Journal of Bone and Joint Surgery, American Volume最新文献

Background: Joint hypermobility may be associated with developmental dysplasia of the hip (DDH), but no definite conclusion has been reached. On the basis of long-term clinical observations, we hypothesized that joint hypermobility was associated with the occurrence, imaging findings, and clinical symptoms of DDH.

Methods: We conducted a case-control study that included 175 Chinese Han patients between 13 and 45 years of age with Hartofilakidis type-A hip dysplasia. All of these patients underwent periacetabular osteotomy (PAO) between November 2021 and February 2023. An additional 76 individuals of comparable age and sex but without hip dysplasia were selected from the general population to serve as healthy controls. The Beighton 9-point scoring system was used to evaluate joint hypermobility, and a score of ≥4 was defined as generalized joint hypermobility. Standing anteroposterior pelvic radiographs were reviewed. For patients with DDH, the lateral center-edge angle, Tönnis angle, Sharp angle, lateralization of the femoral head, and patient-reported outcomes (iHOT-12, HHS, and WOMAC) were also collected to determine the radiographic severity or clinical symptoms of DDH.

Results: Patients with DDH had an elevated prevalence of generalized joint hypermobility compared with that in the healthy population (27% versus 12%; p = 0.009). Among patients with DDH, those with concomitant generalized joint hypermobility had lower lateral center-edge angles (3.55° versus 9.36°; p = 0.012), greater lateralization of the femoral head (13.78 versus 12.17 mm; p = 0.020), greater standardized lateralization of the femoral head (0.64 versus 0.54; p = 0.009), and lower iHOT-12 scores (35.22 versus 40.96; p = 0.009) than did those without concomitant generalized joint hypermobility. Further multivariable linear regression analysis revealed that higher Beighton scores and younger age were predictive of more severe hip dysplasia. However, the Beighton score was not found to be independently associated with patient-reported outcomes according to multivariable linear regression analysis.

Conclusions: The prevalence of generalized joint hypermobility was greater in patients with DDH than in healthy controls. A higher degree of joint hypermobility was also correlated with more severe hip dysplasia. These results suggest that joint laxity, in addition to bone or cartilage factors, is an important factor related to DDH.

Level of evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: The calculation of remaining growth in children and the timing of epiphysiodesis in those with leg-length discrepancy (LLD) is most often done with 4 methods: the Green-Anderson, White-Menelaus, Moseley straight-line graph, and multiplier methods. The aims of this study were to identify the most accurate method with use of bone age or chronological age and to evaluate the influence of including inhibition in the calculations.

Methods: One hundred and ninety-one children (10 to 17 years of age) with LLD who underwent surgical closure of the growth plate and were followed until skeletal maturity were identified from a local health register. Patients had at least 2 leg-length examinations with simultaneous bone-age assessments (according to the Greulich and Pyle method), with the last examination performed ≤6 months before surgery. The accuracy of each method was calculated as the mean absolute prediction error (predicted leg length - actual leg length at maturity) for the short leg, the long leg, and the LLD. Comparisons were made among the 4 methods and among calculations made with chronological age versus bone age and those made with versus those without incorporation of a reduced growth rate (inhibition) of the short leg compared with the long leg.

Results: The White-Menelaus method with use of bone age and a fixed inhibition rate was the most accurate method, with a prediction error of 1.5 ± 1.5 cm for the short leg, 1.0 ± 1.2 cm for the long leg, and 0.7 ± 0.7 cm for the LLD. Pairwise comparison of short-leg length and LLD according to the White-Menelaus and other methods showed that they were significantly different (p ≤ 0.002). The calculated inhibition rate did not increase accuracy.

Conclusions: The White-Menelaus method used with bone age and constant inhibition should be the preferred method when predicting remaining growth and the timing of epiphysiodesis in children between 10 and 17 years of age. One examination is in most cases sufficient for the preoperative clinical investigation when chronological age and bone age are concordant.

Level of evidence: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: The incidence of odontoid fractures among the elderly population has been increasing in recent years. Elderly individuals with dementia may be at increased risk for inferior outcomes following such fractures. Although surgical intervention has been maintained to optimize survival and recovery, it is unclear if this benefit extends to patients with dementia. We hypothesized that patients with dementia who were treated operatively for odontoid fractures would experience improved survival and lower rates of hospice admission but higher rates of delirium and of intensive interventions.

Methods: We used Medicare claims data (2017 to 2018) to identify community-dwelling individuals with dementia who sustained type-II odontoid fractures. We considered treatment strategy (operative or nonoperative) as the primary predictor and survival as the primary outcome. The secondary outcomes consisted of post-treatment delirium, hospice admission, post-treatment intensive intervention, and post-discharge admission to a nursing home or a skilled nursing facility. In all models, we controlled for age, biological sex, race, Elixhauser Comorbidity Index, Frailty Index, admission source, treating hospital, and dual eligibility. Adjusted analyses for survival were conducted using Cox proportional hazards regression. Adjusted analyses for secondary outcomes were performed using generalized estimating equations. To address confounding by indication, we performed confirmatory analyses using inverse probability of treatment weighting.

Results: In this study, we included 1,030 patients. The median age of the cohort was 86.5 years (interquartile range, 80.9 to 90.8 years), 60.7% of the patients were female, and 90% of the patients were White. A surgical procedure was performed in 19.8% of the cohort. Following an adjusted analysis, patients treated surgically had a 28% lower hazard of mortality (hazard ratio, 0.72 [95% confidence interval (CI), 0.53 to 0.98]), but higher odds of delirium (odds ratio, 1.64 [95% CI, 1.10 to 2.44]). These findings were preserved in the inverse probability weighted analysis.

Conclusions: We found that, among individuals with dementia who sustain a type-II odontoid fracture, surgical intervention may confer a survival benefit. A surgical procedure may be an appropriate treatment strategy for individuals with dementia whose life-care goals include life prolongation and maximizing quality of life in the short term following an injury.

Level of evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Background: Vertebral body tethering (VBT) is a well-recognized, non-fusion alternative for idiopathic scoliosis in children with growth remaining. To date, there have been almost no published outcome studies with postoperative follow-up of >2 years. We aimed to fill this gap by evaluating mid-term outcomes in our first 31 consecutive patients.

Methods: We retrospectively assessed additional clinical and radiographic data (mean, 5.7 ± 0.7 years) from our first 31 consecutive patients. Assessments included standard deformity measures, skeletal maturity status, and any additional complications (e.g., suspected broken tethers or surgical revisions). Using the same definition of success (i.e., all residual deformities, instrumented or uninstrumented, ≤30° at maturity; no posterior spinal fusion), we revisited the success rate, revision rate, and suspected broken tether rate.

Results: Of our first 31 patients treated with VBT, 29 (of whom 28 were non-Hispanic White and 1 was non-Hispanic Asian; 27 were female and 2 were male) returned for additional follow-up. The success rate dropped to 64% with longer follow-up as deformity measures increased, and the revision rate increased to 24% following 2 additional surgical revisions. Four additional suspected broken tethers were identified, for a rate of 55%, with only 1 occurring beyond 4 years. No additional patients had conversion to a posterior spinal fusion. We observed a mean increase of 4° (range, 2° to 8°) in main thoracic deformity measures and 8° (range, 6° to 12°) in thoracolumbar deformity measures.

Conclusions: With >5 years of follow-up, we observed a decrease in postoperative success, as progression of the deformity was observed in most subgroups, and an increase in the revision and suspected broken tether rates. No additional patients had conversion to a posterior spinal fusion, which may indicate long-term survivorship.

Level of evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

➢ The alpha angle was originally defined on magnetic resonance imaging (MRI) scans, using a plane, parallel to the axis of the femoral neck. However, much of the literature on the alpha angle has used radiographs or other imaging modalities to quantify the alpha angle.➢ The measurement of the alpha angle can be unreliable, particularly on radiographs and ultrasound.➢ If radiographs are used to measure the alpha angle, the circle of best-fit method should be used on multiple different views to capture various locations of the cam lesion, and "eyeballing" or estimating the alpha angle should be avoided.➢ The cam lesion is a dynamic and 3-dimensional (3D) problem and is unlikely to be adequately defined or captured by a single angle.➢ Modern technology, including readily available 3D imaging modalities, as well as intraoperative and dynamic imaging options, provides novel, and potentially more clinically relevant, ways to quantify the alpha angle.

Background: Acute flaccid myelitis (AFM) is a rare debilitating poliomyelitis-like illness characterized by the sudden onset of flaccid palsy in the extremities. The purpose of this study was to report the mid-term clinical course of knee extension in AFM and the effect of contralateral obturator nerve-to-femoral nerve transfer (CONFNT) for restoration of knee extension in AFM.

Methods: Twenty-six patients with lower extremity palsy due to AFM were referred to our clinic for possible surgical reconstruction. Their median age was 4.0 years, and the first evaluation of the palsy was done at a mean of 6 months after paralysis onset. The paralysis ranged from lower limb monoplegia to quadriplegia. The clinical course of knee extension was assessed using the British Medical Research Council (MRC) grading scale and surface electromyography (EMG). Five patients with unilateral paralysis of knee extension underwent CONFNT.

Results: The mean follow-up period for 19 limbs with complete paralysis of knee extension (MRC grade M0) in 13 patients who were evaluated for spontaneous recovery was 43 months. No patient who had complete paralysis of knee extension at >6 months and paralysis of the hip adductor muscle had improvement of knee extension to better than M2. Five of the original 26 patients were treated with CONFNT and followed for a mean of 61 months. Two of 5 patients had the CONFNT ≤8 months after paralysis onset and obtained M4 knee extension. Only 1 of the 3 patients with CONFNT performed approximately 12 months after paralysis onset obtained M3 knee extension; the other 2 obtained only M1 or M2 knee extension.

Conclusions: The paralysis of the lower extremity in our patients with AFM was similar to that in poliomyelitis. However, in AFM, spontaneous recovery of knee extension was possible if there were signs of recovery from hip adductor paralysis up to 6 months after paralysis onset. CONFNT may enhance the recovery of knee extension and seems to be a reliable reconstruction for restoring knee extension if performed no more than 8 months after paralysis onset.

Level of evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Tranexamic acid (TXA) is commonly utilized to reduce blood loss in adult spinal deformity (ASD) surgery. Despite its widespread use, there is a lack of consensus regarding the optimal dosing regimen. The aim of this study was to assess differences in blood loss and complications between high, medium, and low-dose TXA regimens among patients undergoing surgery for complex ASD.

Methods: A multicenter database was retrospectively analyzed to identify 265 patients with complex ASD. Patients were separated into 3 groups by TXA regimen: (1) low dose (<20-mg/kg loading dose with ≤2-mg/kg/hr maintenance dose), (2) medium dose (20 to 50-mg/kg loading dose with 2 to 5-mg/kg/hr maintenance dose), and (3) high dose (>50-mg/kg loading dose with ≥5-mg/kg/hr maintenance dose). The measured outcomes included blood loss, complications, and red blood cell (RBC) units transfused intraoperatively and perioperatively. The multivariable analysis controlled for TXA dosing regimen, levels fused, operating room time, preoperative hemoglobin, 3-column osteotomy, and posterior interbody fusion.

Results: The cohort was predominantly White (91.3%) and female (69.1%) and had a mean age of 61.6 years. Of the 265 patients, 54 (20.4%) received low-dose, 131 (49.4%) received medium-dose, and 80 (30.2%) received high-dose TXA. The median blood loss was 1,200 mL (interquartile range [IQR], 750 to 2,000). The median RBC units transfused intraoperatively was 1.0 (IQR, 0.0 to 2.0), and the median RBC units transfused perioperatively was 2.0 (IQR, 1.0 to 4.0). Compared with the high-dose group, the low-dose group had increased blood loss (by 513.0 mL; p = 0.022) as well as increased RBC units transfused intraoperatively (by 0.6 units; p < 0.001) and perioperatively (by 0.3 units; p = 0.024). The medium-dose group had increased blood loss (by 491.8 mL; p = 0.006) as well as increased RBC units transfused intraoperatively (by 0.7 units; p < 0.001) and perioperatively (by 0.5 units; p < 0.001) compared with the high-dose group.

Conclusions: Patients with ASD who received high-dose intraoperative TXA had fewer RBC transfusions intraoperatively, fewer RBC transfusions perioperatively, and less blood loss than those who received low or medium-dose TXA, with no differences in the rates of seizure or thromboembolic complications.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.