Journal of the American Academy of Orthopaedic Surgeons最新文献

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.

Hip-spine syndrome (HSS) is characterized by the presence of concurrent hip and spine degenerative conditions. It can be further classified as simple, secondary, complex, or misdiagnosis. Patients may present with a myriad of symptoms, including low back pain, groin pain, radicular leg pain, and neurogenic claudication, with or without neurological deficits. Treatment of HSS is complex and involves a multidisciplinary team of spine surgeons, hip surgeons, pain physiatrists, and physical therapists. In treating HSS, it is imperative to first identify the primary pain generator through a thorough hip and spine examination and diagnostic and therapeutic injections. The decision whether to operate on the hip or spine first is multifaceted and depends on clinical, radiographic, and surgical considerations. In this article, we review the most recent literature on the management of patients with HSS, with an emphasis on surgical treatment.

Introduction: Multimodal analgesia (MMA) is an alternative to patient-controlled analgesia (PCA) that reduces opioid usage after spine surgery and improves time to mobilization. The purpose of this study was to investigate whether MMA improves physical therapy performance, hospital length of stay (LOS), and disposition to home following major spinal reconstructive surgery.

Methods: The study is a pre- and postintervention retrospective cohort study evaluating a unique MMA protocol developed and implemented at our institution in 2022. Data were collected for patients who received PCA for 1 year before MMA implementation and patients who received MMA for 1-year postimplementation. All patients who underwent open, posterior lumbar fusion surgery ± decompression between 2 and 5 levels were included. Minimally invasive, anterior, and lateral procedures were excluded from the study. Data collected included numeric pain scores (0 to 10), LOS, and disposition to home versus inpatient rehabilitation. Chi-squared analysis was used to calculate P values, which were considered notable if P < 0.05. Logistic regression was used to model patient disposition status.

Results: Overall, there were 235 patients in the MMA group and 192 in the PCA group (total n = 427). Patient demographics were similarly matched between the cohorts. The MMA group demonstrated markedly longer walking distance (feet) at all stages of the postoperative period. The MMA group demonstrated shorter LOS and increased likelihood of being discharged home versus inpatient rehabilitation. Logistic regression analysis revealed 2.96 times increased odds of home discharge after MMA.

Conclusion: Our MMA protocol was superior to PCA in treating pain and improving LOS and disposition status in patients undergoing multilevel spinal fusion. Our findings suggest that MMA may be preferable to PCA in the treatment of postoperative pain after multilevel thoracolumbar spinal fusions.

Introduction: Entities such as The Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality include a large swath of heterogenous hip fracture diagnoses together when defining this injury. However, it is unclear if these broad definitions are in line with those of physicians who treat these injuries. We queried orthopaedic surgeons to understand how they would define a hip fracture and how their definition compares with the ones currently in use by healthcare agencies.

Methods: We conducted an internet-based survey of orthopaedic surgeons to ascertain which standard hip fracture types they felt should be included in a modified hip fracture definition (MHFD), along with querying their current treatment practices. We also compared outcomes, medical comorbidities, and spending across patients captured in the different diagnosis groups.

Results: Eighty-five orthopaedic surgeons completed the survey, and almost all of them felt that a femoral neck (96.5%) and intertrochanteric (95.3%) fracture should be included in the MHFD, while almost half (49.4%) would include the subtrochanteric region, and just over a quarter (27.1%) would incorporate the femoral head or a stable greater or lesser trochanter fracture. Treatment practices were largely in line with current research and patients captured by the new MHFD tended to have more procedures performed, have higher inpatient costs, and be discharged to higher levels of care compared with hip fracture patients not included in this new definition.

Conclusion: There should be caution when using current hip fracture definitions from healthcare agencies because they do not align well with those used by practicing orthopaedic surgeons. Efforts to enhance this definition should be explored because quality improvement programs are limited by a heterogenous definition of this injury.

Objective: To determine the prevalence of gluteal tendon pathology among patients with osteoarthritis (OA) undergoing total hip arthroplasty (THA) and to examine potential effects on postoperative outcomes.

Methods: Patients who underwent direct anterior THA for OA between 2010 and 2022 were identified using an institutional total Mayo Clinic Joint Replacement Database. Those with MRI of the surgical hip obtained ≤1 year before surgery were included and categorized according to the presence of gluteal tendon tear, tendinopathy, or no pathology. Postoperative outcomes were evaluated using visual analog scale (VAS) at rest, VAS with use, Hip Disability and Osteoarthritis Outcome Score Pain, Forgotten Joint Score-12, and modified Harris Hip score.

Results: Twenty-three hips with gluteal tears (9 of 23 male, mean age 63.5 ± 29.3 years), 48 with tendinopathy (20 of 48 male, mean age 58.8 ± 10.4 years), and 8 with no pathology on MRI (6 of 8 male, mean age 42.4 ± 18.9 years) were followed for 4.9 ± 3.0 years (range 1.2 to 13.2 years) following THA. Among patients with gluteal tear or tendinopathy, preoperative MRI was done for suspected gluteal pathology in only 3 (13.0%) and 2 (4.2%) cases, respectively, with most cases noted incidentally. Nevertheless, all experienced notable improvement in pain, satisfaction, and functional outcomes following surgery according to modified Harris Hip score score ( P ≤ 0.001 for all), and no differences were observed in VAS at rest, VAS with use, Hip Disability and Osteoarthritis Outcome Score Pain, or Forgotten Joint Score-12 between the groups ( P > 0.050 for all). Of note, no patient exhibited full-thickness preoperative gluteal tendon tearing with retraction on imaging.

Conclusion: Gluteal tears or tendinopathy was detected in 89.9% of patients undergoing direct anterior THA for OA. Despite no intraoperative repair, postoperative improvements in pain and function were similar to those of patients with no gluteal pathology. These findings suggest that although gluteal pathology may be common among patients undergoing THA, patients with partial thickness gluteal tears or tendinopathy generally do well following surgery.

Introduction: Clinical guidelines recommend low-molecular-weight heparin (enoxaparin) to prevent venous thromboembolism in orthopaedic trauma patients. However, a large trial recently found aspirin noninferior to enoxaparin in preventing death and pulmonary embolism in this population. We modeled cost implications for the United States healthcare system if aspirin replaced enoxaparin as the standard of care for thromboprophylaxis in orthopaedic trauma patients.

Methods: The modeling compared spending under two scenarios: continued use of enoxaparin versus switching to aspirin. The model included fracture incidence estimates from the National Inpatient Sample and dose and duration data from the clinical trial. We derived medication costs from current market prices across payer types and care settings (ie, inpatient and postdischarge prescriptions). The model incorporates uncertainty around each parameter based on calculated standard errors and generates bootstrapped estimates of costs and cost savings disaggregated by the payer.

Results: The results indicated that prescribing enoxaparin for thromboprophylaxis to more than 600,000 fracture patients costs $162.7 million annually, whereas thromboprophylaxis with aspirin would cost $1.6 million annually. Spending on thromboembolic events totals $210.7 million under the enoxaparin scenario and $222.1 million with aspirin. Overall, aspirin for thromboprophylaxis in fracture patients would yield annual savings of $149.7 million (95% credible interval: $97 to $208 million) compared with enoxaparin.

Conclusion: Our findings suggest that a widespread switch from enoxaparin thromboprophylaxis to aspirin would lead to more than $100 million in annual cost savings in the United States alone. Insurers stand to benefit most from this practice change. However, patients, especially those without insurance, would realize considerable savings from aspirin thromboprophylaxis.

Level of evidence: Level 1, Economic.

Introduction: Femoral neck fractures are highly morbid injuries, and patients with greater perioperative risk are commonly treated with hemiarthroplasty (HA). Neutrophil-lymphocyte ratios (NLRs) are measures of inflammation and predict mortality after surgery. We hypothesize that patients presenting with a femoral neck fracture and dysregulated inflammatory response treated with delayed hemiarthroplasty (HA) will have lower rates of inpatient mortality than those treated immediately.

Methods: The Premier Healthcare Database was retrospectively reviewed for older adult (age 60 and older) patients with femoral neck fractures who underwent HA. The marginal effect of 2-day versus 0-day delay in surgery on the probability of inpatient mortality was determined for each NLR value. A NLR value >6.9 was associated with a decreased risk of mortality if surgery was delayed by two days. Patients with an NLR >6.9 were identified, and those with a 2-day delay were 1:1 matched to those without a delay on the propensity for delayed surgery. The adjusted odds ratios (aORs) of inpatient mortality were determined through multivariable models accounting for potential confounding. Significance was defined as P < 0.05.

Results: A total of 2,106 patients with an admission NLR >6.9 two days before surgery were matched to 2,106 patients with an NLR >6.9 on the day of surgery. Matching achieved good balance (standardized mean difference of <0.10). A markedly lower rate of inpatient mortality was observed in the delay cohort (1.47% vs. 3.04%; aOR = 0.51 [95% CI, 0.31-0.82]).

Conclusions: Elevated preoperative NLR is associated with mortality risk in older adults undergoing early HA for femoral neck fracture. These findings suggest that the underlying risk profiles of patients presenting with hip fractures are not homogeneous; thus, patient-specific frameworks may be needed to guide optimal care.

Level of evidence: Level III.