Journal of the American Academy of Orthopaedic Surgeons最新文献

Radiation therapy plays an important role in the management of patients with primary and metastatic spine tumors. Technological innovations in the past decade have allowed for improved targeting, dose escalation, and precision of radiation therapy while concomitant improvements in surgical techniques have resulted in improved outcomes with reduced morbidity. Patients with cancer have increasingly complex oncologic needs, and multidisciplinary management is more essential than ever. This review will provide an overview of radiation principles, modern radiation techniques, management algorithms, and expected toxicities of common radiation treatments in the management of spine tumors.

Technological innovation has advanced the efficacy of spine surgery for patients; however, these advances do not consistently translate into clinical effectiveness. Some patients who undergo spine surgery experience continued chronic back pain and other complications that were not present before the procedure. Defects in healthcare value, such as the lack of clinical benefit from spine surgery, are, unfortunately, common, and the US healthcare system spends $1.4 trillion annually on value defects. In this article, we examine how avoidable complications, postacute healthcare use, revision surgeries, and readmissions among spine surgery patients contribute to $67 million of wasteful spending on value defects. Furthermore, we estimate that almost $27 million of these costs could be recuperated simply by redirecting patients to facilities referred to as centers of excellence. In total, quality improvement efforts are costly to implement but may only cost about $36 million to fully correct the $67 million in finances misappropriated to value defects. The objectives of this article are to present an approach to eliminate defects in spine surgery, including a center-of-excellence framework for eliminating defects specific to this group of procedures.

Introduction: Surgical counseling enables shared decision making and optimal outcomes by improving patients' understanding about their pathologies, surgical options, and expected outcomes. Here, we aimed to provide practical answers to frequently asked questions (FAQs) from patients undergoing an anterior cervical diskectomy and fusion (ACDF) or cervical disk replacement (CDR) for the treatment of degenerative conditions.

Methods: Patients who underwent primary one-level or two-level ACDF or CDR for the treatment of degenerative conditions with a minimum of 1-year follow-up were included. Data were used to answer 10 FAQs that were generated from author's experience of commonly asked questions in clinic before ACDF or CDR.

Results: A total of 395 patients (181 ACDF, 214 CDR) were included. (1, 2, and 3) Will my neck/arm pain and physical function improve? Patients report notable improvement in all patient-reported outcome measures. (4) Is there a chance I will get worse? 13% (ACDF) and 5% (CDR) reported worsening. (5) Will I receive a significant amount of radiation? Patients on average received a 3.7 (ACDF) and 5.5 mGy (CDR) dose during. (6) How long will I stay in the hospital? Most patients get discharged on postoperative day one. (7) What is the likelihood that I will have a complication? 13% (8% minor and 5% major) experienced in-hospital complications (ACDF) and 5% (all minor) did (CDR). (8) Will I need another surgery? 2.2% (ACDF) and 2.3% (CDR) of patients required a revision surgery. (9 & 10) When will I be able to return to work/driving? Most patients return to working (median of 16 [ACDF] and 14 days [CDR]) and driving (median of 16 [ACDF] and 12 days [CDR]).

Conclusions: The answers to the FAQs can assist surgeons in evidence-based patient counseling.

Introduction: Pedicle subtraction osteotomy (PSO) is a complex surgical procedure that provides correction of moderate sagittal imbalance. Surgical complications have adverse effects on patient outcomes and healthcare costs, making it imperative for clinical researchers to focus on minimizing complications. However, when it comes to risk modeling of PSO surgery, there is currently no consensus on which patient characteristics or measures should be used. This study aimed to describe complications and compare the performance of various sociodemographic characteristics, surgical variables, and established risk indices in predicting postoperative complications, infections, and readmissions after lumbar PSO surgeries.

Methods: A review was conducted on 191 patients who underwent PSO surgery at a single institution by a single fellowship-trained orthopaedic spine surgeon between January 1, 2018, and December 31, 2021. Demographic, intraoperative, and postoperative data within 30 days, 1 year, and 2 years of the index procedure were evaluated. Descriptive statistics, t -test, chi-squared analysis, and logistic regression models were used.

Results: Intraoperative complications were significantly associated with coronary artery disease (odds ratios [OR] 3.95, P = 0.03) and operating room time (OR 1.01, P = 0.006). 30-day complications were significantly cardiovascular disease (OR 2.68, P = 0.04) and levels fused (OR 1.10, P = 0.04). 2-year complications were significantly associated with cardiovascular disease (OR 2.85, P = 0.02). 30-day readmissions were significantly associated with sex (4.47, 0.04) and length of hospital stay (χ 2 = 0.07, P = 0.04). 2-year readmissions were significantly associated with age (χ 2 = 0.50, P = 0.03), hypertension (χ 2 = 4.64, P = 0.03), revision surgeries (χ 2 = 5.46, P = 0.02), and length of hospital stay (χ 2 = 0.07, P = 0.03).

Discussion: This study found that patients with coronary vascular disease and longer fusions were at higher risk of postoperative complications and patients with notable intraoperative blood loss were at higher risk of postoperative infections. In addition, physicians should closely follow patients with extended postoperative hospital stays, with advanced age, and undergoing revision surgery because these patients were more likely to be readmitted to the hospital.

Thoracic myelopathy can be a challenging condition to diagnose and treat. Successful outcomes depend on early recondition of the pathology and appropriate surgical referral in cases of progressive neurologic deterioration. The thoracic cord is tethered in kyphosis by the dentate ligaments and contains a tenuous blood supply. These conditions make the thoracic cord particularly susceptible to external compression and ischemic damage. Careful preoperative planning with specific attention to the location and source of thoracic stenosis is critical to successful decompression and complication avoidance. The purpose of this discussion is to outline the common sources of thoracic myelopathy and current recommendations regarding diagnosis and management. The review concludes with an overview of the most up-to-date literature regarding clinical outcomes.

Osteoarthritis (OA) is a highly prevalent, disabling, incurable, and expensive disease that is difficult to treat nonsurgically. The pharmacokinetics of drug delivery to joints are such that it is not possible to target antiarthritic agents, especially biologics, to individual joints with OA at sustained, therapeutic concentrations. More than 30 years ago, we proposed that local, intra-articular gene transfer can overcome this barrier to therapy by engineering articular cells to synthesize antiarthritic gene products endogenously. This article summarizes the progress toward this goal. Initially, a retroviral vector was used to deliver cDNA encoding the interleukin-1 receptor antagonist (IL-1Ra) to the joints of experimental animals. Using an ex vivo strategy, cultures of autologous synovial fibroblasts were genetically modified in cell culture and introduced into joints by means of intra-articular injection. Successful development of this technology led to the first-in-human gene therapy trial for arthritis. This Phase I study targeted metacarpophalangeal joints with rheumatoid arthritis. Although successful, for various reasons, subsequent research targeted OA and used adeno-associated virus as a vector to deliver IL-1Ra by direct in vivo injection into the joint. A Phase I human clinical trial has just been completed successfully in subjects with mid-stage OA of the knee, leading to a Phase Ib study that is in progress.

Robot-assisted spine surgery has gained notable popularity among surgeons because of recent advancements in technology. These innovations provide several key benefits, including high screw accuracy rates, reduced radiation exposure, customized preoperative and intraoperative planning options, and improved ergonomics for surgeons. Despite the promising outcomes reported in literature, potential technical challenges remain across various robotic platforms. It is crucial for surgeons to remember that robotic platforms are shared-control systems, requiring the surgeon to maintain primary control throughout the procedure. To ensure patient safety, surgeons should be well versed in common technical pitfalls and strategies to mitigate these limitations.