Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Medicare advantage (MA) enrollment is rising rapidly, now comprising over half of all Medicare beneficiaries. Compared with traditional medicare (TM), MA patients are more likely to be socioeconomically disadvantaged and subject to distinct care coordination barriers, yet few studies have examined how these differences affect postoperative outcomes after total knee arthroplasty (TKA).

Methods: We analyzed a prospective cohort of 7,267 Medicare beneficiaries who underwent primary TKA at a high-volume academic center between 2016 and 2023. Patients were categorized MA or TM based on insurance status at the time of surgery. Primary outcomes included postoperative healthcare utilization: prolonged length of stay (≥2 days), nonhome discharge, 90-day readmission, 90-day emergency department visit, 1-year revision surgery, and 1-year mortality. Multivariable logistic regression models adjusted for demographic, clinical, and socioeconomic covariates.

Results: Of the cohort, 3,293 (45.3%) were MA and 3,974 (54.7%) were TM. MA patients were more likely to be non-White (17.7% vs. 10.2%, P < 0.001), have higher area deprivation index scores (49.0 vs. 42.0, P < 0.001), and higher smoking rates (6.1% vs. 4.0%, P < 0.001). Unadjusted rates of 90-day emergency department visits (16.8% vs. 14.6%, P = 0.011) and 1-year revision surgery (4.4% vs. 3.5%, P = 0.041) were higher in the MA group. However, after adjustment, MA status was not significantly associated with increased odds of any adverse outcome, including revision surgery (odds ratio, 0.85; 95% confidence interval, 0.66 to 1.08; P = 0.181) or mortality (odds ratio, 0.89; 95% confidence interval, 0.73 to 1.10; P = 0.285).

Conclusion: Despite greater baseline social risk, MA patients undergoing TKA at a high-volume academic center experienced comparable short-term outcomes with their TM counterparts. These findings suggest that when standardized care pathways are applied, Medicare subcategory alone does not predict postoperative healthcare utilization. As MA enrollment continues to grow, ensuring equitable outcomes will require adaptation of clinical workflows and research strategies to better reflect the evolving Medicare landscape.

Background: Interscalene nerve blocks (ISB) are commonly used for perioperative pain control after shoulder arthroscopy. Bupivacaine has historically been the primary anesthetic used in ISBs. In 2018, the U.S. Food and Drug Administration approved liposomal bupivacaine for ISBs. This study aims to identify the effect of ISBs using bupivacaine alone (B) versus liposomal bupivacaine + bupivacaine (LBB) on postoperative pain control after arthroscopic rotator cuff repair (RCR).

Methods: A single-center, prospective, double-blinded, randomized, control trial following Consolidated Standards of Reporting guidelines was conducted from January 2020 to April 2024; 128 opiate naive patients undergoing arthroscopic RCR were randomized 1:1 into the B-only group (25 cc of 0.5% bupivacaine) versus the LBB group (133 mg [10 mL] of liposomal bupivacaine + 15 cc 0.5% bupivacaine). Demographics, comorbidities, additional procedures performed, daily morphine milligram equivalents (MME) consumed, and daily visual analog scale (VAS) pain scores for 14 days were collected.

Results: No differences were noted between age, sex, comorbidities, or American Society of Anesthesiologists physical classification system scores. On postoperative day 2, the LBB group consumed markedly lower MMEs (0.0 [0.0 to 7.5] versus 0.0 [0.0 to 15.0]; [P = 0.04]) and demonstrated a notable improvement in VAS scores on postoperative day 2 (4.8 ± 3.0 versus 6.0 ± 2.8; [P = 0.03]). No notable difference was seen in other daily MMEs consumed, daily VAS scores, or total 14-day MMEs. Total median MME consumed in both groups was low (MME 35.6 [7.5 to 88.1] or 5 [1 to 12] oxycodone pills).

Conclusion: Although the use of LBB in ISBs led to markedly lower VAS scores and less narcotic consumption on postoperative day (POD2), these findings can be regarded as not clinically notable. The difference was the equivalent of one oxycodone tablet, and VAS did not meet minimal clinically important difference. No other differences were found in MME consumed or VAS scores during the first 2 weeks postoperatively following RCR. Overall narcotic consumption was low in both groups.

Level of evidence: I.

Introduction: The United States has experienced a notable increase in opioid abuse over the past several years, with orthopaedic surgeons reported as the third-highest prescribers by specialty. Several studies have addressed opioid use after major orthopaedic procedures but largely focused on prescribing practices. There is limited data on the utility of adding adductor canal pain catheters to multimodal regimens following total knee arthroplasty for improved pain control and reduced opioid dependence. The purpose of this preliminary study was to compare single-shot adductor canal blocks to continuous infusion or intermittent bolus catheters, evaluating postoperative pain levels and duration of opioid use.

Methods: Sixty opioid-naive patients participated in a prospective, randomized, double-blinded, placebo-controlled trial. Following total knee arthroplasty, patients were randomized into one of three cohorts based on preoperative pain levels: (1) single-shot adductor canal block with placebo catheter, (2) continuous infusion catheter, or (3) intermittent bolus catheter. Postoperative protocols were similar except for the catheter. Patient outcomes were recorded for 60 days postoperatively.

Results: We found no difference in length of stay, oral morphine equivalents, use of on-demand medication, or pain scores (all P > 0.05) between the groups. Although the single-shot cohort trended toward a longer duration of opioid use (median 21 days) compared with the catheter groups (median 14 days for both), this did not approach statistical significance ( P = 0.59). We found no difference in Knee Injury and Osteoarthritis Outcome Score Jr scores between the groups at 30 or 60 days postoperatively (all P > 0.05).

Conclusion: In our preliminary study, we found no differences in clinical outcomes, pain scores, or patient-reported scores between a single-shot adductor canal block, a continuous infusion adductor canal catheter, and an intermittent bolus adductor catheter following total knee arthroplasty. Larger studies are needed to more definitively assess differences in outcomes between the treatment groups, particularly in the opioid-tolerant population.

Introduction: Learners are rapidly using generative artificial intelligence (AI) models in their education. We assessed the performance of recently released or updated models on the 2024 American Academy of Orthopaedic Surgeons Orthopaedic In-training Examination for their potential applications in orthopaedic education.

Methods: Eleven models with recent enhancements in reasoning and research capabilities were evaluated. A total of 119 text-based questions were entered verbatim into each model. Model outputs were recorded as correct or incorrect. Additional analyses included reasoning time, citation accuracy, confidence in answer selection, and comparison with orthopaedic resident performance. References generated by the top performing model were compared with American Academy of Orthopaedic Surgeon Recommended Readings for incorrectly answered questions.

Results: Ten of 11 AI models exceeded the American Board of Orthopaedic Surgery minimal passing standard (67.7%). Eight models surpassed PGY5 resident performance. OpenAI's o1Pro with Deep Research achieved the highest accuracy (90.8%), outperforming the mean performance of PGY5 residents by 17.8%. More than half of the ResStudy Recommended Readings were cited as supporting references by the top performing model on questions it answered incorrectly. Subspecialty performance varied, with highest accuracy in Shoulder and Elbow and Sports Medicine questions. Longer reasoning times generally correlated with improved accuracy.

Discussion: Advanced AI models demonstrated substantial improvements over previous generations, with more than half of the tested models exceeding senior orthopaedic resident performance. Improved reasoning and research capabilities highlight the evolving capabilities of AI in medical education, although increased understanding of their utilization by learners is needed. Variability among subspecialties may suggest differences in training data or reasoning capabilities.

Conclusions: Modern AI models exhibit high proficiency on the Orthopaedic In-training Examination and may serve as valuable supplemental educational tools. Ongoing evaluation is warranted to understand their optimal integration into orthopaedic training while recognizing limitations in clinical reasoning, lived experience, and imaging interpretation.

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a multicenter variable-based data registry that facilitates surgical quality tracking, hospital benchmarking, and outcome predictions. ACS NSQIP data within Orthopaedic Surgery consist primarily of the 30 most common orthopaedic procedures and collect demographic and 30-day complication metrics for inpatient and outpatient procedures. Although the original intent of this large database was quality improvement, it has also been used extensively in orthopaedic research since 2010 to evaluate risk factors in orthopaedic surgery, despite systematic reviews demonstrating weaknesses in reproducibility and impact. Comparisons of ACS NSQIP to orthopaedic surgery-specific databases demonstrate a shortcoming of NSQIP in identifying patients, prevalence of complications, and tracking complications. Although ACS NSQIP provides a chance for large-scale data analysis in quality tracking and research, its reliability and usefulness in orthopaedic surgery remain to be established.

Background: The use of cannabis for medical and recreational purposes has become increasingly prevalent. Emerging evidence suggests that postoperative cannabis-based medications influence postoperative opioid use for analgesia, although the impact of preoperative cannabis use on acute orthopaedic surgical outcomes remains unclear. The purpose of this study was to explore current literature regarding the associations of preoperative cannabis use with pain and opioid requirements after undergoing orthopaedic surgery.

Methods: A scoping review was conducted through a search of the PubMed, EMBASE, and Scopus databases. Two independent reviewers extracted information on population, measure of cannabis use, and postoperative outcomes, including Patient-Reported Outcomes Measurement Information System scores, pain, and morphine milligram equivalents.

Results: We identified 1,025 studies for potential inclusion. After screening all abstracts and titles, 19 orthopaedic studies were included, comprising 19,719 patients. Most were retrospective cohort studies, with 11 evaluating opioid use, three evaluating postoperative pain outcomes, and five evaluating both. Among the pain-related studies, three reported higher pain scores in their cannabis-user cohorts, one reported lower pain scores among cannabis users, and the remaining found no differences in pain. The studies evaluating opioid use found no notable difference in morphine milligram equivalent consumption between cannabis users and nonusers.

Discussion: Most evidence suggests that preoperative cannabis use has no effect on opioid use after orthopaedic surgery. Few articles investigated the associations of preoperative cannabis use with postoperative pain, and results were mixed, with only one study evaluating cannabis use in upper extremity surgical patients, suggesting the need for further exploration in some fields. No studies were able to measure duration of cannabis use, method of consumption, or potency because the use was either self-reported or based on a diagnosis of cannabis use disorder, indicating the need for future studies to stratify preoperative cannabis use by methods of ingestion and amount consumed.

Background: The Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial was a multicenter randomized clinical trial comparing a 1-day with a 5-day postoperative intravenous antibiotic regimen after lower extremity bone tumor resection and endoprosthetic reconstruction. The trial found no difference in surgical site infections between groups, but a markedly increased risk for antibiotic-related complications in the 5-day group. The study was published in January 2022. The objective of this study was to assess the effect of these findings on the clinical practice of musculoskeletal oncologists.

Methods: We developed an anonymous survey exploring changes in clinical practice after the publication of the PARITY trial and electronically distributed the survey to practicing musculoskeletal oncologists through REDCap in March 2024. Data were analyzed descriptively, and changes in practice from before to after the publication of the PARITY study were analyzed through the Pearson chi-square test.

Results: We obtained 101 responses from surgeons across six continents. Nearly all respondents (94 of 101, 93%) were aware of the PARITY trial results. Forty respondents (40%) reported a meaningful change in clinical practice after PARITY, most frequently a reduction of antibiotic administration in >75% of patients. After PARITY, the proportion of respondents who reported limiting antibiotics to 24 hours increased from 25% to 51% ( P < 0.001), and the proportion prescribing oral antibiotics after discharge from the hospital declined from 23% to 16% ( P < 0.001). Among those who did not change their practice, personal experience/professional opinion was the most frequently cited reason. Adherence to institutional standards was cited as an additional barrier.

Conclusions: Many respondents reported meaningful change in their clinical practice after the publication of the PARITY trial, most notably limiting perioperative antibiotics to 24 hours. The complexities influencing the personal decision to adopt a notable change in clinical practice in response to new evidence warrant additional study.

Level of evidence: IV.

Acetabular fractures are complex injuries that demand a precise understanding of fracture morphology, radiographic interpretation, and surgical strategies. Although the Judet and Letournel classification system remains the benchmark, it poses notable challenges due to its complexity and learning curve. A narrative review was conducted synthesizing key concepts in classification, imaging interpretation, surgical planning, and fracture-specific considerations, with a focus on clinical utility. Established and novel classification systems were evaluated alongside reduction techniques and management pathways. The Judet and Letournel classification system remains clinically relevant, despite limitations in inter- and intraobserver reliability and transitional fracture classification. Surgeons benefit from reframing acetabular fractures into two major pattern families to streamline decision making. This paradigm improves recognition of displacement vectors, constant fragments, and optimal approaches. Ongoing refinement of educational tools and imaging strategies will support better outcomes. Surgical indications, including marginal impaction and geriatric management, are reviewed in detail. A simplified, concept-driven approach to acetabular fracture classification enhances clinical decision making and educational clarity. Integrating this approach with modern imaging and tailored fixation strategies offers a pathway toward improved outcomes in acetabular fracture care.

Background: It is valuable to understand the changing landscape of leadership in orthopaedic surgery given its effect on medical school education, residency and fellowship training, and patient care. The purpose of this study was to provide a 5-year update on the current characteristics of orthopaedic educational leadership.

Methods: Based on the initial study, 159 accredited orthopaedic surgery residency programs were identified through cross-referencing the Accreditation Council for Graduate Medical Education (ACGME) website with the Electronic Residency Application Service Data, including training locations, academic rank, H-index, and publications for both program directors (PDs)and chairs, were obtained from public websites.

Results: One hundred fifty-nine PDs and 151 chairs were identified. Overall, 82 (51.6%) and 55 (36.4%) changes in PD and chairs, respectively, were observed. In addition, there were 18 (11.1%) female PDs in 2020 compared with 23 (14.5%) in 2025 (P = 0.379), and 3 (2.0%) female chairs in 2020 compared with 12 (7.9%) in 2025 (P = 0.016). Chairs were in practice for longer than PDs (26.8 versus 16.6 years [P < 0.001]) and in their position for longer (9.3 versus 7.8 years [P = 0.066]). Chairs were more likely to be professors (75.5% versus 22.6% [P < 0.001]), have higher H-index (30.4 versus 14.2 [P < 0.001]), and have more publications (95.9 versus 35.4 [P < 0.001]). PDs were more likely to have completed residency at their current institution. The most common subspecialties were trauma for PDs and sports for Chairs.

Conclusion: There have been notable changes in orthopaedic surgery leadership positions within the past 5 years, with a significant increase in female Chairs. Those who are interested in pursuing leadership positions or in the changing landscape of orthopaedic leadership may benefit from the findings of this study.

The treatment of degenerative cervical myelopathy (DCM), which encompasses cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, has progressed markedly over the past few decades. The natural history of DCM includes multiple phenotypes: a slow deterioration, a stepwise pattern of decline, and rapidly progressive functional decline. Symptoms include gait disturbance, decreased fine motor abilities, weakness, sensory changes, and neck pain. Classically, those with minimal or early symptoms were treated conservatively with observation; however, newer investigations suggest evidence for early surgical treatment. Those with objective myelopathic symptoms confirmed by imaging demonstrating spinal cord compression are indicated for surgery. Surgical treatment can be accomplished with multiple different technical approaches including anteriorly based surgery, posteriorly based surgery, and combined techniques. Traditionally, anterior surgery included anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), but increasing investigations incorporate cervical disk arthroplasty in this cohort of patients. Historically, laminectomy for posterior decompression was a hallmark of treatment in DCM; however, this led to complications such as postlaminectomy kyphosis and instability which has led to substitution of this treatment by laminoplasty and laminectomy + fusion. Surgical adjuncts such as Riluzole have demonstrated promise in the treatment of DCM patients. Success in surgical treatment is defined by decompression of the spinal cord to halt progression of symptoms and in some patients improve function. Although surgical treatment has yielded success in the treatment of DCM, perioperative complications can be devastating which make surgical technique and patient selection paramount.