Journal of the American Academy of Orthopaedic Surgeons最新文献

Purpose: Surgeons sometimes ascribe inadequate comfort and capability after trapeziometacarpal (TMC) arthroplasty to movement of the trapezium toward the scaphoid (subsidence or reduced trapezial space height [TSH]). We asked the following: (1) What percentage of studies found a relationship between subsidence of the metacarpal toward the distal scaphoid and measures of grip strength, capability, pinch strength, pain intensity, or patient satisfaction after TMC arthroplasty and what study characteristics are associated with having notable correlation? (2) What study factors are associated with greater postoperative TSH? (3) What is the mean subsidence over time?

Methods: We conducted a systematic review by querying PubMed, Cochrane, and Web of Science databases from 1986 and onward. Using inclusion criteria of TMC arthroplasty inclusive of trapeziectomy, ligament reconstruction and tendon interposition, tendon interposition, and prosthetic arthroplasty and a measure of subsidence, 91 studies were identified.

Results: Seven of 31 study groups reported a correlation of subsidence with pinch strength, 5 of 21 with magnitude of incapability, 1 of 16 with grip strength, 2 of 20 with pain intensity, and none of 10 with satisfaction. Study factors associated with a relationship between subsidence and one of these measures included continents other than Europe. Among the 9 studies that measured TSH over time, the mean change in TSH was 5.0 mm ± 2.2 mm SD for visits less than 1 year after surgery and 5.5 mm ± SD 1.0 mm for visits 1 to 3.5 years after surgery.

Conclusion: The observation that most studies find no relationship between radiographic subsidence of an average of 5 millimeters and levels of strength, capability, comfort, or satisfaction after TMC arthroplasty suggests that primary surgeries may not benefit from a focus on limiting subsidence and revision arthroplasty ought not be offered based on this radiographic measure.

Internal hemipelvectomy is preferred to hindquarter amputation for pelvic tumor resection if a functional lower extremity can be obtained without compromising oncologic principles; multidisciplinary advances in orthopaedic and plastic surgery reconstruction have made this possible. The goals of skeletal reconstruction are restoration of pelvic and spinopelvic skeletal continuity, maintenance of limb length, and creation of a functional hip joint. The goals of soft-tissue reconstruction are stable coverage of skeletal, prosthetic, and neurovascular structures, elimination of dead space, and prevention of herniation. Pelvic resections are divided into four types: type I (ilium), type II (acetabulum), type III (ischiopubic rami), and type IV (sacrum). Type I and IV resections resulting in pelvic discontinuity are often reconstructed with vascularized bone flaps and instrumentation. Type II resections, which traditionally result in the greatest functional morbidity, are often reconstructed with hip transposition, allograft, prosthesis, and allograft-prosthetic composites. Type III resections require soft-tissue repair, sometimes with flaps and mesh, but generally no skeletal reconstruction. Extension of resection into the sacrum can result in additional skeletal instability, neurologic deficit, and soft-tissue insufficiency, necessitating a robust reconstructive strategy. Internal hemipelvectomy creates complex deficits that often require advanced multidisciplinary reconstructions to optimize outcomes and minimize complications.

Background: There has been an increase in diversity initiatives regarding selecting speakers for the American Academy of Orthopaedic Surgeons (AAOS) annual meeting and courses. The purpose of this study was to determine the percentage of female or underrepresented minority (URM) speakers for instructional course lectures (ICLs) and AAOS courses over the past 2 decades including a surrogate for expertise.

Methods: For 2002, 2012, and 2022, the academic and demographic information of speakers and the number of publications at the time of their speaking role were obtained and compared by sex and URM status. Owing to the unequal sample sizes between male versus female cohorts and URM versus non-URM cohorts, the Welch t -test was used.

Results: The percentage of ICL and AAOS course speakers who were female increased over time (ICL, AAOS courses): 2002 (2.6%, 3.3%), 2012 (3.9%, 6.3%), and 2022 (11.8%, 15.5%) ( P < 0.001, P < 0.001). The percentage of female AAOS fellows in these years was 2.9%, 4.7%, and 7.4%, respectively. For ICLs and AAOS course speakers, female presenters had fewer publications than male counterparts (ICL, AAOS courses): 2002 ( P < 0.001, P = 0.048), 2012 ( P = 0.003, P < 0.001), and 2022 ( P < 0.001, P < 0.001). For ICLs in 2022, URM speakers had a similar number of publications compared with non-URM speakers. In 2022, URMs comprised 6.9% of ICL speakers and 4% of AAOS fellows. For 2022 ICLs, there were no significant differences in academic institution, position, or region when compared by sex or URM status. For AAOS courses, the percentage of URM speakers increased over time: 2002 (1.1%), 2012 (4.5%), and 2022 (8.6%). For AAOS courses, URM presenters had similar publications compared with non-URM presenters in 2002 and 2022 but less in 2012 ( P = 0.027).

Discussion: The percentage of women and URMs presenting ICLs and AAOS courses has increased over the past 2 decades and exceeded the percentage they represent in the AAOS by over 50%. The female cohort has fewer publications, on average, than the male cohort for all years evaluated, indicating no institutional bias against female speakers.

Introduction: The Walch classification has been widely accepted and further developed as a method to characterize glenohumeral arthritis. However, many studies have reported low and inconsistent measures of the reliability of the Walch classification. The purpose of this study was to review the literature on the reliability of the Walch classification and characterize how imaging modality and classification modifications affect reliability.

Methods: A systematic review of publications that included reliability of the Walch classification reported through intraobserver and interobserver kappa values was conducted. A search in January 2021 and repeated in July 2023 used the terms ["Imaging" OR "radiography" OR "CT" OR "MRI"] AND ["Walch classification"] AND ["Glenoid arthritis" OR "Shoulder arthritis"]. All clinical studies from database inception to July 2023 that evaluated the Walch or modified Walch classification's intraobserver and/or interobserver reliability were included. Cadaveric studies and studies that involved subjects with previous arthroplasty, shoulder débridement, glenoid reaming, interposition arthroplasty, and latarjet or bankart procedure were excluded. Articles were categorized by imaging modality and classification modification.

Results: Thirteen articles met all inclusion criteria. Three involved the evaluation of plain radiographs, 10 used CT, two used three-dimensional (3D) CT, and four used magnetic resonance imaging. Nine studies involved the original Walch classification system, five involved a simplified version, and four involved the modified Walch. Six studies examined the reliability of raters of varying experience levels with none reporting consistent differences based on experience. Overall intraobserver reliability of the Walch classifications ranged from 0.34 to 0.92, and interobserver reliability ranged from 0.132 to 0.703. No consistent trends were observed in the effect of the imaging modalities or classification modifications on reliability.

Discussion: The reliability of the Walch classification remains inconsistent, despite modification and imaging advances. Consideration of the limitations of the classification system is important when using it for treatment or prognostic purposes.

Sideline medical care is typically provided by musculoskeletal specialists and orthopaedic surgeons with varying levels of training and experience. While the most common sports injuries are often benign, the potential for catastrophic injury is omnipresent. Prompt recognition of sideline emergencies and expeditious medical management are necessary to minimize the risk of calamitous events. Paramount to successful sideline coverage are both preseason and game-day preparations. Because the skillset needed for the sideline physician may involve management of injuries not commonly seen in everyday clinical practice, sideline providers should review basic life support protocols, spine boarding, and equipment removal related to their sport(s) before the season begins. Before every game, the medical bag should be adequately stocked, location of the automatic external defibrillator/emergency medical services identified, and introductions to the trainers, coaches, and referees made. In addition to musculoskeletal injuries, the sideline orthopaedic surgeon must also be acquainted with the full spectrum of nonmusculoskeletal emergencies spanning the cardiopulmonary, central nervous, and integumentary systems. Familiarity with anaphylaxis as well as abdominal and neck trauma is also critical. Prompt identification of potential life-threatening conditions, carefully orchestrated treatment, and the athlete's subsequent disposition are essential for the team physician to provide quality care.

Introduction: To improve the delivery of value-based health care, a deeper understanding of the cost drivers in hand surgery is warranted. Time-driven activity-based costing (TDABC) offers a more accurate estimation of resource utilization compared with top-down accounting methods. This study used TDABC to compare the facility costs of open carpal tunnel release (OCTR) and endoscopic carpal tunnel release (ECTR).

Methods: We identified 845 consecutive, unilateral carpal tunnel release (516 open, 329 endoscopic) surgeries performed at an orthopaedic specialty hospital between 2015 and 2021. Itemized facility costs were calculated using a TDABC algorithm. Patient demographics, comorbidities, surgical characteristics, and itemized costs were compared between OCTR and ECTR. Multivariate regression was used to determine the independent effect of endoscopic surgery on true facility costs.

Results: Total facility costs were $352 higher in ECTR compared with OCTR ($882 versus $530). ECTR cases had higher personnel costs ($499 versus $420), likely because of longer surgical time (15 versus 11 minutes) and total operating room time (35 versus 27 minutes). ECTR cases also had higher supply costs ($383 versus $110). Controlling for demographics and comorbidities, ECTR was associated with an increase in personnel costs of $35.74 (95% CI, $26.32 to $45.15), supply costs of $230.28 (95% CI, $205.17 to $255.39), and total facility costs of $265.99 (95% CI, $237.01 to $294.97) per case.

Discussion: Using TDABC, ECTR was 66% more costly to the facility compared with OCTR. To reduce the costs related to endoscopic surgery, efforts to decrease surgical time and negotiate lower ECTR-specific supply costs are warranted.

Level of evidence: Economic and Decision Analysis Level II.