Journal of Orthopaedic Case Reports最新文献

Introduction: Caudal epidural steroid injection (CESI) is a commonly performed interventional procedure for the management of chronic lower backache. The conventional landmark-guided (LG) technique is widely practiced, particularly in resource-limited settings, while ultrasound guidance is increasingly used to improve procedural accuracy and safety.

Objectives: The objective of the study was to compare the clinical efficacy, safety, and need for repeat intervention between LG and ultrasound-guided (USG) CESI in adults with chronic low backache.

Materials and methods: A prospective randomized controlled study was conducted on 200 patients with chronic low backache, equally divided into two groups: Group L (LG CESI) and Group U (USG CESI). Pain intensity, functional disability, and straight leg raise test (SLRT) were assessed at baseline, 1 week, 1 month, and 2 months after injection using the visual analog scale (VAS), Oswestry disability index (ODI), and SLRT. The requirement for repeat injections and procedure-related complications was also recorded.

Results: Both groups demonstrated significant improvement in VAS and ODI scores following CESI. The USG group showed better improvement in right-sided SLRT at 1 week (P = 0.003) and required fewer repeat injections compared to the LG group (8% vs. 11%, P = 0.029). No complications were observed in either group.

Conclusion: Both LG and USG CESI are safe and effective techniques for the management of chronic low backache. Ultrasound guidance provides early functional benefits and reduces the need for repeat injections, while the LG technique remains a practical alternative in resource-constrained settings.

Introduction: Gunshot injuries to the foot can result in complex composite defects requiring comprehensive reconstructive strategies to restore both bony architecture and soft-tissue integrity. These injuries pose significant challenges due to extensive tissue destruction and the need for vascularized bone transfer.

Case report: In this study, we present two cases of foot reconstruction using customized osteocutaneous vascularized fibular flaps following shotgun and rifle injuries, and we compare our approach with existing literature. Despite considerable soft-tissue loss, the primary arterial supply to the foot was preserved, allowing for successful microsurgical reconstruction. Our staged strategy, combining external fixation with vascularized fibular transfer, achieved favorable structural and functional outcomes.

Conclusion: These cases support the feasibility of using vascularized fibular flaps in severe foot trauma and emphasize the importance of meticulous surgical planning to optimize results.

Introduction: Total knee arthroplasty (TKA) is considered the definitive treatment for advanced degenerative disease in the knee and involves replacing the native joint with prosthetic components. Failure mechanisms have been studied extensively due to the ubiquitous nature of these procedures. In this case report, the failure of a press-fit patellar component in a cementless TKA is investigated as a novel complication.

Case report: A 58-year-old male patient presented to an orthopedic clinic complaining of severe left knee pain with ambulation and associated varus alignment. He underwent X-ray imaging, where clear advanced osteoarthritis was visualized, with complete loss of joint space in the articulation of the medial compartment of the knee. Due to the patient's pain levels and decreased mobility, the patient elected to proceed with a TKA. The patient underwent this procedure without immediate complication until he returned 19-months post-operatively. At this time, X-rays demonstrated a failed patellar component from a shear fracture of the single peg prosthesis. A revision surgery was then completed to resolve this issue.

Conclusion: Based on the present reported data on TKA modes of failure, this case describes the first report of a shear fracture of the single peg prosthesis in a cementless TKA.

Introduction: The use of least invasive full-endoscopic spine systems has decreased the amount of tissue dissection, blood loss, and duration of post-operative recovery after intervention for far-lateral disc herniations (FLDH).

Case report: In this technique, docking over the caudal transverse process is described as an efficient alternative approach with a decreased need for manipulation of the exiting nerve root. All cases diagnosed with FLDH in the outpatient department who opted for surgical intervention after a failed non-invasive trial were included. A review of the literature on FLDH regarding the key anatomy used during a far-lateral approach was also performed.

Conclusion: The subjects showed significant improvement at 6-week and 12-week post-operative visits, and at 6-month follow-up had near-complete relief of symptoms, including resolution of lower limb numbness. Prior techniques for full-endoscopic discectomy for FLDH report docking on the facet joint, pars interarticularis, and the cranial transverse process. This technical note details that docking at the caudal transverse process improves upon these established techniques and provides a more straightforward and safer alternative.

Introduction: Coronal tibiofemoral subluxation (CTFS) is a frequently observed radiological feature in varus osteoarthritis (OA) of the knee and may reflect underlying biomechanical misalignment and osseous changes. Understanding its correlation with bone morphometry can help in surgical planning and risk stratification.

Aims: To analyze the coronal tibiofemoral (CTF) in varus OA knee and its correlation with bone morphometry in patients undergoing total knee arthroplasty.

Materials and methods: This retrospective and prospective study was conducted between January 2024 and January 2025. A total of 98 patients with varus OA knees planned for total knee arthroplasty were included. Radiographic parameters, including arithmetic hip-knee-ankle (HKA) angle, joint line obliquity, CTF, lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), coronal plane alignment of the knee (CPAK), and posterior condylar offset ratio (PCOR), were evaluated using standardized full-length scanograms.

Results: Among 98 patients, 60.2% were over 60 years old, and 61.2% were female. Body mass index classification showed that 42.9% were overweight and 25.5% were obese. Right knee involvement was observed in 53.1% of cases. CTF was present in 64 patients (65.3%) with a mean subluxation distance of 6.2 ± 1.5 mm. Most cases (75%) had subluxation distances between 0 and 6 mm. CPAK Type I was predominant (93.9%), whereas Type IV was seen in 6.1%. CTF prevalence was similar between CPAK Type I (65.2%) and Type IV (66.7%) (P = 0.887). Patients with CTF had higher LDFA (89.8° ± 2.1 vs. 87.9° ± 1.8), lower MPTA (84.5° ± 2.2 vs. 87.2° ± 1.9), higher PCOR (0.52 ± 0.06 vs. 0.48 ± 0.05), and more negative HKA angle (-7.2° ± 2.4 vs. -4.9° ± 2) than those without CTF (all P < 0.005). Correlation analysis showed a significant positive correlation of CTF with LDFA (r = 0.36, P = 0.004), PCOR (r = 0.3, P = 0.015), and HKA (r = 0.44, P = 0.003), and a negative correlation with MPTA (r = -0.42, P = 0.002).

Conclusion: CTF is highly prevalent in varus OA knees and is significantly associated with specific morphometric alterations, including increased LDFA and PCOR, decreased MPTA, and a more negative HKA angle. While CPAK Type I predominates in this population, the CPAK classification did not significantly correlate with subluxation presence. These findings underscore the importance of assessing CTFS and bone morphology preoperatively for individualized surgical planning and improved outcomes.

Introduction: Impalement injuries are rare injuries and require immediate limb and life-saving measures. Time is of the essence in such cases, and such situations can be challenging for the emergency care providers.

Case report: We report an unusual case of 47-year-old male farmer who was brought to the emergency department with a rare combination of impalement injuries with metallic rotavator blades of a power-tiller lodged in his ipsilateral knee and ankle joints.

Conclusion: Impalement injuries are difficult and being rare often call for quick hospital mobilization and a multidisciplinary team management. The safe retrieval of a foreign body depends critically on the quality of pre-hospital care received and on a thorough clinical examination, relevant history, and careful pre-operative preparation.

Introduction: The direct anterior approach (DAA) is promoted as a muscle-sparing technique for primary total hip arthroplasty (THA), but comparative benefits and safety remain debated across settings and study designs.

Materials and methods: We performed a Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020-guided systematic review of PubMed, EMBASE, Scopus, Web of Science, MEDLINE, DOAJ, EBSCOhost, and SCIE from inception through 31 December 2023. We included comparative clinical studies of adults undergoing primary THA that directly compared DAA with posterior/posterolateral (and lateral, where available) approaches. Risk of bias was assessed using risk of bias 2 (RoB 2) for randomized trials and a ROBINS-I-aligned framework for observational studies. Random-effects meta-analysis (DerSimonian-Laird) was conducted when ≥2 studies reported comparable outcomes at aligned timepoints.

Discussion: The search identified 2,548 records; after removing 632 duplicates, 1,916 records were screened and 178 full texts were assessed. Seven studies (1 randomized trial and 6 observational cohorts; 4,685 participants) met the inclusion criteria. For the primary pooled outcome (pain, Visual Analog Scale at 3 months; 2 studies; 437 participants), DAA showed lower pain versus comparator (mean difference [MD] -0.49, 95% confidence interval [CI] -0.66 to -0.32; I² = 0%). Secondary pooled outcomes suggested a small pain difference at 6 months (MD -0.10, 95% CI -0.18 to -0.02; I² = 0%) and higher early function at 3 months (Harris hip score MD +7.15, 95% CI 5.28 to 9.02; I² = 0%). Estimated blood loss favored DAA (MD -81 mL, 95% CI -92.60 to -69.68; I² = 0%), whereas operative time and length of stay showed substantial heterogeneity and no consistent difference. The randomized trial had some concerns, and observational studies were mainly limited by confounding, yielding an overall moderate-to-serious risk of bias.

Conclusion: DAA may offer modest early improvements in pain and function after primary THA, with uncertain effects on operative efficiency outcomes that vary by context. Overall certainty of evidence is limited by few poolable studies, mixed designs, and residual confounding; further well-designed pragmatic randomized trials and standardized prospective cohorts are needed.

Aims and background: Dislocation remains one of the most common complications following total hip arthroplasty (THA). Although the classical "Lewinnek's safe zone" for acetabular cup positioning has long guided surgeons, a considerable number of dislocations still occur even within this zone. Recent evidence emphasizes the importance of the dynamic spinopelvic relationship, specifically variations in pelvic tilt and functional anteversion, which directly influence acetabular orientation and joint stability. This study aims to analyze the spinopelvic relationship and its effect on acetabular cup anteversion and femoral head coverage in THA.

Materials and methods: A total of 30 patients aged between 20 and 70 years undergoing primary THA were included in the study. Pre-operative assessment involved X-rays of the lumbar spine and pelvis in both supine and standing positions to determine changes in pelvic tilt. Acetabular anteversion was modified accordingly. Postoperatively, acetabular cup positioning and femoral head coverage were evaluated radiographically using the Woo and Morrey method for anteversion and the lateral center edge angle (LCEA) of Wiberg. Statistical analysis was performed using the Statistical Package for the Social Sciences version 23.

Results: The mean pelvic tilt in supine and standing positions was -3.30° and -5.77°, respectively, with a mean change of -2.44°. The mean target anteversion was 13.32°, and the mean achieved anteversion was 14.65°. The mean LCEA was 50.51°. A weak negative correlation was found between anteversion achieved and LCEA (ρ = -0.27, P = 0.141). The LCEA was highest when acetabular anteversion was within 5°-25°, suggesting optimal femoral head coverage within this range.

Conclusion: The study highlights that a fixed "safe zone" for acetabular cup placement is insufficient. Individualized cup orientation based on spinopelvic parameters enhances joint stability and femoral head coverage. Functional assessment of pelvic tilt and anteversion should be integrated into pre-operative planning to reduce the risk of impingement and dislocation in THA.

Introduction: Fungal musculoskeletal infections are rare and often present diagnostic and therapeutic challenges, particularly in immunocompromised individuals. Phaeohyphomycosis is a dematiaceous fungal infection with a wide clinical spectrum, but isolated prepatellar bursitis due to this organism has not been previously reported. This case highlights the importance of maintaining a high index of suspicion for unusual pathogens in transplant recipients presenting with atypical joint or periarticular infections.

Case report: We report the case of a 55-year-old female renal transplant recipient on long-term immunosuppressive therapy who presented with progressive swelling and pain over the anterior aspect of the knee. Clinical examination revealed localized swelling consistent with prepatellar bursitis, with no systemic features of infection. Initial aspiration yielded dark-colored fluid, and microscopy demonstrated pigmented fungal elements. Fungal culture confirmed the diagnosis of phaeohyphomycosis. The patient underwent surgical bursectomy followed by antifungal therapy, with gradual resolution of symptoms. At the latest follow-up, she remained asymptomatic with no evidence of recurrence.

Conclusion: This case underlines the need for early recognition of unusual infectious agents in immunosuppressed patients with persistent musculoskeletal complaints. Isolated fungal bursitis due to phaeohyphomycosis is extremely uncommon, and timely surgical intervention combined with appropriate antifungal therapy is critical for favorable outcomes. Orthopedic surgeons should be aware of this rare entity, as prompt diagnosis and multidisciplinary management can prevent morbidity and preserve function.

Collaborations foster the exchange of knowledge, promote mentorship, and enhance research quality by uniting diverse healthcare systems and creating opportunities for young orthopedic professionals. It emphasizes the significance of partnerships bridging high-, middle-, and low-income countries to reduce disparities in training opportunities, infrastructure, and healthcare delivery. The piece highlights how international networks enable young surgeons to develop essential skills, such as leadership, management, and research methodology through professional organizations and societies. Membership in these groups provides a platform for lifelong collaborations and mentorship, shaping careers and fostering camaraderie. The integration of mentorship programs emphasizes personal and professional growth, reinforcing self-confidence and career satisfaction. Educational initiatives facilitated by networking, including continuing medical educations, virtual learning platforms, and social media, have revolutionized continuous learning. These technologies make information accessible and adaptable to individual needs, supporting clinicians in staying updated with present evidence-based practices. Virtual discussions and online forums encourage innovative research and collaborative problem-solving. Professional research organizations are showcased as enablers of high-quality research and academic growth. By supporting the dissemination of findings and fostering global collaborations, they play an instrumental role in addressing the challenges faced by low-resource settings. The article underlines the transformative impact of networking in orthopedics. While acknowledging existing challenges, it advocates for enhanced collaboration to achieve equitable and inclusive advancements in orthopedic education, research, and clinical care.