Journal of the American Academy of Orthopaedic Surgeons最新文献

Postoperative urinary retention (POUR), the inability to urinate spontaneously after surgery, affects up to 43% of orthopaedic patients and can lead to pain, bladder injury, urinary tract infections, increased healthcare costs, and delayed rehabilitation. POUR arises from decreased neurologic signaling, reduced bladder sensation and contractility, or mechanical obstruction. Risk factors include advanced age, prior urinary retention, comorbidities (eg, benign prostatic hyperplasia, diabetes, renal dysfunction), anesthesia type, perioperative opioid use, and catheterization. Despite its prevalence, standardized management approaches for POUR are lacking within orthopaedic literature. We propose a structured, evidence-based protocol to be used by orthopaedic surgeons that is centered on specific time and bladder volume thresholds to guide interventions including noninvasive techniques to promote spontaneous voiding, bladder scans, straight catheterization, placement/removal of indwelling catheters, and urology consultation for persistent POUR. The protocol aims to reduce complications, such as infections and bladder injury, by addressing patient- and procedure-specific risk factors, particularly in high-risk groups such as pediatric patients with neuromuscular conditions and geriatric patients undergoing hip fracture fixation.

Objectives: There is a burgeoning body of research suggesting a possible relationship between thyroid function and carpal tunnel syndrome (CTS). This study aimed to investigate the potential causal relationship between various aspects of thyroid function and CTS using a two-sample mendelian randomization (MR) approach. However, their causal relationship has yet to be conclusively determined.

Methods: Using summary data from extensive genome-wide association studies, we conducted a two-sample MR analysis to investigate the potential genetic causal relationship between thyroid function-encompassing hyperthyroidism, hypothyroidism, thyroid-stimulating hormone, free thyroxine (FT4), free triiodothyronine, total triiodothyronine, and their ratios (free triiodothyronine/FT4 and total triiodothyronine/FT4)-and CTS. Our analytical strategy included the inverse-variance weighted (IVW) method, supplemented by MR-Egger regression, weighted median, and weighted mode analyses, with the IVW method regarded the primary analytical approach. Sensitivity analyses were done using Cochran Q test, the MR pleiotropy residual sum and outlier test, MR-Egger regression, and the leave-one-out method.

Results: Robust sets of genetic instrumental variables were identified for different aspects of thyroid function using stringent selection criteria (including F-statistics >10). The IVW method, relying on genome-wide association studies summary data for thyroid function, did not provide evidence a supporting causal effect of genetically predicted thyroid function on CTS (all P > 0.05). Despite observed heterogeneity and pleiotropy in some relationships, the overall findings were consistent and robust across all sensitivity analyses.

Conclusion: Our two-sample MR analysis did not establish a potential causal relationship between thyroid function and CTS, highlighting the necessity for further studies to clarify the complex interplay between these two entities.

Background: Chronic hip abductor insufficiency remains a challenging problem to treat and can result in notable disability in some patients. The use of allograft has become an increasingly common option for surgical reconstruction. The purpose of this systematic review was to analyze the clinical outcomes, complications, and revisions rates of patients who underwent allograft reconstruction for irreparable hip abductor tears.

Methods: PubMed (MEDLINE), Scopus (EMBASE, MEDLINE, COMPENDEX), and Cochrane databases were used to conduct a systematic review. A total of five studies were included, comprising three that used a dermal allograft, one that used an Achilles tendon allograft with a calcaneal bone block, and one that used an extensor mechanism of the knee allograft. Demographics, hip setting (native hip, primary total hip arthroplasty [THA], revision THA), patient-reported outcome measures, presence of Trendelenburg sign, use of walking aids, abduction strength, complication rates, and revision rates were analyzed.

Results: A total of 76 patients (76 hips) underwent hip abductor reconstruction with allograft. The mean age was 63.2 years with 84.2% being female. The mean follow-up was 23.6 months. Four studies reported changes in preoperative to postoperative patient-reported outcome measures, all of which demonstrated an improvement in outcomes. The mean preoperative reported abduction strength was 2.7/5, which improved to 3.9/5 postoperatively (P < 0.001). Two studies demonstrated a persistent postoperative Trendeleburg sign in more than one third of patients. The complication and revision rates were 5.3% (4/76) and 1.3% (1/76), respectively.

Conclusion: Allograft reconstruction is a salvage procedure for a challenging problem that provides satisfactory clinical outcomes in patients with chronic hip abductor insufficiency not amendable to primary repair. Complication and revision rates were notably low. Future research should compare the clinical outcomes of allograft reconstruction with other muscle transfer techniques to determine the optimal surgical treatment for chronic hip abductor deficiency.

Background: Acromial and scapular spine fractures following reverse total shoulder arthroplasty (rTSA) occur with prevalence rates ranging from 0.8% to 7.2%.1-5 This study aimed to identify radiographic risk factors for the development of scapular stress fractures following primary rTSA and to provide quantifiable recommendations for surgeons to decrease risk for stress fracture.

Methods: This was an institutional review board‑approved retrospective case-control study. Electronic medical records were screened for patients who underwent a rTSA from 2010 to 2021. Patients with stress fractures were then matched in a 3:1 ratio for a comparison control group. Radiographs were analyzed and compared at multiple time points.

Results: Patients developed a fracture at a median of 3.4 months postoperatively (n = 14, mean age = 76 years, 79% female) and were compared with matched controls who did not (n = 42, mean age = 76 years, 79% female). Minimal radiographical differences were seen except in those who developed a fracture of lower Hamada classification (1 to 3 vs. 4 to 5) preoperatively (P = 0.005) and wider acromion to lateral humerus distance postoperatively (P = 0.034). Regarding pre- to postoperative change, the fracture group had an increase in acromion to lateral humerus distance by 2.3 mm, whereas the control group had a reduction by 3 mm (P = 0.024). These two variables alone were 80.4% accurate in predicting fractures on logistic regression. For the acromion to lateral humerus distance, receiver operator characteristic analysis identified 9.78 mm as the most discriminant cutoff (area under curve = 0.690).

Conclusion: In our study, the distance from the lateral edge of the acromion to the lateral humerus was a useful tool for identifying risk of acromial fracture. Based on these findings, our current practice is to avoid lateralizing beyond an acromion to lateral humerus distance of 10 mm and to use unicortical screw fixation in the superior half of the glenoid to avoid creation of a stress riser in the scapular spine.

Level of evidence: III.

Orthopaedic surgical decision making is a combination of clinical intuition, radiological measurements, and referenced standards. As clinicians and researchers, we consider hip pathology as a mechanical problem described in geometric and statistical language. For a clinical measurement to be useful, it must be easy to perform, reproducible, and demonstrably associated with the risk of the condition it seeks to diagnose or prevent. Using acetabular dysplasia as an analytic lens, this review discusses what our radiographs actually tell us about hip morphology risk, by separating population reference ("normative") intervals from outcome-anchored decision limits and by tracing the evidentiary lineage of the field's workhorse measurements. We revisit the origins, current use, and statistical power of the lateral center-edge angle, acetabular index/Tönnis angle, femoral head extrusion index, and Graf ultrasonography classification and synthesize what is known about their reproducibility and what clinical decisions can appropriately be made. We examine how nomenclature drift fuels routine miscommunication and show that superficially similar measurements are often tied to reference datasets they were neither derived from nor validated against. The current, normal or not, phenotypic model of risk allocation is considered, and the alternative of a continuous, dose-response relationship is proposed. The aim of this narrative review is to prompt clinicians and researchers to consider has our use of legacy morphological risk models actually curtailed osteoarthritis progression in conditions such as hip dysplasia and can we continue to depend on them? Or do models grounded more in lineage than validation now warrant a fundamental reconstruction.

Purpose: Radial styloid fractures may occur in isolation or as part of complex intra-articular distal radius injuries. Fixation can be achieved using either a cannulated screw or a radial plate. This study aimed to compare these two fixation techniques with respect to surgical time, fracture union, and postoperative complications in patients with isolated radial styloid fractures, thereby eliminating confounding factors related to associated injuries.

Methods: Between 2024 and 2025, a retrospective study was conducted involving 20 patients (mean age, 37.6 ± 6.9 years) with isolated radial styloid fractures. Patients were assigned to undergo open reduction and internal fixation using either a cannulated screw (group A, n = 10) or a radial plate (group B, n = 10). All patients were followed for 6 months. The primary outcomes included surgical time, fracture union, and postoperative complications.

Results: Group A demonstrated a markedly shorter surgical time than group B (34.4 ± 2.4 minutes vs 50.6 ± 3.9 minutes; P < 0.05) and achieved faster fracture union (6.7 ± 0.7 weeks vs 7.6 ± 1.0 weeks; P < 0.05). Temporary extensor tendinitis and implant irritation occurred slightly more frequently in group B (10% vs 0%), although this difference was not statistically significant. The incidence of transient superficial radial neuritis was similar between the groups (10%).

Conclusion: Cannulated screw fixation for isolated radial styloid fractures is a reliable and efficient alternative to radial plate fixation. It provides shorter surgical time, earlier fracture union, and comparable complication rates while minimizing soft-tissue dissection.

Background: Short- to midterm outcomes following anatomic total shoulder arthroplasty (aTSA) are well documented. However, few studies to date have reported on long-term outcomes following aTSA. The purpose of this study was to investigate and report the long-term clinical, functional, and radiographic outcomes of patients who underwent anatomic aTSA at our institution.

Methods: Patients who underwent aTSA with a minimum of 10.0 years of follow-up were included. Range of motion (ROM; forward elevation, external rotation, internal rotation), patient-reported outcomes (American Shoulder and Elbow Surgeons score, simple shoulder test, and visual analog scale scores), and radiographic variables (glenoid morphology, lateral humeral offset, acromiohumeral interval, and humeral lucency) were recorded. Implant failure-free survival was defined as shoulders requiring no revision surgeries following primary aTSA.

Results: Seventy-eight patients (78 shoulders) were included with an average age at surgery of 63.2 ± 8.4 years and a mean follow-up of 15.0 ± 4.5 years. All measurements of ROM saw notable preoperative to postoperative improvements. Overall, forward elevation improved from 118.8° ± 23.9° preoperatively to 147.6° ± 22.6° postoperatively (P < 0.01). External rotation improved from 22.3° ± 25.8° to 54.7° ± 18.6° (P < 0.01); internal rotation improved from L4 to T12 (P < 0.01). American Shoulder and Elbow Surgeons scores improved from 34.8 ± 21.6 preoperatively to 72.6 ± 23.0 postoperatively (P < 0.01). Simple shoulder test scores improved from 3.5 ± 2.6 preoperatively to 8.1 ± 3.4 postoperatively (P < 0.01). Visual analog scale pain scores improved from a mean preoperative score of 6.4 ± 2.7 to a mean postoperative score of 2.3 ± 2.8 (P < 0.01). Implant survivorship was 97% at 10 years and 72% at 20 years.

Conclusion: aTSA provides long-term improvements in pain scores, ROM, and shoulder function. Implant survivorship was excellent and demonstrated aTSA results to be durable at 20 years postoperatively.

Level of evidence: IV.

Background: Tandem spinal stenosis (TSS) is characterized by stenosis in two or more noncontiguous spinal regions. Surgical management may involve simultaneous decompression or staged procedures; however, no universally accepted decision-making algorithm exists.

Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. PubMed, Scopus, and EMBASE databases were searched for studies reporting outcomes of simultaneous and/or staged surgery for TSS. Fifteen studies were included in the qualitative review, and 12 were eligible for meta-analysis. Surgical strategies were compared based on postoperative functional outcomes.

Results: A total of 1,006 interventions (604 staged and 402 simultaneous) were analyzed. Overall, significant postoperative improvement in Japanese Orthopaedic Association scores was observed (pooled SMD, 2.87; 95% CI, 1.88 to 3.86). Subgroup analysis demonstrated the greatest improvement with staged surgery using a cervical-first approach (SMD, 4.31; 95% CI, 3.87 to 4.76; I2 = 0%), followed by simultaneous surgery (SMD, 2.65; 95% CI, 1.76 to 3.53). Lumbar-first staged surgery showed smaller and statistically negligible improvement (SMD, 1.94; 95% CI, -1.69 to 5.56). Complication rates were higher in older patients and in those with longer operative times and greater estimated blood loss.

Conclusions: Surgical strategy for TSS should be individualized. In the presence of myelopathy, staged surgery prioritizing cervical decompression is recommended. In the absence of myelopathy, simultaneous decompression may be considered in patients who can tolerate longer operative times. We propose a treatment algorithm to guide surgical decision-making based on symptom predominance, presence of myelopathy, and patient comorbidities.

Musculoskeletal injuries severe enough to warrant hospitalization commonly co-occur with alcohol misuse and posttraumatic stress disorder (PTSD) symptoms, complicating recovery (return of comfort and capability). Nearly half of trauma patients have detectable alcohol at injury, and over one in five exhibit symptoms of PTSD during recovery. These co-occurring conditions are associated with greater levels of pain intensity and incapability, limited participation in exercises, and adverse events and hospital readmissions. Routine screening and brief interventions such as Screening, Brief Intervention, and Referral to Treatment for alcohol misuse and standardized self-report screening tools such as the Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) have established clinical utility; however, implementation within orthopaedic practice remains inconsistent because of resource limitations, clinician uncertainty, and fragmented care coordination. Integrated, technology-enhanced interventions incorporate psychoeducation, coping-skills training, motivational interviewing, and personalized feedback to concurrently address alcohol misuse, PTSD symptoms, and pain. Digital health platforms-including telehealth and mobile applications-may help overcome barriers to implementing integrated interventions in orthopaedic trauma settings, thereby supporting widespread use and long-term sustainability. Adopting multidisciplinary care pathways tailored to individual risk profiles may facilitate implementation of these interventions, enhancing clinical efficiency, patient adherence, and orthopaedic recovery outcomes.

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been linked to improved outcomes following total knee arthroplasty (TKA). However, it remains unclear whether the observed benefits are attributable to weight loss, glycemic control, or first-line type 2 diabetes mellitus (T2DM) medications such as metformin. This study aimed to evaluate the impact of perioperative GLP-1RA use on TKA outcomes in T2DM patients stratified by obesity status.

Methods: The TriNetX Global Collaborative Network was queried using relevant Current Procedural Terminology and ICD-10 codes for metformin-treated T2DM patients aged 18 years or older undergoing primary TKA. Patients were divided into two groups based on obesity status and further stratified based on GLP-1RA use within three months of surgery. The groups were propensity matched (1:1) based on age, sex, body mass index (BMI), HbA1c, and comorbidities. Surgical outcomes, medical complications, and resource utilization were assessed at 90 days and 1 year. Surgical outcomes and revision rates were also assessed at two years.

Results: In obese patients (n = 8,170), GLP-1RA use was associated with notable reductions in postoperative anemia (odds ratio [OR] 0.714; P = 0.001), acute kidney injury (OR 0.755; P = 0.021), 90-day readmission (OR 0.776; P = 0.001), emergency department (ED) visits (OR 0.836; P = 0.008), and aseptic loosening at two years (OR 0.498; P = 0.037). These patients also demonstrated greater postoperative reductions in BMI and HbA1c. In nonobese patients (n = 1,328), GLP-1RA use was similarly associated with lower rates of 90-day readmission (OR 0.514; P = 0.004) and ED visits (OR 0.649; P = 0.024), although no notable differences in other outcomes were observed.

Conclusion: Among metformin-treated T2DM patients undergoing TKA, GLP-1RA use was associated with reduced resource utilization irrespective of obesity. However, additional reductions in medical complications and aseptic loosening were observed in the obese group, suggesting a potential synergistic effect between weight loss and glycemic control. These findings highlight the effectiveness of GLP-1RAs in optimizing high-risk candidates undergoing TKA.