United States

Background: Ankle fractures are one of the most common fractures that occur in the United States with an estimated incidence of 4.22/10,000 per year. Trimalleolar ankle fractures make up about 7% of all ankle fractures, but these fractures traditionally have worse recovery outcomes as well as a risk of future osteoarthritis. Surgical repair of the ankle after this type of fracture requires the reduction of the malleoli and stabilization of the syndesmosis. However, postoperative complications from this type of fracture include restricted mobility, pain, swelling, and limitation to activities of daily living. Smoking and nicotine use are well described in the literature to increase the risk of bone loss, decrease bone mineral density, and delay the union of fracture sites. The purpose of this study is to evaluate specific postoperative complications between nicotine- and non-nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fracture.

Methods: TriNetX, a global health database with de-identified patient information, was used and analyzed for this study. Cohort A was defined as patients who had surgical open treatment of trimalleolar ankle fractures with or without fixation (Current Procedural Terminology [CPT]: 27822, 27823) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17.2). Cohort B was defined as patients who had surgical open treatment of trimalleolar ankle fractures but did not have a dependence to nicotine. Data were gathered from healthcare organizations over the past 20 years. All post-diagnostic complications were analyzed between 1 and 120 days after the surgical open treatment of trimalleolar ankle fractures.

Results: 4,827 patients in cohort A were propensity matched with 25,467 patients in cohort B for age at the event, ethnicity, race, sex, type 2 diabetes mellitus, and body mass index. Nicotine-dependent patients who had surgical open treatment of trimalleolar ankle fractures experienced a higher associated risk for numerous post-operative complications. When compared to non-dependent patients, nicotine-dependent patients had an increased risk for wound disruption (risk ratio [RR] 1.656, 95% confidence interval [CI] 1.28 – 2.14) and infection (RR 1.836, 95% CI 1.5 – 2.25) following a procedure within 120 days post open treatment of trimalleolar ankle fractures. Instances of avascular necrosis, deep vein thrombosis, pulmonary embolism, and revision surgeries were found not to be statistically different between the two cohorts.

Conclusion: This propensity-matched study showed that nicotine-dependent patients who were surgically treated with open treatment of trimalleolar ankle fractures were correlated with an increased risk for wound disruption and infection compared to their non-nicotine-dependent counterparts.

AMA Research Challenge 2024 

Nicotine Dependence on Postoperative Complications in Trimalleolar Ankle Fractures

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Background
Body mass index (BMI) cutoffs are frequently implemented for total knee arthroplasty (TKA) candidates. However, recent data in primary TKA suggest obese patients have greater improvement in patient-reported outcome measures (PROMs) and no difference in postoperative complications when utilizing standardized medical optimization protocols. This study evaluated the influence of BMI on PROMs following revision TKA using these optimization protocols. The null hypothesis of the study was there would be no difference in PROMs based on BMI following revision TKA.

Methods
Between 2010 and 2022, 572 consecutive revision TKAs were retrospectively reviewed. All patients underwent risk assessment and medical clearance prior to surgery by a designated internal medicine specialist. Cases were dichotomized into two BMI groups, ≥35kg/m2 and <35kg/m2 (range, 20 to 65kg/m2). Activity level, pain, function, and satisfaction were compared between groups, controlling for multiple comorbidities and case characteristics. The BMI ≥35kg/m2 group was younger; had a higher prevalence of depression/anxiety and pre-revision narcotics; and worse pre-revision PROMs (P≤0.090). Multivariate statistical analysis was performed with P<0.05 as significant.

Results
Patients with a BMI ≥35 demonstrated greater improvement in their Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) and experienced less pain when walking and climbing stairs (P≤0.071) over an average of 2.0 years. A higher percentage of patients in the BMI ≥35 group also achieved Minimal Clinically Important Differences (MCIDs) for PROMs (46-67% compared to 59-70%). Moreover, the BMI ≥35 group reported higher satisfaction levels (72.2% versus 66.5%, P=0.254), and more patients indicated that their knee 'always' feels normal (28.4% versus 19.8%, P=0.149). 
The groups did not differ by the indication for revision surgery or the number of components revised (P≥0.108). However, those who needed revision due to aseptic loosening showed significantly greater improvements in PROMs. There was no difference in the rate of re-revisions between the two groups for aseptic loosening or infection.

Conclusion
Despite being more debilitated preoperatively, revision TKA patients with a BMI ≥35 experienced greater improvements in PROMs compared to patients with lower BMIs, independent of revision indication. Given the significant improvements in PROMs with appropriate perioperative optimization, obese patients should not be restricted access to revision TKA when appropriately indicated.

Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Revision Total Knee Arthroplasty

Background
The safety of outpatient versus inpatient total hip arthroplasty (THA) in the higher BMI population has not been described. The current study compared 90-day complications and 5-year revisions in patients following primary THA in the outpatient versus inpatient settings with BMI ≥ 35 kg/m2, a “high-risk” group as defined by prior studies.

Methods 
In this case-control study, adult patients with BMI ≥ 35 kg/m2 undergoing primary THA from 2010 to October 2022 were identified in the PearlDiver Mariner165 orthopedics database. Patients diagnosed with infection, trauma, or neoplasm of the hip within 90 days prior to surgery were excluded. Patients were categorized by service location of THA: inpatient or outpatient. 90-day postoperative adverse events were compared between groups with multivariable logistic regression controlling for age, sex, and Elixhauser Comorbidity Index (ECI). With Bonferroni correction, significance was established at P < 0.004. 5-year revision rates were compared with logrank test.

Results
Of high-BMI patients undergoing THA, 39,396 were inpatient and 11,505 were outpatient. These groups were exact matched 1:1 on age, sex, and ECI, yielding 11,455 patients in each matched group. Multivariate analysis demonstrated that outpatient THA was associated with lower 90-day odds ratios (ORs) for: deep vein thrombosis (OR: 0.47), pulmonary embolism (OR: 0.63), surgical site infection (OR: 0.69), and readmissions (OR: 0.40), in addition to multiple minor adverse events (P < 0.001 for each). Outpatient THA in the study population was not associated with differences in 90-day hip-related adverse events (dislocation, fracture) or 5-year all-cause revisions (P = 0.5).

Conclusion
Compared to inpatient THA, outpatient THA for those with BMI ≥ 35 kg/m2 was associated with lower odds of various severe and minor 90-day adverse events, with similar short-term hip-related outcome measures and 5-year revision rates. These findings are encouraging when considering performing outpatient THA in obese patients.

Outpatient Total Hip Arthroplasty Is Safe in High BMI Patients

Background
Total hip arthroplasty (THA) utilization is increasing significantly. Despite this, it is unknown whether patients have increasing interest in THA, and what patients search online regarding THA. Google Trends provides the relative search volume (RSV) regarding any search term. Therefore, we performed this study utilizing Google Trends to determine whether public interest in THA is increased, and to identify which THA search terms have the most engagement.

Methods
A longitudinal study on United States public interest in THA was performed with Google Trends from January 2013 – December 2022. 50 Google search terms were identified, for which the mean RSV was obtained and compared. RSV ranges from 0 – 100 and represents interest in a search term during at a specific point during the selected timeframe; 0 indicates negligible interest while 100 indicates maximal interest. Linear regression was used with yearly volume to determine if RSV increased significantly over time. We compared the rates of change for various pairs of search terms using an interaction model.

Results
Between 2013–2022, the mean RSV for “hip replacement” increased significantly [2013: 57; 2022: 92; p < 0.001], indicating increasing public interest in THA. Additionally, when comparing 50 search terms about THA, “hip replacement pain” and “hip replacement recovery” had significantly higher mean RSVs than other terms, and the ten highest mean RSV terms also included “hip replacement cost”, “hip replacement therapy”, “hip replacement precautions”, “hip replacement approach”, “how long does hip replacement take”, “hip replacement fracture”, “hip replacement infection”, and “hip replacement rehab” (65 vs 61 vs 20 vs 15 vs 14 vs 12 vs 11 vs 11 vs 10 vs 8; p < 0.001). The mean RSV significantly increased over the last decade for “hip replacement pain” [2013: 44; 2022: 88; p < 0.001] and “hip replacement recovery” [2013: 50; 2022: 73; p < 0.001]. The rate of change of these two terms was significantly more positive over time than all other terms.

Conclusion
Public interest in THA has significantly increased during the past decade, correlating with the increasing volume of THA being performed. Patients have interest in many topics about THA, with pain and recovery having the largest increase in search volume over time. Other topics such as cost, therapy, surgical length/approach, and complications were also commonly searched. Patient information resources should ensure to include these variety of topics to meet changing patient interests.

Patients Have Increasing Interest In Total Hip Arthroplasty In The United States

Introduction. Postoperative pain control is critical in orthopedic surgery. While efficacious analgesics, opiates have rapid tolerance and addictive potential. Metamizole is a non-opioid analgesic primarily inhibiting COX-3, commonly used in Europe and South America, but banned in the U.S. due to concerns about agranulocytosis risk. However, large meta-analyses have not shown significant agranulocytosis when compared to other analgesics. The purpose of this review is to assess the analgesic efficacy of metamizole and potential use in orthopedic surgery.
Methods. An electronic review was conducted of PubMed, Web of Science, Cochrane, Embase, and OVID Medline in October 2023. Studies for inclusion were limited to those in which metamizole use was a primary focus, patients were undergoing orthopedic surgery, studies in human patients, and studies reporting in the English language.
Results. 1,112 studies were identified and 15 (1.3%) met inclusion criteria. The use of metamizole as a single agent or in combination therapy was described to be superior or non-inferior to alternative analgesics in 10 (66.7%) studies. Metamizole decreased rescue analgesia in 5 (33.3%) articles. No patients experienced agranulocytosis.
Conclusions. Metamizole was efficaciously non-inferior to other non-opioid analgesics by demonstrating an opioid sparing effect in over a third of included studies. Metamizole did not have significant differences in incidence or severity of side effects and no cases of agranulocytosis were seen across all studies. These results indicate the potential for metamizole as analgesia in the setting of orthopedic surgery. Future studies should focus on larger cohorts to continue to assess efficacy and risk of agranulocytosis.


Postoperative Pain Management with Metamizole after Orthopedic Surgery: A Systematic Review

Background
Congenital cervical stenosis (CCS) is a rare condition involving a narrowed spinal canal due to developmental anomalies. CCS heightens the risk of neurologic deficits and acute spinal cord injury post-trauma, influencing return-to-play decisions for contact athletes. Additionally, CCS patients are prone to cervical myelopathy as degenerative changes progress with age. Limited evidence-based literature exists on the epidemiology of CCS, including racial effects. We sought to investigate the incidence of CCS as it pertains to race and ethnicity.
Methods
We screened 5395 cervical MRIs from a single institution and identified CCS by a sagittal canal diameter (SCD) of less than 10 mm at 2 or more vertebral levels (C3-7) at the pedicle. Exclusion criteria included patients under 18 and over 50 years, prior cervical spine surgery, congenital fusions, spinal column malignancy, or active smoking history. For each patient, axial measurements were taken at each level, including coronal vertebral body length, anteroposterior vertebral body length, pedicle width, pedicle length, laminar length, anteroposterior lateral mass length, posterior canal distance, apex-to-vertebral body, lamina-disc angle (LDA), lamina-pedicle angle, and anteroposterior spinal cord diameter.
Results
A total of 343 patients met the criteria for CCS: 100 White, 98 Black, 70 Asian, and 75 Hispanic. CCS prevalence varied significantly among ethnic groups; Black (39.3%), Asian (33.6%), and Hispanic (22%) patients had higher CCS rates than White patients (7.5%) [x2 (3, N=343) = 30.04, p <0.05]. The Interrater Correlation Coefficient for the SCD measurements across all levels and patients demonstrated excellent reliability (ICC = 0.926, 95% CI: 0.91-0.94). Black and Asian patients showed consistently smaller SCDs at all pedicle levels compared to White patients, who had the largest SCDs overall (p<0.001). Average SCDs were 11.4 mm (White), 10.4 mm (Black), 10.5 mm (Asian), and 11 mm (Hispanic). Additionally, LDAs were larger in Asians, Blacks, and Hispanics compared to Whites, reducing cross-sectional canal area (p<0.001).
Conclusion
Our study indicates a significant correlation between race/ethnicity and CCS prevalence. Black and Asian patients had the highest CCS rates, smallest SCDs, and largest LDAs. These anatomical differences suggest an increased risk of cervical myelopathy and neurological issues, particularly for contact sport athletes. This emphasizes the need for personalized clinical management and early intervention to address healthcare disparities and improve outcomes in vulnerable populations.

Racial Differences in Congenital Cervical Stenosis

ABSTRACT

Background: Midshaft clavicle fractures are often subject to increased complications when treated nonoperatively, so surgical treatment with open reduction and internal fixation (ORIF) is a favored alternative. Despite safer outcomes, adverse events such as surgical site infections may still persist, particularly in the presence of certain patient characteristics. The objective of this study was to determine risk factors for and the frequency of adverse events following ORIF for clavicle fractures. 

Methods: A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from 2012 to 2021 identified patients undergoing isolated ORIF for clavicle fractures. Patient demographics and 30-day complications were collected. Bivariate analyses with a student’s t-test or chi-square test were used to identify possible predictor variables for either AAE or SSI, and demographic metrics with P<0.2 were included in a multivariable regression model. Multivariable analyses identified significant independent patient risk factors for any adverse event (AAE) or SSI within 30-days of surgery. Adjusted odds ratios were reported for each variable included in the model. Statistical significance was set a prior at P<0.05.

Results: The 6,753 selected patients who underwent ORIF for clavicle fractures between 2012 and 2021 were 38.1±15.3 years of age, BMI 26.2±4.9 kg/m2, and 77.3% male. Of this cohort, 88.4% received treatment on an outpatient basis. Postoperative adverse events were experienced by 128 (1.9%) patients within 30 days of surgery, and SSI were prevalent in 0.77% of patients, followed by wound dehiscence in 0.12% of patients. After controlling for patient demographics and comorbidities, notable risk factors for adverse events included current smoking status (OR=2.036; P<0.001) and patient age (OR=1.025; P<0.001). Outpatient status (OR=0.528; P=0.004) was protective. 

Conclusion: The present study noted significantly increased risk of postoperative adverse events in older patients, as well as patients who smoke. Outpatient setting was significantly protective for adverse events. These findings help to provide further clinical context to guide surgical decision making and inform surgeons on current risks and outcomes.

Risk Factors for Adverse Events after Clavicle Fracture Open Reduction and Internal Fixation: A NSQIP Study

Title: 
Subsequent Total Shoulder Arthroplasty Following Common Shoulder Stabilization and Reconstructive Procedures

Background:
Shoulder stabilization and reconstructive surgeries are indicated based on a variety of pathologies including instability, impingement, and rotator cuff tears. Surgery to restore anatomic and biomechanical normalcy may reduce pain, restore function, or may slow the progression of osteoarthritis. This study analyzes common shoulder stabilization and reconstructive surgeries and compares their odds of future total shoulder arthroplasty (TSA) development.

Methods:
The TriNetX database patient data was queried from the period of May 2004 to May 2024 using ICD10 and CPT codes. Cohorts were built by including patients who underwent a procedure of interest, while the control group used a combination of patients from other procedural cohorts not undergoing the procedure of interest. Cohorts were then propensity matched for age, race, sex, and co-morbidities. Laterality was assessed separately to ensure ipsilateral index procedure and TSA. The primary outcome measured was TSA at 5 and 10 years postoperatively for 13 different shoulder procedures.


Results:
A total of 355,960 patients were divided into procedural cohorts and analyzed. The procedure with the highest rate of subsequent TSA was the Latarjet procedure (3.99% at 5 years; 4.23% at 10 years); whereas the procedure with the lowest rate was arthroscopic capsulorrhaphy (0.91% at 5 years; 0.95% at 10 years. Compared to propensity-matched controls, procedures associated with increased odds of subsequent TSA were the Latarjet procedure (OR 3.34, P<0.0001 at 5 years; OR 3.56, P<0.0001 at 10 years), arthroscopic capsulorrhaphy (OR 1.47, P=0.0042 at 5 years; OR 1.43, P=0.0066 at 10 years), open rotator cuff repair, chronic (OR 1.39, P=0.0005 at 5 years), arthroscopic extensive debridement (OR 1.31, P<0.0001 at 5 years; OR 1.26, P<0.0001 at 10 years), and open biceps tenodesis (OR 1.28, P=0.0003 at 5 years; OR 1.20, P=0.0053 at 10 years). Procedures associated with decreased odds of subsequent TSA were arthroscopic distal clavicle resection (OR 0.56, P<0.0001 at 5 years; OR 0.56, P<0.0001 at 10 years), arthroscopic subacromial decompression (OR 0.65, P<0.0001 at 5 years; OR 0.63, P<0.0001 at 10 years), arthroscopic rotator cuff repair (OR 0.78, P<0.0001 at 5 years; OR 74, P<0.0001 at 10 years), and arthroscopic biceps tenodesis (OR 0.78, P<0.0001 at 5 years; OR 0.76, P<0.0001 at 10 years).

Conclusion:
In general, arthroscopic procedures had decreased associated odds of subsequent TSA when compared to their open counterparts. However, arthroscopic capsulorrhaphy and arthroscopic extensive debridement had increased odds of subsequent TSA. The Latarjet procedure had the highest odds of all procedures for future TSA.

Subsequent Total Shoulder Arthroplasty Following Common Shoulder Stabilization and Reconstructive Procedures 


Background: Achilles tendon rupture is a common orthopedic injury presenting to the clinic and emergency room. Patients with comorbidities are not ideal surgical candidates and often must be treated with cast or boot immobilization. The risk of complications includes pressure sores, skin infections, and joint stiffness. Recently, 3D-printed (3DP) casting has become popular due to customizability and inexpensiveness. This study performs a systematic review on the clinical application of 3D-printed (3DP) for conservative management of injuries.

Methods: The search phrase “(3d printed cast) AND ((fracture) OR (injury) OR (tendon))” was entered into PubMed, yielding 50 results published between 2015 and 2024. 15 articles were included in this review.

Results: 3 studies showed proof-of-concept in a non-clinical setting for 3DP casting using biomechanical and materials testing in both UE and LE models. 5 clinical studies without a control group reported overall patient satisfaction and good to excellent clinical healing of UE fractures with 3DP but also reported incidents of cast breakage. 7 studies in a clinical setting showed that 3DP casting is superior to conventional fiberglass in patient satisfaction and non-inferior in clinical efficacy.

Discussion: Based on the current literature, this study proposes a novel 3D-printed cast that provides immobilization at the maximum plantar flexion required for Achilles tendon healing and eliminates the need for constant cast changes in a non-surgical treatment plan. The proposed device will act to maintain stability and reapproximation for healing at the injury site, whilst providing easy access for hygiene and wound care, thus mitigating the risk of infections and promoting optimal healing. Future direction will establish proof-of-concept using finite element analysis for customization of stress distribution and biomechanical testing for load-bearing analysis. By extending its usage to acute Achilles tendon injuries, 3DP casting has the potential to enhance outcomes for non-surgical candidates.

Systematic Review and Novel Proposal of 3D-Printed Casting for Non-Surgical Treatment of Acute Achilles Tendon Rupture

Background
Females and underrepresented in medicine (URiM) individuals currently comprise 50.5% and 23.8% of all medical student matriculates in the United States, respectively. However, orthopaedics remains the least diverse specialty with 18.3% female and 17.3% URiM residents. There has been an increasing amount of effort to increase diversity, equity, and inclusion (DEI) and remedy these representation gaps, however there remains a gap in the literature regarding the effectiveness of DEI initiatives at the medical student level and their impact on the future diversity of the orthopedic workforce. Thus, the purpose of this systematic review was to analyze the progress and current state of DEI efforts within orthopaedics at the medical student level.
Methods
A systematic review of the English literature was performed according to PRISMA guidelines using the following databases: PubMed, Web of Science, Embase, Scopus, Crochane from inception to October 20, 2023 using a combination of search terms. Eligible full text articles reported on various domains of DEI at the medical student level in the United States such as demographics, initiatives, and perspectives.
Results
A total of 3184 studies were screened and subsequently, 26 full-text articles met inclusion criteria. Eight articles discussed trends in diversity demographics within interest, application, and match with orthopaedics (30.8%), 10 articles discussed initiatives detailing methods and results of how to increase DEI in orthopaedics (38.4%), and 8 articles discussed perspectives on where to focus future outreach endeavors (30.8%).
Conclusion
Efforts to enhance female and URiM representation amongst orthopeadic residency programs at the medical student level have greatly improved over the past 15 years. Evidence shows a strong correlation between both the presence of underrepresented populations in faculty and resident positions as well as the implementation of outreach programs in influencing medical students' application into orthopeadic residency. A large majority of initiatives created for medical students stemmed from outside organizations as opposed to individual residency programs. Future studies should quantify the impact of local initiatives and national organizations on medical students and aim to better understand additional barriers into entrance of residency programs.

The Current State of DEI in Orthopaedics at the Medical Student Level; a Systematic Review

Background: Anterior Cruciate ligament reconstruction (ACLR) is one of the most common surgeries performed in orthopedics. The optimal timepoint for ACLR is not consistently defined. Our study aimed to address this gap by comparing patient-reported outcomes (PROs) in acute versus chronic ACLR groups using 60 days as a marker for chronicity. 



Methods: This historical cohort study was based on prospectively collected PROs following ACLR. Inclusion criteria were based on complete pre-operative and 2-year follow-up. Patients were categorized as acute with an injury to surgery interval of less than 60 days, those over 60 days were considered chronic. Descriptive analysis was conducted using Fisher’s exact tests and Chi-square analysis. A mixed linear model regression analysis was conducted to examine the effect of time on outcome variables using Restricted Maximum Likelihood (REML) across two groups (acute and chronic). The dependent variables were: IKDC Score, EuroQol Score, PROMIS Global Mental and Physical Health Scores, KOOS Score, and VAS Pain Score with time as the primary fixed effect. Data was analyzed using Python version 3.8 with pandas and statsmodels packages. 



Results: 97 out of 1235 patients from the institutional database met the inclusion criteria, with 54 chronic, 43 acute, 62 males, 35 females, and a median age at the time of surgery of 28 [21, 40]. The median BMI was 25.2 [23, 28.2], 26.6 [23.3, 30.1] for chronic cases and 24.2 [22.6, 26.8] for acute cases (p < 0.011). ACL grafts included 25 autografts and 72 allografts. Autograft was used more frequently in acute cases (p < 0.011), while chronic cases had an increased use of allografts (p < 0.011). Overall median PROs improved: from 50.6 to 86.2 (IKDC), 0.7 to 0.8 (EuroQol), 56 to 59 (PROMIS Global Mental Health), 50.8 to 57.7 (PROMIS Global Physical Health), 66 to 92 (KOOS), and 3 to 1 (VAS Pain). Linear mixed model analysis revealed a significant positive effect of time on IKDC (p < 0.001), and a random effects analysis demonstrated a group variance of 2.355, indicating variability in IKDC scores between acute and chronic groups. 



Conclusion: Using a 60-day cut-off for defining acute versus chronic ACLR showed greater improvement in median PROs. The IKDC score is a valuable predictor to compare acute versus chronic ACL injuries using 60 days as a cutoff for chronicity. Using this marker may aid in optimizing future surgical timing and recommendations that will improve individual patient recovery.

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Obesity is Associated With Greater Improvement in Patient-Reported Outcomes Following Revision Total Knee Arthroplasty

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