Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Understanding the role of risk-taking personality and tolerance for treatment-related complications in patients with spine pathology may help tailor surgical recommendations. The aim of this study was to develop a predictive model that integrates standard clinical metrics with psychosocial factors, specifically examining whether patients with higher risk-taking tendencies are more likely to choose high-risk, high-reward surgeries.

Methods: This cross-sectional observational study recruited 1,214 participants from the United States in January 2024 using an online crowdsourcing platform. Participants completed an 84-question survey covering demographics, disability levels, and risk-taking tendencies. They were presented with hypothetical spinal surgery scenarios featuring varying risks of complications (footdrop, paralysis, or death) and chances of improvement. Participants rated their likelihood of choosing surgery on a six-point Likert scale. Predictors included demographics, socioeconomic factors, risk-taking personality (measured by the Domain-Specific Risk-Taking survey), and baseline pain levels (measured by the Oswestry Disability Index). The XGBoost model was used for predictive analysis.

Results: The final sample included 797 (386 male, 411 female) participants. The predictive model achieved an R-squared of 0.75, root mean squared error of 0.81, and mean absolute error of 0.61. Key predictors of the likelihood to opt for surgery included lower complication risk and higher improvement probability, followed by younger age, higher body mass index, and lower scores in Domain-Specific Risk-Taking survey's financial and recreational domains.

Conclusion: Incorporating psychosocial dimensions into predictive models enhances the personalization of surgical risk discussions. This approach ensures that treatment recommendations align with patient values and risk perceptions, enabling more patient-centered care in spine surgery.

Level of evidence: Level 3 (cross-sectional study).

Background: The relationship between testosterone replacement therapy (TRT) and hip fractures remains underexplored. This study aims to investigate this relationship. We hypothesize that patients prescribed TRT experience a lower rate of hip fractures compared with a control group.

Methods: The PearlDiver Mariner165 data set was used to obtain two random cohorts of 500,000 patients. The experimental group received TRT for at least 3 months and the control group did not. We used one-to-one matching to evaluate the effects of TRT in 301,724 patients. The incidence of hip fractures was assessed over a 2-year follow-up using the International Classifications of Disease codes. Multivariable logistic regression identified the association between TRT and hip fractures. Statistical significance was set at P < 0.05.

Results: The patients in the TRT group were associated with a lower incidence of hip fractures compared with the control group (0.13% vs. 0.25%, P < 0.001). The multivariable analysis showed that TRT use was associated with a decreased incidence of hip fractures with an adjusted odds ratio (aOR) of 0.58 (95% confidence interval [CI], 0.51 to 0.66, P < 0.001). After stratifying by sex, the multivariable analysis showed that TRT use in male patients was associated with a decreased incidence of hip fractures with an aOR of 0.61 (95% CI, 0.53 to 0.72, P < 0.001); in female patients, it was associated with a decreased incidence of hip fractures with an aOR of 0.49 (95% CI, 0.38 to 0.63, P < 0.001).

Conclusion: Patients prescribed TRT had a 1.9 times lower likelihood of sustaining hip fractures. Further investigation into the association of TRT and fragility fractures garners continued interest. In addition, this can provide insight into the potential benefits of TRT use and maintaining bone health to improve bone mass and improve results of orthopaedic interventions.

Level of evidence: III.

Introduction: Standard spine surgery machine learning (ML) models often rely on structured clinical data, overlooking nuanced free text, such as preoperative surgical notes. The aims of this work were to develop a multimodal ML model combining structured electronic health record (EHR) data with natural language-processed unstructured clinical narratives.

Methods: After testing against Convolutional Neural Network, Support Vector Machine, LightGBM, and Random Forest algorithms, the XGBoost algorithm was selected for model development. Three models were developed: (1) a structured EHR-based ML model; (2) an NLP-based model using preoperative notes; (3) a combined multimodal model. Perioperative outcomes included extended length of stay (≥8.0 days) and nonhome discharge. Preprocessing included tokenization, stemming, and bag-of-words vectorization. Hyperparameters were tuned through grid search and 10-fold cross-validation. Key performance metrics included area-under-the-receiver-operating characteristic curve, Brier score, calibration slope and intercept, precision, recall, and F1 score.

Results: A total of 486 patients (58.8% female, n = 281) were included, with a median age of 61.0 years (interquartile range: 52.0 to 68.0 years) and median body mass index of 29.4 kg/m 2 (interquartile range: 25.1 to 34.5 kg/m 2 ). For extended length of stay, the multimodal model excelled (ROC-AUC: 0.908, Brier: 0.114, F1: 0.896), followed by the NLP-only model (ROC-AUC: 0.868, Brier: 0.132, F1: 0.877), and the XGBoost-only model (ROC-AUC: 0.736, Brier: 0.201, F1: 0.815). For nonhome discharge, the multimodal model led (ROC-AUC: 0.920, Brier: 0.105, F1: 0.907), compared with the NLP-only model (ROC-AUC: 0.892, Brier: 0.102, F1: 0.916) and XGBoost-only model (ROC-AUC: 0.771, Brier: 0.144, F1: 0.893). Explainable AI revealed that body mass index, age, Medicare insurance, Charlson comorbidity index, Medicaid status, Hispanic ethnicity, fusion history, and thoracolumbar and cervical levels of surgery were the most important model features.

Conclusion: Incorporating unstructured surgeon notes into ML models markedly enhanced the prediction of perioperative outcomes in spinal surgery, suggesting that free-text notes may provide greater predictive utility than standard EHR variables.

Level of evidence: III.

Transplant medications are an indispensable component of treatment for patients with autoimmune diseases, malignancy, or solid organ transplants. These immunosuppressive agents, although life preserving, create unique challenges when patients require orthopaedic surgery. With increased survival rates, immunosuppressed transplant patients frequently require orthopaedic intervention, with approximately 5% developing osteonecrosis, 15% to 20% experiencing osteoporotic fractures, and many developing degenerative joint disease necessitating arthroplasty or reconstructive procedures. By inhibiting inflammatory responses, decreasing collagen synthesis, reducing angiogenesis, and impairing cellular proliferation, transplant medications compromise normal immune function and wound healing processes. This physiological interference leads to elevated risks of surgical site infections, wound dehiscence, delayed union, and implant failure-complications resulting in prolonged hospitalization and poorer functional outcomes. Perioperative management becomes even more complex because of the two to fourfold higher incidence of malignancy in long-term immunosuppressed patients, with orthopaedic surgeons frequently treating individuals on both immunosuppressive and antineoplastic therapies. Despite the growing prevalence of orthopaedic procedures in this population, comprehensive guidance on perioperative wound healing management remains fragmented across the literature. This review systematically examines how transplant medications interfere with tissue repair mechanisms and provides evidence-based recommendations for perioperative medication adjustment to optimize surgical outcomes in this high-risk patient group.

Biologic augmentation, using substances like bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP), shows promise for improving outcomes in foot and ankle surgery, particularly in high-risk patients. Historically, autologous bone graft is the benchmark due to its trifecta of osteogenic, osteoinductive, and osteoconductive properties, despite its associated donor site morbidity. Current evidence supporting orthobiologics remains fragmented and inconclusive, with a lack of high-level randomized controlled trials (RCTs). BMAC shows fusion rates comparable to autograft in some foot and ankle applications, but PRP evidence is often conflicting due to a lack of preparation standardization. The regulatory environment is complex. The Food and Drug Administration (FDA) oversees human cells and tissues (HCT/Ps) through a tiered system: high-risk §351 products (eg, cultured stem cells) require rigorous premarket approval, whereas §361 products (eg, allograft bone) have minimal oversight. BMAC and PRP often bypass this through the Same Surgical Procedure Exemption or are regulated through their processing devices, meaning the biologics themselves are not FDA-approved therapeutics. This regulatory gap and direct-to-consumer marketing necessitate meticulous informed consent, transparently discussing the lack of specific FDA approval, limited evidence, and high out-of-pocket costs. Future success depends on standardized, prospective RCTs and a collaborative "middle-ground pathway" for regulatory approval.

Introduction: Postoperative stiffness is a common complication after total knee arthroplasty (TKA), leading to limited range of motion (ROM), pain, and reduced function. Direct oral anticoagulants (DOACs), such as factor Xa inhibitors, are commonly prescribed for venous thromboembolism (VTE) prophylaxis but may increase the risk of postoperative stiffness due to postoperative bleeding within the knee. This study seeks to evaluate the effect of postoperative VTE prophylaxis (factor Xa inhibitors vs. aspirin) on ROM outcomes in patients undergoing TKA.

Methods: A total of 1,054 patients who underwent primary TKA by the senior author between November 2021 and May 2023 were retrospectively identified from an institutional database. Records were examined at preoperative, 2-week, 6-week, <1-year, and >1-year postoperative visits. Logistic regression models analyzed ROM outcomes, defining success as 90° flexion and 0° extension at 2 weeks and 125° flexion and 0° extension at 6 weeks. Manipulation under anesthesia (MUA) was recorded as a secondary end point.

Results: Factor Xa inhibitors (apixaban or rivaroxaban) did not significantly affect ROM success at 2 weeks (OR = 0.956, 95% confidence interval [CI, 0.866 to 1.054], P = 0.364) or 6 weeks (OR = 0.986, 95% CI [0.892 to 1.089], P = 0.778) postoperatively, compared with aspirin. VTE prophylaxis type was not found to be significantly associated with MUA likelihood.

Discussion: No association was found between postoperative ROM and VTE prophylaxis medication. Previous studies used lower ROM thresholds or focused solely on MUAs. Understanding the effects of DOACs on postoperative stiffness can help guide chemoprophylaxis decisions after TKA.

Background: Ondansetron is a cornerstone medication for preventing postoperative nausea and vomiting (PONV) in numerous international guidelines. Ondansetron oral soluble pellicles (OSP) represent a needle-free PONV prophylaxis administration regimen with favorable practicality. We conducted this study to investigate the optimal dosing regimen by comparing the efficacy and safety of different doses of ondansetron OSP for preventing PONV following total joint arthroplasty (TJA).

Methods: This is a randomized, controlled, and double-masked clinical trial. A total of 198 patients were randomized into three groups: the control group receiving two placebo pellicles orally 1 hour before anesthesia induction; the preoperation (Preop) 8-mg group receiving one ondansetron OSP (8 mg) plus one placebo pellicles; and the Preop 16-mg group receiving two ondansetron OSP (16 mg total). The primary outcome was the incidence and severity (measured by visual analog scale scores) of PONV within 48 hours after TJA. The secondary outcome included the frequency of tramadol and metoclopramide and the occurrence of ondansetron adverse drug reactions.

Results: Both 8 and 16 mg ondansetron OSP markedly reduced PONV incidence. Compared with the Preop 8-mg group, the Preop 16-mg group demonstrated markedly lower PONV incidence and reduced nausea severity at all postoperative time points relative to the control group, with a greater absolute risk reduction, indicating superior prophylactic efficacy. Adverse drug reactions rates did not differ markedly between the groups.

Conclusions: Compared with placebo, ondansetron OSP effectively reduces the incidence of PONV following TJA and demonstrates a favorable safety profile. The findings suggest a trend toward better efficacy with a preoperative oral dose of 16 mg compared with 8 mg.

Trial registration: Chinese Clinical Trial Registry, ChiCTR2500097588. Registered on 21 February 2025.

Objective: There is growing evidence on the relationship between social determinants of health (SDOH) dimensions and utilization and outcomes of joint arthroplasty; however, this literature is not currently guided by a conceptual framework that is specific to this patient population. The purposes of our study were to (1) present a comprehensive evidence-driven conceptual framework of SDOH specific to hip and knee arthroplasty and (2) conduct a narrative systematic review of SDOH literature to assess the extent of SDOH coverage and inform the likely directionality of association between proposed variables and joint arthroplasty outcomes.

Methods: Existing SDOH conceptual frameworks were reviewed to identify all domains relevant to joint arthroplasty. A systematic narrative review of the hip/knee arthroplasty literature was then conducted in PubMed in accordance with PRISMA principles to inform the extent to which SDOH dimensions are covered and the directionality of associations.

Results: The final proposed conceptual framework identified seven dimensions from both Healthy People 2030 and Luong et al. Our narrative review found 25 articles, and most examined about half of the proposed SDOH domains. Only two of 26 studies accounted for all seven domains. The directionality of multivariable associations was reasonably consistent across studies for person-level dimensions but generally not for Healthy People 2030 dimensions.

Conclusion: Our proposed conceptual framework is the first to describe a comprehensive set of SDOH dimensions. Application of the framework to future research will likely lead to a comprehensive assessment of the role of SDOH in potentially influencing a variety of arthroplasty outcomes.

Increased participation in youth sports has led to a corresponding increase in throwing-related injuries among skeletally immature athletes. These injuries often stem from overuse and can in part be attributed to sport specialization leading to year-round sport participation without adequate rest and an increase in volume of practices and games during the season. Injuries that occur in skeletally immature athletes can be unique to this population due to the vulnerability of the open growth plates. Common injuries include Little League shoulder (proximal humeral epiphysiolysis), internal impingement of the shoulder, Little League elbow, medial ulnar collateral ligament injuries, and capitellar osteochondral defects. Diagnosis and management of these injuries requires a high index of suspicion from the treating physician. In addition, prevention strategies and pitching guidelines have been introduced to decrease the burden of injury on this population. Proper treatment, appropriate intervention, and a thorough understanding of injury prevention guidelines can allow these young athletes to undergo a timely recovery and return to sport participation with minimal long-term effect.

Introduction: Durability of surgical treatment is important to patients, providers, and payers. In addition to the obvious effect on clinical outcomes and satisfaction, durability is an important variable when evaluating cost-effectiveness. The purpose of this study was to analyze the prevalence and indications for revision surgery after anterior cervical discectomy and fusion (ACDF).

Methods: A multisurgeon, single-institution database was queried for revision surgery after ACDF from 2014 to 2018 with a minimum follow-up of 4 years (N = 1,652). Demographic data, surgical data, and primary indication for revision surgery were collected by medical record analysis. All statistical analyses were performed using IBM SPSS v28.0 (IBM).

Results: A total of 147 of 1,652 patients (9%) underwent unplanned revision surgery during the study period. The mean patient age was 53.6 years; the mean number of surgical levels was 1.8. The most common indication for revision surgery was nonunion (N = 94, 6%), which occurred at a mean of 33 months postoperatively. The second most common indication was adjacent segment disease (N = 37, 2%), which occurred at a mean of 24 months postoperatively. Patients who had a revision surgery for nonunion had more levels fused (2.06) compared with patients who had no revision surgery (1.65) or had surgery for adjacent segment disease (1.76) ( P < 0.001). Likewise, patients with nonunion had longer surgical time ( P < 0.001) and length of stay ( P = 0.036). Patients who underwent a revision surgery for adjacent segment disease had a higher body mass index (BMI = 33.6) compared with patients without revision surgery (BMI = 30.4) or patients who underwent revision surgery for nonunion (BMI = 31.2) ( P = 0.012). Comorbidities as measured by ASA grade did not differ between groups ( P = 0.633). Smoking status, use of anterior plate, and use of structural allograft did not differ between groups ( P > 0.05). No other differences were found among these groups. Other indications for revision surgery were much less common (<1%) and included evacuation of hematoma (N = 5), repeat decompression (N = 5), infection (N = 2), extension into the thoracic spine (N = 2), and implant reposition (N = 2).

Discussion: ACDF is a relatively durable procedure (91%) as currently indicated and performed in a large multisurgeon spine center. Early revision surgery (<90 days) for hematoma or infection is rare. Late revision surgery (>90 days) for nonunion is more than twice as common as adjacent segment disease and occurred earlier and more commonly when a greater number of levels were fused. These data can help guide clinicians and researchers in future quality improvement initiatives.