Journal of the American Academy of Orthopaedic Surgeons最新文献

Objective: To analyze the risk factors that affect the survival of patients undergoing vertebroplasty and construct a predictive nomogram.

Methods: Retrospective analysis of the survival status for patients age ≥50 years who underwent vertebroplasty in our hospital from January 2013 to August 2022. Demographic information, inpatient data, laboratory examination results, medication records, and other information were extracted from the clinical scientific research database of our hospital. Through proportional hazards assumption, univariate and subsequent multivariate COX regression, the independent risk factors that affect the survival prognosis of patients after vertebroplasty were summarized. A survival prediction nomogram based on these independent risk factors were constructed and validated.

Results: Three hundred fifty-nine patients were enrolled, 251 in the training set and 108 in the validation set. Multivariate COX regression showed that mean serum albumin (hazard ratio [HR] = 0.59565, 95% confidence interval [CI], 0.36160 to 0.9812), number of vertebroplasty (HR = 0.1978, 95% CI, 0.06529 to 0.2197), interval between the first two vertebroplasty procedures (HR = 0.05642, 95% CI, 0.02933 to 0.1085), and number of activating vitamin D prescriptions (HR = 0.34975, 95% CI, 0.19855 to 0.6161) were independent risk factors for the survival prognosis of patients after vertebroplasty. Based on these independent risk factors, a predictive nomogram was constructed. The area under the curve of the 5- and 8-year survival prediction models in the validation set was 0.889 and 0.760, respectively. The calibration curves of the nomogram in the training and validation sets were close to the ideal diagonal. The decision curve analysis showed that the predictive model exhibited good net benefit and predictive ability.

Conclusion: Mean serum albumin, number of vertebroplasty, interval between the first two vertebroplasty procedures, and number of activating vitamin D prescriptions were independent risk factors for the survival prognosis of patients after vertebroplasty. The predictive nomogram constructed based on these risk factors had a good predictive ability and certain potential for clinical decision making.

Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) are two novel microsurgical techniques that can improve prosthetic control and prevent and treat chronic limb pain following amputation. Both techniques use nerve transfer to reroute the neural input from a transected nerve to new muscle targets, thereby preventing neuroma formation and creating a new functional pathway between peripheral nerves and the brain. These techniques were originally developed to improve myoelectronic bioprosthetic control, but both TMR and RPNI have expanded in their indications to the prevention and treatment of symptomatic neuromas, thus improving quality of life and decreasing the narcotic burden in this vulnerable population. This review describes the principles of TMR and RPNI, their indications, the perioperative technique, and the postoperative management of patients undergoing these procedures.

Objectives: The optimal treatment of acetabulum fractures in elderly patients is unknown. The purpose of this study was to review outcomes of open reduction and internal fixation (ORIF) or acute total hip arthroplasty (aTHA) and to determine the age threshold based on treatment using a cost-effectiveness decision model.

Methods: The PubMed database was queried for clinical English language studies from 2002 to 2022 (N > 10), of acetabular fracture patients age >50 years treated with either ORIF or aTHA. Revision surgery and mortality rates were collected. Costs were obtained from the National Inpatient Sample database. Health state utilities were converted to quality-adjusted life years, and a Markov decision analysis model was constructed. Sensitivity analyses were done with regard to the quality of life and cost variables.

Results: Thirty studies met inclusion criteria, including 16 ORIF studies (N = 909) and 18 aTHA studies (N = 403). The ORIF cohort had a mean age of 71 years, follow-up of 3.5 years, mortality rate of 11.7%, and a conversion arthroplasty rate of 19.6%. The aTHA cohort had a mean age of 73 years, follow-up of 3.2 years, mortality rate of 10.7%, and a revision rate of 4.5%. Our model demonstrated that ORIF was a more cost-effective treatment for patients aged 67 years or younger and that aTHA was more cost-effective for patients aged 68 years and older. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost of ORIF and aTHA but highly sensitive to functional outcome variables in the model.

Conclusion: A review of 30 studies demonstrated a conversion arthroplasty rate of 19.6% for patients older than 60 years compared with a revision rate of 4.5% for patients treated with aTHA. Without considering fracture pattern or patient factors, we found that aTHA is a more cost-effective treatment than ORIF for treatment of acetabulum fractures in patients aged 68 years and older.

Level of evidence: Economic Level III.

Background: The relationship between testosterone replacement therapy (TRT) and hip fractures remains underexplored. This study aims to investigate this relationship. We hypothesize that patients prescribed TRT experience a lower rate of hip fractures compared with a control group.

Methods: The PearlDiver Mariner165 data set was used to obtain two random cohorts of 500,000 patients. The experimental group received TRT for at least 3 months and the control group did not. We used one-to-one matching to evaluate the effects of TRT in 301,724 patients. The incidence of hip fractures was assessed over a 2-year follow-up using the International Classifications of Disease codes. Multivariable logistic regression identified the association between TRT and hip fractures. Statistical significance was set at P < 0.05.

Results: The patients in the TRT group were associated with a lower incidence of hip fractures compared with the control group (0.13% vs. 0.25%, P < 0.001). The multivariable analysis showed that TRT use was associated with a decreased incidence of hip fractures with an adjusted odds ratio (aOR) of 0.58 (95% confidence interval [CI], 0.51 to 0.66, P < 0.001). After stratifying by sex, the multivariable analysis showed that TRT use in male patients was associated with a decreased incidence of hip fractures with an aOR of 0.61 (95% CI, 0.53 to 0.72, P < 0.001); in female patients, it was associated with a decreased incidence of hip fractures with an aOR of 0.49 (95% CI, 0.38 to 0.63, P < 0.001).

Conclusion: Patients prescribed TRT had a 1.9 times lower likelihood of sustaining hip fractures. Further investigation into the association of TRT and fragility fractures garners continued interest. In addition, this can provide insight into the potential benefits of TRT use and maintaining bone health to improve bone mass and improve results of orthopaedic interventions.

Level of evidence: III.

Background: Understanding the role of risk-taking personality and tolerance for treatment-related complications in patients with spine pathology may help tailor surgical recommendations. The aim of this study was to develop a predictive model that integrates standard clinical metrics with psychosocial factors, specifically examining whether patients with higher risk-taking tendencies are more likely to choose high-risk, high-reward surgeries.

Methods: This cross-sectional observational study recruited 1,214 participants from the United States in January 2024 using an online crowdsourcing platform. Participants completed an 84-question survey covering demographics, disability levels, and risk-taking tendencies. They were presented with hypothetical spinal surgery scenarios featuring varying risks of complications (footdrop, paralysis, or death) and chances of improvement. Participants rated their likelihood of choosing surgery on a six-point Likert scale. Predictors included demographics, socioeconomic factors, risk-taking personality (measured by the Domain-Specific Risk-Taking survey), and baseline pain levels (measured by the Oswestry Disability Index). The XGBoost model was used for predictive analysis.

Results: The final sample included 797 (386 male, 411 female) participants. The predictive model achieved an R-squared of 0.75, root mean squared error of 0.81, and mean absolute error of 0.61. Key predictors of the likelihood to opt for surgery included lower complication risk and higher improvement probability, followed by younger age, higher body mass index, and lower scores in Domain-Specific Risk-Taking survey's financial and recreational domains.

Conclusion: Incorporating psychosocial dimensions into predictive models enhances the personalization of surgical risk discussions. This approach ensures that treatment recommendations align with patient values and risk perceptions, enabling more patient-centered care in spine surgery.

Level of evidence: Level 3 (cross-sectional study).

Introduction: Standard spine surgery machine learning (ML) models often rely on structured clinical data, overlooking nuanced free text, such as preoperative surgical notes. The aims of this work were to develop a multimodal ML model combining structured electronic health record (EHR) data with natural language-processed unstructured clinical narratives.

Methods: After testing against Convolutional Neural Network, Support Vector Machine, LightGBM, and Random Forest algorithms, the XGBoost algorithm was selected for model development. Three models were developed: (1) a structured EHR-based ML model; (2) an NLP-based model using preoperative notes; (3) a combined multimodal model. Perioperative outcomes included extended length of stay (≥8.0 days) and nonhome discharge. Preprocessing included tokenization, stemming, and bag-of-words vectorization. Hyperparameters were tuned through grid search and 10-fold cross-validation. Key performance metrics included area-under-the-receiver-operating characteristic curve, Brier score, calibration slope and intercept, precision, recall, and F1 score.

Results: A total of 486 patients (58.8% female, n = 281) were included, with a median age of 61.0 years (interquartile range: 52.0 to 68.0 years) and median body mass index of 29.4 kg/m 2 (interquartile range: 25.1 to 34.5 kg/m 2 ). For extended length of stay, the multimodal model excelled (ROC-AUC: 0.908, Brier: 0.114, F1: 0.896), followed by the NLP-only model (ROC-AUC: 0.868, Brier: 0.132, F1: 0.877), and the XGBoost-only model (ROC-AUC: 0.736, Brier: 0.201, F1: 0.815). For nonhome discharge, the multimodal model led (ROC-AUC: 0.920, Brier: 0.105, F1: 0.907), compared with the NLP-only model (ROC-AUC: 0.892, Brier: 0.102, F1: 0.916) and XGBoost-only model (ROC-AUC: 0.771, Brier: 0.144, F1: 0.893). Explainable AI revealed that body mass index, age, Medicare insurance, Charlson comorbidity index, Medicaid status, Hispanic ethnicity, fusion history, and thoracolumbar and cervical levels of surgery were the most important model features.

Conclusion: Incorporating unstructured surgeon notes into ML models markedly enhanced the prediction of perioperative outcomes in spinal surgery, suggesting that free-text notes may provide greater predictive utility than standard EHR variables.

Level of evidence: III.

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.