Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Surgical management of thoracolumbar fractures in patients with ankylosing spinal disorders such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis remains debated. Although several studies have compared minimally invasive surgery to open fixation of thoracolumbar fractures in this patient population, a meta-analysis compiling the literature on this topic is lacking.

Methods: Following the PRISMA guidelines, PubMed, Cochrane, and Google Scholar (pages 1 to 20) were accessed and explored until October 2024. The extracted data consisted of complications, mortality, surgery-related parameters, postoperative back pain, and postoperative Cobb angle. Across all studies, mean differences with 95% confidence intervals were used for continuous data, whereas odds ratio was used for dichotomous data.

Results: Eight retrospective articles were included in the meta-analysis, including 295 patients, with 164 in the MIS group and 131 in the open group. Patients undergoing minimally invasive fixation were found to have lower rates of overall complications (OR = 0.43; 95% CI, 0.25-0.75, P = 0.003), shorter surgical time (MD = -67.79; 95% CI, -91.61 to -43.96, P < 0.001) and hospital stay (MD = -14.08; 95% CI, -25.95 to -2.21, P = 0.02), and less blood loss (MD = -1.52; 95% CI, -2.70 to -0.33, P = 0.01). However, there was no difference in postoperative back pain or Cobb angle between the two groups.

Conclusion: Patients undergoing MIS treatment of fractures through ankylosed spines had lower rates of complications, less EBL, and shorter surgical time and LOS, highlighting the potential benefits of minimally invasive fixation of thoracolumbar fractures. However, studies with longer-term follow-up to assess the longevity of MIS fixation are needed, and furthermore some injury patterns may not be amenable to MIS fixation. Also, some institutions may not have resources to provide MIS techniques, and open fixation remains a safe and reliable option for treatment.

Background: Social determinants of health (SDOH) have been shown to reliably predict outcomes in patients undergoing total joint arthroplasty (TJA). However, there remains a paucity of data in the literature on SDOH in patients being revised for periprosthetic joint infection (PJI). This study aimed to examine the relationship between SDOH, microorganism profile, and clinical outcomes in patients undergoing their first revision procedure for infection.

Methods: Four hundred eighty-five patients undergoing revision arthroplasty for infection were identified using an institutional PJI database. PJI was defined using the 2018 International Consensus Meeting criteria. Data on microorganism profile, antibiotic sensitivity, demographics, and comorbidities were recorded. The area deprivation index (ADI) and four subscales of the social vulnerability index (SVI) were identified using the patient address. High vulnerability to SDOH was defined as the top quartile for ADI and each SVI category.

Results: Two hundred five patients were included. Patients in the high-vulnerability cohort for ADI and SVI were more likely to be Black and had higher rates of type 2 diabetes ( P < 0.001). In a multivariate regression, ADI was found to be an independent risk factor for gram-negative (odds ratio [OR] = 3.23, P = 0.031) and polymicrobial (OR = 3.62, P = 0.044) infections. Having a higher ADI and SVI was a risk factor for increased length of stay (LOS; ß 1.07, P = 0.038; ß 1.24, P = 0.001) and non-home discharge (OR = 3.08, P = 0.027; OR = 2.62, P = 0.013), respectively. The top SVI theme 1 was an independent risk factor for prolonged LOS (ß 1.85, confidence interval, 1.06 to 2.64, P < 0.001).

Conclusion: Patients with an increased ADI and SVI were more likely to experience gram-negative and polymicrobial infections, as well as prolonged LOS and non-home discharge. The findings of this study suggest that the "sociobiome" has an effect on the incidence and postoperative outcomes of PJI. The findings of this study demonstrate that SDOH indices can be a useful tool in categorizing high-risk patients and mitigating health inequalities in septic revision procedures.

Introduction: Treatment approaches and functional outcomes have been shown to be influenced by a patient's socioeconomic status in certain orthopaedic pathologies. In patients with proximal humerus fractures (PHFs), this study aimed to evaluate the relationship between social deprivation and (1) treatment strategy-including the choice between surgical and nonsurgical management, as well as the type of surgical intervention-and (2) patient-reported outcomes.

Methods: We retrospectively reviewed 275 displaced PHFs from a level 1 trauma center. Using the Area Deprivation Index (ADI), patients were assigned social deprivation scores ranging from 0 to 100, with higher scores representing greater deprivation. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used to measure the domains of Physical Function, Upper Extremity, Pain Interference, Depression, and Anxiety. PROMIS scores were grouped into 6-week, 3-month, 6-month, and 1-year follow-up groups, with scores analyzed separately at each time point. The associations between ADI and treatment strategy and PROMIS outcomes were determined using multivariable logistic regression and multivariable linear regression, respectively.

Results: ADI showed no significant association with surgical versus nonsurgical treatment (odds ratio = 0.998 [95% confidence interval, 0.987 to 1.010], P = 0.790) or type of surgical treatment (odds ratio = 1.009 [confidence interval, 0.994 to 1.024], reverse total shoulder arthroplasty vs locking compression plate, P = 0.251). In the 6-week, 3-month, 6-month, and 1-year follow-up analyses, ADI showed no significant associations with PROMIS Physical Function, Upper Extremity, Pain Interference, Depression, or Anxiety.

Conclusion: This study showed that social deprivation was not markedly associated with treatment strategy or patient-reported outcomes in patients with PHFs. Additional prospective research is needed to clarify the impact of social deprivation on patients with PHFs and to determine the appropriate role of area-based deprivation indices in orthopaedic care.

Background: Current reliance on the expedited 510(k) approval pathway has driven rapid commercial availability of novel arthroscopic devices. Despite the low complication rates of arthroscopic procedures, products from this pathway are suspected to increase the rate of recalls and device malfunctions.

Purpose: This study aimed to characterize arthroscopic device recalls, analyze trends in recall incidence, and identify predictors of time to recall.

Methods: A 20-year, retrospective, cross-sectional study was conducted using the Food and Drug Administration (FDA) Recalls database. Recalled devices approved under the FDA 510(k) pathway were identified and categorized by type, manufacturer, recall class, and cause. Statistical analyses included Poisson regression for trends and Cox proportional hazards modeling for predictors of time to recall.

Results: A total of 124 recalls were initiated during the study period (average 6.2 recalls/year), with packaging and process control issues accounting for 50.7% of recalls. Recall incidence remained stable over time, although nearly half occurred in 2008, 2010, 2012, and 2019. Mean recall time was 491 days (95% confidence interval [CI], 444 to 539). Devices recalled due to material/implant contamination had markedly shorter times (HR: 3.73 [95% CI, 1.78 to 7.82]), whereas process control issues prolonged recall times (HR: 0.56 [95% CI, 0.31 to 1.00]). Manufacturer was another predictor of time to recall, with one manufacturer exhibiting substantially extended recall times (HR: 0.45 [95% CI, 0.22 to 0.92]).

Conclusion: Arthroscopic device recalls are largely caused by packaging and process control issues, emphasizing the need for stricter quality assurance during manufacturing. Although recall incidence remained stable over the past two decades, variability in recall times highlights opportunities for improved manufacturer accountability and FDA oversight. Increasing procurement scrutiny, enhancing FDA audit practices, and integrating recall data with clinical outcomes can minimize disruptions in arthroscopic surgery.

Level of evidence: Level III Therapeutic Study.

Femoral neck fractures are common geriatric fractures, with an incidence of approximately 500 per 100,000 people. Utilization rates of cemented femoral components in the treatment of geriatric femoral neck fractures are markedly lower in the United States relative to other Western countries. Surgeons may feel uncomfortable cementing femoral components secondary to a lack of experience or training, increased surgical time, concern for cardiopulmonary injury secondary to bone cement implantation syndrome, and/or concerns for increased rates of perioperative morbidity or mortality. This review covers contemporary data on the use of cemented femoral components for geriatric femoral neck fractures, preoperative considerations when using a cemented femoral implant, intraoperative techniques and communication, and how to avoid/mitigate acute medical complications during cementing.

Shoulder injuries can pose as a diagnostic challenge for clinicians. Owing to the wide variety of pathologies and the fact that they frequently coexist, diagnosis can be difficult. Accurate diagnosis and management not only require a thorough understanding of each condition but the ability to narrow down the broad differential through detailed physical examination. This review article provides an in-depth examination of common shoulder conditions and outlines key physical examination techniques for upper extremity surgeons and other clinicians who manage these conditions. It begins by providing an up-to-date overview of the various pathologies that affect the shoulder girdle, including rotator cuff tears, quadrangular space syndrome, labral instability and glenohumeral bone loss, adhesive capsulitis, superior labral and biceps pathology, thoracic outlet syndrome, acromioclavicular joint degeneration, and glenohumeral osteoarthritis. This review then discusses key physical examination aspects, such as the history of present illness, cervical spine evaluation, range of motion assessment, strength testing, and shoulder girdle-specific maneuvers. This comprehensive review highlights the importance of a thorough understanding of shoulder physical examination and special diagnostic tests, emphasizing history-taking and examination to ensure diagnostic accuracy and optimize patient outcomes for surgeons.

Elbow fractures and fracture-instability injuries are increasingly prevalent. Gaining adequate exposure to the joint surface poses considerable challenges due to the unique articular anatomy and intricacies of the neurovascular structures traversing the elbow. Laterally, the radial head and capitellum are accessed through a classic Kocher or variations of the Kaplan technique. Posteriorly, the distal humerus is exposed by retracting the extensor mechanism through triceps split, reflection, or olecranon osteotomy. The medial approach may expose the coronoid through or around the flexor carpi ulnaris while protecting the ulnar nerve. The anterior elbow is approached by splitting brachioradialis and biceps, but extensile measures are limited. With increasing fracture complexity, posterior approaches are popular due to the access of medial and lateral columns of the distal humerus. Management of the triceps varies by surgeon preference and the need for articular exposure. More extensile techniques with lateral ulnar collateral ligament release provide near-total visualization of the articular surface. In addition, arthroscopic-assisted fracture fixation is an available adjuvant to provide minimally invasive access to the joint. Because of the complexity of elbow anatomy with limited global access, surgeons' familiarity with classic, extensile, and combined exposures is necessary to facilitate surgical reconstruction.

Introduction: Optimizing weight-bearing can enhance fracture recovery, but measuring the response to weight-bearing protocols has been challenging to continuously and reliably study. We investigated whether smartphone-captured mobility metrics could detect functional differences in patients prescribed either early weight-bearing or delayed weight-bearing after lower extremity fractures.

Methods: We conducted a cohort study, including adult patients with lower extremity fractures treated surgically, ≥6 months of follow-up, and an Apple iPhone for ≥1 year before injury. Patients with bilateral lower extremity fractures were excluded. Patients were classified as early weight-bearing or delayed weight-bearing. The primary outcome was step count, measured by the Apple iPhone Health application, within 12 weeks of injury. Secondary outcomes included walking speed and asymmetry, and an extended observation to 26 weeks postinjury. Between-group differences were estimated using linear mixed-effects models, controlling for preinjury mobility, age, sex, open fracture, and fracture location.

Results: We enrolled 74 patients (mean age, 46 [SD, 19] years; 43% female), with 27 patients in the early weight-bearing group and 47 patients in the delayed weight-bearing group. Within 12 weeks of injury, early weight-bearing patients had markedly more daily steps than delayed weight-bearing patients (mean difference, 1,050 steps per day; 95% confidence interval [CI], 373 to 1,727; P = 0.002). Secondary outcomes did not differ between the groups within 12 weeks of injury. However, by 26 weeks after injury, early weight-bearing patients had faster walking speeds (mean difference, 0.13 m/s; 95% CI, 0.04 to 0.22; P = 0.004) and less walking asymmetry (mean difference, -12.2%; 95% CI, -21.3% to -3.1%; P = 0.008) than delayed weight-bearing patients.

Discussion: Among patients with surgically treated lower extremity fractures, smartphone-collected step counts were higher in early versus delayed weight-bearing patients within 12 weeks of injury. These findings suggest that postoperative weight-bearing protocols affect patient mobility and can be measured continuously and remotely.

Level of evidence: Level III, Therapeutic.

Introduction: Total hip arthroplasty (THA) is a commonly performed procedure with wonderful outcomes, but perioperative adverse events, dislocations, and need for revision can arise. This study explores how a surgeon's subspecialty training-arthroplasty, trauma, or nonarthroplasty/nontrauma-correlates with postoperative outcomes after THA.

Methods: Using the 2010 to 2022 M165Ortho PearlDiver Database, patients who underwent elective THA were identified. Patients were grouped based on the subspecialty training of the surgeon performing the procedure: arthroplasty, trauma, or nonarthroplasty/nontrauma. Multivariate analysis, adjusting for patient age, sex, and comorbidities, was used to compare 90-day adverse events and readmission rates between patient groups. Five-year dislocations and revisions were then assessed and compared with Kaplan-Meier analysis.

Results: Of 742,630 THAs identified, nonarthroplasty, nontrauma surgeons conducted 677,094 (91.1%), arthroplasty surgeons conducted 61,826 (8.3%), and trauma surgeons conducted 3,711 (0.5%). Compared with nonarthroplasty nontrauma surgeons, arthroplasty-trained surgeons had lower odds of any adverse events (odds ratio [OR], 0.80; P < 0.001), serious adverse events (OR, 0.83; P < 0.001), and minor adverse events (OR, 0.80; P < 0.001). Specific adverse events with lower odds in the arthroplasty group included pulmonary embolism, sepsis, surgical site infection, acute kidney injury, pneumonia, and urinary tract infections. Compared with nonarthroplasty nontrauma surgeons, trauma-trained surgeons only had higher odds of wound dehiscence (OR, 1.42; P = 0.001). The 5-year revision rates were lowest in the arthroplasty group (3.1%), followed by the nontrauma, nonarthroplasty group (3.5%; P < 0.001) and the trauma group (4.5%; P < 0.001). Similar patterns were observed in the 5-year hip dislocation rates.

Conclusion: Subspecialty training in arthroplasty is associated with lower complication rates and better implant survival after THA. These findings suggest that arthroplasty training is associated with improved outcomes, potentially contributed to experience, volume, and/or care pathways.