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.

Introduction: A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics.

Methods: A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted.

Results: Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance ( P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons.

Conclusion: Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon.

Study description: Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set.

Introduction: Postoperative urinary retention (POUR) is a common barrier to rapid-discharge hip and knee total joint arthroplasty (TJA). We evaluated the efficacy and safety of catheterization intervention methods for POUR before and after discharge.

Methods: A total of 1,659 primary TJAs were retrospectively reviewed. POUR resolutions before and after discharge were evaluated relative to catheterization type and other covariates. Complications before and within 90 days of discharge were quantified. A total of 113 POUR cases comprised the analysis sample of 76 hips and 37 knees in 51 women and 62 men with an average age and body mass index of 68.6 (range 22 to 92) years and 31.7 (range 16 to 49) kg/m 2 .

Results: POUR resolved before discharge for 82.3% (93/113) of patients, with equivalent resolution rates for intermittent catheterization alone (84.2%, 32/38) compared with indwelling catheterization with or without intermittent catheterization (82.6%, 57/69, P < 0.999), equivalent time to resolution ( P = 0.319), and no difference in complication rates ( P = 0.999). Complication rates within 90 days of discharge were higher for patients treated with indwelling catheters before discharge ( P = 0.049). Resolution before discharge was more likely with increasing body mass index ( P = 0.026) and less likely for patients with a history of urinary retention ( P = 0.033). 60 percent (12/20) of patients with unresolved POUR were discharged with self-intermittent catheterization and 40% (8/20) with indwelling catheters, with no differences in efficacy and safety based on the catheterization type ( P = 0.109).

Discussion: Before discharge, we observed equivalent resolution rates and equivalent time to resolution for indwelling and intermittent catheterization alone without compromising patient safety. Intermittent catheterization is favored, however, because in situ catheter exposure is dramatically reduced and postdischarge complication rates are lower. Additional research is needed to develop evidence-based POUR guidelines for outpatient TJA.

Introduction: Although two-stage exchange has been the standard of care for periprosthetic joint infection (PJI) in the United States, single-stage exchange is emerging as an option in select patients. The purpose of this study was to compare outcomes of patients undergoing single-stage and two-stage exchange using strict surgical indications.

Methods: We reviewed a consecutive series of 196 patients with diagnosed PJI undergoing revision total knee and hip arthroplasty from 2017 to 2021. Patients were excluded if they had PJI history, plastic surgery coverage, or extensive bone loss requiring endoprosthesis. We compared the number of patients PJI-free at 1-year follow-up using MusculoSkeletal Infection Society criteria and patients requiring re-revision between the single-stage and two-stage groups.

Results: In total, 126 patients met inclusion criteria. Of 61 knee patients (48.4%), 22 underwent single-stage (36%) and 39 underwent two-stage (63.9%). Of 65 hip patients (51.6%), 38 underwent single-stage (58.5%) and 27 underwent two-stage (41.5%). At a mean follow-up of 1.95 ± 0.88 years, a higher rate of knee patients were classified as having treatment success in the single-stage group (77.3% versus 69.2%, P = 0.501), however with comparable septic failure rates (18.1% single-stage versus 17.9% two-stage; P = 0.982). At a mean follow-up of 1.81 ± 0.9 years, a higher rate of hip patients were classified as having treatment success in the single-stage group (94.7% versus 81.5%, P = 0.089), and more patients had septic failures in the two-stage group (18.5% versus 5.3%; P = 0.089). No differences were observed in the microorganism profile. More total complications ( P = 0.021) and mortalities were found in the single-stage knee cohort than in the two-stage cohort (22.7% versus 2.6%; P = 0.011).

Conclusion: Single-stage arthroplasty is a viable alternative to standard two-stage exchange in patients with PJI without a history of infection and with no bone or soft-tissue compromise. Additional studies with longer term follow-up are needed to evaluate its efficacy.

Improvements in healthcare management have led to a decrease in perioperative and postoperative complications. However, perioperative medical complications and mortality rates continue to increase in patients undergoing elective spinal surgeries. This trend is driven by the increase in the older population and the rise in the number of patients with more than two comorbidities. Managing patients with multiple comorbidities requires additional resources, augmenting the financial and societal burden. Despite the high risk of complications and mortality, patients with multiple comorbidities undergo spinal surgery for degenerative spinal conditions daily. These findings highlight the need for heightened awareness, patient education, and management of comorbidities before elective spinal surgeries. This article comprehensively reviews literature on the effects of medical comorbidities on spinal fusion surgery outcomes to increase awareness of the surgical complications associated with comorbidities. In addition, suggested preoperative and postoperative comorbidity management strategies are outlined.

Purpose: Pain management in orthopaedic manipulation in the emergency department (ED) is crucial to decrease fracture reduction performed in the operating room. This study compared intranasal fentanyl (INF) with oral morphine in time of care and effectiveness on pain during the reduction of bone fractures in a pediatric trauma center.

Methods: A before-and-after INF implementation study was conducted in a pediatric ED with a trauma center on children with a confirmed displaced closed fracture on radiographs with reduction and casting performed in the ED. The time of care, time for sufficient analgesia, effectiveness on pain, and tolerance were compared between both analgesics in 3 consecutive phases.

Results: 77 children were included: 31 children received oral morphine and 46 INF. The time of care was shorter in the INF group (150 [111 to 193] minutes versus 215 [155 to 240], P = 0.01) as the time for sufficient analgesia (10 [9 to 13] minutes versus 80 [53 to 119], P < 0.001) with a higher pain reduction after a dose of INF (3 [0 to 4] versus 6 [3 to 7], P < 0.001) and less dose requirement ( P = 0.002). Although pain scores were similar at arrival in both groups ( P = 0.15), the pain was significantly lower before and during the procedure in the INF group and equivalent after the procedure (2 [0 to 4] versus 3 [0 to 5], P = 0.02, 3 [1 to 5] versus 7 [3 to 9], P < 0.001, and 1 [0 to 2] in both groups, P = 0.87, respectively). Keeping pain levels low during the procedure in the INF group allowed the extension to lower limb fracture reductions ( P = 0.04). No serious adverse events were reported.

Conclusion: INF reduces the time to obtain sufficient analgesia and time of care, with good effectiveness maintained during the procedure in fracture reduction, allowing the extension to lower limb fractures. Thus, this rapid and efficient analgesia facilitates orthopaedic care in the pediatric ED that would otherwise require to be reduced in the operating room under general anesthesia.

Introduction: Distal femur fractures (DFFs) are associated with high complication and mortality rates in the elderly. Using the National Inpatient Sample and Medicare data, we describe trends in the incidence of DFFs by fixation type and associated healthcare costs.

Methods: Annual population rates and volume of inpatient DFFs were estimated using Poisson regression with the US Census as a denominator. We used Current Procedural Terminology codes in Medicare patients to determine episode-of-care cost by treatment, classified as intramedullary nail, open reduction and internal fixation, and distal femur arthroplasty (DFR).

Results: The annual incidence of DFFs in the United States is approximately 27.4 per 100,000. Admission for DFFs increased from 2002 to 2020, with the highest volume and rate in those aged 85 years and older. DFF incidence increased (1.95×) from 142 per 1 million (95% CI: 140 to 144) in 2006 to 281 per 1 million (95% CI: 278-284) in 2019. From 2012 to 2019, the percentage of DFFs treated by intramedullary nail increased from 6.8% to 8.4%, open reduction and internal fixation decreased from 89.9% to 76.6%, and DFR increased from 3.3% to 14.9%. DFR cost was significantly greater than other treatment choices across all years for initial inpatient admission costs and 90-day episode-of-care costs (all P < 0.0001).

Conclusion: DFF volume has increased in the past 20 years, predominantly in elderly patients. Greater than 4.5× increase was observed in the proportion of geriatric DFFs treated with DFR during this study period. The total cost of DFR treatment was consistently greater than other surgical treatments.

Introduction: Academic scholarship is often valued by clinicians, peers, and intuitions. Quantifying the effect of research publications is challenging. Various metrics have been used to assess this. This study aimed to examine the relatively new research metric, relative citation ratio (RCR), introduced by the National Institutes of Health, for pediatric orthopaedic surgeons to establish the benchmarking of research effect within the field and understand the distribution and basis for the use of this metric among pediatric orthopaedic surgeons.

Methods: The RCR indices were assessed for members of the Pediatric Orthopaedic Society of North America using the iCite online web service. The mean RCR (mRCR, the yearly average RCR) and weighted RCR (wRCR, the cumulative RCR score) were assessed for each member. This information was used to perform univariate and two multivariate ordinary least squares regressions for the two metrics. Independent variables were physician sex, years since receiving national provider identifier, MD versus DO degree, whether the physician had a PhD, and geographic region of practice (Northeast, Southeast, Midwest, West, and Southwest).

Results: A total of 770 pediatric orthopaedic physicians were identified. The median [interquartile range] wRCR was 15.6 [4.9 to 54.2], and median mRCR was 1.4 [1.0 to 1.9]. Multivariable squares regression for wRCR showed an independently increased wRCR associated with male sex (39.11), PhD (23.32), years since receiving national provider identifier (4.51), and northeast region (48.44). However, these trends were not notable for mRCR where only southeast region was notable.

Conclusion: Although each has its caveats, both mRCR and wRCR have a place in evaluating an author's publication history and other research metrics. Furthermore, it is important to know the overall research metrics within a field to allow for inter- and intraspecialty comparisons. Understanding RCR is helpful because it allows for new comparisons within and across fields and career lengths.

Background: Congenital femoral deficiency (CFD) is a rare condition, often associated with other skeletal anomalies that make the management more difficult. This study aimed to present the risk factors associated with complications in reconstruction of CFD.

Methods: This was a retrospective cohort study on patients with CFD who underwent femoral reconstruction between 2002 and 2022, from a single center. The preoperative demographic data, lengthening characteristics, complications, and the predisposing conditions were documented.

Results: Thirty-four patients (24 Aitkin A and 10B CFD cases) had 39 lengthening procedures. Twelve cases had simultaneous leg lengthening for associated fibular hemimelia. The mean achieved length was 10.15 ± 3.89 cm, with 72.73 ± 56.19 months follow-up. Although each procedure had 1.8 ± 1.02 complications, 35.8% bowing of regenerate bone and 28.2% fracture; 17.9% hip and 7.7% knee instability were some of the major ones. Hip instability observed in 7 (17.9%) corelated with Aitken type of CFD, preoperative acetabular index, femoral length discrepancy, and achieved length. Bowing in regenerate bone and poor bone consolidation of 15.4% correlated with simultaneous tibial and femoral lengthening (P = 0.018) and higher initial leg-length discrepancy (P = 0.006). The age at reconstruction did not correlate with the number of complications or healing index (P = 0.68, P = 0.15). Five cases received second-time lengthening. Spanning the knee with fixator during lengthening had no notable association with knee instability.

Conclusion: Femoral reconstruction in CFD is a challenging but effective task, with joint instability, bowing, fracture, and poor consolidation as potential adverse effects that correlate with simultaneous fibular hemimelia treatment besides the achieved length.

Introduction: Lumbar disk arthroplasty (LDA) is a relatively novel procedure with limited indications and use in the United States, especially relative to lumbar fusion (LF). This study aimed to determine surgical trends between LDA versus LF over the past 10 years to quantify absolute/relative surgical volume over time and compare baseline patient demographics, readmission, 2-year revision rates, and costs-of-care.

Methods: A total of 714,268 patients were identified from a nationwide database who underwent LF (n = 710,527) or LDA (n = 3,741) from 2010 to 2021. The percentage of patients managed by each surgical procedure was calculated overall and subdivided annually. Baseline demographics were compared between surgical groups, comparing postoperative readmission rates and 2-year revision rates. Linear regression modeling was done to evaluate trends/differences in procedural volume by year.

Results: Beginning in 2010 to 2011, LDA constituted 1.0% of procedures, before the number/proportion of LDA procedures to LF has slowly dropped (1% in 2010 to 0.6% in 2021, P > 0.05). Patients undergoing LDA were younger (42.7 vs. 60.9 years, P < 0.0001) with a higher male proportion (50.9 vs. 42.8, P < 0.0001) and a lower Elixhauser Comorbidity Index (2.5 vs. 4.6, P < 0.0001). Patients undergoing LDA had lower rates of readmission (3.8 vs. 7.6%, P < 0.0001). Both LDA and LF average same-day reimbursements elevated sharply from 2010 to 2015 before decreasing to values lower than initially at 2010, with LF demonstrating a greater reduction in costs ($10,600 vs. $2,600, P < 0.05), although LDA remains cheaper ($2,900 vs. $5,300, P < 0.05).

Conclusion: The surgical volume of LDA has remained steady while dropping in proportion relative to LF over the past decade. Although patients undergoing LDA are younger and have both fewer baseline demographic comorbidities and lower readmission rates, surgeons remain hesitant to perform this procedure over LF.

Study design: Retrospective Cohort Study, Level III Evidence.