Journal of the American Academy of Orthopaedic Surgeons最新文献

Knee dislocations (KDs) are potentially limb-threatening injuries characterized by complete displacement of the tibiofemoral articulation. Historically, most KDs resulted from high-energy trauma and sporting activities. However, KDs occurring in morbidly obese patients from low-energy falls, termed "ultra-low-velocity KDs," are becoming more common. Prompt evaluation and recognition are key to achieving a timely reduction and avoiding potentially devastating complications resulting from popliteal artery injury. A suspected KD should be monitored with serial examinations to assess the vascular status. Emergent vascular surgery consultation is indicated for limbs that have evidence of vascular compromise. KDs that cannot be reduced through closed means should be taken to the operating room emergently for open reduction. Temporary external fixation should be reserved for knees that remain subluxated or grossly unstable after reduction or bracing treatment, in cases with severe open wounds, associated extremity fractures that require stabilization, and in select cases requiring vascular intervention. Controversies in definitive management remain regarding timing of ligament stabilization, repair vs. reconstruction of injured ligaments, and single vs. staged treatment. Complications associated with KDs include vascular injuries with limb loss, arthrofibrosis, compartment syndrome, infection, heterotopic ossification, and nerve recovery challenges and recurrent laxity. Ongoing level 1 clinical trials are being conducted to determine optimal timing of both ligamentous reconstruction and postoperative rehabilitation. Despite the severity of these injuries, many patients are able to return to work and sport-related activities.

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.

Introduction: To describe current opinions of staff orthopaedic trauma surgeons on the surgical treatment of distal femur fractures, with attention to indications for dual-implant constructs, application techniques, and postoperative rehabilitation.

Methods: A 22-question survey was given to fellowship-trained orthopaedic trauma surgeons at institutions visited by the 2022 Orthopaedic Trauma Association Fellows to characterize opinions on techniques, indications, and postoperative weight-bearing status for five example distal femur fractures. Demographic data were collected. Participants responses on implants and weight-bearing were recorded. Opinions on technique of dual-implant fixation were collected.

Results: The survey was returned by 57 surgeons. Most respondents preferred a single implant (retrograde intramedullary nails or lateral locked plate) and weight-bearing as tolerated for the extra-articular and periprosthetic fracture. The preference for dual-implant fixation increased with metaphyseal bone loss (46%) and for nonunion treatment (53%). Articular involvement had the strongest effect on weight-bearing (17% weight-bearing as tolerated with simple articular split, 6% with articular comminution). Respondents preferred a retrograde intramedullary nails plus lateral locked plate over dual-plate fixation. Rationale for dual-implant fixation were early mobilization (32%), poor distal fixation (32%), and absent medial column support (30%).

Discussion: This survey of current practice among institutions participating in the 2022 Orthopaedic Trauma Association Traveling Fellowship demonstrates that common fracture-related indications for dual-implant fixation include nonunion treatment and comminuted fractures with bone loss. The ability for earlier mobilization, poor fixation, and lack of medial column support were the most common indications for dual-implant fixation. This survey highlights the need for further studies investigating best treatment for distal femur fractures and sets the stage for future studies of dual-implant constructs.

Level of evidence: V, descriptive survey study.

Background: Patient complaints and malpractice events can have negative vocational effects on sports or medicine physicians. The purpose of this investigation was to determine the rate of patient complaints and malpractice events among a population of sports medicine patients and physicians. We also aimed to identify risk factors for these events.

Methods: In this single-center retrospective study, all adult patient complaints and malpractice events between January 2012 and December 2022 within a sports medicine division were analyzed. Not all physicians practiced continuously during the study period. Baseline demographics were recorded for all patients seen during the study period and all physicians (both surgical and nonsurgical) employed during this period. Complaints were categorized according to the Patient Report Analysis System, and the reasons for the malpractice events were analyzed. The patient report rate (total patient complaints/total unique patients seen) and the malpractice event rates (total malpractice events/total unique patients seen) were calculated. Bonferroni-corrected statistical comparisons were made between patients with and without complaints.

Results: A total of 74,412 unique patients were seen by 27 sports medicine physicians. The patient report and malpractice event rates were 0.4% and 0.04%, respectively. Communication issues were the most common reason for patient complaints, followed by negative treatment outcomes. Six of 32 malpractice events (19%) resulted in financial settlements. Physicians with >10 years of experience were associated with higher rates of patient complaints, and we observed a moderate correlation between report and malpractice rates.

Discussion: The average patient report and malpractice rates observed in our sports medicine division were 0.4% and 0.04%, respectively. A moderate correlation exists between report and malpractice rates. Physicians with >10 years of experience were associated with higher rates of patient complaints. Communication issues remain the most frequent source of complaints.

Level of evidence: Level III-Prognostic.

Introduction: MRI and CT myelography (CTM) are common diagnostic tests used for preoperative assessment of patients with cervical spondylotic myelopathy. The purpose of this study is to determine if MRI and CTM result in the same quantification regarding the severity of canal stenosis and cord compression.

Methods: Fifty patients with cervical spondylotic myelopathy underwent MRI and CT myelogram within a 6-month time frame preoperatively. Each spine segment (C3-C7) was measured for AP diameter of the canal and spinal cord on MRI axial, CTM axial, MRI sagittal, and CTM sagittal images. Thresholds for surgically relevant stenosis (<7 mm AP canal diameter and >0.8 AP cord:canal ratio) were developed by group consensus and used to stratify the per level data.

Results: The mean age of the cohort was 59.6 years with 30 men and 20 women. Using the <7 mm threshold for surgery, there was 87% agreement for MRI and CTM on sagittal images and 95% agreement on axial images. More levels met criteria for surgery on MRI compared with CTM with 15% on sagittal MRI, 6% on axial MRI, 5% on sagittal CTM, and 3% on axial CTM. Using the >0.8 threshold, there was 83% agreement for MRI and CTM on sagittal images and 86% agreement on the axial images. More levels met criteria for surgery on MRI compared with CTM with 17% on sagittal MRI, 16% on axial MRI, 3% on sagittal CTM, and 3% on axial CTM.

Conclusion: The results of this study show that although MRI and CTM have relatively good agreement (83% to 95%) with regard to quantitative measurements of cervical spinal stenosis and cord compression, MRI may overestimate stenosis severity in approximately 12% of levels. Axial MRI images had the highest level of agreement (95%) when compared with CTM.

Legg-Calvé-Perthes disease has been recognized for more than 100 years. It is an idiopathic osteonecrosis of the femoral head in children that follows a predictable course of bone death, revascularization, bone resorption, and eventually reossification and bone healing. The natural history is often favorable for children younger than 6 years and poor for children older than 8 to 10 years. The final outcome is determined by the shape of the healed femoral head and its congruence with the acetabulum. Treatment is aimed at preserving range of motion, maintaining containment, and limiting mechanical damage to the femoral head. Nonsurgical interventions include restricted weight-bearing, range of motion exercises, and casting or bracing treatment. Surgical interventions include osteotomies of the femur or pelvis or both to maintain containment, as well as joint distraction for containment and decreasing mechanical force. Superiority of a particular treatment strategy has been difficult to demonstrate due to relative rarity of the condition, variable natural history, and long-time horizon to predict final outcome. Recent research has focused on better imaging predictors and understanding and altering the pathophysiology subsequent to the vascular disturbance.

Introduction: Total knee arthroplasty (TKA) restores the mechanical axis of the lower extremity, which is impaired due to gonarthrosis. Foot and ankle pain observed after TKA is not uncommon, and the exact cause has not been determined. This study aims to assess the role of the movement capacity of the subtalar joint and the clinical and radiological risk factors for foot and ankle pain after TKA.

Methods: This study included 184 patients who underwent TKA due to primary varus gonarthrosis. Patients were evaluated clinically and radiologically before and after surgery. Lower extremity mechanical axis, talar-tilt angle, foot ground-talar dome angle, heel alignment ratio, heel alignment angle, heel alignment distance, and postoperative changes were the radiological angles measured. The Oxford Knee Score, American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score, visual analog scale score, and ankle and subtalar joint range of motion examinations were used clinically. Patients were grouped as those whose American Orthopaedic Foot and Ankle Society scores did not worsen after surgery (group 1) and those whose scores worsened (group 2).

Results: The group 1 included 142 patients (77.2%) and group 2 included 42 patients (22.8%). The mean preoperative knee varus degree of group 1 was 11.49 ± 3.45, and that of group 2 was 14.26 ± 4.21 ( P < 0.001). The mean body mass index was 26.67 ± 2.31 for group 1 and 29.47 ± 3.14 for group 2 ( P < 0.001). Although no important difference was found between the groups in preoperative ankle motion capacity ( P = 0.086), subtalar joint motion was found to be markedly limited in group 2 ( P < 0.001).

Conclusion: High preoperative knee varus degree and body mass index values, especially diminished preoperative subtalar joint motion capacity together with these values, are risk factors for postoperative foot and ankle pain after TKA.

Level of evidence: Level III, Retrospective comparative study.

Objective: This study aims to examine the use of dexmedetomidine (DEX) combined with propofol in hip fracture surgery and its effect on postoperative pain and hemodynamics.

Methods: One hundred forty patients undergoing hip fracture surgery were divided into a treatment group (receiving DEX combined with propofol anesthesia) and a control group (receiving propofol anesthesia). The Ramsay Sedation Scale was used to evaluate the sedative effect 24 hours postoperatively, while the Visual Analog Scale was used to assess the analgesic effect 24 hours after surgery. The Montreal Cognitive Assessment (MoCA) scale was used to evaluate cognitive function before and 24 hours after surgery. Heart rate (HR) and mean arterial pressure (MAP) were recorded at different stages of anesthesia, and the incidence of postoperative adverse reactions was also recorded.

Results: Compared with the control group, at 24 hours postoperatively, patients in the treatment group had higher Ramsay sedation scores and lower Visual Analog Scale scores ( P < 0.05). Before surgery, the MoCA scores of both groups showed no significant difference ( P > 0.05), but the treatment group had higher MoCA scores 24 hours after surgery compared with the control group ( P < 0.05). No difference was observed in HR and MAP levels before anesthesia between the two groups ( P > 0.05), while the treatment group performed lower MAP and HR levels than the control group at skin incision and at the end of surgery ( P < 0.05). In addition, the incidence of postoperative adverse reactions was lower in the treatment group than in the control group ( P < 0.05).

Conclusion: DEX combined with propofol for composite anesthesia in hip fracture surgery effectively meets the requirements for surgical anesthesia, maintains hemodynamic stability, and exhibits good postoperative analgesic and sedative effects.

Orthopaedic surgery is widely perceived as one of the most demanding medical specialties, with long work hours, heavy surgical volumes, and extensive administrative responsibilities often leaving little room for personal needs. This environment has perpetuated a myth that work-life balance is incompatible with professional excellence. Consequently, burnout, manifested by emotional exhaustion, depersonalization, and a diminished sense of accomplishment, has become pervasive among both residents and attending surgeons. Despite a growing awareness of burnout's effect, many existing interventions fall short because they focus on surface-level solutions, such as mandatory wellness seminars, rather than addressing the systemic and cultural elements that sustain chronic stress. This narrative review critically examines the misconceptions that deter surgeons from pursuing healthier work-life integration. It also illustrates how deeply ingrained beliefs, such as equating balance with reduced commitment, hinder meaningful progress. Drawing on experiences from diverse orthopaedic models, the review highlights successful strategies that include redesigning clinical workflows to reduce after-hour documentation, fostering mentorship networks that address trainees' individual needs, and implementing flexible scheduling policies to ensure adequate rest and recovery. These strategies move beyond quick fixes to target the root causes of burnout, offering a blueprint for cultivating a sustainable culture of well-being within orthopaedics.

Osteochondritis dissecans (OCD) of the elbow occurs mainly in adolescents and young adults. It can be debilitating and difficult to manage. It occurs frequently in the capitellum of athletes who experience repetitive stress on the elbow, such as gymnasts and overhead throwers. OCD of the elbow produces insidious pain that can be deep and difficult to localize. Patients with free floating cartilage experience catching or locking sensation in the elbow throughout range of motion. Lesions can be characterized as stable, partially detached, or completely detached (fragmentation with free bodies in the elbow). Evaluation of these OCD lesions includes radiography, ultrasonography, CT, and magnetic resonance imaging. Nonsurgical treatment of OCD lesions is commonly used for stable lesions, with protective weight bearing or complete immobilization for at least 4 weeks and progression to full activity over 6 months. Recently, casting with immobilization has shown to be effective in the management of stable lesions. Surgical management is indicated for lesions that are unstable, produce mechanical symptoms, or have failed nonsurgical treatment. Surgery includes arthroscopic and open procedures such as microfracture, fragment removal, autologous chondrocyte implantation, osteochondral autograft transplantation (OAT), wedge osteotomy, osteochondral allograft, and ultrapurified alginate gel with grafting.