Journal of the American Academy of Orthopaedic Surgeons最新文献

Objective: This study aims to examine the use of dexmedetomidine (DEX) combined with propofol in hip fracture surgery and its effect on postoperative pain and hemodynamics.

Methods: One hundred forty patients undergoing hip fracture surgery were divided into a treatment group (receiving DEX combined with propofol anesthesia) and a control group (receiving propofol anesthesia). The Ramsay Sedation Scale was used to evaluate the sedative effect 24 hours postoperatively, while the Visual Analog Scale was used to assess the analgesic effect 24 hours after surgery. The Montreal Cognitive Assessment (MoCA) scale was used to evaluate cognitive function before and 24 hours after surgery. Heart rate (HR) and mean arterial pressure (MAP) were recorded at different stages of anesthesia, and the incidence of postoperative adverse reactions was also recorded.

Results: Compared with the control group, at 24 hours postoperatively, patients in the treatment group had higher Ramsay sedation scores and lower Visual Analog Scale scores ( P < 0.05). Before surgery, the MoCA scores of both groups showed no significant difference ( P > 0.05), but the treatment group had higher MoCA scores 24 hours after surgery compared with the control group ( P < 0.05). No difference was observed in HR and MAP levels before anesthesia between the two groups ( P > 0.05), while the treatment group performed lower MAP and HR levels than the control group at skin incision and at the end of surgery ( P < 0.05). In addition, the incidence of postoperative adverse reactions was lower in the treatment group than in the control group ( P < 0.05).

Conclusion: DEX combined with propofol for composite anesthesia in hip fracture surgery effectively meets the requirements for surgical anesthesia, maintains hemodynamic stability, and exhibits good postoperative analgesic and sedative effects.

Orthopaedic surgery is widely perceived as one of the most demanding medical specialties, with long work hours, heavy surgical volumes, and extensive administrative responsibilities often leaving little room for personal needs. This environment has perpetuated a myth that work-life balance is incompatible with professional excellence. Consequently, burnout, manifested by emotional exhaustion, depersonalization, and a diminished sense of accomplishment, has become pervasive among both residents and attending surgeons. Despite a growing awareness of burnout's effect, many existing interventions fall short because they focus on surface-level solutions, such as mandatory wellness seminars, rather than addressing the systemic and cultural elements that sustain chronic stress. This narrative review critically examines the misconceptions that deter surgeons from pursuing healthier work-life integration. It also illustrates how deeply ingrained beliefs, such as equating balance with reduced commitment, hinder meaningful progress. Drawing on experiences from diverse orthopaedic models, the review highlights successful strategies that include redesigning clinical workflows to reduce after-hour documentation, fostering mentorship networks that address trainees' individual needs, and implementing flexible scheduling policies to ensure adequate rest and recovery. These strategies move beyond quick fixes to target the root causes of burnout, offering a blueprint for cultivating a sustainable culture of well-being within orthopaedics.

Osteochondritis dissecans (OCD) of the elbow occurs mainly in adolescents and young adults. It can be debilitating and difficult to manage. It occurs frequently in the capitellum of athletes who experience repetitive stress on the elbow, such as gymnasts and overhead throwers. OCD of the elbow produces insidious pain that can be deep and difficult to localize. Patients with free floating cartilage experience catching or locking sensation in the elbow throughout range of motion. Lesions can be characterized as stable, partially detached, or completely detached (fragmentation with free bodies in the elbow). Evaluation of these OCD lesions includes radiography, ultrasonography, CT, and magnetic resonance imaging. Nonsurgical treatment of OCD lesions is commonly used for stable lesions, with protective weight bearing or complete immobilization for at least 4 weeks and progression to full activity over 6 months. Recently, casting with immobilization has shown to be effective in the management of stable lesions. Surgical management is indicated for lesions that are unstable, produce mechanical symptoms, or have failed nonsurgical treatment. Surgery includes arthroscopic and open procedures such as microfracture, fragment removal, autologous chondrocyte implantation, osteochondral autograft transplantation (OAT), wedge osteotomy, osteochondral allograft, and ultrapurified alginate gel with grafting.

Background: There are more than 100 million obese American individuals, with number expected to rise. Lumbar stenosis is a neurodegenerative disease causing narrowing of the spinal canal. Little is known about the role of obesity in the pathophysiology of spinal stenosis. Therefore, the purpose of this study was to analyze patient body mass index (BMI) and radiologic measurements of (1) spinal canal width; (2) thickness of ligamentum flavum and (3) spinal canal cross-sectional area at spinal levels of L2-3, L3-4, and L4-5, respectively, to determine whether there exists a correlation between obesity and the development of lumbar spinal stenosis.

Methods: Hospital data from January 1, 2016, to December 31, 2021, were used to identify patients who underwent a lumbar MRI to determine the development of radiological lumbar spinal stenosis. Patients older than 17 years and whose BMI's ranged from <20 to >40, who had complete lumbar MRIs, with no preexisting bony pathology, neoplasm, or previous lumbar surgery were included in this study. We assessed the thickness of the ligamentum flavum, width of the spinal canal, and the cross-sectional area of spinal canal at the level of the facet joint. Linear regression models were performed on each assessed variable at each spinal level measured.

Results: A significant negative association was found between BMI and spinal canal width at all levels measured (L2-3: B = -0.31, P < 0.001; L3-4: B = -0.29, P < 0.001; L4-5: B = -0.27, P < 0.001). No significant association was found between BMI and thickness of the ligamentum flavum ( P = 0.94 at L2-3; P = 0.70 at L3-4; P = 0.62 at L4-5). Furthermore, no significant association was found between BMI and cross-sectional area of the spinal canal ( P = 0.43 at L2-3; P = 0.55 at L3-4; P = 0.22 at L4-5).

Conclusion: This study found that patients with elevated BMI have decreased lumbar spinal canal width and provides new insight into the role of obesity in neurodegenerative diseases.

Levels of evidence: III.

The posterior cruciate ligament (PCL) is crucial for normal knee kinematics and stability. An improved understanding of the long-term consequences of PCL injuries has led to greater focus on accurate injury diagnosis and improvements in surgical instrumentation and techniques. However, controversy remains regarding indications for surgical versus nonsurgical management, as well as optimal surgical techniques such as PCL repair versus reconstruction, single-bundle versus double-bundle reconstruction, transtibial versus tibial inlay fixation, and graft choice. Recognition of concomitant injuries and posterior tibial slope, as well as considerations in pediatric patients, warrants additional attention to ensure satisfactory outcomes. The purpose of this review was to evaluate the current state of the literature on PCL injuries and variables associated with injury decision making based on reported outcomes.

Introduction: Clinical guidelines rely heavily on expert opinions and institution protocols to provide recommendations for administration of systemic antibiotic prophylaxis for open extremity fractures to prevent fracture-related infections. The purpose of this study was to determine evidence-based (1) durations; (2) types; (3) dosing regimens of systemic perioperative antibiotic prophylaxis following Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity open fractures, and isolated lower extremity open fractures to prevent fracture-related infections.

Methods: Guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analysis, Cochrane, and the GRADE approach were implemented to structure and synthesize this study. Five databases (PubMed, Cochrane Library, Web of Science, Scopus, CINAHL) were systematically and independently searched for randomized controlled trials (RCTs) meeting eligibility criteria. Included patients had open extremity fractures and were treated with prophylactic systemic antibiotics administered perioperatively (preoperative, intraoperative, postoperative). Meta-analyses were done of the data.

Results: Twenty-one (n = 21) RCTs met eligibility criteria (Gustilo-Anderson type I = 6, Gustilo-Anderson type II = 4, Gustilo-Anderson type I/II = 12, Gustilo-Anderson type III = 4, Gustilo-Anderson type I/II/III = 21). Summary tables were generated to provide evidence-based durations and types of systemic antibiotic prophylaxis after Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity (hand) open fractures, and isolated lower extremity open fractures.

Discussion: Although data were derived primarily from older studies, we summarized the strongest available evidence from RCTs for antibiotic prophylaxis following Gustilo-Anderson types I, I/II, II, III, and I/II/III, for upper and lower extremity open fractures, isolated upper extremity open fractures, and isolated lower extremity open fractures.

Introduction: Nonsurgical management is the standard of care for most distal radius fractures involving the epiphyseal plate. However, because of the lack of remodeling potential in adolescents, nonanatomic reduction can result in a symptomatic malunion necessitating late complex surgical correction. Guidelines outlining optimal management strategies for SH2 distal radius fractures in the adolescent population are needed.

Methods: This study is a retrospective review of isolated SH2 distal radius fractures from two, large, regional, referral pediatric ACS trauma level 1 hospitals between 2017 and 2020 in patients aged 9 to 18 years. Patients were identified by Current Procedural Terminology coding associated with their fracture management. Demographics, timing and type of treatment, and fracture displacement at relevant time points were recorded. Bivariate analysis was used to identify predictors of decision for acute surgery and/or correlates with the need for malunion correction. A Classification and Regression Tree model was fit to identify predictors of surgeon decision making for acute surgical intervention.

Results: Sixty (11%) of 556 patients underwent acute surgical intervention following closed reduction. Seventeen cases (3%) were done to correct late malunion. A Classification and Regression Tree model correctly classified the decision for acute surgery in 77% of patients using sagittal translation post reduction of ≥35% followed by age at injury of ≥12 years. The decision for acute surgery included older patients (median age 13.8 vs. 12.6 years, P < 0.001), with greater coronal (11.6% vs. 0%, P < 0.001) translation, sagittal (30% vs. 0%, P < 0.001) translation and increased dorsal tilt (5.2° vs. 0°, P < 0.001).

Conclusion: Decision for acute surgical intervention of SH2 distal radius fractures is done most often with persistent deformity of sagittal translation ≥35% in patients ≥12 years following closed reduction at the time of injury. Additional parameters are identified as associated with the decision for acute surgery and progression to symptomatic malunion.

Introduction: Cervical disk arthroplasty (CDA) has emerged as a motion-preserving alternative to anterior cervical diskectomy and fusion, offering the potential to reduce adjacent segment degeneration while maintaining cervical spine mobility. Although previous studies have highlighted the increasing adoption of CDA, trends within the broader Medicare population, including those enrolled in Medicare Advantage (MA), remain less defined. This study retrospectively analyzed Medicare Part B National Summary data from 2009 to 2022 to assess historical utilization patterns of single-level and multilevel CDA and applied statistical modeling to project future procedure volumes through 2040.

Methods: Medicare Part B National Summary data from 2009 to 2022 were analyzed to quantify single-level and multilevel CDA procedure volumes. Data adjustments accounted for MA enrollment using established correction factors. Forecasting models-including log-linear, Poisson, negative binomial regression, and autoregressive integrated moving average-were applied to project utilization trends. Model performance was assessed using mean absolute error and root mean square error. The Poisson regression model was selected for final projections due to its optimal balance of predictive accuracy and stability.

Results: From 2009 to 2022, single-level CDA volume increased by 1,454% (108 to 1,679 cases), while multilevel CDA volume grew by 609.5% from 2015 to 2022 (147 to 1,042 cases). Forecasting projected a 23.5% annual growth rate for single-level CDA and 24.4% for multilevel CDA through 2040. By 2040, single-level CDA is expected to reach 96,430 procedures annually (95% confidence interval, 95,822 to 97,039), while multilevel CDA will reach 63,362 procedures (95% confidence interval, 62,869 to 63,856).

Conclusion: CDA utilization among all Medicare beneficiaries, including those enrolled in MA, has grown substantially and is projected to continue increasing through 2040. These trends reflect rising demand for motion-preserving cervical spine procedures and highlight the importance of healthcare planning, surgeon training, and equitable reimbursement policies to accommodate future growth.

Rotator cuff repair (RCR) failure and retear remain a persistent problem and concern in shoulder surgery. Successful healing is paramount for long-term functional results. Failure of rotator cuff healing can be broadly separated into biologic and structural complications. Biologic issues include poor host variables such as healing ability and blood flow. Structural problems include tendon thinning and loss as well as poor time-zero fixation. Recently, commercial grafts or "patches" designed for rotator cuff augmentation have increased dramatically. Various grafts aim to enhance biology, provide structure, or both. In addition, grafts are designed to be placed either on-lay, over an RCR, or interpositional, at the bone-tendon interface. Graft may be allograft, xenograft, or fully synthetic. This article discusses the current RCR augmentation graft types and representative products currently available.