Journal of the American Academy of Orthopaedic Surgeons最新文献

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.

Back pain that is associated with lumbar spine pathology is a growing issue in the athlete population. As an aging population continues to remain active, it is essential for primary care physicians, general orthopaedic surgeons, and spine surgeons alike to understand the nuances of diagnosis and management in the recreational athlete population. This is a unique population due to the increased importance placed on returning to high levels of activity, but, by definition, they enjoy less resources and financial incentive to optimize their rehabilitation and return to sport compared with professional athletes. Lumbar disk herniation, spondylolysis, and disk degeneration are common pathologies in this population. Most the time, these pathologies in recreational athletes can be managed nonsurgically with excellent outcomes. In recreational athletes who have failed nonsurgical treatment and/or have risk of neurological injury, surgical treatment is a viable option with good outcomes. Evidence suggests that most athletes can return to sport after both nonsurgical or surgical management. A rapidly expanding number of easily accessible, minimally invasive, surgical options continue to gain popularity and may gain further indication in this population. Future studies focused on the return to activity for the unique population of recreational athletes is warranted.

Introduction: Exercise-based physiotherapy is an established treatment of rotator cuff injury. Objective assessment of at-home exercise is critical to understand its relationship with clinical outcomes. This study uses the Smart Physiotherapy Activity Recognition System to measure at-home physiotherapy participation in patients with rotator cuff injury based on inertial sensor data captured from smart watches. Relationships between participation and clinical outcomes, long-term durability of outcome improvements, and factors predictive of participation were evaluated.

Methods: Patients participated in a 12-week rotator cuff physiotherapy program in a prospective single-center study. Patients wore smart watches during supervised weekly in-clinic physiotherapy sessions and while performing exercises at home. Demographic information and rotator-cuff diagnosis were collected at baseline and assessed as predictors of physiotherapy participation. Outcome measures (pain, disability [Disabilities of the Arm, Shoulder and Hand], strength, range of motion) were collected over duration of treatment and at 12-month follow-up (pain and disability). Machine learning algorithms identified and classified periods of exercise to evaluate participation and adherence.

Results: One hundred ten patients enrolled and initiated treatment, with 92 patients included in the analysis. All outcomes showed significant improvements from baseline at each time point. Mean total weekly at-home participation decreased from 35.6 ± 28.9 minutes in weeks 0 to 4 to 28.9 ± 25.7 minutes in weeks 8 to 12 (t = 2.23, P = 0.023). For the full cohort, significant relationships were found between physiotherapy participation and disability, manual strength, external rotation, internal rotation, and abduction. Significant predictors of participation included greater age, being unmarried, diagnosed rotator cuff tear, and measures of self-efficacy, social support, and comorbidity. Higher participation rates led to significant improvements in outcomes for partial thickness/no-tear patients but not for full-thickness tears.

Discussion: Machine learning methods applied to data collected from smart watches enabled objective assessment of physiotherapy participation in the home setting. Although most patients improved with physiotherapy, patients with full-thickness rotator cuff tears were not similarly responsive to higher exercise volumes.

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.