Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Pediatric olecranon fractures are uncommon periarticular injuries with unclear treatment guidelines for varying magnitudes of intra-articular displacement. Similar to other pediatric elbow fractures, minimally displaced fractures are treated nonsurgically, and potential for further displacement following nonsurgical treatment exists. This study assesses the incidence and risk factors for further displacement after nonsurgical treatment of minimally displaced pediatric olecranon fractures.

Methods: A retrospective review was conducted on patients aged 0 to 15 years with isolated olecranon fractures treated nonsurgically at a single institution. Radiographic measurements of intra-articular and nonarticular displacement on lateral views were collected with follow-up imaging done until confirmed radiographic union. Patients with more than 1-mm change in displacement on the articular side during treatment were identified. Fractures were classified at specified locations, including zone 1 (proximal 1/3), zone 2 (middle 1/3), and zone 3 (distal 1/3).

Results: A total of 64 patients met inclusion criteria, 42 (65.6%) were males, and the average age at injury was 8.25 years. Casting without closed reduction was the definitive treatment method in 59 patients (92.2%). Of the fractures observed, 30 (46.9%) occurred in zone 1, followed by 23 patients (35.9%) in zone 2 and 11 patients (17.2%) in zone 3. Interval displacement was seen in 14 patients at follow-up visits (21.9%) with greater body mass index observed in the redisplacement group (P = 0.053). Change in management was required in two patients (3.1%). Displacement of ≥1 mm at initial evaluation did not affect the rate of subsequent displacement at follow-up visit (P = 0.571). Neither fracture zone nor fracture configuration were statistically significant for change in fracture displacement.

Conclusion: Further displacement was observed in 20% of minimally displaced olecranon fractures regardless of the zone and magnitude of initial displacement with a small percentage leading to a change in the management. Close radiographic follow-up for nonsurgically treated olecranon fractures is recommended.

Introduction: Suspected changes in adolescent idiopathic scoliosis (AIS) demographic distribution compared with historical cohorts emphasize the need for an updated understanding of epidemiological trends. We aimed to characterize AIS trends in the United States from 2016 to 2023, compare these findings with historical cohorts, and project trends through 2030.

Methods: AIS cases from 2016 to 2023 were identified using the TriNetX US Collaborative platform. A subanalysis examined patients who underwent posterior spinal fusion (PSF) and cases during the COVID-19 pandemic. Primary outcomes included prevalence, incidence proportion (IP), and incidence rate (IR). Historical AIS cohorts were identified through a systematic search. Regression modeling projected trends to 2030.

Results: In 2023, the TriNetX platform reported a notable rise in AIS prevalence of 110 cases per 100,000 patients compared with 2016 (P < 0.05). The IP and IR of AIS also rose, with 14,733 additional cases identified in 2023. PSF occurred in 5,990 cases per 100,000 AIS patients. Female patients had higher AIS prevalence than male patients (140 vs. 71.3 cases per 100,000) and higher PSF prevalence (6,400 vs. 5,350 cases per 100,000 AIS patients) in 2023. Incidence of AIS was markedly lower compared with historical cohorts; however, the female-to-male ratio was comparable. The most marked decrease (16.52% decrease from 2019 to 2020) and increase (22.15% increase from 2020 to 2021) in cases occurred during the COVID-19 pandemic. Regression analysis indicated linear increases in both AIS and PSF, projecting a national AIS prevalence of 17,000 cases per 100,000 patients nationally and PSF prevalence among AIS patients of 10,230 cases per 100,000 patients by 2030.

Conclusion: These findings highlight rising national rates of AIS diagnoses and PSF procedures among AIS patients. Further research is warranted on the etiology underlying increased incidence of AIS in male patients and potential healthcare burdens associated with projected increases in AIS prevalence.

Background: To investigate the effect of immediate weight-bearing (WB) status on mortality in geriatric distal femur patients. Secondary aims included determining the effect of WB status on surgical complications and ambulatory ability at 90 days.

Methods: This was a retrospective review of geriatric (age >60 years) patients with distal femur fracture (OTA/AO 33 A, 33C) from 9 level 1 trauma centers that underwent surgical fixation from 2012 to 2019. Mortality, ambulatory ability at 90 days, and surgical complications were compared between postoperative non-WB (NWB) versus WB (touch-down/partial/WB as tolerated) groups. A propensity-weighted regression model including demographics, tobacco-use, preinjury ambulatory status, injury mechanism, and American Society of Anesthesiologists classification was used to compare outcomes between the NWB and WB cohorts.

Results: Four hundred four patients were included where most of the patients (72%) underwent open reduction, internal fixation and most of the patients were NWB after surgery (63%). Most of the patients (328/404, 81%) were discharged to a nursing facility. Older patients, patients with ground-level fall, and American Society of Anesthesiologists I/II patients were more likely to be WB. Six-month mortality was 14%. Sixty-nine percentage of patients were able to ambulate without human assistance by 90 days. In the propensity-weighted analysis, there was no association with WB and mortality (hazard ratio [HR], 1.50; confidence interval [CI, 0.77, 2.92]; P = 0.24). No association was observed between WB and deep infections (HR, 2.86; [CI, 0.82, 9.93]; P = 0.10) or nonunion surgery (HR, 1.7; [CI, 0.71, 4.09]; P = 0.23). Finally, there was no association with WB and in ambulatory ability within 90 days (odds ratio [OR], 1.48; [CI, 0.65, 3.35]; P = 0.35). HRs/ORs >1 indicate higher risk/odds for the WB group.

Conclusions: Based on this study, there was no association with prescribed postoperative WB and patient mortality, reoperations, or ambulatory ability within 90 days of surgery.

Level of evidence: III PROGNOSTIC.

Introduction: An estimated 50% of orthopaedic surgeons change practices early in their careers, with recent data showing that approximately 6% make a transition within just two years. Currently, the factors that lead to orthopaedic surgeons changing jobs are not well understood. The purpose of this preliminary study was to analyze the self-reported factors that influence an orthopaedic surgeon's decision to change practices.

Methods: Upon obtaining institutional review board exemption status, a 25-question unvalidated survey was created using Microsoft Forms. A total of 100 orthopaedic surgeons who are members of the American Academy of Orthopaedic Surgeons were randomly selected to participate in this study. Consent was obtained through the survey, followed by questions related to demographics, including age, race, and sex, and region of practice. Respondents were asked to indicate the factors that played a role in their most recent change of practice. Descriptive statistical analysis was then conducted.

Results: In total, 27 participants completed our survey (response rate = 27%). Among them, 17 (63.0%) had changed practices at least once. The most frequently reported factors that influenced their decision to change practices included compensation (12, 70.6%), work flexibility (10, 58.8%), cost of living (5, 29.4%), and proximity to friends and family (4, 23.5%). Those who did not change practices (n = 10) were asked to convey the factors that contributed to their decision to remain at their current practice. Those factors included proximity to friends and family (6, 60%), work flexibility (5, 50%), and compensation (4, 40%).

Conclusion: In this preliminary study, compensation and work flexibility were the most important factors that orthopaedic surgeons considered when deciding to change practices. Such information may provide trainees with greater insight into what they might need to consider when pursuing jobs. Hospitals and administrators may also choose to emphasize such factors, thereby encouraging greater surgeon recruitment and retention.

Introduction: We conducted an initial orthopaedic resident-based evaluation of a novel three-dimensionally (3D) printed model simulating a displaced, unstable distal radius fracture (DRF). We hypothesized the model would have construct validity, enhance beginner resident performance when used for teaching, and be rated as beneficial.

Methods: Thirty-three residents across all postgraduate years (PGY) from multiple institutions participated. We gathered baseline clinical DRF experience levels for each through Accreditation Council for Graduate Medical Education case logs. We block randomized 14 PGY-1 residents into two groups: no exposure versus formal teaching with the model before testing. All other residents carried out testing without prior exposure. All PGY residents completed a single model testing session including reduction, splinting, and fluoroscopy, with standardized performance assessments by a board-certified hand surgery fellowship-trained orthopaedic surgeon. Performance metrics for each session included a global rating scale (GRS), an objective structured assessment of technical skills, reduction/splinting time, final radiographic sagittal tilt, and a DRF written examination. We also gathered anonymous feedback on the model.

Results: PGY-1 residents taught with the model scored markedly better per GRS (P < 0.05). No notable differences were found between the randomized PGY-1 groups for the objective structured assessment of technical skills, procedure times, or examinations (P > 0.05). PGY-1 residents with no prior exposure had markedly longer group-level procedure times than all other PGY residents with no prior exposure, supporting construct validity for the model (P < 0.05). Furthermore, PGY level markedly correlated with better GRS and examination scores and procedure times (P < 0.05). Baseline DRF experience was also markedly associated with better GRS scores (P < 0.05). Anonymous resident feedback indicated that they would recommend the 3D-printed DRF models to improve education.

Discussion: Our 3D-printed unstable DRF model demonstrated construct validity across multiple domains. PGY-1 residents taught with the model scored better on the GRS, suggesting potential improved skill acquisition and assessment. All PGY residents recommended the models for DRF education.

Introduction: Trimalleolar ankle fractures are associated with high complication rates and unplanned healthcare utilization. This study aimed to (1) characterize the demographic and clinical profile of patients requiring 90-day readmission; (2) identify risk factors for 90-day emergency department (ED) utilization; and (3) determine comorbidities most strongly linked to 90-day readmissions following trimalleolar open reduction and internal fixation (ORIF).

Methods: Using the PearlDiver Mariner database from 2010 to 2021, patients undergoing trimalleolar ankle fracture ORIF were identified through current procedural terminology codes 27822 and 27823. Ninety-day postoperative ED visits and hospital readmissions were evaluated. Patients with ED utilization (N = 636) were compared with controls without ED visits (N = 79,956). Logistic regression was used to identify demographic and comorbidity risk factors for both ED utilization and readmission, with statistical significance set at P < 0.05.

Results: ED utilization was higher among older patients (peak 70 to 74 years, P < 0.001). Comorbidities markedly associated with 90-day ED revisits included congestive heart failure (CHF) [odds ratio (OR) 1.55, P = 0.001], fluid and electrolyte disorders (OR 1.35, P = 0.001), pathologic weight loss (OR 1.34, P = 0.012), hypertension (OR 1.26, P = 0.043), and peripheral vascular disease (PVD) (OR 1.25, P = 0.038). Risk factors for 90-day readmission included fluid and electrolyte disorders (OR 1.98, P < 0.001), coagulopathy (OR 1.44, P < 0.001), CHF (OR 1.35, P < 0.001), PVD (OR 1.33, P < 0.001), and pathologic weight loss (OR 1.44, P < 0.001).

Conclusion: Postoperative ED visits and readmissions following trimalleolar ORIF are driven largely by patient comorbidities. Older, medically complex patients represent a high-risk group, and targeted perioperative optimization may reduce complications and unplanned healthcare utilization.

Anatomic reduction is fundamental to successful osteosynthesis, yet it remains one of the most challenging surgical skills to teach and master. Although no framework can encompass the full complexity of fracture surgery, this article distills some aspects of the "art" of reduction into foundational concepts to guide surgical strategy. We review these principles through intuitive metaphors: the "key" (distract, reorient, compress), the "door" (establish a hinge and close), and the "puzzle" (reduce the easiest piece first). These concepts are integrated with the biomechanical distinction between tension-sided failures, which are often amenable to direct reduction, and compression-sided failures, sometimes better suited for indirect reduction through ligamentotaxis. The practical application of this conceptual framework is demonstrated across a spectrum of common fractures, including those of the proximal and distal humerus, acetabulum, femoral neck, and tibial plateau. By providing a systematic toolkit, these principles aim to transform fracture reduction from an abstract challenge into a more logical, approachable problem for surgeons at all levels of training.

Background: Distal radius fractures are common injuries in older adults. There is disagreement on the optimal treatment options for distal radius fractures in this patient population. The Wrist and Radius Injury Surgical Trial (WRIST) was a randomized clinical trial comparing the most common treatment options for distal radius fractures in this population (casting, closed reduction and percutaneous pinning [CRPP], external fixation [EFP], and volar locking plate systems [VLPS]). The objective of this review is to summarize the findings across all articles stemming from the data collected in the WRIST study.

Methods: This was a scoping review that involved identification of and data collection from all articles published by the WRIST group, including the initial WRIST study and all secondary analyses of the data collected.

Results: No notable differences were found in functional outcomes between patients treated with casting vs. surgery (or between the three surgical options) at 12 months posttreatment. Patients treated with VLPS recovered faster and had improved outcomes at 6 weeks posttreatment. Complications were common and highest in the casting group, although malunion was not associated with inferior outcomes. Highly active patients recovered faster, especially when treated with VLPS. Casting was the most cost-effective option, followed by CRPP.

Conclusion: There is no single best option for the treatment of distal radius fractures in older adults across all domains. This allows physicians to engage in a shared decision-making conversation with each patient about their goals posttreatment in the context of their fracture pattern and overall lifestyle.

Background: Press-fit femoral osseointegrated limb replacement (FOLR) allows for a direct transcutaneous skeletal connection between an artificial leg and the residual femur in a single-stage procedure that can be performed open or percutaneously. A skeletally anchored prosthesis can offer enhanced mobility, balance, and proprioception to amputees, as well as eliminate problems associated with socket mounted prostheses, such as skin problems, ulcers, and pain. The purpose of this research is to describe the safety, functional, and patient-reported outcomes for this technique.

Methods: We retrospectively reviewed all patients at our institution who underwent press-fit FOLR between January 2017 to May 2023 (at least 1 year postsurgery). The primary outcome was adverse events prompting additional surgery. Secondary outcomes were changes in mobility (timed up and go), 2-minute walk test (2MWT), 6-minute walk test (6MWT), prosthetic use, walking aids, and patient-reported quality of life surveys (Limb Deformity-Scoliosis Research Society, QTFA, and patient-reported outcomes measurement information system).

Results: Sixty-seven FOLR procedures in 65 patients were included in this cohort. The total revision surgery rate was 40.3%, including 12 débridements (17.9%), six fracture repairs (9.0%), 14 soft-tissue revisions (20.9%), and two implant removals (3.0%). Thirty limbs (44.8%) developed drainage or inflammation around their aperture and were successfully treated with antibiotics alone. Implant survival was 98.4% at 1 year, 98.4% at 2 years, and 93.0% at 5 years. Large statistically significant improvements were found in mobility (2MWT, 6MWT), walking aids, and patient-reported outcomes scores (Limb Deformity-Scoliosis Research Society, patient-reported outcomes measurement information system) in patients who underwent FOLR, as well as improvements in prosthetic use in patients who initially presented with a prosthesis.

Conclusion: Osseointegration of the femur reliably improves function and quality of life for transfemoral amputees. There is a high rate of complications and revision surgery, but the problems encountered are manageable in most instances.

Introduction: Several statistical models have been developed to predict the stability of distal radius fractures after closed reduction, but their findings have not been consistently reproduced. We aimed to develop a machine learning (ML) model to predict radiographic outcomes of nonsurgically treated distal radius fractures based on pre-reduction and postreduction radiographic parameters and demographic variables.

Methods: Adults with displaced distal radius fractures at a single institution between 2012 and 2024 were identified through retrospective chart review. Inclusion criteria required closed reduction in the emergency department, with radiographs obtained before reduction, immediately after reduction, and 6 weeks after reduction. At 6 weeks, treatment outcomes were classified as "success" or "failure" based on American Academy of Orthopaedic Surgeons acceptable reduction parameters. Five ML models were trained to predict 6-week outcomes using demographic data and pre-reduction and postreduction radiographic measurements. The 10 parameters with highest Shapley values for predictive ability were used to create an interpretable composite model.

Results: Among 1,227 patients, 152 met the inclusion criteria (mean age: 61.4 ± 20.2 years; 75.7% female). The composite model correctly predicted outcomes in 25 of 31 patients, achieving an accuracy, precision, and recall of 81%; area under the curve of 0.84; and F1 score of 0.81. Restoration of postreduction palmar tilt, radial height, and excellent reduction based on the Lindstrom score were most predictive of 6-week radiographic outcomes. The best performing decision tree showed the following cutoffs predictive of treatment failure: +4.7 mm of pre-reduction ulnar variance, 8° of postreduction dorsal tilt, and <18.8° of postreduction radial inclination.

Conclusion: This study developed an ML model that accurately predicts 6-week radiographic outcomes in nonsurgically treated distal radius fractures. Postreduction parameters were the strongest predictors, underscoring the importance of a high-quality closed reduction. This study validates the potential of ML as a predictive tool in this setting.