Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Durability of surgical treatment is important to patients, providers, and payers. Lumbar diskectomy is one of the most commonly performed spinal surgeries. Understanding the specific indications for revision surgery can help guide future research and quality improvement initiatives.

Methods: A multisurgeon, single-institution database was queried for revision surgery following a primary lumbar diskectomy (CPT = 63,030) from 2014 to 2018 with a minimum follow-up of 4 years (N = 1,133). The mean patient age was 44.93 years, levels decompressed was 1.08, mean body mass index was 30.45 kg·m -2 , mean American Society of Anesthesiologists (ASA) score was 2.33, length of stay was 0.44 days, and mean OR time was 115.41 minutes. Primary indication for revision surgery was collected through medical record analysis.

Results: A total of 185 of 1,133 patients (16%) underwent unplanned revision surgery during the study period. The most common indication for revision surgery was repeat decompression (N = 80, 7%) at a mean of 334.2 days postoperatively. The second most common indication was instability requiring fusion (N = 53, 5%) at a mean of 640.89 days postoperatively. Surgery for infection (N = 22, 1.9%) occurred at a mean of 37.77 days postoperatively. Other indications for revision surgery were less common and included: adjacent segment disease (N = 13, 1.1%) at a mean of 682.31 days postoperatively, durotomy repair (N = 13, 1.1%) at a mean of 26.77 days postoperatively, evacuation of hematoma/seroma (N = 4, 0.3%) at a mean of 6.75 days postoperatively. Binary logistic regression showed that age ( P = 0.368), number of surgical levels ( P = 0.694), and ASA grade ( P = 0.152) were not associated with revision surgery. The only factor associated with revision surgery was BMI ( P = 0.005; odds ratio: 1.042; 95% CI, 1.01-1.07).

Discussion: The results of this study show that lumbar diskectomy is a relatively durable procedure (84%) as currently indicated and performed in a large multisurgeon spine center. Early revision surgery (<90 days) for infection, hematoma/seroma, or durotomy repair is rare (3.3%). Late revision surgery (>90 days) for same segment pathology including recurrent stenosis with or without instability (12%) is much more common than adjacent segment disease (1.1%). These data can help guide clinicians and researchers in future quality improvement initiatives.

Objective: This study examined the effects of a 20-minute mindfulness-based intervention (MBI) on preoperative pain, desire for pain medication, and anxiety among adults scheduled for knee or hip arthroplasty, compared with a pain psychoeducation intervention (control condition).

Design: A single-site, two-arm, parallel-group, randomized, controlled trial.

Methods: Participants attending a preoperative education program were randomized to either a MBI or pain psychoeducation intervention, which were matched in format (group), duration (20 minutes), and frequency (once). Pain intensity, pain unpleasantness, desire for pain medication, and anxiety symptoms were assessed using 0 to 10 numeric rating scales immediately before and after the intervention. T-tests evaluated within-group change. Intention-to-treat generalized linear mixed modeling evaluated between-group pre-post changes in outcomes.

Findings: Among 170 enrolled participants (86 MBI; 84 control), 160 (94%) completed all study procedures. Both MBI and control participants markedly reduced their pain-related and anxiety symptoms postintervention; however, only the MBI group reduced their pain medication desire. Generalized linear mixed modeling revealed that the MBI group, compared with the control group, markedly decreased their pain intensity (P < 0.001; d = 0.85), pain unpleasantness (P < 0.001; d = 0.64), desire for pain medication (P = 0.008; d = 0.41), and anxiety symptoms (P < 0.001; d = 0.55). On average, the MBI decreased pain intensity by over two points, and a higher percentage of participants in the MBI condition reported clinically meaningful reductions in pain intensity (ie, by at least 30%) compared with the control participants (60% versus 26%, respectively, P < 0.001).

Conclusions: These findings suggest the effectiveness of a brief MBI in reducing preoperative pain and anxiety among adults preparing for knee or hip arthroplasty, underscoring the potential of MBIs to safely address pain and anxiety in surgical settings.

Background: Transforaminal lumbar interbody fusion (TLIF) and lateral approaches such as lateral lumbar interbody fusion (LLIF) are widely used to treat degenerative lumbar disk disease. Although both restore disk height and achieve fusion, comparative advantages in radiographic, perioperative, and patient-reported outcomes (PROs) remain debated.

Purpose: To perform an updated meta-analysis comparing TLIF and LLIF with respect to perioperative outcomes, radiographic parameters, complication rates, and PROs.

Study design: Systematic review and meta-analysis.

Methods: A comprehensive search of PubMed, Cochrane, and Google Scholar (2000 to 2025) was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies directly comparing TLIF and LLIF were included. Random-effects models were used for pooled analyses. Radiographic outcomes were grouped into immediate and 1- to 2-year follow-up. PROs were stratified by early (≤6 months) and late (>6 months) follow-up.

Results: Twenty-seven studies (6,047 patients) met inclusion criteria: 4,098 underwent TLIF and 1,949 underwent LLIF. LLIF was associated with shorter surgical time (-14.3 minute; P = 0.04), lower estimated blood loss (-88.3 mL; P < 0.0001), and reduced length of stay (-0.35 days; P = 0.01). LLIF showed greater immediate improvements in mean disk height (+1.68 mm; P = 0.006), foraminal height (+1.80 mm; P < 0.0001), and segmental lordosis (+2.16°; P = 0.03), with lower subsidence risk (odds ratio: 0.40; P = 0.004). TLIF achieved greater immediate canal decompression (+49.8 mm 2 ; P < 0.0001). At late follow-up, LLIF maintained superior disk height (+2.21 mm), foraminal height (+2.33 mm), and segmental lordosis (+3.01°). LLIF was also associated with improved late leg pain scores (Δ -0.23; P = 0.02).

Conclusion: LLIF and TLIF each offer distinct advantages. LLIF was associated with lower subsidence risk, reduced blood loss, shorter surgical time, decreased length of stay, and improved radiographic correction. Most PROs were comparable, but TLIF demonstrated improved late leg pain relief.

Level of evidence: III.

Introduction: Comparisons made between spine-trained neurosurgeons (Neuro) and orthopaedic surgeons (Ortho) can be a delicate matter. Considering most authors are spine surgeons, one may wonder if study results inappropriately favor authors' own specialties. The purpose of this study was to perform a bibliometric analysis of all studies comparing spine surgeons of each training pathway and to evaluate potential biases when reporting study results.

Methods: A systematic review was conducted according to the PRISMA statement. All literature comparing Neuro and Ortho before May 2022 were identified. Included articles were categorized according to the training backgrounds of the first and last authors ("Neuro-Neuro," "Ortho-Ortho," or "Author Diverse"), evaluated for inclusion of both Neuro and Ortho authors from the total author list, and classified by journal type of publication ("Neuro Journal," "Ortho Journal," or "Combined Journal"). A Neuro and Ortho spine surgeon each independently reviewed a subset of articles evaluating postoperative outcomes, categorizing the articles' stated conclusions (Pro-Neuro, Pro-Ortho, Neutral). Student t -test and Chi-squared analyses were used when appropriate to test for significance. Alpha level was set at <0.05.

Results: A total of 80 studies were identified. Overall, 26 Neuro-Neuro articles, 34 Ortho-Ortho articles, and 20 Author Diverse articles were included. Neuro-Neuro authors were found to publish more in Neuro Journals ( P < 0.001). No differences were observed for inclusion of both Neuro and Ortho authors between studies published by the three different author types. Overall, there were 22 articles comparing postoperative outcomes: 15 articles (68%) reported no notable differences, whereas 3 (14%) found improved outcomes with Neuro, and 4 (18%) found improved outcomes with Ortho. No notable differences were found in outcomes when analyzed according to author type ( P = 0.531), journal type ( P = 0.962), and database used ( P = 0.636).

Conclusions: The growing body of literature comparing Neuro and Ortho spine surgeons shows little differences in surgical outcomes and no evidence of bias.

Level of evidence: V.

Background: Periprosthetic joint infection (PJI) is a frequent complication after oncologic endoprosthetic reconstruction and is associated with high complication and amputation rates. Current challenges for adequate treatment of endoprosthetic PJIs include insufficient data on infection microbiology and inconsistencies in classification of surgical strategies. Our study sought to examine the microbiology and treatment success of PJIs in this population before and after standardization.

Methods: A systematic review following the PRISMA guidelines was done. The PubMed and Embase databases were queried, and studies were screened for inclusion and exclusion criteria. Five major treatment strategies were established: débridement, antibiotics, and implant retention (DAIR), DAIR plus, one-stage revision, two-stage revision, and amputation. DAIR entailed irrigation and débridement without component exchange, whereas DAIR plus comprised modular component exchange and implant retention. One-stage revision required the exchange of all implants in a single surgery, whereas two-stage revision involved this process over two surgeries with temporary spacer insertion. PJI treatment success was evaluated for each surgical strategy, comparing outcomes based on the original nomenclature used by study authors to those after reclassification. A total of 22 studies comprising 975 patients with endoprosthetic PJIs were included.

Results: The most commonly isolated microorganisms were coagulase-negative Staphylococcus (36.4%) and Staphylococcus aureus (27.5%). Culture-negative PJIs occurred in 10.3% of cases. After reclassification, the treatment success rates of DAIR plus increased from 45.8% to 63.1% ( P < 0.001), whereas that of DAIR diminished from 51.8% to 39.7% ( P = 0.01). The treatment of one-stage revision improved from 60.2% to 75% ( P = 0.01), whereas that of two-stage revision (71.8% versus 73.5%, P = 0.2) and amputation (100% in both) remained unchanged after reclassification.

Conclusion: Reclassification using standardized definitions demonstrated changes in reported treatment efficacy. Our study underscored the influence of stem removal on the efficacy of surgical treatment.

Level of evidence: III.

Introduction: Periprosthetic femur fractures (PFFs) are a leading cause of revision following primary total hip arthroplasty. Although triple-tapered, noncemented, collared stems have been associated with a lower incidence of PFFs, most studies are from single institutions. The purpose of this work was to investigate PFF incidence and early device survivorship of a modern-designed, noncemented, collared stem as reported in the American Joint Replacement Registry (AJRR).

Methods: All primary total hip arthroplasty cases in patients older than 65 years from January 2021 to December 2024, submitted to AJRR as of September 2024, with Medicare data, were queried in this 2-year analysis. Data were stratified into three treatment cohorts: a recently introduced noncemented collared stem, aggregated noncemented collarless stems, and aggregated cemented stems in the US market. This analysis included 8,432 noncemented collared stems, 74,300 noncemented collarless stems, and 9,293 cemented stems. Cumulative 2-year revision and PPF incidence were determined per International Classification of Diseases 9 and 10 codes. The AJRR data were linked to Medicare claims data through a unique identifier provided by the Research Data Assistance Center (ResDAC).

Results: The noncemented collared stem had the lowest all-cause 2-year revision incidence of 1.32% compared with cemented (2.02%) and noncemented collarless (2.22%) cohorts ( P < 0.001). The 2-year PFF incidence was equivalent between the noncemented collared (0.19%) and cemented (0.20%) cohort ( P = 0.99). The 2-year PPF incidence was markedly lower for the noncemented collared cohort than the noncemented collarless cohort (0.19% vs. 0.65%, P < 0.001).

Conclusion: In this large retrospective AJRR cohort, markedly lower 2-year all-cause revision were observed with a modern, triple-tapered, noncemented, collared stem compared with noncemented, collarless stems. Notably, the incidence of PFF with this noncemented, collared stem was threefold lower than all noncemented, collarless stems and equivalent to all cemented stem designs.

Background: Total knee arthroplasty (TKA) is increasingly performed in younger, high-demand patients, raising concerns about the long-term durability of traditional cemented implants. Noncemented TKA offers the potential for biologic fixation and improved longevity, but its cost-effectiveness remains uncertain.

Methods: A Markov decision model was used to compare the 20-year cost of cemented versus noncemented primary TKA in a cohort of 10,000 patients beginning at age 50 years. The model incorporated implant costs, revision rates, operating room (OR) time, and other relevant clinical variables. Sensitivity analyses were conducted to assess the impact of implant failure rates, implant cost markups, and OR time savings.

Results: The 20-year cost of noncemented TKA ($20,829) was slightly higher than cemented TKA ($20,573). However, key variables markedly influenced cost-effectiveness. When the noncemented failure hazard ratio was reduced to 0.8, a cost savings of $1,676 was observed. Conversely, a hazard ratio of 1.2 led to a $1,768 increase in cost. A cost-neutral threshold was achieved with a 19% noncemented implant markup or 13 minutes of OR time saved. Additional savings were observed when OR time costs exceeded $54 per minute. Other variables, such as cement cost and patient age, had minimal impact.

Conclusion: Cementless TKA can be cost-neutral or cost saving over 20 years if specific conditions such as implant pricing and reduced OR time are met. Although clinical outcomes appear comparable between implant types, careful consideration of cost drivers and institutional practices is necessary. Noncemented TKA may be a viable, cost-effective option in selected patient populations, although further research is needed to refine these thresholds and evaluate long-term outcomes.

Chordomas are rare, slow-growing tumors originating from the notochord, commonly occurring in the sacrum and mobile spine. These tumors have a high rate of local recurrence and potential for metastasis. Local management continues to evolve. The primary treatment approach involves en bloc resection aiming for negative margins, but even with this aggressive strategy, late recurrences occur in up to 50% of cases within 10 to 15 years. Advanced radiation therapy techniques, such as stereotactic body radiation therapy, proton therapy, and carbon ion therapy, play an ever-increasing role as adjuvants to surgery, particularly when negative margins are not achieved, and, in select cases, as standalone treatment. Despite these advancements, chordomas remain challenging to treat due to their tendency for late recurrences and metastases. Emerging therapies such as immunotherapy provide hope for improved treatment with less morbidity. The management of chordoma requires a multidisciplinary approach integrating surgery, radiation therapy, and systemic therapies to optimize local control and long-term survival outcomes. Continued research and clinical trials are essential for improving treatment efficacy and developing novel therapeutic strategies for this locally aggressive tumor type.

Patients with complex anatomy and osseous deformity undergoing primary and revision total shoulder arthroplasty can pose challenges to surgeons and render off-the-shelf implants insufficient. The advent of three-dimensional printing has enabled the emergence of patient-specific instrumentation and custom implants which offer tailored solutions to address each patient's unique anatomy. This article examines the principles, indications, and clinical outcomes of patient-specific instrumentation and custom implants in total shoulder arthroplasty.

Background: Periprosthetic femur fractures are a known complication after hip hemiarthroplasty (HA) in geriatric patients. The relationship between femoral stem design and fracture risk remains unclear. This study aimed to assess (1) the association between stem geometry and fixation on periprosthetic femur fracture risk and (2) the effect of a femoral stem collar.

Methods: The American Joint Replacement Registry data were analyzed for HA cases in patients aged 70+ years from 2012 to 2021. We identified 56,828 primary HAs for the diagnosis of femoral neck fracture. Patient demographics and revision surgery for periprosthetic femur fracture in the form of open reduction with internal fixation or revision arthroplasty were documented. Stems were categorized into tapered wedge or fit and fill, and cemented stems were categorized into composite beam or taper slip. Cox models and Benjamini-Hochberg adjustments were used for statistical analysis.

Results: Cemented composite beam stems accounted for 38% of implants, followed by fit-and-fill stems at 32%, tapered wedge stems at 29%, and cemented taper slip stems at 1%. A collar was present in all cemented composite beam stems, 23% of tapered wedge stems, and 20% of fit-and-fill stems. After applying inverse probability weighting adjustment, cemented composite beam stems showed a markedly lower periprosthetic femur fracture risk over other stems. Compared with cemented composite beam stems, collarless tapered wedge demonstrated a markedly higher hazard ratio (HR) (3.63; P < 0.001), as did both collarless (HR, 3.4; P < 0.001) and collared fit-and-fill stems (HR, 3.45; P < 0.001). The presence of a collar reduced periprosthetic femur fracture risk across all designs, with the most pronounced reduction seen in tapered wedge stems (0.90% versus 0.41%).

Conclusion: For HA in patients aged 70 years and older, cemented composite beam stems with a collar were associated with the lowest risk of periprosthetic femur fractures in the American Joint Replacement Registry database. However, these findings reflect implant utilization patterns up to 2021 and may not fully account for the recent rise in triple taper collared stem use. Surgeons should consider these implants when selecting fixation strategies for HA.

Level of evidence: Level III.