Journal of the American Academy of Orthopaedic Surgeons最新文献

Medial opening wedge high tibial osteotomy has been established for treatment of medial symptomatic knee arthrosis with varus malalignment in young and elderly but active patients. To obtain satisfactory results, it is essential for surgeons performing osteotomy to identify, prevent, and treat potential intraoperative adverse events. Lateral hinge fracture (LHF) is the most common intraoperative complication while popliteus artery injury is rare but limb-threatening. Computed tomography is the benchmark to detect LHF, the risk of which increased markedly with the opening gap larger than 11 mm. Setting the lateral hinge in a safe zone is the most important preventive measure. Medial long locking plate fixation may allow patients even with unstable hinge fractures to start early full weight bearing. Additional fixation of LHF is optional, and bone void filling is not routinely used. For protection of popliteus artery injury, flexing the knee joint is unreliable. It is paramount to place a protective retractor just behind the posterior tibial cortex toward the proximal tibiofibular joint before osteotomy, particularly in case of aberrant artery. A repertoire of surgical pearls is described in detail in this review to identify, prevent, and manage those intraoperative complications.

Introduction: Patient-reported outcome measures (PROMs) are used in orthopaedic surgery to measure aspects of musculoskeletal function that are important to patients, such as disability and pain. However, current assessments of function using PROMs do not necessarily consider a patient's functional demands in detail. A patient's functional demands could serve as a confounder to their perception of their functional ability. Hence, functional demands may need to be adjusted for when PROMs are used to measure musculoskeletal function.

Methods: We conducted a cross-sectional study in which new orthopaedic patients completed a questionnaire regarding demographics, function [Patient-Reported Outcomes Measurement Information System], functional demand (Tegner Activity Level Scale), pain self-efficacy, and symptoms of depression. 169 eligible patients with diverse orthopaedic conditions were enrolled in the study from an orthopaedic clinic, and 19 were excluded for incomplete questionnaires.

Results: The mean Patient-Reported Outcomes Measurement Information System score was 36.5 ± 9.1, and the mean Tegner score was 2.6 ± 2.0. In the multivariable regression model, patient-reported function was significantly associated with functional demand (β = 0.17, P < 0.001). Significant associations were observed for pain self-efficacy (β = 0.15, P < 0.001), acuity (β = -0.10, P = 0.004), and age 80 years or older (β = -0.16, P = 0.004). No notable association was observed with depression or age 65 to 79 years.

Discussion: Higher patient-reported physical function is associated with higher levels of functional demand when controlling for psychosocial factors, acuity, and age. Because of its confounding effect on measuring physical function, functional demand should be assessed and included in models using PROMs before and after surgery. For example, payment models using improvements in PROMs, such as the short form of the Hip dysfunction and Osteoarthritis Outcome Score and the Knee injury and Osteoarthritis Outcome Score after joint arthroplasty, should include functional demand in the model when assessing quality of care.

Level of evidence: Level II.

Objective: To determine prescription trends across specialties in the perioperative care of patients undergoing spine surgery from 2018 to 2021.

Summary of background data: A range of measures, including implementation of state prescription drug monitoring programs, have been instituted to combat the opioid epidemic. Considering the continued presence of opioids for spine-related pain management, a better understanding of the patterns of opioid prescription practices may be important for future intervention.

Methods: All patients aged 18 years and older who underwent elective posterior lumbar decompression and fusion, transforaminal lumbar interbody fusion, and anterior cervical diskectomy and fusion from 2018 to 2021 were retrospectively identified. Patient demographics and surgical characteristics were collected through a Structured Query Language search and manual chart review. Opioid prescription data were collected through Pennsylvania's Prescription Drug Monitoring Program (PDMP) database and grouped into the following prescriber categories: primary care, pain management, physiatry, and orthopaedic surgery.

Results: Of the 1,062 patients, 302 (28.4%) underwent anterior cervical diskectomy and fusion, 345 (32.4%) underwent posterior lumbar decompression and fusion, and 415 (39.1%) underwent transforaminal lumbar interbody fusion. From 2018 to 2021, there were no significant differences in total opioid prescriptions from orthopaedic surgery (P = 0.892), primary care (P = 0.571), pain management (P = 0.687), or physiatry (P = 0.391) providers. Pain management providers prescribed the most opioids between 1 year and 2 months preoperatively (P = 0.003), between 2 months and 1 year postoperatively (P = 0.018), and overall (P < 0.001).

Conclusion: Despite increasing national awareness of the opioid epidemic and the establishment of statewide prescription drug monitoring programs, prescription rates have not changed markedly in spine patients. Pain management and primary care physicians prescribe opioids at a higher rate in the chronic periods before and after surgery, likely in part because of longitudinal relationships with these patients.

Level of evidence: III.

Study design: Retrospective Cohort Study.

Background: Short-keeled tibial implants may be at higher risk of aseptic loosening. Stem augmentation has been suggested to improve its fixation. We aimed to assess whether this technique could decrease the loosening rate of such tibial implants.

Methods: We retrospectively studied the knees receiving stemmed versus nonstemmed versions of a short-keeled prosthesis. A total of 932 patients undergoing total knee arthroplasty using a Persona prosthesis with >24-month follow-up (mean 53.7) were included, of whom 212 were at high risk of loosening due to osteoporosis or high body mass index (BMI). The rate of tibial aseptic loosening in high-risk patients and in the whole cohort was compared between those with and without stem extension. Multivariable analysis was conducted to identify the risk factors of loosening.

Results: In the whole cohort, in 203 knees (21.8%), a cemented short stem was used, versus 729 knees (78.2%) without. The tibial implant revision rates for loosening were 2.06% and 0.99% for nonstemmed and stemmed cases, respectively (P = 0.551). When the cohort was categorized based on the loosening risk factors, the loosening risk was significantly higher in the high-risk than in the low-risk group, regardless of stem status (log-rank test = 8.1, hazard ratio = 2.17, 95% CI = 1.78, 2.57, P = 0.005). 212 patients were at high risk of loosening, due to high BMI or osteoporosis, among whom the risk of aseptic loosening was higher when a stem was not used (log-rank = 32.1, hazard ratio = 4.95, 95% CI = 4.05, 5.86, P < 0.001). In multivariate analysis, osteoporosis, BMI ≥35, and smoking were correlated with loosening.

Conclusion: The failure rate was markedly lower in the stemmed group of the patients at elevated risk of aseptic loosening due to osteoporosis and/or high BMI. In the entire cohort, the risk of loosening in stemmed tibial implants was similar to the nonstemmed group. The findings support a protective role for the stem in patients at high risk of failure of the cemented tibial implant.

Level of evidence: III therapeutic.

Introduction: There remains a lack of consensus on the optimal treatment of isolated distal radius fractures in young adults. The primary aim of this study was to identify differences in treatment of isolated distal radius fractures in patients aged 17 to 21 years treated by adult versus pediatric orthopaedic surgeons. The secondary aim was to identify whether there is a variation in utilization of open reduction and internal fixation (ORIF) versus closed reduction and percutaneous pinning when treated surgically by adult versus pediatric orthopaedic surgeons.

Methods: Patients aged 17 to 21 years with isolated distal radius fractures who were treated by adult or pediatric orthopaedic surgeons at 1 of 3 hospitals were identified through retrospective chart review. 72 patients in the pediatric surgeon cohort and 64 patients in the adult surgeon cohort were included. Demographic details were recorded, and radiographs from the initial clinic visit and final follow-up were obtained. Bivariate analysis was used to evaluate for primary and secondary aims.

Results: 40 of 136 patients were treated surgically. Bivariate analysis showed that factors associated with surgical treatment were treatment by an adult orthopaedic surgeon, higher body mass index, radiographic severity, AO classification, intraarticular involvement, distal radial-ulnar joint involvement, and meeting AAOS clinical practice guideline surgical criteria. Factors associated with ORIF compared with closed reduction and percutaneous pinning included treatment by an adult orthopaedic surgeon, older age, higher body mass index, and greater articular step-off.

Discussion: In comparable cohorts of young adult patients with distal radius fractures with similar fracture characteristics, there was notable variation in treatment between adult and pediatric orthopaedic surgeons. Surgical treatment was used more by adult surgeons, and when treated surgically, ORIF was used more by adult surgeons. Variation among surgeons illustrates the persistent lack of consensus on the optimal treatment in this population and highlights the need for additional research on this topic to guide management.

Level of evidence: Level IV.

With the recent trends toward outpatient shoulder surgery, standardized protocols for perioperative analgesia are critical for reducing length of stay and optimizing outcomes. There are a variety of described anesthetic and analgesic options for shoulder surgery, and the literature is variable regarding optimal choice as patient, provider, and institutional factors often play a role. With general anesthesia alone becoming less utilized, regional methods require critical examination. Knowledge of the differing, and novel, regional anesthetic procedures in conjunction with recent orthopaedic and anesthetic literature is imperative to providing patients with optimal and efficient care.

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.

Acute brain injuries are caused by a variety of etiologies, each potentially disrupting neurological function. The neurologic impairments are on a spectrum of severity often creating functional barriers to completing activities of daily living. Initial treatment starts immediately upon diagnosis and requires a multimodal approach working to prevent systemic changes. Therapy, bracing treatment, injections, and pharmacologic treatments are the mainstay of early intervention. Worsening upper motor neurological impairment associated with involuntary muscle hyperactivity can lead to a spastic equinovarus foot deformity. Spastic equinovarus foot deformities secondary to anoxic brain injuries or traumatic brain injury pose a challenging situation for orthopaedic surgeons because of associated cognitive impairment, spastic tone, and extensive soft-tissue contractures prohibiting bracing treatment. Tendon releases and transfers in combination with functional bracing treatment are initially attempted, and selective fusions are performed for severe cases. Surgical indications are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot.

Latent or subtle syndesmotic instability is defined as an injury to the syndesmosis which is not apparent on static radiographs of the ankle. Syndesmotic injuries have also been referred to as high ankle sprains. Injury to the syndesmosis typically occurs with collision sports and often involves an external rotation force to the ankle. Diagnosis can be delayed because of negative initial imaging studies. Physical examination tests including the external rotation test, proximal squeeze test, and fibular shuck test can assist in the diagnosis. Advanced imaging modalities such as MRI and weight-bearing CT have been studied and can provide prognostic indications for management, although arthroscopic stress evaluation remains the benchmark for diagnosis. Both surgical and nonsurgical management techniques have been described, which can assist patients in returning to their preinjury level of function.