthopaedic care.

Introduction: Gender disparities persist across surgical specialties including orthopaedic surgery and neurosurgery, which may limit workforce diversity and potentially influence care delivery. Understanding representation among spine surgeons performing common procedures such as anterior cervical diskectomy and fusion (ACDF) may identify opportunities to enhance equity.

Methods: This was a retrospective cross-sectional study of spine surgeons performing ACDF using Medicare Provider Utilization and Payment Data from 2013 to 2021. The total representation of female spine surgeons performing ACDF, including their case volumes, practice characteristics, and payments, was compared with that of male spine surgeons.

Results: A total of 2,492 spine surgeons who performed 139,456 ACDF cases were included in the sample. Of these, 58 female spine surgeons (2.3%) performed 2,733 cases (2.0%). The percentage of female surgeons increased from 0% (0/1,124) in 2013 to 1.8% (12/651) in 2021 (β = 0.163, R2 = 0.263, P < 0.001). The average annual volume of ACDF procedures was similar between female and male surgeons (16.8 ± 3.6 vs. 17.2 ± 7.6, P = 0.712). No difference was observed in academic teaching hospital affiliation between female and male surgeons (13.9% vs. 11.8%, P = 0.697). No difference was found in mean standardized Medicare reimbursement for ACDF procedures over the study period (P = 0.145). In 2021, female surgeons treated a higher proportion of female patients (56.8% vs 55.0%, P = 0.043).

Conclusions: Although representation of female spine surgeons increased modestly, gender disparities remain pronounced within the Medicare workforce. Strategies are needed to increase the number of female trainees interested in a career in spine surgery.

Introduction: Implant-implant impingement in total hip arthroplasty remains a primarily clinical diagnosis, with little technology available to demonstrate impingement radiographically. The purpose of this study was to determine the effectiveness of external rotation stress CT scans in evaluating for posterior impingement in patients with painful total hip prostheses.

Methods: Sixty-seven patients presenting with CT IMA (implant movement analysis) scans previously used for evaluation of potential aseptic loosening were identified between May 2021 and May 2024. Plain radiographs were evaluated to assess for acetabular cup abduction. CT IMA scans in external rotation IMA protocol position were evaluated to measure acetabular implant version and the distance between the femoral and acetabular components. Patients were separated into impingement and nonimpingement groups based on whether a clinical or intraoperative diagnosis of impingement had been made. Cup version, abduction, and implant-implant distances on the external rotation CT were compared between the groups. A receiver operating characteristic curve was created, and the area under the curve was calculated to determine an optimal implant-implant distance for diagnosing impingement.

Results: Overall, 29 patients were diagnosed with impingement and 38 patients were diagnosed with other sources of hip pain. Linear regression showed a notable negative correlation (P = 0.004) of measured cup version versus implant-implant distance. Implant-implant distance was markedly smaller in the impingement group versus the non-impingement group (P < 0.0001). The receiver operating characteristic curve demonstrated 100% sensitivity and 89% specificity impingement when the implant-implant distance was <5 mm, with an area under the curve of 0.98 ± 0.02.

Conclusion: External rotation stress CT scans used by the IMA protocol were 100% sensitive and 89% specific in identifying patients with posterior impingement when an implant-implant distance of <5 mm was considered. This technology may help clinicians objectively define a diagnosis of impingement in total hip prostheses in the absence of other clinically identifiable sources of pain.

Objective: The aim of this study was to investigate the effect of high "depressive burden" on patient-reported outcome measures (PROMs) after lumbar fusion surgery.

Methods: Adult patients who underwent elective 1-3 level lumbar fusion at a single institution (2017 to 2023) were identified. PROMs included Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) Back and Leg, Mental Component Summary (MCS), and Physical Component Summary (PCS). High depressive burden was defined as an average preoperative and 3-month postoperative MCS score below 45, a threshold used in the psychiatry literature to indicate depression requiring intervention. PROMs and minimal clinically important difference (MCID) were compared between patients with and without high depressive burden.

Results: A total of 418 patients were included (127 [30.4%] had high depressive burden). Patients with high depressive burden were younger (60.6 vs. 63.9 years; P = 0.004) and more commonly Black (13.7% vs. 5.94%; P = 0.031) compared with patients without high depressive burden-otherwise, the two groups were demographically similar. Patients with high depressive burden had longer cut-to-close times (240 vs. 215 minutes; P = 0.031) but otherwise were surgically similar. High depressive burden was associated with a higher 2-year revision surgery rate (13.4% vs. 5.15%; P = 0.007). High depressive burden was associated with worse scores for all PROMs at 6 months and 1 year postoperatively. Multivariable regression identified depressive burden as independently predictive of a decreased likelihood of achieving MCID for 1-year ODI (odds ratio [OR]: 0.19; P < 0.001) and PCS (OR: 0.35; P = 0.002) and of requiring revision surgery within 2 years (OR: 2.98; P = 0.006).

Conclusions: High depressive burden provides a more robust measurement of mental health in the preoperative and early postoperative period. High depressive burden was associated with a higher 2-year revision surgery rate and worse performance on all PROMs at 6 months and 1 year. High depressive burden was also independently predictive of decreased likelihood of achieving MCID for ODI and PCS at 1 year and of requiring revision surgery within 2 years.

Introduction: Outcomes research for spinal surgery has typically focused on patient, diagnosis, or procedure as a predictor of surgical results; the impact of surgeon experience remains uncertain. Although experience improves scoliosis correction and total disk arthroplasty outcomes, its effects on common procedures, including lumbar fusions, anterior cervical diskectomy and fusion (ACDF), and posterior cervical decompression and fusion (PCDF), remain understudied. This study evaluates the impact of surgeon experience on outcomes in a large, multisurgeon, multisite academic center, examining prospectively collected data.

Methods: We analyzed 1,567 ACDF, 248 PCDF, and 1,834 lumbar fusion cases (2003 to 2023) from a multisite academic center. Data were captured prospectively but reviewed retrospectively. Cohorts were stratified by levels of fusion and procedure type. Outcomes assessed included readmissions, sepsis, surgical site infection (SSI), wound dehiscence, and long-term complications. Multivariate logistic regression was done, adjusting for age, body-mass index, sex, race, diagnoses, primary surgeon, and Elixhauser comorbidities.

Results: Increased surgeon experience markedly reduces long-term complications in lumbar fusion (odds ratio [OR]: 0.83, confidence interval [CI], 0.79 to 0.88, P < 0.001) and PCDF (OR: 0.71, CI, 0.60 to 0.85, P < 0.001), along with decreasing SSI rates in lumbar fusion (OR: 0.84, CI, 0.75 to 0.94, P = 0.002). Similar effects were observed in lumbar fusion subgroups, stratified by level (single- or multilevel) and procedure (anterior lumbar interbody fusion or posterior lumbar fusion/transforaminal lumbar interbody fusion). No notable associations with experience were observed for ACDF, including long-term complications (OR: 0.93, CI, 0.76 to 1.13, P = 0.440). Notably, a notable increase in sepsis risk correlated with increased experience in lumbar fusion (OR: 1.32, CI, 1.04 to 1.68, P = 0.024).

Level of evidence: Level III.

Conclusion: Surgeon experience markedly reduces complications and improves lumbar fusion and PCDF outcomes, emphasizing its value in optimizing care while challenging the notion that surgeons are interchangeable.

Background: Ultrasonic scalpels (USs) have been widely used in various cancer surgeries due to their advantages of minimal thermal damage, effective vascular/lymphatic sealing, and reduced complications. However, robust evidence supporting their efficacy in soft-tissue sarcoma (STS) surgery remains limited, especially for large-size thigh STS (≥8 cm)-a subgroup characterized by high intraoperative bleeding risk and frequent wound healing issues. This study aimed to comprehensively evaluate the efficacy of USs in the surgical management of large thigh STS (≥8 cm).

Patients and methods: We conducted a retrospective study of patients who underwent surgical resection of large thigh STS (≥8 cm) between January 2019 and December 2024. Patients' clinical characteristics and treatment details were meticulously collected, and key metrics analyzed included intraoperative blood loss, hospital stays, and wound complications. To reduce selection biases, propensity score matching was applied. We defined the matched cases wherein US was used as the "using group" and the other matched cases as the "non-using group." Outcomes were compared between the groups.

Results: After propensity score matching, 36 patients were included in each group. The ultrasonic using group showed markedly reduced estimated intraoperative blood loss (204.2 vs. 505.6 mL; P = 0.041) and shorter hospital stay (6.9 vs. 11.4 days; P = 0.002). In addition, the incidence of major wound complications (Clavien-Dindo grade III or higher) was markedly lower (13.9% vs. 38.9%; P = 0.031). Multivariate logistic regression analysis confirmed that US use was independently associated with fewer major wound complications (odds ratio, 0.118; 95% confidence interval, 0.026 to 0.531; P = 0.005).

Conclusions: The application of USs in the surgical resection of large thigh STS (≥8 cm) is associated with reduced intraoperative blood loss, shorter hospital stay, and lower rates of major postoperative wound complications. These findings support the potential value of US as a technical adjunct in complex STS surgery and warrant further validation in prospective randomized controlled trials.

Introduction: The purpose of this study was to determine the rate of conversion to total elbow arthroplasty (TEA) following open reduction and internal fixation (ORIF) with olecranon osteotomy for intraarticular distal humerus fractures.

Methods: This retrospective case series included adult patients who underwent ORIF with olecranon osteotomy for AO/OTA 13C distal humerus fractures between January 2010 and April 2024 at two academic level 1 trauma centers. The primary outcome was the rate of conversion to TEA. Secondary outcomes included indications for conversion, TEA complications associated with the osteotomy, osteotomy revision surgery rates (for nonunion, fixation failure, symptomatic implant, and infection), and the rate of osteotomy union.

Results: A total of 148 patients were included, with a median age of 58 years (interquartile ranges: 42 to 69) and 78 (53%) were female. Three patients (2.0%) required conversion to TEA at 2, 4, and 21 months post-ORIF because of fixation failure, distal humerus nonunion, and posttraumatic osteoarthritis, respectively. Among geriatric patients, two of 51 (3.9%) required conversion to TEA. One conversion involved complications with ulnar component insertion because of the osteotomy. Regarding osteotomy revision surgeries, four patients (2.7%) underwent revision surgery for nonunion, three (2.0%) for fixation failure, 14 (9.5%) for symptomatic implant, and eight (5.4%) for infection. Osteotomy union was achieved in 145 patients (98%).

Conclusions: Approximately one in 50 patients required conversion to TEA, with only one case involving a TEA complication associated with the prior olecranon osteotomy. When stratified by age, approximately one in 100 patients younger than 65 years and one in 25 geriatric patients required conversion. Revision surgery rates for osteotomy nonunion and fixation failure were similarly low, with 98% of osteotomies achieving union. These findings suggest that ORIF with olecranon osteotomy can be performed for 13C distal humerus fractures with minimal concern for subsequent TEA, osteotomy revision surgery, or nonunion.

Level of evidence: Therapeutic level IV.

Background: Patients with relapsed or refractory multiple myeloma (MM) often have a high burden of skeletal disease and may be at risk for pathologic fracture. These patients may be eligible for chimeric antigen receptor T-cell (CAR-T) therapy. However, little is known about the effect of CAR-T therapy on a patient's fracture risk. The purpose of this study is to evaluate this effect.

Methods: A consecutive cohort of MM patients undergoing treatment with CAR-T therapy were reviewed retrospectively. Patients were required to have a PET-CT before CAR-T infusion and at least one PET-CT surveillance imaging 90 days following treatment. The minimum follow-up for surviving patients was set at 3 months. The primary outcome measure was fracture risk as characterized by a modified Mirels criteria. The secondary outcome measure was change in lesion avidity, measured as standardized uptake value units, on PET-CT. Survival was investigated by Kaplan-Meier method.

Results: We identified 139 patients who underwent CAR-T for MM. Overall, 71 patients (51.4%) had a discrete long bone lesion, and 37 patients (27.8%) were characterized as being "at risk" for fracture before infusion. After CAR-T, three patients (2.5%) were identified as being at risk ( P = 0.004). The mean PET-CT standardized uptake value between at risk patients and those at low risk was markedly different before infusion (9.18 vs. 6.75, P = 0.03). For these same patients, no difference was identified after CAR-T therapy (5.75 vs. 4.67, P = 0.26). Three fractures occurred in the posttransfusion period; 33 patients (23.7%) died of disease after CAR-T therapy at a mean of 6.6 months.

Conclusion: Following CAR-T infusion, a notable reduction was observed in fracture risk, suggesting that CAR-T could be valuable not only in managing MM but also in managing the risk of pathologic fracture that comes with this malignancy.

Calcaneus fractures remain challenging fractures that are prone to complications. Surgery was previously restricted only to those with soft-tissue envelopes amenable to the extensile lateral approach. However, with the development of the sinus tarsi approach and other percutaneous techniques, more prompt surgical interventions with lower complication rates have become possible. Restoration of hindfoot morphology and facet congruity are the primary goals of surgery. Complications including posttraumatic subtalar arthritis, infection, wound dehiscence, and malunion can be minimized with deliberate treatment decisions.

Congenital scoliosis encompasses a highly variable, heterogenous group of vertebral anomalies, the mere presence of which is not an indication for intervention; documentation of curve progression is a prerequisite for treatment. Initial evaluation should include investigations to diagnose concomitant genitourinary and cardiac anomalies primarily, and the morphology of the vertebral anomaly should be classified for prognostic purposes. Although sometimes considered only a delaying tactic, bracing treatment and casting can have definite value in controlling flexible congenital curves. Surgical options include prophylactic in situ fusion for the child with mixed vertebral anomalies involving ≤5 segments and a small curve. For young patients without coronal imbalance and ≤5 anomalous segments, a convex growth arrest/hemiepiphysiodesis can be effective for growth modulation, and it can be augmented with a concave growing rod, either traditional or magnetically controlled to improve balance and correction. Although traditional growing rod methods have been used for congenital scoliosis, crankshafting and adding-on may occur due to lack of apical fixation. Thus, apical control techniques have been recently added to traditional growing rod to minimize this cause of curve progression. Finally, an isolated hemivertebra excision with short segment fusion is a mainstay of treatment for progressive curves <50° in young children. In the more mature patient, generally at least 8 to 10 years old, a single definitive correction and fusion gives the most reliable outcomes.