Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Total knee arthroplasty (TKA) is a well-established treatment option for advanced knee osteoarthritis, yet some patients remain unsatisfied after surgery. Evaluation of various psychosocial parameters may improve patient optimization and outcomes. The primary aim was to assess whether preoperative resilience remained stable and influenced decision regret postoperatively while the secondary aim was to evaluate its correlation with joint-specific and global health patient-reported outcome measures.

Methods: A total of 1,269 patients undergoing elective unilateral TKA were included. Patients completed the Brief Resilience Scale preoperatively and postoperatively and were stratified into low, normal, and high resilience cohorts. Decision regret scale scores were obtained postoperatively, and patients were stratified into no regret, mild regret, and moderate/severe regret cohorts. Patients' knee pain and function were assessed using the Knee Osteoarthritis Outcome Score Joint Replacement survey. Physical and mental quality of life was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS-10).

Results: Preoperatively, 8% of patients were categorized as having low resilience, 67% had normal resilience, and 25% had high resilience. Resilience among each cohort remained relatively static. A statistically significant negative correlation between Brief Resilience Scale and decision regret scale scores was observed at 12-month follow-up (P < 0.001). The high resilience cohort demonstrated the lowest decision regret scale scores at all time points. The low resilience cohort reported higher decision regret scale scores at all time points but had the most improvement over the 12-month follow-up (P < 0.001). Knee Osteoarthritis Outcome Score Joint Replacement scores had a weak-to-low positive correlation with preoperative resilience (r = 0.29, P = 0.05). Preoperative resilience had a low positive correlation with PROMIS-10 Physical scores (r = 0.36, P < 0.05), but a moderately strong positive correlation with PROMIS-10 Mental scores (r = 0.47, P < 0.05).

Conclusion: Preoperative resilience can markedly influence decision regret after TKA. These findings are valuable because they can help surgeons appropriately counsel patients, leading to improved satisfaction after surgery.

Introduction: Lower estimated glomerular filtration rate (eGFR) in patients who have chronic kidney disease (CKD) is associated with increased risk of complications following total knee arthroplasty (TKA). However, there is a lack of literature that identifies eGFR levels those are associated with notable differences in risk of these complications. The purpose of this study was to create eGFR strata for CKD patients that are associated with varying risks of 90-day major complications following TKA.

Methods: Nondialysis patients who have CKD and known eGFR levels one month before primary TKA were identified using a national database. Stratum-specific likelihood ratio (SSLR) analysis was used to construct data-driven eGFR strata associated with varying risks of 90-day major complications. The incidence rates were recorded for each stratum. Each stratum was propensity score matched to the highest eGFR stratum. The risk ratio with a corresponding 95% confidence interval for 90-day major complications was recorded for each stratum.

Results: A total of 24,895 patients with CKD who underwent TKA were included in this study. SSLR identified four data-driven eGFR strata: 15-31, 32-44, 45-54, and 55+. The unmatched 90-day major complication incidence increased sequentially as the eGFR strata decreased: 55+ (10.72%), 45-54 (13.87%), 32-44 (17.30%), and 15-31 (25.16%). When compared with the matched highest eGFR strata (55+), the risk of sustaining a 90-day major complication increased sequentially as the eGFR strata decreased (RR: 1.27, 1.56, 2.06, P < 0.001). The risk of death within 90 days was higher in the 15-31 stratum (RR: 3.08, P < 0.001) when compared with the matched 55+ stratum.

Conclusion: Using SSLR analysis, four data-driven strata were identified with varying risks of 90-day major complications following TKA. These eGFR thresholds were created specifically for TKA and can therefore be appropriately used to risk-stratify CKD patients in the preoperative setting when discussing TKA.

Introduction: Food insecurity is the condition of limited access to healthy and safe food. Malnutrition resulting from food insecurity is a concern particularly in the surgical population due to the association with impaired healing. This aim of this study was to report the incidence and risk factors for food insecurity in the orthopaedic trauma population.

Methods: Orthopaedic trauma centers at three distinct regions of the United States enrolled patients who had undergone extremity or pelvis fracture fixation within the previous 6 months. Participants completed the United States Department of Agriculture Household Food Insecurity Survey, and food insecurity was defined as a score ≥3. In addition, participants recorded patient demographics and injury/treatment/household characteristics and completed information about diet quality. Diet quality was compared between households with and without food insecurity using chi-square or Fisher exact tests. Logistic regression was used to create a multivariable model of factors associated with greater odds of food insecurity.

Results: Food insecurity was documented in 11.5% (81/703) of households. Households with food insecurity were less likely to report daily consumption of fruit, vegetables, and protein-rich foods. We found a greater odds of food insecurity among households with a yearly income of <$50,000 (odds ratio = 4.30 [95% confidence interval = 2.07 to 8.92], P < 0.001), tobacco use (2.33 [1.26 to 4.28], P = 0.007), Medicaid or no insurance (2.34 [1.19 to 4.62], P = 0.014), and Hispanic or Latino ethnicity (4.55 [1.69 to 12.24], P = 0.003), for each 10-year decrease in age (1.19 [1.00 to 1.40], P = 0.045), multiple surgically treated fractures (2.41 [1.08 to 5.35], P = 0.031), and for each additional 15 minutes of travel time to the nearest grocery store (2.12 [1.37 to 3.26], P < 0.001).

Conclusion: Food insecurity is common in the orthopaedic trauma population, and households with food insecurity are more likely to have low diet quality. Nutrition supplementation during the healing phase after trauma and referral to nutrition assistance programs has the potential to mitigate malnutrition and prevent negative outcomes resulting from food insecurity.

Introduction: Clinical outcome measures used under value-based reimbursement models require risk stratification of patient demographics and medical history. Only certain perioperative patient factors may be influenced by the surgeon. The study evaluated surgeon-influenced modifiable factors associated with achieving literature-defined KOOS score thresholds to serve as the foundation of the newly established alternative payment models for total knee arthroplasties (TKA).

Methods: We retrospectively reviewed a consecutive cohort of 4,324 patients undergoing TKA. Surgeon-influenced modifiable risk factors included thromboprophylaxis with aspirin, tourniquet use, tranexamic acid (TXA), body mass index, smoking, alcohol or illicit drug use, surgical time, length of stay (LOS), and bilateral TKA. Outcomes included complications, 90-day readmissions, discharge disposition, knee injury and osteoarthritis outcome score (KOOS) minimal clinically important difference (MCID), KOOS patient acceptable symptom state (PASS), and short form-12 (SF-12) MCID achievement. A bivariate analysis and regression were built to determine the likelihood of primary outcomes based on modifiable factors.

Results: Bilateral TKA was associated with a higher odds ratio (OR) for home discharge (OR = 5.40, P < 0.001), KOOS MCID (OR = 2.60, P < 0.001), PASS (OR = 2.4, P ≤ 0.001), and SF-12 PCS MCID achievement (OR = 3.21, P < 0.001). Similarly, LOS was inversely associated with KOOS MCID (OR = 0.88, P = 0.002) and PASS (OR = 0.81, P < 0.001) but directly associated with home discharge (OR = 2.5, P ≤ 0.001) in-hospital complications (OR = 1.50, P < 0.001) and 90-day readmissions (OR = 1.23, P = 0.005). The KOOS MCID and PASS achievement was positively influenced by TXA (OR = 1.33, P = 0.008; OR = 1.29, P = 0.020) use and negatively influenced by aspirin use (OR = 0.68, P = 0.013; OR = 0.73, P = 0.040). In-hospital opioid use was an independent risk factor for not achieving SF-12 MCS MCID (OR = 0.56, P = 0.006).

Conclusion: In this study, modifiable perioperative variables, such as TXA, aspirin use, opioid use, LOS, and bilateral TKA, were found to markedly increase quality metrics threshold achievement and should be considered as risk variables in the current value-based care models. Future studies should investigate the effect of modifiable risk factors on quality metrics to build new risk adjustment tools that incentivize patient perioperative optimization.

Background: Declining reimbursement rates can lead to decreased access and utilization of common orthopaedic surgeries for patients on Medicare, which is a particularly vulnerable population for musculoskeletal injuries.

Methods: Using the Centers for Medicare & Medicaid Services Physician Fee Schedule Look-Up Tool from 2016 to 2024 and utilization data for Medicare and part B beneficiaries from 2016 to 2022, we analyzed reimbursement and utilization trends. Simple linear regressions were executed to measure the annual trends, and Wilcoxon matched-pairs signed rank test were used to analyze the statistical significance of price and utilization changes.

Results: Between 2016 and 2024, mean reimbursements for all evaluated orthopaedic surgeries decreased 26.2% with a -3.34% compound annual growth rate, from $1,558 to $1,150 (P < 0.0001). Comparatively, reimbursement rates for evaluation and management (E/M) services fell by 15.82% or a -1.91% compound annual growth rate, from $102.3 to $86.12 (P < 0.0021). The federal utilization of all orthopaedic surgeries fell from 2016 to 2022 (P < 0.0001), although no significant changes were seen for E/M services (P = 0.9102).

Conclusion: We observe that Medicare reimbursement rates for orthopaedic surgeries from 2016 to 2024 have fallen consistently with a large drop in utilization, especially during the Covid-19 pandemic. Reimbursements for E/M services have fallen at attenuated rates with minimal changes in utilization. This demonstrates the supportive role that declining reimbursement rates may play in utilization and accessibility of orthopaedic surgery.

Because of the crucial role of the menisci in maintaining cartilage and joint health, meniscal tears affect the long-term health of the knee. Although partial meniscectomy has a role in the treatment of complex degenerative tears and tears with low healing capacity, advances in the concepts and understanding of meniscal repair, along with improvements in repair techniques and instrumentation, have expanded the indications for meniscal repair. With appropriate patient selection and preoperative planning, repair of meniscal tears can lower the rate of degenerative changes when compared with meniscectomy. The purpose of this review is to provide a concise overview of current repair indications, techniques, instrumentation, and outcomes for a variety of commonly encountered meniscal tears (radial, vertical, horizontal, oblique, ramp, root) in the knee.

Introduction: This study aims to evaluate whether Instagram engagement data affect residency application volumes for orthopaedic surgery residency programs and rank the top 50 Instagram accounts associated with programs based on engagement.

Methods: Data from January 1, 2020 to June 30, 2023 were collected in August 2023 for Instagram metrics through Popsters social media analytic tool for business accounts and manually for nonbusiness accounts, as well as applicant numbers through the Association of American Medical College (AAMC) Residency Explorer Tool. Top 50 rankings were created from 2020 to 2022 based on engagement score, number of applicants, and growth in application numbers. Correlational analysis was done for programs with active Instagram accounts and full AAMC data from 2020 to 2022. A list of the top 50 most influential programs' Instagram accounts was compiled from January 1, 2020, to June 30, 2023, based on engagement scores including follower count.

Results: Of 210 programs, 163 (78%) had a total of 184 Instagram accounts. The average number of likes and comments per post for each account increased from 60 to 98 and 1.4 to 2.3 from 2020 to June 2023 (r = 0.95 to 0.9). For the 153 programs with active accounts and corresponding AAMC applicant data from 2020 to 2022, an increase in average engagement score (2,938 to 3,483) and the number of applicants (636 to 824) were observed with a weak positive correlation (2020: r = 0.15, P = 0.06; 2021: r = 0.18, P = 0.02; 2022: r = 0.20, P = 0.01).

Conclusion: Instagram has become a useful tool that orthopaedic surgery residency programs are leveraging to highlight aspects of their programs to prospective applicants. The findings of this study demonstrate a positive correlation between social media engagement and applicant numbers from 2020 to 2022, with the strength of correlation increasing each subsequent year. Several influential orthopaedic surgery residency programs, based on high engagement scores, received the most applications in the previous three cycles, reinforcing the value of social media, particularly Instagram, in promoting residency programs.

Introduction: Despite the high effectiveness of Ponseti casting in treating idiopathic clubfoot, patient-reported outcomes (PROs) are not studied well in the literature, necessitating further investigation into PROs to evaluate the effect on patients' lives. We used the Patient-Reported Outcomes Measurement Information System (PROMIS) to evaluate PROs in children with Ponseti-treated clubfoot and assess the effect of recurrence on these PROs.

Methods: This study retrospectively reviewed medical records from patients ages 5 to 18 years treated for idiopathic clubfoot at a single institution from 2002 to 2023 with available PROMIS data for mobility, pain, and peer relationships. Exclusion criteria included initial treatment other than Ponseti casting, presentation to our institution after age 2 years, and PROMIS scores taken less than 6 months postsurgery. Recurrence was defined as patients who required further treatment with casting or surgery after initial correction.

Results: Among 50 patients eligible for this study, 78% (39) were male and 34% (17) had bilateral clubfoot. Average age when the most recent PROMIS data were collected was 6.1 years. Average PROMIS scores were 51.1 mobility, 44.2 pain interference, and 51.9 peer relationships. Notably, patients with recurrence showed similar PROMIS scores across all domains when compared with nonrecurrent patients: 50.7 ± 8.1 vs. 51.5 ± 9.8 (P = 0.753) mobility, 45.5 ± 8.9 vs. 43.1 ± 8.7 (P = 0.334) pain interference, and 52.5 ± 9.7 vs. 51.3 ± 9.1 (P = 0.634) peer relationships.

Conclusion: To our knowledge, this is the first study to use PROMIS scores to evaluate the effect of recurrence on PROs in children with Ponseti-treated clubfoot. The findings of this study suggest that children who sustained recurrence did not have markedly different PROMIS outcomes compared with nonrecurrent children, regardless of treatment modality for recurrence, indicating limited effect of recurrence on PROs at an average 5-year follow-up.

Introduction: Postoperative urinary retention (POUR) is a common concern after total joint arthroplasty (TJA). However, overdiagnosis of POUR by bladder scans may lead to unnecessary interventions and associated complications. The purpose of this study was to determine the viability of a selective bladder scanning protocol to reduce overdiagnosis of POUR following TJA.

Methods: A study of 500 consecutive patients operated on by 13 surgeons underwent a novel bladder scanning protocol designed to reduce overdiagnosis of POUR (selective protocol) through selective bladder scanning of only patients symptomatic for urinary retention. The protocol was then compared with the previous bladder scanning protocol under which 500 patients received routine bladder scans following TJA regardless of symptoms. The primary outcome of interest was the catheterization rate. Chi-squared and Student t-tests were used for analyses.

Results: Catheterization rates were markedly reduced when following the novel protocol (46.6% standard versus 38.2% selective; P = 0.009). Prevoid bladder scan volumes were markedly higher in the selective protocol cohort (459 ± 278 mL, 746 ± 226 mL; P ≤ 0.001), whereas postvoid bladder scan volumes were the same (247 ± 250 mL, 243 ± 271 mL; P = 0.859). Preoperative evaluation of urinary problems, intraoperative urinary complications, postoperative urinary symptoms, and spinal medication type were similar in each cohort. Length of service, rate of same-day discharge, total surgical time, and readmission rate were also similar.

Conclusion: The selective protocol led to a notable reduction in catheterizations when compared with the standard protocol. This was done safely, without increased rates of urinary-related complications during or following surgery. These findings suggest that the selective protocol should be considered as a viable alternative to reduce overdiagnosis of POUR in TJA patients.

Thoracolumbar spinal deformities are a pervasive condition affecting the adolescent and adult patient population. These deformities represent three-dimensional alterations in the coronal, sagittal, and transverse planes with implication on the local, regional, and global alignment. With continued studies, the importance of the overall correction on long-term outcomes has been established. Surgical techniques for correcting deformities aim to restore coronal and sagittal alignment of the spine, as well as manage the rotational components in the transverse plane. Through a proper understanding of spinal biomechanics and spinal instrumentation, we can gain better understanding of how to harness the biomechanical properties of the spinal anatomy through the application of deformity correction techniques to optimize the three-dimensional correction of spinal deformities.