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

Background: The cause of hallux rigidus remains controversial. However, it is assumed that dysfunction of the windlass mechanism and metatarsus primus elevatus play a role in the pathology. Three-dimensional (3D) computed tomography (CT) imaging is ideal for analysis of movements of the foot, which involve 3D and rotational motion. The purpose of the present study was to compare the windlass mechanism in healthy normal feet with that in feet with hallux rigidus by 3D CT imaging.

Methods: A total of 17 feet with hallux rigidus and 21 normal feet were selected. Hallux rigidus was classified as grade 1 or 2 with use of the Coughlin and Shurnas system. CT imaging was performed during weight-bearing and non-weight-bearing with the first metatarsophalangeal joint in a neutral position or in 30° of dorsiflexion. We measured the rotation of each joint and the height of the navicular during dorsiflexion and weight-bearing. We also compared changes in the tarsometatarsal joint and metatarsus primus elevatus in the neutral position between the non-weight-bearing and weight-bearing conditions.

Results: During dorsiflexion, there were significant differences between the 2 groups in eversion and adduction at the talonavicular and talocalcaneal joints (p < 0.05), with less movement of bones in the hallux rigidus group. There was a significantly greater increase in height of the navicular in the control group than in the hallux rigidus group (1.2 ± 0.6 mm versus 0.7 ± 0.6 mm; p = 0.02). There was also a significant difference in metatarsus primus elevatus during the non-weight-bearing and weight-bearing conditions (p < 0.01).

Conclusions: Hallux rigidus restricts the movement of the Chopart joint and hindfoot associated with dorsiflexion of the first metatarsophalangeal joint, suggesting an association between hallux rigidus and windlass mechanism dysfunction.

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

Background: Whether an adductor canal block (ACB) is more effective when administered before or after total knee arthroplasty (TKA) is unclear. This study compared pain, stress, and functional outcomes between patients who received the block before surgery and those who received the block after surgery.

Methods: In this double-blinded trial, 100 patients at our hospital were randomized to receive an ACB at either 30 minutes before general anesthesia or postoperatively in the post-anesthesia care unit (PACU). All patients received periarticular local infiltration analgesia during surgery. The 2 groups were compared with respect to the primary outcome, the postoperative consumption of morphine as rescue analgesia, and in terms of the secondary outcomes, including the time from the end of surgery to the first rescue analgesia or discharge, intraoperative and postoperative stress, postoperative pain, functional recovery, the incidence of chronic pain, and complications.

Results: All included patients were Asian (Chinese) in race/ethnicity. The 2 groups had similar demographic information. Compared with the postoperative ACB, the preoperative ACB was associated with significantly lower morphine consumption within the first 24 hours postoperatively and lower total morphine consumption. It was also associated with a longer time until the first rescue analgesia, lower intraoperative consumption of opioids and inhaled anesthetic, fewer episodes of hypertension during surgery, a lower rate of rescue analgesia in the PACU, lower levels of cortisol and adrenocorticotropic hormone in serum on the morning of postoperative day 1, lower pain on a visual analog scale while at rest or during motion within 12 hours postoperatively, better range of knee motion on postoperative day 1, and a lower incidence of chronic pain at 3 months postoperatively. The 2 groups did not differ significantly with respect to postoperative ambulation distance, time until discharge, or complication rates.

Conclusions: Administering an ACB before rather than after TKA may lead to lower opioid consumption during hospitalization, lower intraoperative and postoperative stress responses, better pain relief during hospitalization, and a lower incidence of chronic pain at 3 months postoperatively.

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

Background: To date, no studies have evaluated the longevity of calcaneal lengthening osteotomy (CLO) in patients with cerebral palsy (CP) and pes planovalgus. This study aimed to explore the changes in foot alignment following CLO in patients with CP, utilizing both radiographic evaluations and dynamic foot-pressure assessments.

Methods: A retrospective study of 282 feet in 180 ambulatory patients was performed. The mean patient age at the surgical procedure was 8.9 ± 2.6 years. The mean follow-up period was 8.0 ± 4.3 years, and the mean age at the final follow-up 16.9 ± 4.4 years. Weight-bearing radiographs at 3 separate time points (before the surgical procedure, 6 months postoperatively, and at the final follow-up) were used. The feet were classified as corrected, undercorrected, or overcorrected on the basis of the radiographic parameters.

Results: At the final follow-up, we classified 98 feet (34.8%) as corrected, 58 (20.6%) as undercorrected, and 126 (44.7%) as overcorrected. Foot-pressure analysis demonstrated that the undercorrected feet had higher relative vertical impulses in the medial forefoot and medial midfoot than in the other groups, whereas the overcorrected feet had higher impulse in the lateral midfoot. There were no significant differences in preoperative radiographic parameters between the 3 groups, except for the calcaneal pitch angle. At 6 months after the surgical procedure, we classified 181 feet (64.2%) as corrected, 58 (20.6%) as undercorrected, and 43 (15.2%) as overcorrected. However, 53.6% of initially corrected feet changed to being undercorrected or overcorrected during further follow-up, 43.1% of the undercorrected feet became corrected or overcorrected, and 16.3% of the overcorrected feet became corrected. A younger age at the surgical procedure and lower naviculocuboid overlap at 6 months after the surgical procedure were the risk factors for overcorrection.

Conclusions: Although CLO is an effective method for correcting planovalgus foot deformities and enhancing foot-pressure distribution, the extent of correction observed early after the surgical procedure was not necessarily sustained over the follow-up period in individuals with CP. Furthermore, our findings highlight a noticeable tendency toward the overcorrection of the deformity, as evidenced by increased pressure exerted on the lateral midfoot.

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

Background: Although delays in musculoskeletal care in low- and middle-income countries (LMICs) are well documented in the open fracture literature, the impact of surgical delays on closed fractures is not well understood. This study aimed to assess the impact of surgical delay on the risk of infection in closed long-bone fractures treated with intramedullary nailing in LMICs.

Methods: Using the SIGN (Surgical Implant Generation Network) Surgical Database, patients ≥16 years of age who were treated with intramedullary nailing for closed diaphyseal femoral and tibial fractures from January 2018 to December 2021 were identified. Infection was diagnosed based on the assessment by the treating surgeon. A logistic regression model, adjusting for potential confounders, was used to analyze the association between delays to surgery (in weeks) and infection.

Results: Of the 9,477 closed fractures that were included in this study, 58% were femoral fractures and 42% were tibial fractures. The mean age was 35 years, and 76.2% of the patients were men. The mean delay to surgery was 10.5 days, and the median delay to surgery was 6 days. The overall infection rate was 3.1%. The odds of developing an infection increased by 9.2% with each week of delayed surgical treatment (odds ratio,1.092; 95% confidence interval, 1.042 to 1.145). Increasing delays were also associated with longer surgery duration and higher rates of open reduction.

Conclusions: Surgical delays in LMICs were associated with an increased risk of infection in closed long-bone fractures. This study quantified the increased risk of infection due to delays in receiving care, highlighting the importance of timely surgery for closed fractures in LMICs.

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

Background: Periprosthetic joint infections (PJIs) are a major complication of total joint replacement surgeries. This study investigated the enhancement of mechanical properties and antibiotic release in ultra-high molecular weight polyethylene (UHMWPE) through the encapsulation of submicron gentamicin sulfate (GS) particles, addressing the critical need for improved implant materials in orthopaedic surgery, particularly in managing PJIs.

Methods: The present study involved embedding submicron GS particles into UHMWPE flakes at concentrations of 2% to 10% by weight. These particles were prepared and blended with UHMWPE flakes using a dual asymmetric centrifugal mixer, and the blends were consolidated. The present study compared the mechanical properties and antibiotic release rate of UHMWPE containing submicron, medium (as-received), and large (resolidified) GS particles.

Results: UHMWPE samples with submicron GS particles exhibited superior mechanical properties, including higher ultimate tensile and Izod impact strengths, compared with samples with larger particles. Additionally, the submicron GS UHMWPE blends demonstrated a markedly higher and more sustained antibiotic release rate.

Conclusions: This study highlights the potential of incorporating submicron GS particles into UHMWPE to drastically improve the feasibility of using these therapeutic and functional spacer implants in expanded indications.

Clinical relevance: By offering improved mechanical strength and effective, prolonged antibiotic release, this innovative material could be used as a spacer implant to reduce the considerably high morbidity and mortality associated with PJIs. This material has the potential to prevent PJIs not only in high-risk revision cases but also in primary total joint arthroplasty procedures.

Background: Limb-salvage surgery for malignant bone tumors can be associated with considerable perioperative blood loss. The aim of this randomized controlled trial was to assess the safety and efficacy of the intraoperative infusion of tranexamic acid (TXA) in children and adolescents undergoing limb-salvage surgery.

Methods: All participants were <18 years of age at the time of surgery and diagnosed with a malignant bone tumor of the femur that was treated with resection and reconstruction with a megaprosthesis. Exclusion criteria included anatomic locations other than the femur, reconstruction with a vascularized fibular graft, and a previous history of deep venous thrombosis, coagulopathy, or renal dysfunction. Participants were randomly allocated to either the TXA group (a preoperative loading dose infusion of 10 mg/kg of TXA followed by a continuous infusion of 5 mg/kg/hr until the end of surgery) or the placebo group (the same dosage but with TXA substituted with an infusion of normal saline solution). Intraoperative and perioperative blood loss were calculated with use of the hemoglobin balance method. Perioperative blood loss at postoperative day 1 and at discharge from the hospital were calculated. The total volumes of blood transfused intraoperatively and postoperatively were recorded. A statistical comparison between the groups was performed for blood loss and blood transfusion as well as for possible independent variables other than TXA, including age, body mass index, histopathologic diagnosis, tumor volume, preoperative hemoglobin level, type of resection, and the duration of surgery.

Results: A total of 48 participants, with a mean age of 12.5 ± 3.44 years (range, 5 to 18 years) and a male-to-female ratio of 1.18, were included. All participants were Egyptians by race and ethnicity. There were no minor or major drug-related adverse events. There was no significant difference between the groups with respect to intraoperative blood loss (p = 0.0616) or transfusion requirements (p = 0.812), but there was a significant difference in perioperative blood loss at postoperative day 1 (p = 0.0144) and at discharge from the hospital (p = 0.0106) and in perioperative blood transfusion (p = 0.023).

Conclusions: TXA can be safely infused intraoperatively in children and adolescents undergoing limb-salvage surgery, and it contributes significantly to the reduction of perioperative blood loss and transfusion requirements.

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

Background: The aim of this study was to develop an accurate and clinically relevant prediction model for 30-day mortality following hip fracture surgery.

Methods: A previous study protocol was utilized as a guideline for data collection and as the standard for the hip fracture treatment. Two prospective, detailed hip fracture databases of 2 different hospitals (hospital A, training cohort; hospital B, testing cohort) were utilized to obtain data. On the basis of the literature, the results of a univariable analysis, and expert opinion, 26 candidate predictors of 30-day mortality were selected. Subsequently, the training of the model, including variable selection, was performed on the training cohort (hospital A) with use of adaptive least absolute shrinkage and selection operator (LASSO) logistic regression. External validation was performed on the testing cohort (hospital B).

Results: A total of 3,523 patients were analyzed, of whom 302 (8.6%) died within 30 days after surgery. After the LASSO analysis, 7 of the 26 variables were included in the prediction model: age, gender, an American Society of Anesthesiologists score of 4, dementia, albumin level, Katz Index of Independence in Activities of Daily Living total score, and residence in a nursing home. The area under the receiver operating characteristic curve of the prediction model was 0.789 in the training cohort and 0.775 in the testing cohort. The calibration curve showed good consistency between observed and predicted 30-day mortality.

Conclusions: The Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30) was developed and externally validated, and showed adequate performance in predicting 30-day mortality following hip fracture surgery. The RHMP-30 will be helpful for shared decision-making with patients regarding hip fracture treatment.

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