Journal of the American Academy of Orthopaedic Surgeons最新文献

Objectives: The Femoral Neck System (FNS) is a fixed-angle side plate device approved for use in fixation of femoral neck fractures. The FNS perforates the lateral cortex of the subtrochanteric femur, which may increase the risk of postoperative subtrochanteric fractures compared with the inverted triangle cannulated screw (CS) construct. The purpose of this biomechanical study was to compare forces required to create subtrochanteric fractures in FNS and CS constructs in a synthetic bone biomechanical model.

Methods: Osteopenic sawbones were divided into five groups: Noninstrumented femurs, CS with the inferior screw proximal to the midpoint of the lesser trochanter ("normal position," CSN), CS with the inferior screw distal to the lesser trochanter ("low position," CSL), one-hole FNS, and two-hole FNS. Models were loaded to failure on a Servohydraulic Test System. Means and standard deviations were calculated for load to failure. Each group was paired and analyzed using two-sample t-tests.

Results: Constructs in order of greatest to lowest load to failure include the following: Control (2950 N), one-hole FNS (2542 N), two-hole FNS (2444 N), CSN (2318 N), and CSL (2102 N). Load to failure was greater for the CSN group compared with CSL ( P = 0.04). Load to failure was greater for one-hole FNS versus CSL ( P = 0.002) and CSN ( P = 0.05). Load to failure was greater for two-hole FNS versus CSL ( P = 0.006) but not versus CSN ( P = 0.16). Load to failure was similar between one- and two-hole FNS ( P = 0.24).

Conclusion: The FNS demonstrated failure at the subtrochanteric femur in this synthetic femora biomechanical model. The load to failure of FNS was superior compared with CS placed below the level of the lesser trochanter. The load to failure of the one-hole FNS was also superior to CS placed proximal to the midpoint of the lesser trochanter.

Introduction: Developmental dysplasia of the hip (DDH) poses challenges for component positioning during total hip arthroplasty (THA) secondary to abnormal bone morphology, soft-tissue contractures, and hip center migration. The objective of this study was to evaluate the radiographic and clinical outcomes of THA for DDH performed with robotic assistance versus manual (M) technique.

Methods: A retrospective review identified 115 patients with Crowe II to IV dysplasia undergoing primary THA at a single institution from 2016 to 2022. There were 59 (51%) M-THAs and 56 (49%) RA-THAs. The median age was 49 years, the median body mass index was 28, and 94 (82%) patients were women. No difference was seen in Crowe classification between cohorts. The mean follow-up was two years.

Results: No difference was observed in mean surgical time between robotic-assisted THA (RA-THA) and manual THA (M-THA) cohorts (118 vs. 135 minutes, P = 0.23). Postoperatively, there was no difference in leg length discrepancy or hip center restoration. The RA-THA cohort had a lower rate of acetabular implant malposition (inclination and/or anteversion; n = 7, 15%) versus the M-THA (n = 16, 40%) cohort ( P = 0.01). There were two (3%) dislocations in the M-THA cohort versus no dislocations in the RA-THA cohort ( P = 0.17). There were three (5%) revision surgeries in the M-THA cohort, including one acetabular revision for recurrent instability, one femoral implant revision for aseptic loosening, and one femoral osteotomy with retrograde intramedullary lengthening nail for residual leg length discrepancy correction. There were no revision surgeries in the RA-THA cohort ( P = 0.09) or component revisions ( P = 0.17).

Conclusion: In this series of primary THA for DDH, RA-THA was associated with decreased rates of acetabular implant malpositioning. In addition, RA-THA trended toward lower rates of dislocation and revision surgery with equivalent surgical times to M-THA, demonstrating its feasibility and efficacy in primary THA for DDH.

Some orthopaedic surgery residents may find that another residency program is more appropriate for them to succeed either personally or professionally. Currently, there is a paucity of information on the available avenues for residency program transfers in orthopaedic surgery. In this review, the authors discuss common reasons for orthopaedic surgery residency program transfer including logistical considerations, keys to success, and potential pitfalls during this process.

Introduction: Two-stage exchange arthroplasty is commonly used for the management of chronic periprosthetic joint infection (PJI). Along with many other aspects of this technique, the optimal duration of antibiotic holiday during the interstage period remains contentious. We aimed to answer this question through a systematic review and meta-analysis by synthesizing evidence from the current literature.

Methods: Systematic review was conducted for studies reporting on two-stage exchange arthroplasty for the management PJI in total hip or total knee arthroplasty (TKA) published between January 1, 2013 and May 1, 2024. The meta-analysis included 14 studies reporting outcomes of two-stage exchange arthroplasty with antibiotic holidays for the treatment of chronic PJI following primary total hip arthroplasty or TKA, and the proportion of failed cases were analyzed using prediction models.

Results: The pooled proportion of failed cases across studies of any length for antibiotic holiday was 18% (95% confidence interval [CI], 0.16 to 0.20). The proportion of failed cases in studies using an extended duration antibiotic holiday was 18% (95% CI, 0.16 to 0.20) versus 18% (95% CI, 0.15 to 0.23) for studies using a short duration.

Conclusion: With the number available, the findings identified no notable difference in treatment failure rates with short (<2 weeks) or extended (≥2 weeks) antibiotic holiday duration between the two stages. However, the evidence is limited by substantial heterogeneity among studies, and further studies are necessary to appropriately address this topic.

Background: Orthopaedic surgeons face increasing pressure to align clinical decision making with evidence-based practices. However, the adoption of such practices can be inconsistent because of variability in surgical techniques, patient factors, and entrenched habits. This systematic review evaluates interventions designed to change orthopaedic surgeons' clinical decision making across cost optimization, diagnostic ordering, and prescribing behaviors.

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses and MECIR-adherent search was conducted across seven databases (MEDLINE, PsycINFO, EMBASE, Cochrane Library, Business Source Premier, SPORTDiscus, and Scopus) to identify studies from the United States and Canada reporting interventions aimed at modifying orthopaedic surgeons' clinical decision making. Studies were included if they evaluated changes in practice patterns in at least one of the three domains: procedure costs, orders (tests/procedures), or medication prescribing. Two independent reviewers conducted screening, data extraction, and quality assessment using the Effective Public Health Practice Project tool.

Results: Of 9,065 records identified, 28 studies met inclusion criteria: education (n = 24), physician reminders (n = 3), and incentive systems (n = 1). Most used before-and-after designs (n = 23) and were of moderate quality (n = 21). Three of five studies (60%) on procedure costs demonstrated statistical significance in cost reduction after intervention (P ≤ 0.05), with the largest from a surgeon "scorecard" initiative ($694 per total knee arthroplasty case, P < 0.001). Four of 14 studies (29%) on diagnostic/procedural ordering demonstrated statistical significance in clinical decision-making change. All nine studies on prescribing behaviors, predominantly opioid stewardship, showed statistically significant clinical decision-making change, including reductions in morphine milligram equivalents and improved guideline compliance.

Conclusions: Evidence-based interventions, particularly education combined with audit and feedback, can meaningfully shift orthopaedic surgeons' clinical decision making. Sustained change is less well studied, highlighting the need for prospective trials with long-term follow-up. This synthesis provides a framework for designing future interventions that improve adherence to best practices.

Level of evidence: Level III.

Background: Traumatic injuries of the upper extremity and hand (UE) can result in notable financial ramifications particularly if they involve surgical intervention. Although most studies in orthopaedics address direct costs, little is known about the personal experience with financial distress following UE trauma surgery.

Methods: Fourteen patients, identified as having markedly high financial distress using self-reported validated surveys, who received UE trauma surgery were interviewed. Semistructured interviews were conducted until thematic saturation was achieved after sequential thematic analysis by two independent researchers. Interviews were recorded, transcribed, and qualitative methodology was used to create a final conceptual model.

Results: Most patients (57%) were female, uninsured (36%) with an average age of 37.7 years. Distal radius fractures (29%) were the most common injuries, and most injuries received open reduction and internal fixation (71%). A total of 14 unique, overarching subthemes emerged, which were collated to create a conceptual model comprising (1) community and personal impact; (2) insurance challenges and legal struggles; and (3) consequences of debt and catastrophic loss. Methods for improving support for future patients also emerged during the interview process.

Conclusion: The costs related to upper extremity trauma surgery affects patients' families and communities and may result in unexpectedly large material loss and distress beyond the known direct physical impact of injury, such as the loss of access to care, inadequate insurance coverage, and inability to self-actualize. Understanding these reverberating effects is critical, as surgeons seek to holistically understand, care for, and study the patient experience after surgery while also effectively advocating for targeted interventions in policy.

Level of evidence: Prognostic Level II.

Artistic gymnastics is a complex and challenging sport. The specific demands of gymnastics place athletes at unique risk of injuries to the spine, as well as upper and lower extremities. Changes to the rules and scoring system since the 2004 Olympics have encouraged athletes to perform more challenging skills, adding to the risk of injury. Single-sport specialization occurs at a young age among competitive gymnasts, introducing an increased risk of overuse injuries. Common injuries include spondylolysis, medial-sided elbow injuries, gymnast's wrist, ligamentous injuries of the knee, and Achilles tendon ruptures. It is important to understand these injury patterns to properly prevent, treat, and safely return these athletes to play.

Extensor tendon disruptions are frequently seen in emergency rooms and hand surgery offices. Traumatic open injuries are more familiar, but spontaneous closed extensor tendon ruptures represent an important clinical entity. Often occurring without any prodromal warning, they can surprise patients and their providers alike. Spontaneous extensor tendon ruptures often occur in the setting of systemic medical conditions or hand and wrist pathology, with the mechanisms that lead to rupture often dependent upon the underlying comorbidities. Remaining knowledge of the factors that place patients at risk of developing these problems is vital to maintain the necessary suspicion to ensure prompt diagnosis and facilitate proper treatment.

Introduction: Cryoablation can be used to palliatively and/or definitively treat bone tumors. In transpedicular cryoablation of spine tumors, hydrodissection is frequently used in attempts to protect local anatomy, like nerves. No studies have investigated the direct clinical benefits of hydrodissection in spinal tumor cryoablation.

Methods: To assess for any meaningful rise in temperature around the pedicle when using hydrodissection, cryoprobes were placed through the pedicles bilaterally at six vertebral levels, and a 10-minute freeze cycle was initiated. At each level, one pedicle served as a control and the other received hydrodissection. Temperature measurements were taken every minute at the inferior pedicular cortex, medial pedicular cortex, and at midline of the spinal canal. Distance measurements between the thermometers and cryoprobe were obtained with the aid of three-dimensional reconstruction software.

Results: In a time-temperature regression model, the distance from the cryoprobe demonstrated a polynomial relationship with an overtly positive effect on temperature. Time, predictably, resulted in more negative temperatures. The positive polynomial relationship was maintained when looking at the final time point in isolation. Interestingly, no statistically significant change in temperature was demonstrated with use of hydrodissection. Analysis revealed an average temperature difference of 1.89°C (95% confidence interval, -2.26 to 6.05°C) throughout a 10-minute freeze cycle and -1.40°C (95% confidence interval, -8.03°C to 5.24°C) at the final.

Conclusion: These results suggest that hydrodissection with saline during transpedicular cryoablation may not result in clinically relevant increases in local temperatures. As such, the time devoted to hydrodissection may be better devoted to attaining a well-placed cryoprobe.