United States

Background

In recent years, the use of 3-dimensional (3D) printing in orthopedic surgery has greatly expanded, including the application of 3D-printed implants following bone tumor excision. After complete bone tumor excision, bone defects are typically reconstructed and implanted with a prosthetic. Historically, commercially produced implants have been used, but recent research explores the benefit of individualized 3D-printed prostheses (3DPs). These custom implants more accurately match the complex shapes of orthopedic defects and are especially useful in areas where unusual implants are necessary. The purpose of this review is to compile the available literature surrounding 3D-printed bone tumor prostheses and use patient outcomes to evaluate the efficacy of 3DPs compared to conventional prostheses. This review aims to assess the benefits and limitations of 3DPs and determine if they are a viable alternative to traditional implants.

Methods:
A systematic review was conducted, and the literature search was limited to studies with a comparable non-3DP control. A variety of bone tumor types and locations were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied. Outcome measures of 3DPs and conventional implants were compared in the context of the tumor location and procedure type. The selected outcome measures include operative duration, intraoperative blood loss, hospital stay, cost, complication rate, implant dislocation, and Musculoskeletal Tumor Society Scoring System (MSTS) score.

Results

Operative duration was decreased with 3DP use in 4 studies of pelvic and periacetabular tumors, with a reduction of 125, 70, 63, and 41 minutes respectively. Conversely, thoracolumbar 3DPs showed an average increased operative duration of 54 minutes. Compared to control, reduced intraoperative blood loss was seen in pelvic, periacetabular, and thoracolumbar 3DP procedures. MSTS score, a quality of life measure, was improved in the 3DP group compared to control in all four studies of pelvic and periacetabular tumors. In two cases of pelvic tumors, the 3DP group demonstrated an average decreased risk of implant dislocation by 11.22%. In thoracolumbar tumors, the risk decreased by 7.2%.

Conclusion

Compared to conventional controls, our review demonstrates the benefits of 3DPs in improving patient outcomes and the efficiency of surgical procedures. Intraoperative blood loss, complication rate, and implant dislocation occurrence were all shown to be reduced with the use of 3DPs. 3DP use also revealed an improvement in MSTS score and tumor resection accuracy. Additional studies with comparable controls are necessary to further evaluate the benefits of 3DPs and assess their long-term efficacy.

AMA Research Challenge 2024 

Clinical Outcomes of the Use of 3-Dimensional Printing Implants in Cases of Bone Tumors: A Meta-Analysis

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Abstract Title
Comparison of Clinical Outcomes in Patients with Primary Versus Ipsilateral Revision ACL Reconstruction

Background
Up to 30% of young active patients with a previous anterior cruciate ligament reconstruction (ACLR) suffer a second ACL rupture within the first two years after surgery. To our knowledge, few studies have determined if individuals who undergo a second ACLR report worse knee function and psychological response to injury recovery when compared to individuals who undergo primary ACLR. The aim of this study is to investigate whether there is a difference in functional and psychological outcomes in patients who have undergone an ipsilateral revision ACL reconstruction compared to patients with a primary ACL reconstruction. 

Methods
Data were combined from ongoing retrospective and prospective cohort studies at a single medical center. Patients were included in this study if they were 13-40 years old, underwent primary uncomplicated ACLR or ipsilateral revision ACLR at our institution, and participated in our standardized return to sport testing protocol at least 5 months post-ACLR. Patients were excluded if they experienced perioperative complications that resulted in a delayed standard of care. Surgical characteristics were confirmed via chart review. Primary outcomes of interest included knee function measured by the International Knee Documentation Committee Subjective Knee Evaluation score (IKDC), psychological readiness for return to sport measured by the ACL-RSI score, and isokinetic (60°/s) quadriceps and hamstring strength limb symmetry index (%). Patient-reported and strength outcomes were compared between patients in the primary and revision ACLR groups using ANCOVA while controlling for the effects of age and time since surgery. A-priori alpha level was established as p < 0.05. 

Results
Patients in the primary ACLR group were younger (p=0.002) and the groups also differed based on graft source (p=0.013), and medial meniscus (p=0.041) treatment (meniscectomy, repair, or no treatment) at the time of ACLR. After accounting for time since surgery and age, there were no significant differences between groups for IKDC score (p=0.740), ACL-RSI score (p=0.762), nor knee extension strength LSI (p=0.393); however, the primary ACLR group displayed greater knee flexion strength LSI (p=0.020). 

Conclusion
Patients that underwent revision ACLR had similar outcomes in terms of patient-reported psychological readiness to return to sport, patient-reported knee function, and knee extension strength compared to those who underwent primary ACLR. However, the revision ACLR group demonstrated decreased knee flexion strength. This finding may suggest that patients undergoing recovery from revision ACLR may benefit from increased incorporation of hamstring-specific strength building exercises during rehabilitation to restore knee flexion function and prevent future injury.

Comparison of Outcomes in Revision vs. Primary ACL Reconstruction

Introduction: Reverse total shoulder arthroplasty (RSA) has gained popularity in recent years as an alternative to anatomic total shoulder arthroplasty (TSA) for the treatment of glenohumeral arthritis. The current literature suggests RSA carries a higher all-cause postoperative complication rate than anatomic TSA. The present study aims to more comprehensively compare risk for orthopedic complications and infection in the 90-day period following TSA vs. RSA among patients with osteoarthritis (OA) affecting the shoulder. Materials and Methods: The TriNetX Research NLP network was queried to identify all patients between 65-90 years old who underwent RSA or TSA for OA between the years 2006-2024. Common orthopedic complications (i.e., fracture, dislocation, mechanical failure, stiffness, rotator cuff injury, hematoma) and musculoskeletal infections (i.e., infective arthritis, prosthetic joint infection, osteomyelitis, and other infections involving bone) associated with anatomic TSA were analyzed for risk difference between RSA and TSA. A subsequent multivariate logistic regression was performed to identify patient risk factors for orthopedic complications and infection. Results: Propensity score matching resulted in a cohort of n = 7,755 each for RSA and TSA. RSA carried increased risk compared to TSA for orthopedic complications (OR = 2.251; p<0.0001) and musculoskeletal infections (OR = 2.908; p<0.0001). Significant risk factors (p<0.05) for both orthopedic complications and infection included diabetes, hypertension, depression, liver diseases, and cardiac arrhythmias. Discussion/Conclusion: To our knowledge, this is the largest database study performed to date comparing risk for both infection and orthopedic complications between TSA and RSA performed for OA. RSA carries a greater risk for orthopedic complications and infection than TSA in the 90-day postoperative period when considering elderly patients undergoing surgery for OA. ​​These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes.

Complications and Risk Factors Following Reverse vs. Anatomic Total Shoulder Arthroplasty for Osteoarthritis

Background
Mental health disorders are associated with increased complication rates and poorer postoperative outcomes for multiple orthopedic procedures. This study aims to analyze the influence of diagnosed mental disorders on postoperative outcomes of individuals undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. 

Methods
Using the TriNetX global health network database, we evaluated postoperative outcomes of patients who underwent arthroscopic ACL reconstruction over a 20-year period. Patients with a documented mental health disorder (e.g., anxiety or depression) within 1 year preceding surgery were compared to patients without mental health disorders. The cohorts were propensity-matched for demographic and medical factors, including hypertension, type 2 diabetes, and obesity. Short- and longterm outcomes were evaluated within 90 days and 3 years postoperative, respectively. Chi-square analysis was performed to compare outcomes between the 2 cohorts. 

Results
A total of 8,351 patients with diagnosed mental health disorders were propensity-score matched at a 1:1 ratio with 82,127 patients without diagnosed mental health disorders. Within 90 days postoperative, patients with diagnosed mental health disorders demonstrated significantly higher odds of postoperative infection (P = 0.0042), lower limb mononeuropathy (P = 0.025), acute postoperative pain (P < 0.0001), knee stiffness (P < 0.0001), and emergency department visits (P < 0.0001). Within 3 years postoperative, these patients had significantly higher odds of opioid abuse (P = 0.0015), knee pain (P < 0.0001), patella fracture (P = 0.0008), and arthrocentesis/aspiration/injection (P = 0.0005), but significantly lower odds of ACL tear (P < 0.0001) and repeat ACL reconstruction (P = 0.0033). 

Conclusion
Diagnosed mental health disorders were associated with increased shortand long-term postoperative complications following ACL reconstruction, but also demonstrated a potentially protective association with multiple postoperative outcomes, including decreased odds of additional ACL tears and reconstructions.

Diagnosed Mental Health Disorders are Associated With Higher Rates of Postoperative Complications, Additional Procedures, and Lower ACL Tears and Revisions Following Anterior Cruciate Ligament Reconstruction

Background: Patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) often report fluctuations in pain levels associated with weather conditions. Despite common clinical observations, the literature on this relationship remains inconclusive. This study aims to evaluate the correlation between postoperative pain scores and weather parameters, considering demographic and comorbidity factors. 

Methods: A retrospective chart review was conducted on 558 patients from the University of Texas Medical Branch who underwent TKA or THA between January 1, 2020, and December 31, 2023. Inclusion criteria included patients without significant comorbidities affecting surgical outcomes. Postoperative pain scores, recorded using a numerical rating scale (NRS), were correlated with historical weather data (temperature, barometric pressure, humidity) from appointment dates. 

Results: The mean pain score reported was 3.87 (SD 3.0). Weather parameters, including temperature and barometric pressure, did not yield significant correlations or linear regression results with pain scores. Analysis revealed a significant negative correlation between age and pain scores (r = -0.293, p < 0.001), indicating that older patients reported lower pain levels. Body mass index (BMI) was positively correlated with pain scores (p < 0.05), while sex and race/ethnicity showed no significant associations (p > 0.05). Notably, mental health diagnoses significantly influenced pain ratings (p < 0.05). 

Conclusions: This study found no significant relationship between postoperative pain and weather parameters in TKA/THA patients, challenging common assumptions that weather significantly influences pain perception. However, age, BMI, and mental health were identified as significant factors affecting postoperative pain experiences. These findings underscore the need for personalized pain management strategies that account for individual patient characteristics rather than environmental factors.

Do Arthroplasty Patients Have Increased Weather-Related Pain Postoperatively?

Introduction: Patients with pre-existing psychiatric diagnoses have been reported to have suboptimal post operative outcomes in various surgical fields, however, few such studies exist in the orthopaedic surgery literature. The goal of this study was to examine the affect a pre-operative psychiatric diagnosis had on short-term post-operative outcomes in patients undergoing surgical fixation of a pelvic fracture. 

Methods: The American College of Surgeons – Trauma Quality Improvement Program (TQIP) was queried using ICD10 procedure codes to identify patients undergoing operative fixation of a pelvic fracture from 2017-2021. The patient cohort was stratified into two groups, those with a pre-existing psychiatric diagnosis versus those without a pre-existing psychiatric diagnosis. Psychiatric diagnoses included in the TQIP variable were schizophrenia, bipolar disorder, major depressive disorder, social anxiety disorder, posttraumatic stress disorder, and antisocial personality disorder. Our primary outcome measure was pooled infection rate. Secondary outcome measures included infections that comprised the pooled infection variable, as well as other post-operative sequela captured in the TQIP database. Outcome measures between the two cohorts were compared using chi-square and Fisher’s exact test. 

Results: A total of 107,748 patients undergoing pelvic fixation were identified, as well as 11,306 with a mental health/personality disorder at time of admission. Patients with pre-existing psychiatric diagnoses were more likely to also have comorbid conditions than those without a pre-existing psychiatric diagnosis. Furthermore, these patients were more likely to have a positive drug screen on admission compared to those without a pre-existing psychiatric diagnosis. In terms of overall infection, individuals with a pre-existing psychiatric diagnosis were more likely to experience infection overall, as well as dSSI, sSSI, organ space infection and osteomyelitis, compared to those without a psychiatric history (p<0.05).

Conclusions: Patients with pre-existing psychiatric diagnoses represent a unique and significant portion of patients undergoing pelvic fracture surgery. These patients are more likely to suffer from substance misuse and comorbid conditions at time of admission, thus requiring increased attention and optimization both before and following surgery to help mitigate risk of post-operative complications.

Do Patients with Pre-Existing psychiatric Diagnoses Experience Increased Rates of Post-Operative Complications Following Pelvic Fracture Surgery?

Background
The current study aimed to: (1) evaluate the prevalence of delays in first-start case times over the course of one year for trauma-related orthopedic surgery on weekends, (2) identify the cited cause for delay, and (3) estimate the cost created by delays identified in this study. We hypothesize that weekend days with first-start orthopedic trauma cases will experience delays more frequently that weekdays with similar cases.

Methods
An institutional database was used to query weekend first start OR cases from 2022-2023. Patients undergoing operative intervention for orthopedic trauma related hospital presentations were identified by retrospective chart review. Incidence and documented reasons for weekend first start cases were recorded. On-time first start case was defined as in-room time of 7:30AM.

Results
Of the 106 weekend days included in this study, 88 first-start cases were recorded, while 18 days did not have a first-start case that met the inclusion criteria outlined in this study. The mean time (AM =/- SD minutes) for assigned room, pre-op, surgeon ready, in room, OR ready, anesthesia ready, anesthesia start, and case start were 4:47 (± 2:14), 07:25 (± 0:56), 7:26 (± 0:38), 8:09 (± 0:38), 7:46 (±0:35), 8:26 (± 0:39), 8:07 (± 0:38), 8:50 (± 0:41) respectively. Of the possible causes, a reason was not recorded in 27% of cases. This was followed by patient factors, insufficient anesthesia coverage, transport, OR delays, surgeon factors, “weekend” as the stated reason, and pre-op delays. There was no notable difference in on-time first start cases based on weekend day or time of year. Of the 88 cases included in this study, the median “in room” time was 08:02. This represents a 32-minute delay based on the scheduled “in room” time of 07:30. When totaled over all 88 cases, this amounts to 2,816 minutes of delay, or roughly $84,000 in lost revenue, in first start orthopedic trauma cases on weekends in 2022. 

Conclusion

Our institution had 0% of weekend first-start cases start on time. The common occurrence of delays in weekend cases highlights the need for process improvement and schedule adjustment to maximize efficiency and personnel usage.


Evaluation of Causes and Financial Impact of Weekend Operating Room Delays at a Level 1 Trauma Center: A One-Year Retrospective Analysis

Abstract Title
Factors predictive of season-ending upper extremity injuries in MLB pitchers and the implementation of the pitch clock.

Background
The 2024 MLB season has seen high profile pitchers succumb to season ending upper extremity injuries (SEI), raising concerns regarding pitcher injuries. The sports community remains divided between factors such as the newly initiated pitch clock, banning of sticky substances and increasing pitch velocity as the main culprit. No study has yet demonstrated a correlation between any one factor and pitcher injuries. This study attempts to identify specific factors associated with season ending injuries in MLB pitchers.

Methods
A retrospective cohort study of all MLB pitchers from 2015–2023 was performed utilizing publicly available data on MLB injuries (prosportstransactions.com) and pitch-by-pitch metrics (baseballsavant.mlb.com). Pitcher demographics, average number of pitches thrown per game, and pitch-specific metrics were analyzed for each pitcher. Multivariable binary logistic regression was utilized to determine metrics predictive of SEI. Comparison of seasons surrounding the initiation of the pitch clock were done utilizing Pearson's Chi-squared test.

Results
6,569 pitcher-seasons were analyzed with 405 instances resulting in an SEI from the 2015 - 2023 seasons, excluding 2020. Multivariable logistic regression showed SEI is significantly associated with increasing number of pitches per game (OR, 1.011, 95% CI, 1.008-1.015, p < 0.001), pitch velocity (OR, 1.049, 95% CI, 1.009-1.091, p < 0.05) and acceleration (OR, 1.034, 95% CI, 1.003-1.065, p < 0.05) in the x-dimension. SEI’s were not associated with pitch release speed, release extension, velocity/acceleration in the y- or z-dimension or pitcher demographic measures (pitcher height, weight, BMI). SEI decreased significantly following initiation of the pitch clock from 50 (5.9%) in 2022 to 17 (2.0%) in 2023 (p<0.0001). SEI did not significantly change after banning of sticky substances.

Conclusion
Increasing SEI’s with increasing pitch count, velocity, and acceleration per game reflects an expected consequence of higher volume and faster pitching in the MLB year-over-year. The significant decrease in upper extremity SEI’s after introduction of the pitch clock could be due to anything from teams managing pitchers more carefully, to biomechanical differences with less rest between pitches. More seasons with the pitch clock will help elucidate the cause. Banning of sticky substances had no effect on injuries likely because sticky substance helps pitchers add spin and movement which are not associated with SEI’s. Further research is underway to evaluate injuries further by anatomic location and/or structure, as well as other positions.

Factors predictive of season-ending upper-extremity injuries in MLB pitchers and the implementation of the pitch clock

Background
Hip fractures present a significant public health challenge, with between 260,000 to
300,000 admissions for hip fractures in the US and projections of more than 500,000 per year by 2040. The rising incidence and substantial burden on healthcare systems necessitate proper evaluation and management of these already frail patients as hip fractures are associated with increased mortality and morbidity. Frailty scales have been used extensively within the orthopedic literature as a potential preoperative risk stratification tool. This study aims to compare the effectiveness of frailty as measured by the Revised Risk Analysis Index (RAI-rev) and the 5-Factor Modified Frailty Index (mFI-5) in predicting 30-day postoperative outcomes in surgically managed hip fracture.

Methods
The ACS-NSQIP database was queried for patients with a diagnosis of traumatic hip
fracture undergoing surgical intervention from (2011-2020). Frailty was assessed using the RAI-rev and mFI-5. Thirty-day outcomes included mortality, extended length of stay (eLOS) and non-home discharge (NHD). Multivariate analysis was conducted to assess predictive value of frailty scales, presented as odds ratio (OR). Discriminatory accuracy was assessed using Receiver operating characteristic (ROC) curve and quantified using C-statistic. Significance was determined by p<0.05.

Results
There were 160,446 patients included with a median age of 83 years, with 68.9% females and 91.86% white. The RAI-rev classified 16,175 patients as robust, 89,815 as normal, 46,531 as frail, and 7,925 as very frail. Multivariate analysis revealed increasing frailty as measured by the RAI-rev had greater odds for 30-day mortality (normal: OR 2.10 (1.73 -2.59), frail: OR 5.35 (4.35 - 6.63), very frail: OR 11.32 (9.13 - 14.13), p<0.001) than the mFI-5 (prefrail: OR 1.39 (1.29 - 1.50), frail: OR 2.15 (1.99 - 2.32) severely frail: OR 3.70 (3.39 -4.04) , p<0.001). ROC analysis demonstrated that compared to the mFI-5, the RAI-rev had superior discriminatory accuracy for 30-day mortality (RAI: 0.74, mFI-5: 0.62, p<0.001), eLOS (RAI-rev: 0.57, mFI-5: 0.56, p<0.001), and NHD (RAI-rev: 0.57, mFI-5: 0.54, p<0.001).

Conclusion
The RAI-rev demonstrated superior predictive capability and discriminatory accuracy for assessing 30-day mortality, eLOS, and NHD, when compared to the mFI-5. These findings support the use of the RAI-rev in preoperative risk assessment for hip fractures in an increasingly frail population. In doing so, surgeons may identify high risk patients missed without obvious multimorbidity, thus reducing postoperative morbidity and mortality in patients with traumatic hip fracture.

Frailty as a Predictor of 30-Day Postoperative Mortality in Hip Fracture Patients

Title: Fructosamine as a Predictor of Adverse Post-Operative Outcomes in Total Shoulder Arthroplasty Patients
Background: Serum fructosamine has been shown to be a significant predictor of post-operative adverse outcomes in joint replacement patients. Fructosamine is a measure of blood sugar over a shorter time period of 14 to 21 days, making it a more useful marker of blood sugar control pre-operatively. The objective is to assess adverse post-operative outcomes after both anatomic and reverse total shoulder arthroplasty (TSA) in relation to fructosamine, HbA1c, and blood glucose.
Methods: This prospective cohort study includes patients undergoing TSA from multiple providers. Pre-operative data was collected that includes demographics, diabetic status, insulin dependence, Visual Analog Scale (VAS), Range of Motion data (ROM), PROMIS surveys, and patient fructosamine, HbA1c, and fasting blood glucose levels. Follow-up data was obtained at 6 weeks and 3 months post-operatively. This included data for superficial infection, deep infection, medical complications, emergency room visits, hospital readmissions, reoperations, VAS scores, and updated ROM.
Results: A total of 101 patients were recruited for the study, comprised of 44 males and 57 females. Mean age was 68.5, ranging from 34 to 90 years. Of the total, 25 patients had a pre-operative diagnosis of diabetes. None of these patients experienced medical complications, superficial infections, deep infections, hospital readmissions, or reoperations. A total of 7 patients experienced medical complications with only 2 having reoperation. Only 1 of these patients that reoperated had elevated fructosamine (>292 µmol cut-off) and an elevated HbA1c (>6.5% cut-off). The average fructosamine was 221.8 µmol, with a range from 106.6 µmol to 404.2 µmol. The average HbA1c was 5.8, with a range from 3.4 to 8.7. Blood glucose and HbA1c showed no significant relationship with any of the tested variables. Elevated fructosamine showed a positive association with a decreased active external rotation (ER) (p=0.01) which is lost at the 3-month follow-up post-operatively (p=0.59). No other significance was found with VAS, ROM, or PROMIS through 3 months post-operatively. 
Conclusions: Preliminary data analysis suggests that fructosamine, HbA1c, and blood glucose are not reliable predictors of post-operative outcomes. The only significant outcome was decreased active ER with higher levels of fructosamine 6 weeks post-operatively. No significant determination can be made at this time as the study is actively recruiting patients to increase study power.

Fructosamine as a Predictor of Adverse Post-Operative Outcomes in Total Shoulder Arthroplasty

Introduction
In the United States, deep vein thrombosis (DVT) and pulmonary embolism (PE) rank high in terms of preventable hospital deaths. Victims of trauma are at a higher risk of developing thromboembolic complications. The aim of this study is to compare the incidence of DVT/PE in trauma patients before and after a June 2022 policy intervention to continue prophylactic anticoagulation at an academic trauma center.

Methods
A retrospective review was conducted to compare DVT/PE rates in trauma patients requiring surgery from January 1, 2018, through December 31, 2023. Clinical information relating to trauma date, surgery date, injury type, anticoagulant administration, DVT/PE development, and death, if applicable, was obtained from patient charts.

Results
DVT/PE development was 14.553 times more likely pre-policy change when anticoagulation was held prior to surgery compared to post-policy change when anticoagulation was administered before surgery (X2 (3, N=374) =14.553, p=.002).

Conclusions
Findings suggest that DVT/PE rates have significantly decreased post policy change. Limitations include the presence of comorbidities in patients, varying trauma mechanisms and injury severity, and missing documentation. 

Authors
1. Armarion Stegall
2. John T. Watson, MD
3. Heidi Israel, PhD
4. Letitia Bradford, MD, FAAOS, FACS, Nth Dimensions

Affiliations
1. Mercer University School of Medicine, Columbus, GA
2. Saint Louis University, St. Louis, MO
3. Nth Dimensions


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