Journal of the American Academy of Orthopaedic Surgeons最新文献

Distal radius fractures are one of the most common injuries of the upper extremity. Although nonsurgical management is common, surgical intervention, particularly using volar and dorsal plate fixation, is essential in a subset of injuries. Historically, dorsal plates were avoided due to a high rate of extensor tendon irritation and rupture. Volar locking plates were developed in the early 1990s and first published in 2000 to avoid the complications associated with dorsal plating and have since become widely considered the workhorse for most distal radius fractures. Despite advancements, both fixation methods are still associated with complications, warranting careful selection based on fracture patterns. The purpose of this review is to summarize the most recent literature on the complications associated with the use of volar and low-profile dorsal distal radius plates.

Introduction: The popularization of generative artificial intelligence (AI), including Chat Generative Pre-trained Transformer (ChatGPT), has raised concerns for the integrity of academic literature. This study asked the following questions: (1) Has the popularization of publicly available generative AI, such as ChatGPT, increased the prevalence of AI-generated orthopaedic literature? (2) Can AI detectors accurately identify ChatGPT-generated text? (3) Are there associations between article characteristics and the likelihood that it was AI generated?

Methods: PubMed was searched across six major orthopaedic journals to identify articles received for publication after January 1, 2023. Two hundred and forty articles were randomly selected and entered into three popular AI detectors. Twenty articles published by each journal before the release of ChatGPT were randomly selected as negative control articles. 36 positive control articles (6 per journal) were created by altering 25%, 50%, and 100% of text from negative control articles using ChatGPT and were then used to validate each detector. The mean percentage of text detected as written by AI per detector was compared between pre-ChatGPT and post-ChatGPT release articles using independent t-test. Multivariate regression analysis was conducted using percentage AI-generated text per journal, article type (ie, cohort, clinical trial, review), and month of submission.

Results: One AI detector consistently and accurately identified AI-generated text in positive control articles, whereas two others showed poor sensitivity and specificity. The most accurate detector showed a modest increase in the percentage AI detected for the articles received post release of ChatGPT (+1.8%, P = 0.01). Regression analysis showed no consistent associations between likelihood of AI-generated text per journal, article type, or month of submission.

Conclusions: As this study found an early, albeit modest, effect of generative AI on the orthopaedic literature, proper oversight will play a critical role in maintaining research integrity and accuracy. AI detectors may play a critical role in regulatory efforts, although they will require further development and standardization to the interpretation of their results.

Purpose: Although the hematologic benefits of tranexamic acid (TXA) have been thoroughly evaluated, an additional value demonstrated in knee arthroplasty and rotator cuff repair is improved early postoperative range of motion (ROM). This study aims to evaluate whether TXA given during total shoulder arthroplasty (TSA) confers improved early postoperative ROM or pain.

Methods: We did retrospective review of 653 TSAs (223 anatomic TSA [aTSA] and 430 reverse TSA [rTSA]) performed in 596 patients at a single institution from 2007 to 2022. Intraoperative TXA use was implemented on a case-by-case basis starting in 2014 then became standard practice in 2016. Pre- to postoperative improvement in ROM was evaluated at 6 weeks, 3 months, 6 months, 1 year, and 2-years of follow-up. Mixed-effects models were used to evaluate whether administration of TXA intraoperatively improved ROM or pain at each follow-up time point.

Results: TXA was administered to 26% (n = 58) of aTSAs and 43% (n = 179) of rTSAs. Patients with a history of hypertension received TXA at a higher rate for both aTSA (P = 0.009) and rTSA (P = 0.005). Intraoperative TXA was not associated with improved ROM or pain for aTSA or rTSA at any time point investigated. Average estimated intraoperative blood loss was markedly less in the TXA group for both aTSA [250 to 300 mL] (P < 0.001) and rTSA [200 to 300 mL] (P < 0.001) when compared with the non-TXA groups [300 to 400 mL for both].

Conclusion: Intraoperative TXA does not improve ROM or pain after TSA. However, intraoperative blood loss was reduced, further supporting the routine use of TXA to reduce hematologic complications and improve intraoperative visibility.

Hereditary sensory and autonomic neuropathies (HSANs) encompass a diverse group of inherited neuropathies characterized by notable sensory and autonomic involvement that affects musculoskeletal structures and systemic function. There are 8 recognized types of HSAN. The orthopaedic manifestations of HSAN are complex and diverse, including spinal deformity, Charcot arthropathy, osteomyelitis, fractures, osteonecrosis, osteoporosis, and skeletal deformities. The sensory neuropathy with involvement of small nerve fibers can lead to unnoticed burns, fractures, and joint trauma. Spinal involvement includes progressive scoliosis/kyphosis and acute neurologic compromise. Diagnosis is dependent on clinical suspicion and confirmed with genetic analysis. Treatment is focused on the eradication of infection, stabilization of fractures, and prevention of joint instability in the spine and extremities. This review focuses on the orthopaedic manifestations to aid healthcare professionals in the recognition and treatment of these conditions.

Introduction: Tobacco use elevates the incidence of postoperative complications and remains a key modifiable risk factor of perioperative surgical optimization. It remains unclear whether non-tobacco nicotine dependence confers an increased risk of surgical complications. This study evaluates postoperative complications in patients with non-tobacco nicotine dependence for total knee arthroplasty (TKA).

Methods: We queried the TriNetX health database using Current Procedural Terminology and International Classification of Diseases, 10th Revision (ICD-10) codes and identified two cohorts for evaluation. Cohort A was defined as patients who had a TKA; had a dependence on nicotine; did not have nicotine dependence to cigarettes, chewing tobacco, other tobacco products; and were between the ages of 35 and 90 years. Cohort B was defined as patients who had a TKA but did not have a dependence on nicotine or a personal history of nicotine dependence and were between the ages of 35 and 90 years.

Results: This study analyzed a total of 10,594 non-tobacco nicotine-dependent patients and 175,079 non-dependent patients who underwent TKA. In the analysis of propensity-matched cohorts, non-tobacco nicotine-dependent patients demonstrated an increased rate of various postoperative complications within 90 days. Dependent patients saw a significantly increased risk of infection after a procedure ( P < 0.001), deep vein thrombosis ( P < 0.001), pulmonary embolism ( P < 0.001), sepsis ( P = 0.0065), and prosthetic joint infection ( P = 0.0361) and a higher 3-year revision rate ( P = 0.0084).

Discussion: Non-tobacco nicotine dependence demonstrated an increased associated risk of postoperative surgical complications for patients undergoing TKA. Orthopaedic surgeons should consider evaluating non-tobacco nicotine dependence within their surgical optimization protocol.

Level of evidence: Level III, Prognostic.

The three primary factors involved in preservation of the hip joint include femoroacetabular impingement (FAI), hip dysplasia/instability, and femoral torsion abnormalities. Each of these factors affects the health of the acetabular labrum and femoroacetabular cartilage. The appropriate surgical treatments for each of these factors include arthroscopic or open femoroplasty/acetabuloplasty for FAI, periacetabular osteotomy for hip dysplasia/instability, and derotational femoral osteotomy for femoral torsion abnormalities. When evaluating patients with prearthritic hip conditions, orthopaedic surgeons should be aware of the various factors involved in hip joint preservation and, if surgery is indicated, the surgeon should be sure to address all factors that need surgical treatment rather than focusing on the commonly diagnosed issue or visible injury, for example, a labral tear. If any of these factors is ignored, the hip joint may not thrive. The purpose of this review was to explain the importance of the most common factors involved in hip joint preservation and the appropriate surgical treatments for pathology in these factors.

Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.

Introduction: Matching into an orthopaedic surgery residency consistently reinforces a competitive landscape, challenging the applicants and programs. A group of orthopaedic surgery residency programs implemented video prompts asking applicants to respond to a standardized question by video recording. Assessing the impact of this video on the decision to offer an interview can help guide programs and applicants through the interview process.

Methods: Twenty residency applications to one institution requiring video prompts were randomly selected and deidentified. Thirteen experienced faculty from various orthopaedic surgery programs served as applicant reviewers. The reviewers evaluated the electronic residency application service (ERAS) application and determined whether they would grant the applicant an interview ("no," "maybe," or "yes") before and after watching the video prompt. The reviewer also scored the impact of the applicant's dress, facial presentation, and video background distractions on their evaluation of the video. Multivariable logistic regressions were conducted using a group of applicants where interview status was not impacted by the video compared with the group of applicants where the interview status changed after video review. An alpha value of 0.05 was used to define significance.

Results: The video prompt impacted the decision to offer an interview 29.3% of the time; 15.8% were switched from "yes" or "maybe" to "no" and 13.5% were switched from "no" or "maybe" to "yes." For the positively impacted applicants, facial presentation score was significantly higher ( P = 0.005). No recorded variables were associated with decreased chance of interview.

Discussion: Video prompts impacted the decision to offer interviews to orthopaedic surgery applicants approximately one-third of the time, with a similar number of applicants being positively and negatively impacted. Facial presentation score was associated with increased chance of interview, and no variables were associated with decreased chance of interview. Thus, the answer to the videos presumably negatively impacted applicants.

Introduction: Quantitative parameters for diagnosis of congenital lumbar stenosis (CLS) have yet to be universally accepted. This study establishes parameters for CLS using CT, assessing the influences of patient sex, race, ethnicity, and anthropometric characteristics.

Methods: Interpedicular distance (IPD), pedicle length, canal diameter, and canal area were measured using 1,000 patients between 18 and 35 years of age who were without spinal pathology.

Results: Irrespective of disk level, threshold values for CLS were 16.1 mm for IPD, 3.9 mm for pedicle length, 11.5 mm for canal diameter, and 142.5 mm 2 for canal area. Notable differences based on patient sex were observed, with men demonstrating larger CLS threshold values with respect to IPD and canal area across all vertebral levels from L1 to L5. Based on patient anthropometric factors, no strong or moderate associations were observed between any spinal measurement and patient height, weight, or body mass index across all levels from L1 to L5. However, notable differences were observed based on patient race and ethnicity from L1 to L5. Asian patients demonstrated the largest pedicle lengths, followed by White, Hispanic, and Black patients in descending order. White patients demonstrated the largest IPD, canal AP diameter, and canal area, followed by Asian, Hispanic, and Black patients in descending order. Black patients demonstrated the smallest values across all anatomic measurements relative to Asian, White, and Hispanic patients.

Conclusion: This study reports 25,000 measurements of lumbar central canal dimensions to establish quantitative thresholds for the diagnosis of CLS. Although not influenced by patient height, weight, or body mass index as one might intuit, canal dimensions were influenced by patient sex, race, and ethnicity. These findings may help explain differences in predisposition or prevalence of lumbar nerve root compression among patients of different races, which can be important when considering rates of surgery and access to care.

Introduction: Infection is a common mode of failure in lower extremity endoprostheses. The Prophylactic Antibiotic Regimens in Tumor Surgery trial reported that 5 days of cefazolin had no difference in surgical site infection compared with 24 hours of cefazolin. Our purpose was to evaluate infection rates of patients receiving perioperative cefazolin monotherapy, cefazolin-vancomycin dual therapy, or alternative antibiotic regimens.

Methods: A single-center retrospective review was conducted on patients who received lower extremity endoprostheses from 2008 to 2021 with minimum 1-year follow-up. Three prophylactic antibiotic regimen groups were compared: cefazolin monotherapy, cefazolin-vancomycin dual therapy, and alternative regimens. The primary outcome was deep infection, defined by a sinus tract, positive culture, or clinical diagnosis. Secondary outcomes were revision surgery, microorganisms isolated, and superficial wound issues.

Results: The overall deep infection rate was 10% (30/294) at the median final follow-up of 3.0 years (IQR 1.7 to 5.4). The deep infection rates in the cefazolin, cefazolin-vancomycin, and alternative regimen groups were 8% (6/72), 10% (18/179), and 14% (6/43), respectively ( P = 0.625). Patients not receiving cefazolin had an 18% deep infection rate (6/34) and 21% revision surgery rate (7/34) compared with a 9% deep infection rate (24/260) ( P = 0.13) and 12% revision surgery rate (31/260) ( P = 0.17) in patients receiving cefazolin. In those not receiving cefazolin, 88% (30/34) were due to a documented penicillin allergy, only two being anaphylaxis. All six patients in the alternative regimen group who developed deep infections did not receive cefazolin secondary to nonanaphylactic penicillin allergy.

Conclusion: The addition of perioperative vancomycin to cefazolin in lower extremity endoprosthetic reconstructions was not associated with a lower deep infection rate. Patients who did not receive cefazolin trended toward higher rates of deep infection and revision surgery, although not statistically significant. The most common reason for not receiving cefazolin was a nonanaphylactic penicillin allergy, highlighting the continued practice of foregoing cefazolin unnecessarily.