Journal of the American Academy of Orthopaedic Surgeons最新文献

Endoscopic spine surgery (ESS) represents a development in minimally invasive procedures, offering the potential benefits of reduced tissue disruption, shorter recovery times, and enhanced precision. This review traces the historical development of ESS, explores its core techniques-including transforaminal, interlaminar, and biportal approaches-and evaluates its role in treating conditions like herniated disks and spinal stenosis. By comparing clinical outcomes of ESS with standard open surgery, this article highlights the importance of patient selection, surgeon expertise, and evidence-based practice. Challenges, such as the steep learning curve, limitations in visualization, and risk of complications, are discussed, along with strategies for integrating ESS into modern spine care. The review concludes by identifying research gaps and opportunities for technological advancements, aiming to guide surgeons in adopting ESS and improving patient outcomes.

Background: Standard cost analyses of robotic total hip arthroplasty (THA) have been done. However, no studies have used time-driven activity-based costing (TDABC), a novel cost calculation method that more accurately reflects true resource utilization in health care. This study aimed to compare healthcare facility costs between robotic and manual THA using TDABC.

Methods: We conducted a retrospective analysis of 384 consecutive THAs performed between 2019 and 2023. Total healthcare facility costs, comprising personnel and supply costs, were calculated using TDABC. Separate analyses including and excluding implant costs were done. Multiple regression was used to determine the independent effect of robotic assistance on facility costs.

Results: A total of 384 THAs (190 manual, 194 robotic) were analyzed. Patients undergoing robotic THA had a significant shorter length of stay (1.9 vs. 2.3 days, P = 0.033), but similar surgical times (1.00x, P = 0.936) and total personnel costs ( P = 0.080). Robotic THAs had higher total supply costs and facility costs when including (1.19x, P < 0.001; 1.08, P = 0.017) and excluding (1.91x, P < 0.001; 1.10x, P = 0.013) implant cost. However, when controlling for demographics and comorbidities known to influence costs in arthroplasty, similar total facility costs between robotic and manual THA, when including ( P = 0.095) and excluding ( P = 0.087) implant cost, were noted. A comparison of perioperative outcomes revealed no significant difference in 90-day emergency department visits, 90-day readmissions, 90-day complications, reoperations, or revision surgeries.

Conclusion: Using TDABC, total healthcare facility costs of robotic THA were similar to those of manual THA when controlling for variables known to influence costs in total joint arthroplasty. This study offers patient-level cost insights on the economic feasibility of robotic THA. Additional studies evaluating the long-term outcomes of robotic THA are needed to determine its long-term advantages.

Background: Tranexamic acid (TXA) is frequently used in knee and hip arthroplasty because of its benefits. The literature is scarce on TXA and total ankle arthroplasty (TAA). The current systematic review aims to present the available literature on the subject.

Methods: Two independent authors performed a systematic literature search using the following databases: PubMed, Embase, and the Cochrane Library. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis protocol and the Cochrane Handbook guidelines were followed. The search criteria were based on TAA and TXA. The MINORS score criteria were used to evaluate the strength and quality of the selected studies.

Results: A total of eight studies including 263 TAA were completed with the usage of TXA and 228 TAA were without TXA. The average blood loss and change in hemoglobin in the TXA group was 335.4 mL and 1.45 g/dL, respectively. In the non-TXA group, average blood loss and change in hemoglobin was 441.8 mL and 1.78 g/dL, respectively. The total number of complications and wound complications reported in all studies for the TXA group were 19% and 6.8%; in the non-TXA group, 33.3% and 16.7% were observed, respectively. The difference in wound complication rate was statistically significant ( P = 0.014). Trends favoring the TXA group were found for lower transfusion, pulmonary embolism, deep vein thrombosis, and cerebrovascular accident.

Conclusion: The utilization of TXA in TAA appears to be safe and effective. Wound complication rate was the only finding with a notable difference favoring the TXA group. The rest of the data from this systematic review demonstrate a trend toward lower in blood loss, hemoglobin decrease, and total complications when using TXA in TAA. Larger prospective studies and randomized controlled trials are needed to further guide evidence-based guidelines.

Background: Degenerative changes secondary to hip dysplasia may be treated with total hip arthroplasty (THA) through a direct anterior approach. However, this may be challenging due to altered pathoanatomy and difficult visualization of the femur. The purpose of this study was to compare patient-reported outcome measures between patients with hip dysplasia and matched controls with osteoarthritis who underwent direct anterior THA.

Methods: Patients who underwent direct anterior THA were retrospectively reviewed. Dysplastic hips were propensity matched to hips with osteoarthritis on a 1:4 basis. Patient-reported outcome measures, including visual analog scale pain at rest and with use, Hip Disability and Osteoarthritis Outcome Score Pain, and Forgotten Joint Score-12, were obtained at follow-up. In addition, modified Harris Hip scores (mHHS) were obtained both preoperatively and at the final follow-up.

Results: Thirty-eight hips with dysplasia and 152 control hips were followed for a mean of 5.1 ± 2.8 years. Eighty-seven percent of the dysplastic hips had Grade I hip dysplasia based on the Crowe classification, whereas 5.3% had Grade II, 2.6% had Grade III, and 5.3% had Grade IV. Both cohorts demonstrated notable preoperative to postoperative improvements in mHHS ( P < 0.001). No differences were observed at the final follow-up between the dysplasia and osteoarthritis cohorts for VAS at rest (0.5 vs. 0.5, P = 0.828), visual analog scale with use (0.7 vs. 1.1, P = 0.231), Hip Disability and Osteoarthritis Outcome Score Pain (93.8 vs. 92.3, P = 0.518), Forgotten Joint Score-12 (82.2 vs. 81.4, P = 0.856), and mHHS (91.9 vs. 91.4, P = 0.793). Revision rates were comparable between the dysplasia and osteoarthritis cohorts (5.3% vs. 1.3%, P = 0.179).

Conclusion: Patients with hip dysplasia and osteoarthritis who underwent direct anterior THA achieved comparable outcomes in this propensity-matched analysis. Patients with hip dysplasia can expect reduced pain, improved functional outcomes, and similar revision surgery rates to those with osteoarthritis following primary THA.

Introduction: External fixation is a critical method for temporizing musculoskeletal injuries. Limited guidance exists on how to achieve appropriate external fixator pin depth without image guidance. We sought to validate a standardized technique for placing external fixation pins in the lower extremity without fluoroscopy.

Methods: Adults undergoing external fixation of lower extremity injuries at a level I trauma center were prospectively enrolled over 12 months. A standardized technique was used for pin placement, and pins were placed by attendings or trainees at PGY2 to PGY6 levels. Complications related to pin placement were recorded and classified as major, potential major, or minor. Major complications included neurovascular injury, pin tract osteomyelitis, and septic arthritis. Potential major complications included soft-tissue pin placement, unicortical pins, deep pin overpenetration (≥26 mm), and pins placed within or near a fracture or joint. Minor complications included pin tract infections and shallow pin overpenetration (9 to 25 mm). "Successful" external fixation application was defined as placement without any major or potential major complications.

Results: Thirty-seven constructs (101 pins) were included. A total of 36 constructs (97.3%) and 99 pins (98.0%) were placed successfully. No major complications were observed. Potential complications occurred in one construct (2.7%) in which two pins (2.0%) were placed unicortically. Minor complications occurred in two pins (2.0%) demonstrating shallow overpenetration. Most pins (n = 97; 96%) were placed bicortically without overpenetration. The mean overpenetration of bicortical pins was 3.2 ± 2.3 mm. Overpenetration depth decreased with increasing training levels and increasing experience with the technique.

Conclusion: Placement of pins without image guidance during external fixation of lower extremity injuries resulted in successful placement of 98% of pins and 97% of constructs. This straightforward, reproducible technique can be used by surgeons of varying skill levels and done to safely apply external fixation in settings that lack fluoroscopic capabilities.

Spinopelvic sagittal alignment has been shown to play an important role in pediatric and adult thoracolumbar spinal deformity. However, less is understood about the importance of sagittal alignment in the cervical spine and patients with adult cervical deformity. The purpose of this review article is to provide a comprehensive overview of contemporary principles pertaining to adult cervical deformity. Upper cervical parameters, regional cervical parameters, cervical shape classifications, and cervical deformity classifications will be reviewed based on the current literature.

Objective: To identify radiographic and MRI imaging markers associated with failure after lumbar tubular microdecompression (LTM) without stabilization or fusion.

Background: LTM is a minimally invasive option for treating lumbar spine pathology without instability. Stabilization procedures are considered but may be associated with increased blood loss, risk of future adjacent segment disease, and higher costs and should be used only when required.

Methods: Four hundred sixty-eight patients undergoing LTM for central, lateral recess and foraminal/extraforaminal stenosis between 2014 and 2023, including unilateral laminotomy, unilateral laminotomy for bilateral decompressions, and far lateral decompression, were included. Preoperative imaging was reviewed for evidence of static and dynamic degenerative spondylolisthesis, facet effusions, and synovial cysts. The primary outcome was failure following LTM, which was defined as undergoing fusion, open laminectomy, or revision LTM at the same level of the index procedure for recurrent symptoms during the exposure period. Poisson regressions were done and controlled for age, sex, body mass index, and smoking status, with an offset for total follow-up time.

Results: Static spondylolisthesis was not associated with failure (1.00 [95% CI, 0.97 to 1.03], P = 0.996), whereas increases in dynamic spondylolisthesis (1.13 [95% CI, 1.01 to 1.26], P = 0.034) and facet effusions (1.22 [95% CI, 1.01 to 1.48], P = 0.040) predicted increased risk for failure. Presence of spinal synovial cysts was not associated with failure (0.6 [95% CI, 0.1 to 2.4], P = 0.469).

Discussion: The presence of dynamic spondylolisthesis and facet effusions suggest that decompression alone may result in a greater likelihood of failure, and the addition of stabilization procedures should be considered.

Study design: Retrospective cohort study.

Background: Periacetabular osteotomy (PAO) is a common procedure for the treatment of symptomatic acetabular dysplasia in adolescent patients. Despite concerns regarding surgical outcomes and complications in patients with hypermobility spectrum disorders (HSD), the outcomes of PAO in such patients are not well documented.

Methods: We conducted a retrospective cohort review of patients who underwent PAO for the treatment of symptomatic acetabular dysplasia. Radiographic parameters including the lateral center edge angle of Wiberg (LCEA), medial center edge angle (MCEA), anterior wall index (AWI), posterior wall index (PWI), and Tönnis angle were measured. Patient-reported outcomes (PROs) were also collected.

Results: The mean duration of follow-up of non-HSD and HSD patients was 2.86 ± 0.73 years and 3.00 ± 1.11 years, respectively. No significant differences were found in mean age (P = 0.289), sex, body mass index (P = 0.125), laterality (P = 0.192), or the duration of follow-up (P = 0.636). Postoperatively, LCEA and AWI in patients with HSD were higher than those in non-HSD patients (P = 0.002, P = 0.007, respectively). No notable differences were observed in Modified Harris Hip Score, Nonarthritic Hip Score, International Hip Outcome Tool, Hip Dysfunction and Osteoarthritis Outcome Score, or mean changes in PROs between the non-HSD and HSD groups at preoperative, 1-year postoperative, and most recent follow-up timepoints. However, patient-reported satisfaction with surgery in the HSD group (9.39 ± 1.04) was significantly higher than the non-HSD group (8.35 ± 1.95; P = 0.047).

Conclusion: Patients with HSD exhibited similar outcomes to patients without HSD after PAO for symptomatic acetabular dysplasia. Postoperative AWI and LCEA were markedly greater in patients with HSD consistent with our technical bias toward increased correction in such hips, suggesting greater anterolateral coverage of the femoral head after PAO may be a promising strategy to achieve improved outcomes in patients with HSD.

Injuries to the chest wall are common after blunt thoracic trauma, which can cause injury to the ribcage and intrathoracic structures. Such trauma can result in a spectrum of injuries, ranging from minor injuries such as an isolated rib fracture to extensive injuries such as multiple rib fractures/flail segments with underlying lung or intrathoracic injury. The primary focus of this article will be on the assessment and treatment of injuries of the bony chest wall, with an emphasis on flail chest and multiple rib fractures. Patient evaluation, treatment, and outcomes differ depending on the severity of injury. The use of CT scans has become routine in the diagnosis and evaluation of injury severity. Treatment options include both nonsurgical care (analgesia, regional anesthetic techniques, and mechanical ventilation) and surgical fixation of the chest wall. While there has been notable interest in surgical fixation of flail chest injuries over the past two decades, there remains controversy regarding the potential benefits of surgery and the indications for surgical management. However, it is clear that patients with flail chest injuries are best managed by a multidisciplinary team, including collaboration between orthopaedic and trauma surgery.

Acetabular fractures are becoming more common, especially in the elderly population. Standard goals of management include restoring stability and articular congruity to the hip joint in an effort to minimize the risk of posttraumatic arthritis. This is most commonly achieved through open reduction and internal fixation, from which outcomes are generally positive. However, several preoperative risk factors have been identified that correlate with poor outcomes, such as severe acetabular impaction, femoral-sided lesions, and older age. Furthermore, goals of management in the increasingly encountered elderly acetabular fracture may predominantly consist of postoperative mobilization and minimizing revision surgery. In the select patient with identifiable risk factors, acute total hip arthroplasty with or without concurrent fracture fixation may be able to improve outcomes. Specifically, acute total hip arthroplasty appears to reduce the risk of revision surgery in comparison to fracture fixation alone and may improve complication profiles in comparison to conversion arthroplasty after failed fixation, albeit at the expense of an increased surgical insult at the initial surgery. However, given the heterogeneity and short-term nature of the available data, more robust and long-term data will be required before definitive conclusions can be drawn.