Journal of the American Academy of Orthopaedic Surgeons最新文献

Dilute povidone-iodine (polyvinylpyrrolidone iodine [PVP-I]) irrigation in spine surgery and total joint arthroplasty has seen a rapid and substantial increase in its use during the past decade. Yet, most surgeons do not know the chemistry and biochemistry that explain its efficacy in preventing infections. PVP-I forms a complex with molecular iodine (I2), facilitating the delivery of I2 to the membrane of the infectious organism. Here, PVP-I establishes an equilibrium between complexed and noncomplexed (free) I2 in the aqueous solution. The I2 acts at numerous cellular targets of infecting organisms augmenting its role as a biocidal molecule. The paradoxical increase in the concentration of I2 that occurs with dilution of PVP-I is a result of equilibrium kinetics and is associated with an enhanced antimicrobial activity. Cytotoxicity studies have yielded conflicting results, but most endorse diluted concentrations as being less damaging to tissues. Clinical studies have verified notable reductions in surgical site infections with a 3-minute soak of 0.35% dilute povidone-iodine irrigation. Guidelines from the World Health Organization, Centers for Disease Control and Prevention, and International Consensus Meeting on Musculoskeletal Infection support the use of prophylactic incisional wound irrigation with aqueous PVP-I to reduce and prevent surgical site infections.

Purpose: This study aimed to evaluate the impact of implementing a standardized opioid prescription protocol on prescription practices post-elective ACS surgery at a large academic institute.

Methods: A prospective cohort study with a retrospective control group was conducted following institutional review board approval. A standardized protocol was created and implemented which specified opioid prescriptions post-surgery. Data on opioid doses, total and daily Morphine Milligram Equivalents requirements, and the need for refills were collected and compared between both cohorts.

Results: The study included 83 patients in the post-protocol cohort compared with 315 age- and sex-matched patients in the pre-protocol cohort. The postprotocol cohort received markedly lower daily and total doses at discharge compared with the preprotocol group (P < 0.01). No increase was observed in prescription refills before the initial follow-up in the postprotocol cohort (P = 0.35). At 12 weeks postsurgery, fewer patients in the postprotocol group remained on opioids compared with the preprotocol group (P = 0.14).

Conclusion: Standardizing opioid prescriptions post-ACS surgery effectively reduces opioid doses prescribed without increasing refill rates. The findings support the efficacy of procedure-specific opioid prescription guidelines in reducing unnecessary opioid use and associated health and economic burdens.

Robot-assisted spine surgery has gained notable popularity among surgeons because of recent advancements in technology. These innovations provide several key benefits, including high screw accuracy rates, reduced radiation exposure, customized preoperative and intraoperative planning options, and improved ergonomics for surgeons. Despite the promising outcomes reported in literature, potential technical challenges remain across various robotic platforms. It is crucial for surgeons to remember that robotic platforms are shared-control systems, requiring the surgeon to maintain primary control throughout the procedure. To ensure patient safety, surgeons should be well versed in common technical pitfalls and strategies to mitigate these limitations.

Introduction: As the US obesity epidemic continues to grow, so too does comorbid hip and knee arthritis. Strict body mass index (BMI) cutoffs for total hip and knee arthroplasty (THA and TKA) in the morbidly obese have been proposed and remain controversial, although current American Academy of Orthopaedic Surgeons guidelines recommend a BMI of less than 40 m/kg 2 before surgery. This study sought to compare patient-reported outcomes and 30-day complication, readmission, and revision surgery rates after THA or TKA between morbidly obese patients and nonmorbidly obese control subjects.

Methods: All patients undergoing primary THA and TKA at our institution from May 2020 to July 2022 were identified. Patient demographics, surgical time, length of stay and 30-day readmission, revision surgery, and complication rates were prospectively collected. Preoperative and postoperative Hip and Knee Society (Hip Osteoarthritis Outcome Score [HOOS] and Knee Osteoarthritis Outcome Score [KOOS]) were collected. Patients were stratified by BMI as ideal weight (20 to 24.9), overweight (25 to 29.9), class I obese (30 to 34.9), class II obese (35 to 39.9), and morbidly obese (>40 m/kg 2 ).

Results: A total of 1,423 patients were included for final analysis. No difference was observed in 30-day unplanned return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Morbidly obese patients undergoing THA had lower preoperative HOOS (49.5 versus 54.5, P = 0.004); however, there was no difference in postoperative HOOS or KOOS at 12 months across all cohorts.

Discussion: No difference was observed in 30-day return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Despite a lower preoperative HOOS, there was no difference in 12-month HOOS or KOOS when stratified by BMI. These findings suggest that such patients may achieve similar benefit from arthroplasty as their ideal weight counterparts.

Reverse shoulder arthroplasty (RSA) will soon reach its 20-year anniversary in the United States and has now become the most performed shoulder arthroplasty in the United States. The evolution from Grammont style implants to lateralized designs continues to generate debate as comparable outcomes have been reported with both types of systems. While early literature focused on fixation and expanded indications, recent studies have evaluated component design and position and their effect on functional outcomes and complications. The purpose of this article was to provide a synopsis of design rationales of current RSA prostheses and review outcomes related to RSA design and position.

Introduction: There is a paucity of research comparing postoperative complication rates between manual total knee arthroplasty (M-TKA) and robotic-assisted total knee arthroplasty (RA-TKA). This study aims to compare 90-day postoperative complication, readmission, and emergency department rates between RA-TKA and M-TKA.

Methods: A retrospective review of a multihospital database identified patients who underwent TKA between January 2016 and May 2023. Surgeons who used the robotic-assisted surgery technique in <10% or >90% of their cases annually were excluded. This resulted in 15,999 cases (8,853 RA-TKAs; 7,146 M-TKAs) from 282 surgeons. RA-TKA and M-TKA cohorts were one-to-one matched based on patient sex, age, body mass index, hospital setting, surgeon experience, primary payer, and anesthesia type. Each cohort consisted of 7,146 patients (N = 14,292). 90-day revisits, specifically readmissions, readmissions with >23 hours of observation, and ED visit rates were compared between cohorts. Complications were classified according to the Clinical Classification Software schema and compared between cohorts. Mann-Whitney U, chi-squared, and Fisher exact tests, along with Bonferroni correction, were used to statistically compare cohorts.

Results: All-cause 90-day readmission rates were 2.4% for RA-TKA and 2.6% for M-TKA ( P = 0.36). RA-TKA had fewer revisits (RA-TKA: 7.8%; M-TKA: 8.8%, P = 0.027) and rates of readmission with >23 hours of observation (RA-TKA: 1.4%; M-TKA: 2.0%, P = 0.003). RA-TKA had fewer hospital revisits due to joint stiffness (RA-TKA: 17 revisits; M-TKA: 42 revisits, P = 0.002) and chronic pain (RA-TKA: 1 revisit; M-TKA: 8 revisits, P = 0.039). Fewer readmissions were observed for acute injuries (lower extremity muscle/tendon strains) in the RA-TKA cohort (RA-TKA: 1; M-TKA: 9, P = 0.021). RA-TKA had fewer ED visits due to hematomas (RA-TKA: 0 visits; M-TKA: 7 visits, P = 0.016).

Conclusion: In this retrospective matched cohort analysis, RA-TKA was associated with markedly fewer revisits and readmissions with >23 hours of observation compared with M-TKA. No differences in all-cause 90-day readmission were observed between cohorts.

Level of evidence: Level III.

Study design: Retrospective review.

Background: Cemented fixation is recommended in the hemiarthroplasty treatment of geriatric femoral neck fractures. Certain cemented stems have similarly designed "low-demand" counterparts, but it is unclear whether they yield comparable clinical outcomes. The purpose of this study was to evaluate the revision risk associated with two low-demand stems, Summit Basic (DePuy Synthes) and Versys LD/Fx (Zimmer Biomet), in comparison to their standard counterparts, Summit (DePuy Synthes) and Versys Advocate (Zimmer Biomet).

Methods: Using our U.S. integrated healthcare system's Hip Fracture Registry, we identified patients aged ≥60 years who were treated with one of these four cemented hemiarthroplasty devices (2009-2022). Low-demand stems were compared with standard stems on the basis of aseptic revision rates (primary outcome measure) as well as periprosthetic fracture and 90-day complications (secondary outcome measures). Multivariable Cox proportional hazards regression was used to adjust for potential confounders.

Results: Overall, there were 9,828 cemented hemiarthroplasties (69.0% female, 78.9% White), including 3,713 low-demand stems and 6,115 standard stems. In the adjusted analysis, low-demand stems were associated with a higher risk of aseptic revision compared with standard designs (hazard ratio [HR] 1.53, 95%CI 1.06-2.22, P = 0.024). This difference was driven primarily by a higher risk of periprosthetic fracture in the low-demand stems (HR 3.40, 95%CI 1.54-7.51, P = 0.003). Similar findings were observed when separately comparing Summit Basic with Summit and Versys LD/Fx to Versys Advocate, and when restricting to procedures performed by experienced total hip arthroplasty surgeons.

Conclusions: In this study of 9,828 hip fracture patients treated with cemented hemiarthroplasty, low-demand stems were associated with a higher risk of aseptic revision as compared with their standard counterparts. Further research is required to determine the features of the low-demand stems which could be contributing to this finding, as well as the circumstances under which usage of low-demand stems could still be justified based on cost.

Introduction: Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic surgeries in the United States, yet little information exists regarding its utilization in different settlement types. This study aimed to determine the number of TKA-performing surgeons by settlement type and assess trends in the volume of TKAs in urban, micropolitan, small town, and rural settings.

Methods: Using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners database, the number of orthopaedic surgeons performing primary and revision TKAs from 2013 to 2020 was determined. The zip code where TKA was performed was used to identify the rural-urban commuting area codes (RUCA) and classify locations into one of four settlement types: urban/metropolitan, micropolitan (large town), small town, or rural. Correlations in surgeon number and TKA volume by settlement type were evaluated by Mann-Kendall tests.

Results: Between the years of 2013 and 2020, TKAs were billed by up to 7,192 orthopaedic surgeons. The proportions of TKAs occurring in settlement types were the following: urban/metropolitan, 85.2%; micropolitan, 11.5%; small town, 2.6%; rural, 0.6%. Areas without RUCA data had 32.9 TKAs per surgeon per year, the highest overall median surgeries per year over the 8-year period. The median number of TKAs per surgeon per year was 28, 25.4, 21.4, and 20.7 for urban/metropolitan, micropolitan, small towns, and rural areas, respectively.

Conclusion: A considerable difference exists in both the number of surgeons and the proportion of TKAs conducted across various settlement types. Twenty percent of population in the United States lives in rural areas; however, only 0.6% of billed TKAs occurred in these areas over the study period, indicating a gap in orthopaedic care access. It is imperative to understand TKA surgeon distribution and focus on strategies aimed at attracting and retaining proficient surgeons to address the healthcare needs of these underserved regions.

Research among orthopaedic surgery residents provides numerous benefits, which include but are not limited to development of critical thinking skills, greater understanding of study design and statistical analysis, strengthened fellowship applications, networking, and the ability to practice evidence based medicine. Research has been increasingly emphasized among orthopaedic surgery residency directors, and residency programs have uniformly implemented protected research time into their formal clinical training. Despite this, there are few resources describing the ability to conduct research effectively during residency. The purpose of this review is to provide an outline for implementing a successful, productive, high-output, resident-centric, research infrastructure leveraging resources available at clinical orthopaedic surgery residencies.

Background: Although Vancouver B2 periprosthetic fractures (PPFs) have been historically managed with revision total hip arthroplasty (rTHA), open reduction and internal fixation (ORIF) has been proposed as an alternative option for reasons including lower cost and surgical time. The purpose of this study was to, therefore, create a Markov model to assess the cost effectiveness of ORIF versus rTHA for Vancouver B2 periprosthetic femur fractures and evaluate various inflection points for varying costs and outcome measures.

Methods: A Markov model was built using discrete and mutually exclusive health states of the hypothetical patient with Vancouver B2 PPF. A decision tree was created on possible outcomes for each health state, using probabilities defined in the recent PPF literature. Direct costs and quality-adjusted life-years for each surgery and complication state were also collected. One-way and two-way deterministic sensitivity analyses were conducted to better understand the effect of 1 to 2 variables on the incremental cost-effectiveness ratio.

Results: The hypothetical patient with a Vancouver B2 PPF that was treated with rTHA incurred a cost of $52,559.64 with an effectiveness of 0.71. When treated with ORIF, the cost was $47,371.97 with an effectiveness of 0.38. The incremental cost and effectiveness of rTHA over ORIF were found to be $5,187.67 and 0.33, respectively. The cost of rTHA, the cost of ORIF, and the effectiveness of ORIF were the most influential variables in the model. On two-way sensitivity analysis, rTHA was more cost effective than ORIF within realistic healthcare parameters.

Discussion: From the payer perspective, we estimate that rTHA is more cost effective than ORIF for the treatment of Vancouver B2 PPFs within certain cost and quality-of-life parameters.