Journal of the American Academy of Orthopaedic Surgeons最新文献

The posterior ligamentous complex (PLC) provides critical structural support in the thoracolumbar spine. Its role in resisting progressive flexion is particularly important at the thoracolumbar junction due to the transition from the rigid thoracic spine to the more mobile lumbar region. Each component of the PLC contains anatomic features that contribute to both the structure and function of the PLC as a whole. Understanding the nuances of each structure is important in determining injury severity and may serve as a foundation for future directions of research. Violation of the PLC results in an unstable spine, thus requiring surgical management. It is associated with greater injury severity and neurologic deficit in patients who sustain thoracolumbar fractures, which adds complexity to the postoperative course and patient outcomes. Although plain radiographs and CT scans provide reliable indirect measures of PLC disruption, these modalities may be subject to diminished sensitivity based on patient positioning and do not directly measure soft-tissue injury. Modern classification systems include the integrity of the PLC in surgical decision making, and care must be taken to scrutinize the possibility of ligamentous disruption before proceeding with nonsurgical management to avoid adverse patient outcomes.

Introduction: The purpose of this study was to review rates of infection after civilian ballistic fractures and assess the effect of early antibiotic administration (EAA) on infection rates.

Methods: This was a retrospective cohort study done at an urban Level 1 Trauma Center. Patients ages 16 years and older with ballistic orthopaedic extremity injuries between May 2018 and December 2020 were enrolled. A total of 827 ballistic fractures were identified, and 371 fractures were analyzed after exclusions. The primary outcome measure was the incidence of infection within 90 days postinjury, correlated with the timing of antibiotic administration.

Results: Seventy percent of the extremity injuries received EAA (<3 hours of hospital admission) and 30% did not. Infections occurred in 6.9% of patients with EAA and in 7.3% of those without. We found no notable association between EAA and infection on multivariate logistic regression (odds ratio [OR] 1, 95% Confidence Interval [CI] 0.4 to 2.4, P = 0.99). Compartment syndrome (OR 5.4, 95% CI 1.1 to 26.4, P = 0.04) and surgical treatment of fracture (OR 12.9 95% CI 1.7 to 97.9, P = 0.01) were independently associated with higher odds of infection. We found no notable association between vascular injury or visceral injury and infection. Lower extremity fracture location was markedly associated with infection on multivariate logistic regression (OR 2.8; 95% CI 1 to 7.8; P = 0.05) when compared with upper extremity, hand, and foot locations. The highest infection rate was observed in tibial shaft fractures at 22%.

Conclusions: Early antibiotic treatment did not markedly reduce infection odds in civilian low-energy ballistic fractures. The study underscores the need for context-specific, evidence-based treatment strategies.

Level of evidence: III (retrospective cohort study).

Background: Social drivers of health (SDOH) are area-level, nonmedical factors that affect health outcomes. By contrast, health-related social needs (HRSNs) are individual patient reported and are being deployed in some payment models. SDOH are often used to broadly represent health disparities of communities through metrics, such as the Social Vulnerability Index (SVI); however, the association of area-level SVI to individual HRSNs has not been well studied in hand surgery, which has implications for addressing social risks to improve health and in quality measurement.

Methods: We conducted a prospective cohort study of new patients presenting to an outpatient hand surgery clinic. Patients completed a questionnaire that included demographic information, zip code, the Accountable Health Communities HRSNs Screening Tool, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH). Following completion of the survey, zip code was used to calculate SVI. Cohen kappa coefficients (k) were calculated to measure interrater agreement between SVI and HRSNs, SVI and QuickDASH, and HRSNs and QuickDASH.

Results: We included 80 patients in the study. The most commonly reported HRSNs were safety (33, 41.25%) followed by housing (14, 17.5%) and food (11, 13.75%). Seven SVIs were represented across the cohort. No notable agreement was observed between SVI and HRSNs. In addition, no notable agreement was observed between SVI or HRSNs and QuickDASH score.

Conclusion: Although the importance of identifying SDOH is growing, the ability of these area-level measures to accurately reflect individual HRSNs is not well understood. HRSNs may represent an opportunity for patient-centered assessments of needs and to guide resource deployment to improve outcomes for hand surgery patients.

Level of evidence: Level II prognostic study.

Introduction: Previous research has highlighted conflicts of interest stemming from industry funding and education of orthopaedic surgeons. This study sought to define the nature and magnitude of industry payments to orthopaedic surgery fellowship program directors (FPDs) in the United States.

Methods: This was a retrospective cohort study of orthopaedic surgery FPDs during 2021. Data were obtained from the Accreditation Council for Graduate Medical Education (ACGME) and Centers for Medicare and Medicaid Services. Profiles of orthopaedic surgery FPDs were obtained for ACGME-accredited and non-ACGME-accredited training programs. Nonresearch industry payments from 2015 to 2021 were extracted and adjusted for inflation. Temporal trends were analyzed through the calculation of compound annual growth rates. Comparisons were made with nonparametric tests.

Results: Of 600 orthopaedic surgery FPDs, 596 received industry funding (99%), which totaled $340.6 million over the study period. A trend toward greater total annual industry payments over the study period was observed (compound annual growth rate = 3.3%, P = 0.009). Most industry payments were for royalties or licensing ($246.6 million, 72.4%) and consulting fees ($53.6 million, 15.7%). The median total payment per orthopaedic surgery FPD was $49,971 (interquartile range [IQR], $291,674), with 22% receiving between $100,000 and $500,000 and 17% receiving more than $500,000. The highest annual industry payments existed in shoulder and elbow ($41,489, IQR, $170,613) and spine surgery ($26,103; IQR, $84,968). ACGME accreditation status did not influence the magnitude of industry compensation to orthopaedic surgery FPDs across subspecialties ( P > 0.05). Men had higher total median annual industry payments versus women ($7,799 [IQR, $47,712] versus $1,298 [IQR, $6,169], P < 0.001).

Discussion: Industry payments to orthopaedic surgery FPDs are ubiquitous, but the magnitude varies by subspecialty. Most industry funding was found in shoulder and elbow and spine surgery. Standards for orthopaedic fellowship education, such as those upheld by accrediting bodies, should include guidelines on how FPDs handle and disclose financial relationships with industry.

Introduction: Nontobacco nicotine products, including e-cigarettes and vaping, are marketed as healthier alternatives to tobacco. However, the literature on nontobacco nicotine dependence (NTND) is scarce. It is important to analyze the influence of these products as they pertain to medical and surgical postoperative complications. This study hypothesizes that patients with NTND will experience more postoperative complications.

Methods: Using the TriNetX database, which aggregates deidentified medical records from 89 healthcare organizations in the Research Network, Current Procedural Terminology and 10th revision of the International Classification of Diseases codes were used to identify patients undergoing primary shoulder arthroplasty (SA) from January 2012 to February 2024. Patients were divided into cohorts based on their NTND status before surgery. 90-day major medical complications and 2-year implant-related complications were assessed. Statistical analyses involved calculating risk ratios for postoperative complications.

Results: This study analyzed a total of 89,910 SA patients, of which 6,756 were 1:1 propensity matched into NTND or control cohorts. Within the 90-day postoperative period, the NTND cohort exhibited significantly higher rates of sepsis (1.80 vs. 1.20, P = 0.012), surgical site infection (1.20 vs. 0.70%, P = 0.007), and wound disruptions (0.70 vs. 0.40%, P = 0.048), average opioids prescribed (4.46 vs. 3.338, P < 0.001), readmission (10.20% vs. 6.20%, P 0.001) compared with the non-NTND cohort. At the 2-year follow-up, mechanical loosening was notably higher in the NTND group (1.10 vs. 0.30%, P 0.001), as were rates of prosthetic joint infections (2.20 vs. 1.20%, P 0.001). No significant difference was observed for revision rates (3.20% vs. 2.90%, P = 0.269).

Discussion: NTND is associated with higher 90-day rates of wound distruptions, infections, sepsis, as well as increased rates of mechanical loosening and prosthetic joint infection at 2 years postoperatively after SA. These results highlight the need for comprehensive NTND preoperative screening and tailored patient counseling in this patient population.

Introduction: Orthopaedic surgery has consistently been one of the most competitive specialties in the US residency selection process. This is due in part to the steady upward trend in average applications received per program and average applications submitted per applicant, which is of growing concern. With the implementation of the Preference Signaling Program, the total number of applications has now dropped for the first time in many years, indicating signaling may improve the application process. The hypothesis is that signaling has led to a decrease in applications sent by applicants and a decrease in applications received by programs.

Methods: A 7-question survey regarding their interview and match statistics was sent to orthopaedic surgery residency programs that participated in the Electronic Residency Application Service during the 2023-2024 application cycle. A response from the program director/administrator was then recorded.

Results: Our program search yielded 159 programs with 106 respondents (66.7%). 82 programs (78.8%) solely interviewed applicants who signaled their program. 92.7% of current interns signaled the program where they matched, and 88 programs (84.6%) matched only applicants who signaled. 95 programs (89.6%) revealed that implementing signaling has improved the application process.

Conclusion: Most of the programs only interviewed applicants who also signaled, and nearly all matched orthopaedic surgery applicants from the 2022-2023 cycle signaled their matching program. Orthopaedic surgery applicants should consider only applying to 30 programs and using all 30 available signals. Applicants should also be more confident knowing that beyond the 30 signals they use, there is limited support to say that they will receive an interview outside of these 30 applications. Orthopaedic surgery programs will also now have the ability to allocate more time to applicants most interested in their program, given the reduction of applications.

Introduction: Unicompartmental knee arthroplasty (UKA) is increasingly favored in clinical practice due to its favorable long-term survival rates, positive clinical outcomes, and expedited recovery. Periprosthetic joint infections (PJIs) remain a formidable complication in knee arthroplasty, and guidelines for the management are limited. This study aims to assess the failure rates of débridement, antibiotics, and implant retention (DAIR) in UKAs, providing insights into optimal treatment management and infection-free survival for PJI in this context.

Methods: Twenty-five patients met the inclusion criteria of PJI, as defined by Musculoskeletal Infection Society criteria, and were retrospectively reviewed from January 2000 to September 2023. Surgical treatment included 17 DAIRs (78%), six one-stage revision procedures (20%), and three two-stage revision procedures (12%). Seventeen patients (78%) had acute hematogenous infections (<3 weeks of symptoms). Kaplan-Meier survivorship analysis was done for reinfection and revision procedures.

Results: The overall infection-free survival and all-cause survival regardless of management at 3 years was 60.1% (95% confidence interval [CI], 45.7% to 89.6%) and 55.8% (95% CI, 38.2% to 81.5%), respectively. Both two-stage and one-stage revision procedures had an infection-free survivorship of 100% at 3 years (95% CI, 100% to 100%). DAIR treatment had an infection-free survival at 3 years of 41.6% (95% CI, 22.4% to 77.4%). Nine of 17 patients (53%) undergoing DAIR were unsuccessful and required subsequent second DAIR, one-stage, or two-stage revision procedures.

Discussion: The efficacy of DAIR following PJI in UKA is notably limited, suggesting a need for reevaluation of its role in managing UKA PJIs. Given the absence of established guidelines for PJI management specifically tailored to UKA, there is an urgent and compelling need for future studies to elucidate optimal clinical strategies to allow for the best treatment for patients.

Level of evidence: Level III, retrospective comparative study.

Background: Acquiring microsurgical anastomosis skills requires considerable time and effort. Moreover, appropriate and systematic training for acquiring microsurgical anastomosis skills is lacking. Therefore, this study investigated the learning curve for acquiring microsurgical anastomosis techniques among orthopaedic surgery residents.

Methods: The study involved 12 orthopaedic surgery residents without experience in microsurgical anastomosis. The residents were divided into two groups: the 'Experienced group' with more than 6 months of suturing experience and the 'Inexperienced group' with no suturing experience. Each participant underwent 30 practice sessions, suturing a 3.5-mm diameter silastic tube. The time taken for each anastomosis and its quality were evaluated. Individual learning curves were derived, and the number of trials required to reach the time plateau was determined.

Results: The Experienced group reached the time plateau after an average of 16.3 ± 1.4 attempts while the Inexperienced group reached it after an average of 24.2 ± 2.5 attempts. The time required for the first two attempts was 40.4 ± 6.2 min for the Experienced group and 61.2 ± 8.6 min for the Inexperienced group (P < 0.001). The time required for the last two attempts was 11.4 ± 0.7 min for the Experienced group and 12.8 ± 0.8 min for the Inexperienced group. Comparing the quality scores of the first two attempts, the Experienced group scored 4.3 ± 0.5 points and the Inexperienced group scored 3.1 ± 0.5 points (P < 0.001). The Experienced group scored 7.8 ± 0.5 points for the last two attempts while the Inexperienced group scored 6.9 ± 0.3 points (P < 0.001).

Conclusions: Individuals new to suturing improved anastomosis time and quality by approximately 30 times. This finding suggests that practitioners can optimize their training while educators can refine the curriculum by predicting learning curves and providing timely feedback to enhance skill development.

Introduction: Hip, knee, and lumbar spine surgeries are prevalent with arthroplasty often preceding lumbar surgery. The objective of this analysis was to ascertain whether previous arthroplasty was associated with patients' postlumbar surgery fulfillment of expectations.

Methods: Identical systematically acquired data were pooled from 3 prospective studies that included assessments of preoperative expectations of lumbar surgery and 2-year postoperative assessment of fulfillment of expectations using a valid survey with points assigned for amount of improvement expected for symptoms and function. The proportion of expectations fulfilled was defined as total points for improvement received postoperatively divided by total points for improvement expected preoperatively (range 0 [no expectations fulfilled] to >1 [expectations surpassed]). Enrollment data included the expectations survey, demographic/clinical characteristics, Oswestry Disability Index (ODI) scores, and previous hip/knee arthroplasty. Postoperative data included follow-up expectations survey, ODI scores, and any spine complications. The proportion was the dependent variable in multivariable linear regression with demographic/clinical independent variables.

Results: 1137 patients were included (mean age 59 years, 51% male); 993 (87%) did not have previous arthroplasty, and 144 (13%) had arthroplasty (51 hip only, 77 knee only, 16 both hip/knee). Patients with any arthroplasty had similarly high expectations compared with patients with no arthroplasty but lower proportion of expectations fulfilled (0.69 versus 0.76, P = 0.03). In multivariable analysis, variables associated with a lower proportion of expectations fulfilled were greater preoperative expectations ( P < 0.0001), not working ( P < 0.0001), positive depression screen ( P = 0.0002), previous lumbar surgery ( P < 0.0001), previous arthroplasty ( P = 0.03), surgery on ≥3 vertebrae ( P = 0.007), less preoperative-to-postoperative ODI improvement ( P < 0.0001), and postoperative complications ( P < 0.0001).

Conclusions: After accounting for a spectrum of highly associated covariates, patients with previous arthroplasty still had less fulfillment of expectations of subsequent lumbar surgery. For patients with previous arthroplasty, surgeons should discuss potential differences between arthroplasty and lumbar surgery during preoperative evaluations and during shared postoperative assessments of the outcome.

Since the advent of Neer's total shoulder arthroplasty in 1974, glenoid implant design has evolved to optimize patient function and increase implant longevity. Glenoid loosening continues to be a major cause of total shoulder arthroplasty failure due to both patient and implant factors. The more recent development of posterior augmented glenoids, peg fixation with ingrowth potential, inlay implants, zoned conformity implants, and convertible glenoids have all shown promising results in improving glenoid fixation and survival in different clinical circumstances. The increased utilization of 3D CT scans, preoperative planning, and patient-specific instrumentation has paralleled innovation in glenoid implants with the aim of improving the accuracy of glenoid implant placement to further optimize patient function and implant longevity. Specific indications for the variety of glenoid implants available today are still being studied. The shoulder arthroplasty surgeon should consider patient and implant factors and patient goals when determining the appropriate implant for each individual.