Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Total knee arthroplasty (TKA) is one of the most commonly performed orthopaedic surgeries in the United States, yet little information exists regarding its utilization in different settlement types. This study aimed to determine the number of TKA-performing surgeons by settlement type and assess trends in the volume of TKAs in urban, micropolitan, small town, and rural settings.

Methods: Using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners database, the number of orthopaedic surgeons performing primary and revision TKAs from 2013 to 2020 was determined. The zip code where TKA was performed was used to identify the rural-urban commuting area codes (RUCA) and classify locations into one of four settlement types: urban/metropolitan, micropolitan (large town), small town, or rural. Correlations in surgeon number and TKA volume by settlement type were evaluated by Mann-Kendall tests.

Results: Between the years of 2013 and 2020, TKAs were billed by up to 7,192 orthopaedic surgeons. The proportions of TKAs occurring in settlement types were the following: urban/metropolitan, 85.2%; micropolitan, 11.5%; small town, 2.6%; rural, 0.6%. Areas without RUCA data had 32.9 TKAs per surgeon per year, the highest overall median surgeries per year over the 8-year period. The median number of TKAs per surgeon per year was 28, 25.4, 21.4, and 20.7 for urban/metropolitan, micropolitan, small towns, and rural areas, respectively.

Conclusion: A considerable difference exists in both the number of surgeons and the proportion of TKAs conducted across various settlement types. Twenty percent of population in the United States lives in rural areas; however, only 0.6% of billed TKAs occurred in these areas over the study period, indicating a gap in orthopaedic care access. It is imperative to understand TKA surgeon distribution and focus on strategies aimed at attracting and retaining proficient surgeons to address the healthcare needs of these underserved regions.

Research among orthopaedic surgery residents provides numerous benefits, which include but are not limited to development of critical thinking skills, greater understanding of study design and statistical analysis, strengthened fellowship applications, networking, and the ability to practice evidence based medicine. Research has been increasingly emphasized among orthopaedic surgery residency directors, and residency programs have uniformly implemented protected research time into their formal clinical training. Despite this, there are few resources describing the ability to conduct research effectively during residency. The purpose of this review is to provide an outline for implementing a successful, productive, high-output, resident-centric, research infrastructure leveraging resources available at clinical orthopaedic surgery residencies.

Background: Although Vancouver B2 periprosthetic fractures (PPFs) have been historically managed with revision total hip arthroplasty (rTHA), open reduction and internal fixation (ORIF) has been proposed as an alternative option for reasons including lower cost and surgical time. The purpose of this study was to, therefore, create a Markov model to assess the cost effectiveness of ORIF versus rTHA for Vancouver B2 periprosthetic femur fractures and evaluate various inflection points for varying costs and outcome measures.

Methods: A Markov model was built using discrete and mutually exclusive health states of the hypothetical patient with Vancouver B2 PPF. A decision tree was created on possible outcomes for each health state, using probabilities defined in the recent PPF literature. Direct costs and quality-adjusted life-years for each surgery and complication state were also collected. One-way and two-way deterministic sensitivity analyses were conducted to better understand the effect of 1 to 2 variables on the incremental cost-effectiveness ratio.

Results: The hypothetical patient with a Vancouver B2 PPF that was treated with rTHA incurred a cost of $52,559.64 with an effectiveness of 0.71. When treated with ORIF, the cost was $47,371.97 with an effectiveness of 0.38. The incremental cost and effectiveness of rTHA over ORIF were found to be $5,187.67 and 0.33, respectively. The cost of rTHA, the cost of ORIF, and the effectiveness of ORIF were the most influential variables in the model. On two-way sensitivity analysis, rTHA was more cost effective than ORIF within realistic healthcare parameters.

Discussion: From the payer perspective, we estimate that rTHA is more cost effective than ORIF for the treatment of Vancouver B2 PPFs within certain cost and quality-of-life parameters.

Background: Total hip arthroplasty (THA) practices are evolving under the influence of the current value-based healthcare system and bundled payment models. This study aimed to (1) evaluate national trends in discharge disposition and postoperative outcomes after THA, (2) compare discharge cohorts on episode-of-care parameters, and (3) determine predictors of nonhome discharge from 2011 to 2021.

Methods: The National Surgical Quality Improvement Program database was queried for THA data from 2011 to 2021. A total of 328,380 patients undergoing THA were identified between 2011 and 2021. Of these patients, 276,710 were discharged home and 51,670 were discharged to nonhome locations. Trends of annual discharge disposition, healthcare utilization parameters, and proxies for postoperative complications were reported. A multivariable logistic regression analysis was conducted to identify potential risk factors for nonhome discharge.

Results: The percentage of patients who were discharged to home increased from 70.20% in 2011 to 92.42% in 2021. In those discharged to home, 30-day readmission rates, 30-day major complication rates, length of stay, any wound complications, and need for transfusion all decreased within the past decade. The percentage of patients who were discharged to nonhome locations decreased from 29.80% in 2011 to 7.58% in 2021. In this group, major complication rates within 30 days, length of stay, and need for mechanical ventilation increased from 2011 to 2021. Greater age, female sex, body mass index of <18.5, race, smoking, higher comorbidity burden, and functional status were associated with greater odds ratios of nonhome discharge.

Conclusion: Home discharge after THA has increased substantially over the past decade, with more than 90% of patients now being discharged home. However, a small subset of higher-risk patients still requires nonhome discharge and experience worse outcomes. Focused efforts based on known discharge risk factors may allow implementing perioperative optimization strategies to further improve outcomes in this population.

Introduction: Postoperative infections are a leading cause of morbidity following fracture repair. The purpose of this study is to develop a risk score predicting fracture-related infection (FRI) that will require one versus multiple revision surgeries related to infection eradication and bone healing.

Methods: This is a retrospective cohort study conducted at a single level I trauma center from 2013 to 2020. Adults with FRIs were identified through review of an institutional database on musculoskeletal infections maintained jointly by the infectious disease division and the orthopaedic surgery department. Inclusion criteria were surgically managed fracture of the humerus, olecranon, radius/ulna, clavicle, pelvis, femur, tibia/fibula, and calcaneus with an FRI and adequate documentation present in the electronic medical record. Exclusion criteria included infected chronic osteomyelitis from a non-fracture-related pathology and follow-up less than 6 months. Risk factors leading to multiple surgeries in FRIs, including demographics, comorbidities, injury characteristics, perioperative data, and microbiology, were recorded. Logistic regression was done to select variables predictive of multiple revision surgeries. Four prespecified methods of covariate selection were used.

Results: Eighty-eight patients underwent one FRI revision surgery, whereas 208 patients underwent two or more revision surgeries. From multivariable logistic regression, age older than 45 years (P < 0.001), purulent drainage at infection presentation (P < 0.001), and incomplete bone union at infection presentation (P = 0.013) were all markedly associated with multiple revision surgeries. The model of best fit was used to generate the risk score (area under ROC curve = 0.789). Variables included in the final risk score were age ≥ 45 years, purulent drainage, incomplete bony union, and wound dehiscence at infection presentation.

Conclusion: This study described a risk score for predicting multiple revision surgeries in patients with infection following fracture repair. Age older than 45 years, purulent drainage, and incomplete bony union at infection presentation were all markedly associated with multiple infection revision surgeries.

Level of evidence: III.

Background: In modern conflicts, extremities are mainly affected, with limb amputations required for approximately 5% of severely injured combatants and 7% of those with serious limb injuries. Amputations are some of the most challenging injuries endured by survivors, significantly affecting the patients and the healthcare system. This study aims to describe the rates, characteristics, and risk factors of limb amputations in patients with serious extremity trauma during the 2023 conflict in Israel.

Methods: This nationwide retrospective cohort study, based on the Israel National Trauma Registry, includes all patients with serious extremity injuries (abbreviated injury score ≥3) from October 7 to December 31, 2023. Demographic and clinical characteristics, as well as outcomes of patients with limb amputations were compared with those who were not amputated. Multivariable logistic regression was used to identify risk factors for amputations.

Results: Among the 1,815 combat-related casualties, 1,318 (72.6%) sustained extremity injuries, and 451 (24.8%) had serious limb injuries. Most patients with severe limb injuries were young males, with 287 of 451 being soldiers. 150 of 451 were injured by explosions, and 158 of 451 had severe and critical injuries (ISS ≥16). Of 451 patients, 52 (11.5%) underwent limb amputations (43 lower limbs, eight upper limbs, and one both). Amputees were significantly more likely to be injured by explosions (76.9% vs. 27.6%, P < 0.001), have an ISS of ≥16 (75.0% vs. 29.8%, P < 0.001), and have polytrauma (46.1% vs. 27.1%, P = 0.004). Independent risk factors for amputation included explosions (adjusted odds ratio [aOR] 9.74, 95% confidence interval [CI] 4.83 to 21.32, P < 0.001), fasciotomy (aOR 8.51, 95% CI 2.82 to 25.74, P < 0.001), and polytrauma (aOR 1.98, 95% CI 1.03 to 3.78, P = 0.04). Vascular injuries were not associated with amputations (aOR 0.87, 95% CI 0.39 to 1.85, P = 0.72).

Conclusions: In recent conflicts, amputation rates have risen, likely due to increased tissue destruction from modern weaponry and improved survival rates among severely injured patients. Those with multiple severe injuries, blast injuries, or requiring fasciotomies face a higher risk of amputation.

Introduction: Patients undergoing hip fracture surgery face notable risks of postoperative morbidity and mortality, and racial and socioeconomic disparities in outcomes exist. This study examined the effect of social vulnerability on outcomes after hip fracture surgery using the CDC's Social Vulnerability Index (SVI).

Methods: A retrospective study of 464 patients undergoing hip fracture surgery at a single institution from July 2020 to June 2023 was conducted. Demographics, comorbidities, time to surgery, length of stay (LOS), and postoperative outcomes were compared between patients with low versus high social vulnerability. SVI was calculated based on patient's zip code of residence. The 50th percentile of national SVI scores was used to divide patients into low and high vulnerability groups. Univariate and multivariable analyses were done to compare patient characteristics and outcomes between the groups. The primary outcome of interest was 1-year postoperative mortality.

Results: No notable differences were observed in demographics, comorbidities, or procedure performed between the groups. Patients with increased social vulnerability had a higher rate of mortality within 1 year (low vulnerability: 12.2 vs. high vulnerability: 24.0%, P = 0.005) and a shorter time to mortality (340.7 vs. 138.9 days, P < 0.001). Patients with higher social vulnerability had longer LOS (β = 1.12, 95% CI: 0.35-1.88, P = 0.004), were 2.37 times more likely to experience mortality within 1 year (OR = 2.37, 95% CI: 1.30-4.27, P = 0.004), and 1.75 times more likely to experience mortality at any time (OR = 1.75, 95% CI: 1.01-2.99, P = 0.045).

Conclusion: Patients residing in areas of increased social vulnerability were more likely to experience a longer LOS, and more likely to die within 1 year, or at any time after undergoing hip fracture surgery, when compared with those living less socially vulnerable regions. These findings highlight the need for interventions aimed at addressing social factors within hip fracture care pathways to mitigate socioeconomic disparities in patient outcomes.

Introduction: Multiple sclerosis (MS) may negatively influence the patient-reported outcomes measures (PROMs) when undergoing total knee arthroplasty (TKA). However, functional outcomes in this select population remains poorly characterized. This study aimed to compare clinical outcomes and rate of achieving Minimal Clinically Important Difference for Improvement (MCID-I) and Minimal Clinically Important Difference for Worsening (MCID-W) between MS and non-MS TKAs.

Methods: We did a retrospective analysis of 61 TKAs in MS patients performed between 2015 and 2022 and it was propensity matched in a 3:1 ratio with 123 non-MS patients. Preoperative and postoperative assessments included Patient-Reported Outcomes Measurement Information System Global Health Mental and Physical, Patient-Reported Outcomes Measurement Information System Physical Function short form 10-a (PF-10a), and Knee injury and Osteoarthritis Outcome Score-Physical Function Short-form scores. Patients were categorized based on achieving MCID-I, MCID-W, or showing "no change" after TKA.

Results: A total of 244 TKAs (61 MS and 183 matched non-MS) were analyzed. MS TKAs had similar length of stay but lower rate of home discharges (73.8% vs. 90.2%, P = 0.003) compared with non-MS patients. Notably, both cohorts had similar rates of achieving MCID-I and MCID-W among all four PROM scores. However, MS patients had a notable higher rate of 90-day postoperative complications (26.2% vs. 12.6%, P < 0.001), revision surgeries (11.5% vs. 4.4%, P = .045), and revisions (6.6% vs. 0.5%, P = 0.004).

Conclusion: Using MCID methodology, this study found that MS patients have similar rates of achieving MCID-I and MCID-W but have higher rate of postoperative complications, revision surgeries, and revisions when compared with non-MS patients. These findings highlight that despite the elevated risks of complications, MS patients can achieve similar improvements to their non-MS counterparts. Further investigations into the long-term outcomes of MS patients are warranted to the determine the effectiveness of this intervention.

Introduction: Mental illnesses are well-known factors that contribute to poor outcomes among total hip arthroplasty (THA) patients. However, a dichotomized mental illness diagnosis may not reflect the complex biopsychosocial factors contributing to a patient's health. Investigating patients who achieve positive outcomes despite having risk factors, known as positive deviants, may help identify protective characteristics and decrease health disparities among this growing population of patients. Using preoperative Mental Health T-scores (MHT) from the PROMIS-10 Global Health questionnaire among patients with a mental illness diagnosis, the purpose of this study was to explore whether patients with above-average MHT, or positive deviants, experienced a different immediate postoperative recovery path compared with patients with below-average MHT.

Methods: This was a retrospective chart review of patients undergoing elective primary THA. Patients with a formal diagnosis of a mental health condition were divided based on their MHT (above average [AA] >50, average [A] 40 to 50, below average [BA] <40). Postsurgical parameters included total opioid consumption, self-reported pain scores, and discharge disposition.

Results: A total of 299 patients were analyzed. After controlling for length of stay and type of mental illness, patients in the AA-MHT and A-MHT groups used 33.8 and 29.8 morphine milligram equivalents less than patients in the BA-MHT group during the inpatient stay, respectively. Patients in the AA-MHT group reported a 1.0 lower pain with activity score at discharge compared with patients in the BA-MHT group.

Discussion: The intersection between patients with a mental illness in need of a THA is becoming more commonplace. Data suggest that patients with a mental illness who report AA-MHT on the PROMIS-10 Global Health questionnaire may represent positive deviants or those with a more positive in-hospital recovery path compared with those patients with BA-MHT.

Level of evidence: Diagnostic study-retrospective cohort study.

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.