Journal of the American Academy of Orthopaedic Surgeons最新文献

Background: Unicompartmental knee arthroplasty (UKA) is an option for unicompartmental osteoarthritis. With medial or multicompartment joint wear being the most common clinical scenarios, lateral UKA (L-UKA) is less commonly considered than other knee joint arthroplasty procedures. As such, the postoperative outcomes of L-UKA relative to medial UKA (M-UKA) and total knee arthroplasty (TKA) remain poorly characterized at a national level in the United States.

Methods: Patients undergoing L-UKA were identified from the PearlDiver M170Ortho Database and separately matched 1:4 with M-UKA and TKA patients by age, sex, and Elixhauser Comorbidity Index. Multivariable logistic regression compared 90-day adverse events, emergency department visits, readmissions, and 5-year implant-related issues.

Results: First, 343 L-UKAs were assessed relative to 1,295 M-UKAs. L-UKA demonstrated higher odds of 90-day severe adverse events (odds ratio [OR], 1.83; P = 0.037), infection (OR, 1.41; P = 0.022), wound dehiscence (OR, 3.60; P = 0.008), readmission (OR, 1.67; P = 0.047), and 5-year prosthetic joint infection (OR, 2.57; P = 0.001). Second, 425 L-UKAs were assessed relative to 1,700 TKAs. L-UKA demonstrated higher odds of 90-day wound dehiscence (OR, 2.13; P = 0.025), 5-year prosthetic joint infection (OR, 1.64; P = 0.028), and revision (OR, 2.00; P = 0.007), but lower odds of 5-year stiffness (OR, 0.45; P < 0.001).

Discussion: In the first study of L-UKA using national-level US data, L-UKA demonstrated mixed outcomes compared with both M-UKA and TKA. While L-UKA demonstrated lower stiffness rates than TKA, the elevated risk of 90-day postoperative complications and inferior 5-year revision-free survival suggest the need for careful consideration of L-UKA and future prospective analysis to further elucidate whether these associations can be generalized across surgeons with differing case volumes.

Background: The prognostic value of initial tendon gap distance following acute Achilles tendon rupture (ATR) remains unclear. The present systematic review and meta-analysis aimed to investigate the effect of tendon gap distance on clinical outcomes following nonsurgical management of acute ATR.

Methods: Our review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used PubMed, EMBASE, and Cochrane Library databases for studies investigating the influence of tendon gap distance on functional outcomes following nonsurgical management of acute ATR. Data investigated included patient demographics, functional scores, including the Achilles Tendon Rupture Score (ATRS), gap size, and rupture location. The association between tendon gap distance and functional outcomes was investigated. Additional analyses examined secondary associations among age, sex, and rupture location and functional outcomes.

Results: A total of eight studies comprising 288 patients with acute ATRs were included in our review. Of these, four studies met criteria for quantitative synthesis and were included in the meta-analysis. With a cutoff of 10-mm gap distance, the pooled analysis demonstrated a markedly lower ATRS in patients with a larger gap size (>10 mm versus ≤10 mm; Cohen d = -0.39; 95% CI = -0.76 to -0.02; P = 0.04). Secondary analyses revealed lower ATRS in patients older than 50 years (d = -0.70; P < 0.001) and female patients (d = -0.58; P = 0.01), whereas rupture location had no notable effect (P = 0.85).

Conclusion: Our review demonstrated that a larger initial tendon gap is associated with lower functional outcomes following nonsurgical management of acute ATR, particularly with a cutoff of 10 mm. Furthermore, factors such as age and sex may also influence clinical outcomes. However, the result should be interpreted with caution due to heterogeneity across studies.

Level of evidence: Level 3, systematic review and meta-analysis.

Effective pain management is essential in pediatric orthopaedic procedures to ensure optimal patient outcomes and recovery. Although opioids are an important component of pain control, their misuse remains a notable public health concern. Pediatric patients often encounter opioids for the first time after orthopaedic procedures, underscoring the need for stringent prescribing protocols. The Pediatric Orthopaedic Society of North America guidelines provide a comprehensive framework for tailoring pain management to procedure intensity. Despite their potential, implementation challenges and variability persist. This review examines the Pediatric Orthopaedic Society of North America guidelines, barriers to adoption, and opportunities to optimize postoperative pain management while mitigating risks. Future research and guideline evolution are necessary to uphold patient safety and combat the opioid crisis.

Introduction: Isolated posterior lumbar decompression (PLD) is commonly performed for degenerative indications. However, the various factors that predict revision surgery for subsequent fusion remain poorly understood. To this end, the purpose of the current study was to investigate demographic and lumbar imaging findings at the time of PLD that are associated with subsequent fusion.

Methods: Adult patients who underwent isolated 1-2-level PLD between L3-S1 (2014 to 2020) were retrospectively identified. Subsequent fusion within 2 years was determined. Preoperative lumbar magnetic resonance imaging (MRI) was reviewed for (1) sagittally aligned facet (SAF) joints, (2) facet tropism, (3) facet degeneration, (4) disk height, and (5) Pfirrmann grade. Radiology reports were used to categorize the foraminal stenosis severity. Associations between MRI findings before PLD and the need for revision surgery for fusion were investigated using multivariable logistic regression.

Results: Among the 202 PLD patients, 21.3% underwent fusion within 2 years. Patients requiring fusion had a higher Charlson comorbidity index (2.07 ± 2.19 versus 1.30 ± 1.73, P = 0.023). No differences were observed in facet tropism, SAF joints, disk height, or stenosis severity between the subsequent fusion and no fusion groups. Patients who did not undergo fusion had higher average facet degeneration scores (1.90 ± 0.76 versus 1.64 ± 0.71, P = 0.030) and a greater proportion of Pfirrmann grade 5 disks (37.8% versus 18.6%, P = 0.013). Multivariable regression identified CCI as the only independent predictor of subsequent fusion (odds ratio: 1.32, cI, 1.03 to 1.72, P = 0.034).

Conclusion: This study found that higher CCI at the time of PLD is an independent predictor of requiring fusion within 2 years. Increased lumbar degeneration alone was not associated with a greater risk of fusion. Decreased remaining motion, lower functional demands, or a greater propensity for autofusion may have lowered the need for subsequent fusion among these PLD patients with greater degeneration. Further research is needed to support these results.

Study design: A retrospective cohort study.

Objective: To evaluate the impact of discharge disposition on the rates of return to the emergency department (ED) and readmission following elective lumbar fusion surgery (ELFS).

Methods: This study retrospectively reviewed patients aged ≥18 years old who underwent ELFS for degenerative pathology at a single academic institution between 2018 and 2022. A review of medical records was conducted to collect data on patient and surgical characteristics. Patients were categorized into two groups: Home Health and Skilled Nursing Facility (SNF) and Inpatient Rehabilitation Facility (IRF). ED visits and readmissions within 3 months postoperatively were recorded. Univariate and multivariate regression models were used to identify independent factors associated with ED presentation or readmission.

Results: A total of 495 patients were included. Of the patients, 414 were discharged home, and 81 were discharged to a SNF/IRF. In the univariate analysis, discharge to a SNF or IRF was associated with 3.81 times higher odds of readmission (P < 0.01) and 1.51 times higher odds of ED visits (P = 0.15) compared with discharge to home. After adjusting for confounders in the multivariate analysis, the odds ratios for readmission and ED visits were 2.24 (P = 0.012) and 1.03 (P = 0.927), respectively.

Conclusion: Patients discharged to a SNF or IRF after ELFS had markedly higher odds of readmission within 3 months postoperatively, even after adjusting for patient and surgical factors. However, this association was not observed for ED visits. These findings underscore the need for careful consideration of discharge planning to optimize postoperative outcomes and reduce healthcare utilization following ELFS.

Background: Venous thromboembolism (VTE) is uncommon in adolescents but remains a serious postoperative complication in orthopaedic surgery. Current prophylaxis practices are largely based on adult data. This study evaluated independent risk factors of postoperative VTE in adolescents undergoing lower extremity (LE) fracture surgery using a large multicenter data set.

Methods: A retrospective case-control study using the TriNetX Research Network identified adolescents aged 13 to 20 years who underwent LE fracture surgery from 2003 to 2025. Patients were grouped by the presence or absence of VTE within 90 days. Demographics and comorbidities were analyzed with univariate and multivariate logistic regression.

Results: Of 86,134 patients, 627 (0.73%) developed VTE. Overweight/obesity, diabetes, and tobacco use were significant on univariate analysis, but only overweight/obesity remained independently associated with VTE (adjusted OR 1.8).

Conclusion: Obesity was the only independent predictor of postoperative VTE. These findings highlight the need to incorporate BMI into preoperative risk assessment and develop adolescent-specific prophylaxis guidelines.

Level of evidence: Therapeutic Level III.

Introduction: Bone health is critical to spine surgery. Studies have demonstrated the role and benefit of optimizing bone health before spinal surgery. However, bone health screening and treatment patterns vary considerably among spine surgeons. The purpose of this study was to assess the global screening, prevention, and treatment of osteoporosis and bone health in spine surgery.

Methods: A 34-item questionnaire was created and distributed anonymously, globally to AO Spine subscribers. The word responses were analyzed manually and categorized. Each participant was assigned a region: Asia, Africa, Central America, Europe, North America, or South America. Quantitative outcomes include the frequency and proportion of respondents who selected each answer. Qualitative outcomes include written responses to select prompts. Chi-squared tests was performed to compare proportions based on categories.

Results: The response rate was 3.4%; 36.2% of respondents were from Asia, 28.7% Europe, 12.8% South America, 9.8% North America, 9.6% Africa, and 2.9% Central America. 69.8% finished residency in orthopaedic surgery, 24.5% in neurosurgery, and 5.7% in others; 58.6% completed a spine fellowship. Before instrumented fusion, 61.1% routinely checked dual-energy radiograph absorptiometry (DXA). If osteoporosis is detected on DXA before an instrumented fusion, 65.1% would alter their treatment plan; 64.7% refer the patient to treatment first. The rate of DXA screening before instrumented fusion differed based on the region (P < 0.001): the highest was in North America at 89.5%, and the lowest was in Africa at 36.6%. Before instrumented fusion, fellowship-trained surgeons screened DXA more routinely than those without a fellowship, at 67.9% and 52.5%, respectively (P = 0.002).

Conclusions: Globally, bone health screening before spine surgery has increased. However, large regional variations in practice patterns exist regarding the screening of bone health pre- and perioperatively.

Background: Ketorolac is commonly used as part of multimodal analgesia after orthopaedic surgery; however, concerns persist regarding its potential effects on postoperative wound healing and fracture union. While previous studies have evaluated ketorolac use in arthroplasty and long bone fractures, data specific to ankle open reduction and internal fixation (ORIF) remain limited. This study evaluated the association between perioperative ketorolac use and short-term postoperative complications and longer term healing outcomes after ankle ORIF.

Methods: This retrospective cohort study obtained data from a healthcare database platform from January 1, 2015, to January 1, 2025. Adult patients (≥18 years) who underwent ankle ORIF were identified using standardized Current Procedural Terminology (CPT) codes. Patients were stratified based on perioperative ketorolac exposure on the day of surgery and compared with a control cohort without ketorolac exposure within a defined perioperative washout window. Cohorts were balanced using 1:1 propensity score matching. Outcomes were assessed at 90 days and 2 years postoperatively.

Results: After propensity score matching, 29,920 patients remained in each cohort. At 90 days, perioperative ketorolac use was associated with higher rates of deep and superficial surgical site infection, wound dehiscence, and implant-related infection. Ketorolac use was also associated with lower transfusion rates, although transfusion was rare in both cohorts, and a modestly lower rate of opioid prescribing, although this reflects prescription documentation rather than analgesic efficacy. No significant differences were observed in pulmonary embolism, acute renal failure, or inpatient readmissions. At 2 years, there were no significant differences between cohorts in rates of nonunion, malunion, revision surgery, or below-knee amputation.

Conclusions: In this retrospective database analysis, perioperative ketorolac use after ankle ORIF was associated with increased early wound-related and infection-related complications but not with adverse long-term fracture healing or limb outcomes. These findings suggest a nuanced risk-benefit profile for ketorolac in ankle fracture fixation and underscore the importance of individualized perioperative analgesic decision making, particularly for patients at higher risk of soft-tissue complications.

Level of evidence: Level 3, systematic review and meta-analysis.

Background: Lower extremity amputation (LEA) is performed by diverse specialties, including orthopaedic surgery and vascular surgery; whether outcomes differ by specialty remains uncertain. This study compared early postoperative outcomes after LEA performed by orthopaedic and vascular surgeons.

Methods: Patients who underwent LEA surgeries were identified within the National Surgical Quality Improvement Program database. National Surgical Quality Improvement Program was queried for above-knee amputation, below-knee amputation, and foot amputations performed by orthopaedic or vascular surgeons. Patients were matched in a 1:1 ratio using propensity scores using a mixed exact/caliper approach. Primary outcomes were 30-day mortality, readmission, and revision surgery; secondary outcomes included cardiac, pulmonary, wound-related issues, and discharge disposition.

Results: A total of 26,925 LEA cases were identified. After propensity matching, 3,580 cases remained: orthopaedic surgery 1790 versus vascular surgery 1790, including 3,180 matched below-knee amputation, 806 matched above-knee amputation, and 334 matched foot amputations. Final cohorts had a similar distribution of demographic variables, indicating appropriate matching. Mortality of 4.0% versus 4.0%, readmission of 10.7% versus 11.7%, and revision surgery of 7.6 versus 8.3% were equivalent between orthopaedics and vascular surgery, respectively. The vascular cohort demonstrated higher rates of any postoperative complication: the sum of secondary outcomes (77.9% vs 70.4%; P < 0.001), driven primarily by increased non-home discharge (69.7% vs 60.8%) and transfusion within 72 hours (19.5% vs 16.3%). When non-home discharge was removed, there was no difference in early postoperative complication (32.2% vs 35.5%; P = 0.382). By contrast, the orthopaedic group had slightly higher rates of organ/space infection (4.1% vs 2.2%; P = 0.001) and postoperative pneumonia (3.8% vs 2.5%; P = 0.029), consistent with the higher proportion of contaminated/dirty wounds: 44.4% versus 36.0% and longer surgical duration: 79.5 ± 43.5 versus 68.3 ± 46.1 observed in this group.

Conclusions: The present analysis represents the first matched comparison of LEA outcomes by surgical specialty. When baseline patient risk is balanced, orthopaedic and vascular surgeons achieve comparable 30-day major outcomes: mortality, readmission, and revision surgery following LEA. Residual differences in complication profiles appear driven by clinical context, such as wound class, transfusion exposure, and rehabilitation needs, rather than by specialty itself.

Level of evidence: Level III.

Background: The thoracic vertebrae, ribs, and sternum, provide structural and protective support for the upper body. The unique framework of the region suggests that fractures involving both the thoracic spine and sternum occur with notable spinal instability. Despite their clinical relevance, the short-term medical and surgical outcomes of combined sternal and thoracic spinal fractures remain poorly understood compared with thoracic fractures alone. This study aims to compare the 90-day complication rates and surgical intervention requirements in patients with concomitant sternal and thoracic vertebral fractures with those with isolated thoracic vertebral fractures.

Methods: Patients presenting with acute sternal and thoracic spine fractures in the same admission were identified using the PearlDiver database. Patients with sternal and vertebral fractures were propensity matched in a 1:1 ratio with a control group by age and Elixhauser comorbidity index. Medical complications, rate of spinal cord injury, and rates of surgical intervention were assessed at 90 days.

Results: A total of 9,026 patients were identified in this study with 4,513 patients presenting with sternal and thoracic spine fractures and 4,513 patients in the control group. Sternal and vertebral fracture coinjury was associated with higher rates of spinal cord injury (P < 0.0001), higher rates for spinal decompression/fusion (odds ratio = 4.38, P < 0.0001), and higher rates of thoracic surgery (odds ratio = 3.0, P < 0.0001). These patients were also statistically markedly more likely to develop hemodynamic, respiratory, cardiac, and renal complications (P < 0.001) at 90 days.

Discussion: Patients with thoracic spine fractures who sustain simultaneous sternal fractures are markedly more likely to have concomitant spinal cord injury, require spinal stabilization or decompression, and develop medical complications. Our findings point toward the role of the sternum as a fourth column of stability in cases of thoracic spinal fractures, which mitigate complications, surgery, and neurologic injury in cases of trauma.