Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Severe osteoarthritis is commonly managed with total hip/knee arthroplasty (THA/TKA). A subset of patients present with bilateral osteoarthritis and undergo staged total joint arthroplasty (TJA). Among those who ultimately proceed with both stages, we hypothesize that the decision to proceed with the second surgery is likely influenced by their initial TJA.

Methods: Adults who underwent staged bilateral THA or TKA between 2018 and 2023 were included. Daily Visual Analog Scale (VAS) pain scores (0 to 10) were tracked from 30 days preoperatively to 90 days postoperatively for all patients. Mean preoperative and postoperative pain score plateaus were described and compared after the first and second operations. Hospital-related and patient-reported outcomes were also collected and compared. Finally, optimal intervals between surgeries that maximized pain improvement were also identified.

Results: A total of 193 staged bilateral THA (64 years, 54% female) and 280 staged bilateral TKA (70 years, 55% female) patients were included. Patients had higher preoperative pain scores (THA: first = 6.7 vs. second = 5.4, TKA: 5.7 vs. 4.7) and larger absolute reductions in pain scores (THA: -5.3 vs. -4.0, TKA: -3.8 vs. -2.2) after their first TJA (P < 0.05). In addition, they had higher procedural satisfaction scores (THA: 4.8/5.0 vs. 4.7/5.0, TKA: 4.7/5.0 vs. 4.6/5.0) and higher rates of emergency department (THA: 11% vs. 6%, TKA: difference not significant) or urgent care (THA: difference not significant, TKA: 5% vs. 1%) visits after their first procedure (P < 0.05). Furthermore, they had worse preoperative patient-reported outcome measures and larger preoperative to postoperative improvements after their initial operation (P < 0.05). VAS pain improvement was greatest in those waiting 6 to 12 months between THAs and TKAs (P < 0.05).

Conclusion: Patients undergoing their second contralateral TJA had lower preoperative pain scores and similar postoperative pain levels compared with their first procedure, resulting in smaller absolute pain reductions. Greater pain improvement was observed when the second operation was done >6 months after first TJA.

In the evolving healthcare landscape, orthopaedic surgeons are increasingly required to demonstrate not only clinical excellence but also strategic thinking, leadership, and financial literacy. This review explores the intersection of business principles and surgical practice, highlighting foundational concepts frequently taught in MBA programs: project management, value proposition, the time value of money, cost accounting, and operations management. This article presents an evidence-based discussion on how these principles can enhance surgical efficiency, as well as long-term financial and career planning.

Background: Periacetabular metastatic disease can cause notable morbidity, prompting potential surgical intervention. Open approaches, including the Harrington type reconstructive with a total hip replacement and cemented gap cup, have been the standard approach; however, these surgeries are invasive. Minimally invasive techniques, including screw fixation with cementation and potential ablation, aim to reduce morbidity. This study compares surgical and short-term postoperative outcomes between open reconstructive techniques and minimally invasive treatments in patients with periacetabular metastatic disease.

Methods: Prospectively maintained institutional medical records were used to retrospectively identify patients who had undergone an open approach, who would be minimally invasive candidates, and patients who have undergone the minimally invasive procedure. Demographic, surgical data, and postoperative outcomes of patients with minimum 3-month follow-up were collected. Wilcoxon rank-sum test, chi-squared, and minimal clinically important difference (MCID) tests were used to determine statistical and clinical differences.

Results: Seventeen open and 48 minimally invasive patients were identified. Minimally invasive patients had statistically significant lower rate of surgical blood loss, transfusion rates, surgical time, and length of stay (P < 0.05). Fourteen open and 32 minimally invasive patients had minimum 3-month follow-up. No notable difference was found in the need for secondary procedures, complications, death within 90 days, or Pain and Ambulatory Function Scores (P > 0.05). 57.1% of the open cohort and 43.8% of the minimally invasive cohort met the MCID threshold. Minimally invasive patients had statistically significant quicker return to adjuvant therapies (P < 0.05).

Discussion: Our cohort study demonstrated that minimally invasive techniques reduced surgical morbidity while achieving similar short-term (3 month) postoperative outcomes and a faster return to potentially life-prolonging therapies. Larger patient sample will help determine patients at risk for failure of both approaches and the need for secondary procedures to further define patients who might benefit from the different techniques.

Background: Pathologic fractures of the tibia represent only 3% to 7% of all pathologic long bone fractures, with reported 12-month survival rates below 30%. Although intramedullary nailing (IMN) has become the preferred fixation strategy for pathologic fractures, data specific to tibial lesions remain limited, with existing studies including fewer than 10 patients and focusing primarily on survival or implant failure rather than functional outcomes.

Methods: We conducted a retrospective review of 30 patients who underwent IMN for pathologic tibial fractures at two tertiary care academic medical centers between January 2000 and December 2024. Primary outcomes included overall survival, revision surgery rates, pain scores (visual analogue scale), weight-bearing status, Eastern Cooperative Oncology Group scores, and Combined Pain and Ambulatory Function scale measurements assessed longitudinally through 2-year follow-up.

Results: Overall survival was 48.7% at 1 year and 38.3% at 2 years, with a median survival of 8.9 months. Three patients (10%) required revision surgery at a median of 13 months, with two patients (7%) ultimately requiring implant revision. Median pain visual analogue scale scores decreased markedly from 38 preoperatively to six at 1 month (P = 0.005), with sustained improvement at all subsequent time points (P < 0.01). The proportion of patients achieving full weight-bearing increased from 29% preoperatively to 73% at 3 months, whereas patients with good functional status (Eastern Cooperative Oncology Group 0 to 1) increased from 40% preoperatively to 75% at 6 months and 100% at 2 years.

Conclusion: IMN for pathologic tibial fractures provides durable pain relief, low complication rates, and meaningful functional recovery. These results support IMN as an effective palliative intervention that can markedly enhance the quality of life in this population.

Level of evidence: III.

The pathoanatomy of anterior glenohumeral dislocations in elderly patients is different from those in younger patients in that rotator cuff tears, large glenoid fractures, and peripheral nerve injury are more common. In addition, decision making is made more complex by the wide spectrum of preexisting degenerative pathology, functional demands, and social considerations, such as arthritis, chronic rotator cuff tears, and upper extremity demand for ambulation. Many patients with a first-time dislocation can be treated conservatively with a brief period of immobilization followed by physical rehabilitation. Rotator cuff repair is advisable for most active patients with symptomatic, acute tears. Capsulolabral repairs can be considered for similarly active patients with recurrent instability. Fixation of large glenoid fractures should be considered for patients with displaced fragments >25% of the glenoid width and/or demonstrating humeral subluxation through the fragment if there is adequate bone quality and healing potential. Reverse shoulder arthroplasty plays a large role in managing recurrent instability in patients with limited potential for soft-tissue or bone healing, inability to comply with soft-tissue repair postoperative protocols, and preexisting degenerative changes.

Introduction: Restoring alignment of complex tibiotalar fractures is challenging when anatomical landmarks are obscured. This study defined the tibiotalar station (TS) using CT and evaluated its correlation with radiographs.

Methods: Patients (≥18 years) with a normal lower extremity CT at two level 1 trauma centers between May 2022 and May 2024 were identified. A secondary cohort had intraoperative fluoroscopic ankle imaging. The TS (reported as median [interquartile range]) was defined as the shortest distance from the tibial axis to the center of the talus in the coronal and sagittal planes on CT, radiographs, and fluoroscopy. In addition, the distance from the tibial axis to the lateral talar process in the sagittal plane was measured on CT and fluoroscopy. Negative values indicated the tibial axis was lateral or posterior. Correlations between CT and radiographic measurements were assessed using Pearson correlation coefficients. Interobserver reliability was evaluated with intraclass correlation coefficients.

Results: The primary cohort included 132 patients (median age 66 years, 50% female); 21 had ipsilateral normal ankle radiographs. On CT, the tibial axis intersected the talus -0.68 mm (lateral) to its center and -2.05 mm (posterior). Correlations between CT and radiographic measurements were strong (coronal, r = 0.82; sagittal, r = 0.70). On fluoroscopy, the tibial axis intersected the talus -0.45 mm (lateral) to its center and -1.15 mm (posterior). The tibial axis was -4.45 mm (posterior) to the lateral talar process on CT and -3.55 mm on fluoroscopy. Interobserver reliability ranged from good to excellent across all measurements.

Conclusion: The TS is a reliable metric for assessing tibiotalar alignment, with the tibial axis intersecting the talus slightly lateral and posterior to its center. The lateral talar process also serves as a useful reference for assessing sagittal alignment. These findings can help orthopaedic surgeons restore tibiotalar alignment during external fixation, fracture fixation, and arthrodesis.

Level of evidence: Diagnostic level III.

Endoprosthetic reconstruction has revolutionized the treatment of pediatric and adolescent lower limb sarcoma. These malignancies commonly affect the knee region, the site of the most actively growing physes of the lower limb. Modular and expandable endoprostheses have addressed the challenge of limb length discrepancy following physeal resection, with newer designs allowing noninvasive lengthening. However, decision making in pediatric tumor patients is complex, particularly given the potential number of reconstructive options, necessitating shared decision making between surgeons, patients, and families. The goal of surgery in achieving an R0 resection is nonnegotiable; reconstruction follows this. Endoprosthetic planning requires a nuanced approach involving both pediatric and arthroplasty orthopaedic considerations. Complication rates of endoprostheses are high and include infection, aseptic loosening, and those specific to certain anatomic locations. Future research should focus on standardized methods of outcome assessment, including patient-reported outcomes, to allow careful comparison across surgical techniques. Progress with regard to implant durability, complication reduction, and enhanced adjuvant therapies are the next steps in optimizing both survival and quality of life in this vulnerable population.

Introduction: Despite increasing awareness, women remain underrepresented in academic spine surgery. This study assessed whether women were equitably represented among spine surgeon PIs of clinical trials for degenerative spine disease research.

Methods: This was a retrospective cohort study of spine surgeon principal investigators (PIs) in the United States (2015 to 2022). ClinicalTrials.gov was queried for the most common diagnoses and surgeries for degenerative spine diseases. Characteristics of spine surgeon PIs were collected from academic profiles. Participation-to-prevalence ratios (PPRs) were calculated for men and women PIs relative to their prevalence among spine surgery faculty at accredited training programs. A PPR of 0.8 to 1.2 indicated equitable sex representation. A PPR <0.8 was defined as underrepresentation and >1.2 as overrepresentation.

Results: In total, 129 spine surgeon PIs of 91 clinical trials were included in this study. Overall, there were 125 male (97%) and four female (3%) spine surgeon PIs. Overall, women were underrepresented among spine surgeon PIs (PPR = 0.64), whereas men had equitable representation (PPR = 1.02). From 2015 to 2018, female spine surgeons were underrepresented (PPR = 0.33), but achieved equitable representation from 2019 to 2022 (PPR = 0.95). Male spine surgeons had consistently equitable representation across the study period (PPR range 1.00 to 1.03). Women had equitable representation at assistant (PPR = 1.08) and associate (PPR = 0.31) professor ranks, but were underrepresented at the full professor rank (PPR = 0). PIs were funded by industry (54%), academic institution (44%), and US Federal (2%) sources. No differences were observed in funding sources by sex ( P = 0.36).

Discussion: There are a limited number of female spine surgeon PIs for degenerative spine disease clinical trials, which may have negative implications on the vitality of the specialty moving forward. Future investigations are needed to understand the barriers women face in obtaining clinical trial leadership positions.

Introduction: Online reviews play a notable role in patient decision making when selecting healthcare providers, especially in orthopaedics where 38.4% of patients rely heavily on the internet for choosing their physician. Social media platforms offer orthopaedic surgeons tools to enhance their online presence, with the goal of potentially influencing higher ratings on physician review websites. We hypothesize that social media activity differs across orthopaedic subspecialties and is positively associated with physician review website ratings among orthopaedic surgeons.

Methods: Active members from the directories of Pediatric Orthopedic Society of North America, American Orthopedic Society for Sports Medicine, North American Spine Society, American Orthopaedic Foot & Ankle Society, American Association for Hand Surgery, American Association of Hip and Knee Surgeons, and Orthopedic Trauma Association were randomly selected from each US state. Data included average ratings and total number of reviews from Google and Healthgrades, social media metrics from Facebook, X (Twitter), Instagram, YouTube, and LinkedIn, alongside demographics such as age, sex, years in practice, board certification, and PubMed-indexed publications. Analysis of variance assessed the relationship between social media posts, subspecialties, and practice settings, while multivariate regressions identified predictors of average ratings and total reviews.

Results: A total of 1,039 surgeons were included. Social media engagement markedly differs across subspecialties; for example, the surgeons of American Association of Hip and Knee Surgeons have the most LinkedIn followers (120,962), while Pediatric Orthopedic Society of North America surgeons show no YouTube activity. Analysis of variance showed a significant difference in posting frequency among subspecialties ( P = 0.018), but no difference between private and academic settings ( P = 0.09). Regression analyses indicated that private practice (B = 0.27; P = 0.0036) and Facebook total posts (B = 0.001; P = 0.034) were associated with higher average Google ratings, while years in practice (B = 0.02; P < 0.001) and being in private practice (B = 0.28; P = 0.006) were associated with higher average Healthgrades ratings.

Conclusion: Social media activity among orthopaedic surgeons is associated with online ratings in a multifaceted manner, varying by platform and subspecialty. However, the strength of these associations was modest, with regression models demonstrating limited explanatory power for variations in online ratings across subspecialties. Strategic engagement-particularly on platforms aligned with a subspecialty's audience-may enhance a surgeon's digital presence and perceived reputation.