Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Periprosthetic joint infection (PJI) after total joint arthroplasty (TJA) poses substantial economic and quality-of-life challenges. With the rising incidence of hip and knee arthritis globally, understanding the changing profile of PJIs across different age groups becomes crucial. While various studies have explored risk factors, the influence of age on PJI remains debated, with potential bimodal relationships. This study aims to investigate the causative organisms of PJIs in patients of different age groups undergoing TJA.

Methods: Conducted as a retrospective cohort study at a high-volume PJI referral center, the study adhered to Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data spanned from January 1, 2001, to December 31, 2022, including patients with documented PJI undergoing revision TJA. Patients were categorized into age quintiles, and outcomes analyzed included causative organisms, difficult-to-treat infections, antimicrobial resistance, and Gram stain characteristics. Statistical analyses used descriptive statistics, chi-square tests, and sensitivity analyses for hip and knee patients separately.

Results: The study comprised 2,392 patients, with 60.7% undergoing hip arthroplasty and 39.3% undergoing knee arthroplasty. 1,080 women (45.2%) and 1,312 men (54.8%) were included. Older patients were markedly more likely to have gram-negative infections and atypical infections. Patients in the youngest age group had the lowest rates of methicillin-resistant Staphylococcus aureus infection. Results were similar between hip and knee PJIs.

Conclusions: The study reveals age-related variations in the characteristics of PJIs after TJA, emphasizing higher risks of atypical and resistant infections in older patients. These findings underscore the importance of tailored preventive measures and potential considerations for adjunctive or prolonged antibiotic therapies, especially in the elderly population. Recognizing the unique infection patterns in older patients may inform better prevention and treatment strategies, with implications for enhanced patient care and outcomes. Future directions should focus on patient-specific strategies for preventing and treating PJIs, particularly in high-risk populations.

Purpose: Pain management in orthopaedic manipulation in the emergency department (ED) is crucial to decrease fracture reduction performed in the operating room. This study compared intranasal fentanyl (INF) with oral morphine in time of care and effectiveness on pain during the reduction of bone fractures in a pediatric trauma center.

Methods: A before-and-after INF implementation study was conducted in a pediatric ED with a trauma center on children with a confirmed displaced closed fracture on radiographs with reduction and casting performed in the ED. The time of care, time for sufficient analgesia, effectiveness on pain, and tolerance were compared between both analgesics in 3 consecutive phases.

Results: 77 children were included: 31 children received oral morphine and 46 INF. The time of care was shorter in the INF group (150 [111 to 193] minutes versus 215 [155 to 240], P = 0.01) as the time for sufficient analgesia (10 [9 to 13] minutes versus 80 [53 to 119], P < 0.001) with a higher pain reduction after a dose of INF (3 [0 to 4] versus 6 [3 to 7], P < 0.001) and less dose requirement (P = 0.002). Although pain scores were similar at arrival in both groups (P = 0.15), the pain was significantly lower before and during the procedure in the INF group and equivalent after the procedure (2 [0 to 4] versus 3 [0 to 5], P = 0.02, 3 [1 to 5] versus 7 [3 to 9], P < 0.001, and 1 [0 to 2] in both groups, P = 0.87, respectively). Keeping pain levels low during the procedure in the INF group allowed the extension to lower limb fracture reductions (P = 0.04). No serious adverse events were reported.

Conclusion: INF reduces the time to obtain sufficient analgesia and time of care, with good effectiveness maintained during the procedure in fracture reduction, allowing the extension to lower limb fractures. Thus, this rapid and efficient analgesia facilitates orthopaedic care in the pediatric ED that would otherwise require to be reduced in the operating room under general anesthesia.

Introduction: Distal femur fractures (DFFs) are associated with high complication and mortality rates in the elderly. Using the National Inpatient Sample and Medicare data, we describe trends in the incidence of DFFs by fixation type and associated healthcare costs.

Methods: Annual population rates and volume of inpatient DFFs were estimated using Poisson regression with the US Census as a denominator. We used Current Procedural Terminology codes in Medicare patients to determine episode-of-care cost by treatment, classified as intramedullary nail, open reduction and internal fixation, and distal femur arthroplasty (DFR).

Results: The annual incidence of DFFs in the United States is approximately 27.4 per 100,000. Admission for DFFs increased from 2002 to 2020, with the highest volume and rate in those aged 85 years and older. DFF incidence increased (1.95×) from 142 per 1 million (95% CI: 140 to 144) in 2006 to 281 per 1 million (95% CI: 278-284) in 2019. From 2012 to 2019, the percentage of DFFs treated by intramedullary nail increased from 6.8% to 8.4%, open reduction and internal fixation decreased from 89.9% to 76.6%, and DFR increased from 3.3% to 14.9%. DFR cost was significantly greater than other treatment choices across all years for initial inpatient admission costs and 90-day episode-of-care costs (all P < 0.0001).

Conclusion: DFF volume has increased in the past 20 years, predominantly in elderly patients. Greater than 4.5× increase was observed in the proportion of geriatric DFFs treated with DFR during this study period. The total cost of DFR treatment was consistently greater than other surgical treatments.

Introduction: Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and cardiovascular compromise during cementation in arthroplasty cases. This study examines the association between anesthetic regimen and risk of BCIS in cemented hemiarthroplasty for hip fractures. We hypothesized that neuraxial anesthesia would be associated with markedly lower BCIS incidence compared with general anesthesia alone or in combination with regional anesthesia.

Methods: This retrospective cohort study included patients aged 50 years or older who underwent cemented hemiarthroplasty for hip fractures at a single institution between January 2017 and December 2022. Patient demographics, comorbidities, procedural factors, anesthetic characteristics including anesthetic regimen (general, general plus regional, or neuraxial), cement timing, BCIS development, postoperative complications, and mortality data were extracted. BCIS was identified by changes in postcementation vitals and its severity classified according to previously established criteria. Univariate statistical analyses and multivariate logistic regression were conducted.

Results: Of the 137 included patients, 58 (43%) developed BCIS. No notable differences were observed in demographics, comorbidities, or procedural characteristics between patients who developed BCIS and those who did not. However, anesthetic regimen was markedly correlated with BCIS development, with general anesthesia demonstrating the highest rates (26/43, 55%), followed by general plus regional anesthesia (26/58, 45%) and neuraxial anesthesia (6/32, 19%; P = 0.005). Compared with neuraxial anesthesia, general anesthesia and general plus regional anesthesia conferred 6.8 and 5.5 times greater odds of developing BCIS, respectively. The development of BCIS was associated with significantly higher rates of postoperative hypoxia (P = 0.04) and unplanned prolonged intubation (P = 0.04).

Conclusion: BCIS was highly prevalent among patients undergoing cemented hemiarthroplasty for hip fractures. The anesthetic regimen was the only variable markedly associated with BCIS development and is a potentially modifiable risk factor.

Level of evidence: III.

Medical students without a home orthopaedic surgery program face unique challenges due to the absence of institutional connections and mentorship opportunities. This review explores the hurdles faced by these students, including financial constraints, emotional strains, mentorship gaps, and networking hurdles. Drawing from empirical evidence and scholarly research, tailored advocacy strategies to empower these medical students pursuing orthopaedic surgery residency are proposed, including mentorship programs, financial assistance, psychosocial support, and community-building initiatives.

Introduction: The opioid epidemic in the United States has contributed to a notable economic burden and increased mortality. Total shoulder arthroplasty (TSA) has become more prevalent, and opioids are commonly used for postoperative pain management. Prolonged opioid use has been associated with adverse outcomes, but the role of surgeons in this context remains unclear. This study aims to investigate the incidence and risk factors of prolonged opioid utilization after primary TSA.

Methods: After obtaining institutional review board approval, a retrospective review of 4,488 primary total shoulder arthroplasties from 2014 to 2022 at a single academic institution was conducted. Patients were stratified by preoperative and postoperative opioid use, and demographic, clinical, and prescription data were collected. Prescriptions filled beyond 30 days after the index operation were considered prolonged use. Multivariate analysis was conducted to determine the independent risk factors associated with prolonged opioid utilization.

Results: Among 4,488 patients undergoing primary TSA, 22% of patients developed prolonged opioid use with 70% of prolonged users being opioid-exposed preoperatively. Independent risk factors of prolonged use include patient age younger than 65 years (Odds Ratio (OR) 1.02, P < 0.001), female sex (OR 1.41, P < 0.001), race other than Caucasian (OR 1.36, P = 0.003), undergoing reverse TSA (OR 1.28, P = 0.010), residing in an urban community (OR 1.33, P = 0.039), preoperative opioid utilization (OR 6.41, P < 0.001), preoperative benzodiazepine utilization (OR 1.93, P < 0.001), and increased postoperative day 1-30 milligram morphine equivalent (OR 1.003, P < 0.001).

Discussion: Nearly 22% of patients experienced prolonged opioid use, with preoperative opioid exposure being the most notable risk factor in addition to postoperative prescribing patterns and benzodiazepine utilization. Surgeons play a crucial role in opioid management, and understanding the risk factors can help optimize benefits while minimizing the associated risks of prolonged opioid use. Additional research is needed to establish standardized definitions and strategies for safe opioid use in orthopaedic surgery.

Introduction: Increasingly, national accrediting bodies and professional societies for musculoskeletal oncology recognize the need for more standardized training. This study elucidates recent trends in reported case volume during Accreditation Council for Graduate Medical Education (ACGME)-accredited musculoskeletal oncology fellowship training relative to case minimum requirements.

Methods: We conducted a retrospective cross-sectional analysis of fellows at ACGME-accredited musculoskeletal oncology fellowships (2017 to 2022). Percentiles in reported case volumes were calculated across ACGME-defined case categories and temporal changes assessed by linear regression. Variability between the highest (90th percentile) and lowest (10th percentile) deciles was calculated as fold differences. Sensitivity analyses were conducted to estimate the number of fellows not meeting ACGME-defined case minimum requirements.

Results: Case logs from 95 musculoskeletal oncology fellows were analyzed. From 2017 to 2022, total relevant oncology procedures increased from 191 ± 49 to 228 ± 73 (P = 0.066). Pediatric oncology accounted for a minority of cases (range, 6 to 8%). A mean of 222 total relevant oncology procedures were reported. Most were in management of metastatic disease (21%), soft-tissue resection/reconstruction (20%), and limb salvage (13%). Variability in total relevant oncology procedures was 2.6 and greatest in spine/pelvis (4.6), pediatric oncologic cases (4.4), and surgical management of complications (4.4). No clear trends were observed in case volume variability over the study period (P > 0.05). Analysis of case volume percentiles identified at least 30% of musculoskeletal oncology fellows not achieving minimum requirements for pediatric oncologic cases (n = 29 fellows) and 10% of fellows not achieving minimum requirements for total relevant oncology procedures (n = 10 fellows).

Discussion: Results from this study may help future musculoskeletal oncology fellows and faculty identify potential areas to increase case exposure and reduce variability during fellowship training. More investigation is needed to determine evidence-based case minimum requirements including surgical learning curves and other competency-based assessment tools in musculoskeletal oncology.

Purpose: The illicit injection of xylazine has recently been designated as an emerging public health threat. The use of this drug is associated with devastating soft-tissue necrosis that may lead to limb amputation. This study aimed to (1) report cases of soft-tissue injury from xylazine and (2) describe a staging and management algorithm for wounds related to xylazine use.

Methods: A retrospective review was conducted to identify patients treated for xylazine-related soft-tissue necrosis at a trauma center. Clinical cases, treatment strategy, and available outcomes were presented. In addition, a comprehensive literature search was conducted using the keywords "xylazine" and "soft tissue."

Results: The management of seven patients with xylazine-related upper extremity soft-tissue necrosis was included, in addition to summarizing findings of five studies reporting on 13 additional cases. These cases were managed with local wound care (2 patients), soft-tissue reconstruction (4 patient), osseous reconstruction (1 patient), and limb amputation (10 patients).

Discussion: Acute treatment of xylazine-related soft-tissue necrosis is ideal to minimize morbidity and prevent limb loss. Management strategies of these wounds should be based on the depth of tissue involvement. Superficial ulceration involving the skin and subcutaneous tissue (Stage 1) should be managed with local wound care. Deeper ulceration involving tendons and/or muscle (Stage 2) requires surgical débridement and soft-tissue reconstruction. Deeper ulceration involving bone (Stage 3) requires osseous débridement and reconstruction. Finally, when all tissues in the extremity are involved (Stage 4), amputation is often necessary.

Introduction: The field of orthopaedic surgery has disproportionately low numbers of women and underrepresented in medicine (URM) groups. Although the representation of women and URM in orthopaedics has increased over the past several years, the growth has not kept up with other surgical specialties.

Methods: This is a retrospective review of data presented by the Association of American Medical Colleges (AAMC) regarding US medical school faculty and department chair makeup in 2018 to 2022 and 2015 data from the AAMC Group on Women in Medicine and Sciences reports. Data regarding the sex and race/ethnicity of faculty and department chairs in orthopaedic surgery, a comparable surgical specialty (otolaryngology), surgery, and all medical fields were assessed. Otolaryngology was chosen as a comparable specialty because orthopaedic surgery and otolaryngology are the only two surgical specialties classified within the AAMC faculty report, separate from any medical counterpart.

Results: Among orthopaedic surgery, otolaryngology, surgery, and all clinical sciences, the representation of women and individuals from URM groups increased between 2015 and 2022. During this time, orthopaedic surgery had the lowest growth rate of the four groups in female faculty (+0.63%/year), URM faculty (+0.32%/year), and URM department chairs (+0.11%/year). However, orthopaedic surgery did have an increase in female department chairs (0.96%/year to 7% in 2022), similar to increases seen in surgery and all clinical sciences.

Discussion: The increase in representation in female and URM faculty and department chairs in orthopaedic surgery lags behind comparable fields and medicine as a whole. In addition, orthopaedic surgery had the lowest representation of female and URM faculty in 2015 and 2022. Improving the representation of female and URM orthopaedic faculty and department chairs is critical because this may encourage more diverse medical students to consider pursuing a career in the field.