Journal of Orthopaedic Science最新文献

Background: Hypertension is a common comorbidity among patients undergoing knee arthroplasty and has been associated with postoperative complications; however, its clinical impact in Japanese populations remains unclear. This study evaluated the association between hypertension and in-hospital complications following total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA).

Methods: A retrospective cohort study was conducted using Japan's nationwide Diagnosis Procedure Combination database (April 2016-March 2023). Postoperative outcomes-including deep vein thrombosis (DVT), pulmonary embolism (PE), cerebrovascular events, surgical site infection, and periprosthetic fracture-were compared between hypertension and non-hypertension groups. Propensity score (PS) matching (1:1) was performed using demographic variables, comorbidities, anesthesia type, and surgical procedure. Multivariate logistic regression was used to identify independent predictors of DVT.

Results: Of 257,319 eligible patients, PS matching yielded 77,637 patients per group. Hypertension was associated with a significantly higher incidence of DVT after matching, with an absolute risk difference of 1.82 %. Although hypertension was also associated with an increased relative risk of surgical site infection, the absolute risk difference was modest (0.46 %). Logistic regression identified hypertension (Odds ratio: 1.24; 95 % CI: 1.20-1.29) as an independent risk factor for DVT. Hypertension was also associated with longer hospitalization and greater transfusion volume on the day of surgery. Sensitivity analyses confirmed these findings.

Conclusion: Hypertension independently increased the risk of postoperative complications after knee arthroplasty, particularly DVT. Although hypertension increased the relative risk of surgical site infection, the absolute risk difference was modest. These findings highlight the importance of perioperative risk stratification and venous thromboembolism prevention in patients with hypertension.

Background: Hypophosphatasia is an inherited metabolic bone disorder characterized by cartilage and bone abnormalities. Adult hypophosphatasia presents with a wide range of symptoms, including refractory fractures, recurrent fractures, stress fractures, and reduced bone mineral density, along with extraskeletal manifestations such as myalgia, muscle weakness, and fatigue. Some patients with these symptoms may have undiagnosed hypophosphatasia. While hypophosphatasia is treatable with enzyme replacement therapy, early diagnosis is often difficult owing to its diverse clinical presentations. This study aimed to create a screening method for identifying suspected hypophosphatasia cases.

Methods: We retrospectively reviewed all adult patients of orthopedics (2392 cases; 859 men and 1533 women, mean age 71.0 ± 18.7 years) who underwent serum alkaline phosphatase testing at our hospital between April 1, 2022, and March 31, 2023. Patients with at least one alkaline phosphatase level below the lower limit of normal (38 U/L) were included. Patients who consistently showed low alkaline phosphatase levels in all tests were classified as suspected hypophosphatasia cases. We investigated the fracture history, musculoskeletal symptoms, and alkaline phosphatase levels of these patients to identify potential hypophosphatasia cases.

Results: Eight patients (0.33 %) were suspected of having hypophosphatasia. Of the two patients who were followed up, one was diagnosed with hypophosphatasia through genetic testing.

Conclusions: Our screening method can extract suspected hypophosphatasia cases. Our study is the first to propose and apply a targeted screening approach for adult hypophosphatasia in an orthopaedic cohort-an at-risk population that has not been previously examined in this context. Orthopaedic surgeons should be aware of the possibility of hypophosphatasia in patients presenting with fractures or pain and consider alkaline phosphatase levels cautiously.

Background: The survivors from crush syndrome are often disabled due to the affected limbs, with excessive fibrosis changes at damaged muscle tissue. We previously reported that a zinc chelator (N,N,N',N'-tetrakis-(2-pyridylmethyl)-ethylenediamine: TPEN) administration to the crush syndrome mice model inhibited neutrophil activation induced by ischemia-reperfusion, alleviating the inflammatory response. In the present study, we investigated the effects of TPEN administration on fibrosis in affected limb muscles.

Methods: Eight-week-old C57BL/6J mice were subjected to bilateral hindlimb compression using a rubber tourniquet for 2 h to create a crush syndrome model. Compression was then released to allow reperfusion. Gait evaluations and muscle tissue analyses were performed up to 4 weeks post-reperfusion. We investigated the effects of TPEN administration on functional recovery and histopathology of the affected muscles.

Results: In the chronic phase of the crush syndrome model, the gait function was impaired owing to muscle tissue fibrosis. The affected muscle tissue sustained sarcolemma hyperpermeability caused by basement membrane disruption and mitochondrial fission, resulting from elevated neutrophil elastase expression. In muscle tissue, PECAM-1-positive vascular endothelial cells co-expressed Notch1 and αSMA, indicating induction of endothelial-to-mesenchymal transition (EndMT) was occurring following persistent mitochondrial fission. TPEN administration reduced neutrophil elastase expression, improving the sarcolemma integrity due to the reduced infiltration of neutrophils. This led to the inhibition of EndMT, which minimized fibrosis and accelerated muscle regeneration, allowing for better functional recovery.

Conclusions: This study demonstrates that zinc chelator administration not only alleviates fibrosis in muscle tissues damaged by crush syndrome but also stimulates tissue regeneration in the chronic phase. Our findings provide insight into the mechanism of muscle fibrosis and may represent a breakthrough in the treatment of crush syndrome, potentially minimizing long-term disability in the affected limbs.

Background: Hallux valgus, a common deformity of the forefoot, is characterized by lateral deviation of the hallux at the metatarsophalangeal joint, often requiring surgery. Juvenile hallux valgus, defined by its development during childhood or adolescence, has a high postoperative recurrence rate. However, its etiology remains unclear. Several studies have found that the radius of curvature of the first metatarsal head is smaller in individuals with adult hallux valgus than in healthy controls, possibly contributing to progression of deformity or recurrence. However, to our knowledge, no detailed morphological analysis focused on juvenile hallux valgus has been published. In the present study, we aimed to characterize juvenile hallux valgus morphology, emphasizing radius of curvature.

Methods: The cohort of this retrospective, single-center study comprised patients aged ≤20 years who were allocated to juvenile hallux valgus (53 feet, 32 patients) and typically developing group (56 feet, 56 patients). An adult hallux valgus group (102 feet, 63 patients) was also analyzed. Both juvenile and adult hallux valgus were defined by a hallux valgus angle ≥20°. Radius of curvature was measured on weight-bearing radiographs using ImageJ software and normalized by metatarsal length. Additional parameters investigated included hallux valgus angle, M1-M2A, M1-M5A, distal metatarsal articular angle, sesamoid position, round sign, 1:2 metatarsal ratio, epiphyseal line status, cuneiform obliquity, calcaneal pitch, and Meary's angle.

Results: Radius of curvature was significantly smaller in the juvenile hallux valgus group than in both typically developing and adult hallux valgus groups (p < 0.001). Logistic regression identified radius of curvature (p = 0.02), distal metatarsal articular angle (p = 0.002), and female sex (p = 0.002) as independent predictors of juvenile hallux valgus.

Conclusions: A smaller first metatarsal head radius of curvature may contribute to metatarsophalangeal joint instability and the pathogenesis of juvenile hallux valgus.

Level of evidence: Level III, comparative study.

Background: The size and location of the glenoid defect have been extensively studied in patients with anterior shoulder instability. However, in patients with traumatic posterior instability, little is known regarding the location and size of the bony defect of the glenoid. The purpose of the present study was to clarify the location and extent of the glenoid defect in shoulders with traumatic posterior instability with use of CT images.

Methods: Forty-three shoulders of 42 patients with traumatic posterior instability treated at 7 hospitals were included. Three-dimensional images of the glenoid reconstructed from computed tomography were assessed using image analysis software. The location and size of the glenoid defect were investigated and described on a clock face of the glenoid.

Results: Thirty-eight of 43 shoulders (88 %) had a glenoid bony defect. Eleven shoulders (26 %) had a bony fragment. The defect width of the glenoid was 2.5 ± 1.3 mm (mean ± standard deviation), which was equivalent to 9.1 ± 5.3 % of the glenoid width. The mean orientation of the defect was pointing toward 8:12, at a mean angle of 246° ± 13.2° from the 12-o'clock direction in the right shoulder. The glenoid defects were located between 5:37 and 10:38.

Conclusion: The prevalence of the glenoid bony defect in patients with traumatic posterior shoulder instability was as high as that in patients with anterior shoulder instability. However, its size was smaller than the anterior instability and it was located posteroinferiorly. IRB APPROVAL: #2022-1-1168.

Background: This study evaluated the 1-year mortality rate and decrease in walking ability in older patients with fragility fractures of the pelvis (FFPs), considering the impact of demographic factors and treatment strategies on clinical outcomes.

Methods: Conducted across 12 hospitals from 2014 to 2020, this retrospective analysis included 588 FFP patients aged over 65 years. Mortality and mobility were assessed according to patient demographic factors, the Charlson Comorbidity Index (CCI), and radiographic findings. A subgroup analysis was also performed for patients with unstable Type III and IV fractures to compare outcomes between surgical and conservative treatment.

Results: The study revealed a one-year survival rate of 91.6 %. A lower body mass index (BMI) and a higher CCI were significantly correlated with increased mortality. Loss of walking ability was observed in 32.4 % of patients. Fracture type and preoperative walking ability were identified as significant prognostic factors. In the subgroup analysis of unstable fractures, no significant difference was found in survival or final walking ability.

Conclusions: In older FFP patients, a lower BMI and higher CCI predict greater mortality, and certain fracture types predict a decrease in walking ability. Surgical treatment did not significantly impact mortality or mobility outcomes, suggesting the need for careful consideration of treatment modalities.

Level of evidence: This study provides Level IV evidence from a retrospective cohort study on the factors influencing mortality and mobility in older patients with FFPs.

Background: Sarcomas of bone requiring an intercalary resection of femur are rare and challenging. In the absence of set guidelines, they are variously managed with intercalary prosthesis, cement spacers, allografts, recycled tumor bone, and autografts. We have used recycled tumor bone and/or vascularised fibula over the years for such resections. In this first-of-its-kind study on Indian patients, we aim to analyse the outcome of these procedures in femur.

Materials and methods: Twenty six patients undergoing an intercalary resection of femur from 2011 to 2024 by a single surgeon were analysed, of which one was excluded. All the patients underwent intercalary resection and reconstruction using recycled tumor and/or vascularised fibula. The demographic and surgical details, time to union, functional outcome and complications were analysed. 21 patients were treated with reimplantation of recycled tumor bone (extracorporeal radiation therapy (ECRT) in 15 and cryotherapy in 6). A vascularised fibula graft was used in 17 patients; as a stand-alone graft in 4 and in combination with recycled tumor bone in 13.

Results: After a mean follow up of 61.3 months (3-144 months), all patients showed union. Addition of a vascularised fibula graft to recycled tumor bone reduced the time to union (p = 0.02) without increasing the risk of a complication. Additionally, patients undergoing cryotherapy had shorter time to union (6.83 months) when compared to those who underwent ECRT (14.43 months), with fewer complications. (P = 0.02). Use of a vascularised fibula as a stand-alone graft took the maximum time to union. Resection length did not correlate with complication rates and functional outcome.

Conclusions: Biological reconstruction after an intercalary resection of femur gives excellent long term results, with acceptable complication rates. We recommend the addition of a vascularised fibula graft to recycled tumor bone for intercalary resections of femur. Pedicled cryotherapy for recycling of tumor bone, when feasible, leads to fastest rehabilitation to optimal function.

Background: Single-bundle (SB) and double-bundle (DB) are the primary techniques used for anterior cruciate ligament (ACL) reconstruction. Several studies have compared the outcomes for SB versus DB reconstruction; however, the evidence is inconclusive regarding anatomical ACL reconstruction. We conducted a systematic review and meta-analysis by searching the CENTRAL and MEDLINE databases for interventional and observational studies published between May 2016 and December 2023 comparing the clinical outcomes of anatomical SB and anatomical DB ACL reconstruction. The minimum follow-up period was at least 24 months postoperatively.

Methods: Random effects models were used to estimate summary risk ratios (RRs), mean differences (MDs), and 95 % confidence intervals (CIs) for the association between SB and DB reconstruction and the clinical outcomes of re-rupture, pivot-shift test, anterior laxity, graft failure, Lysholm score, Knee Injury and Osteoarthritis Outcome Score, Tegner activity scale, meniscus tear, osteoarthritis change, and complications.

Results: After screening, 20 articles (11 interventional studies (n = 664 patients); 9 observational studies (n = 1866 patients)) were included in this meta-analysis. Compared to SB reconstruction, DB reconstruction demonstrated significantly lower residual pivot-shift test (RR: 0.42; 95 % CI: 0.30-0.60, p < 0.01) and higher Lysholm score (MD: 1.94; 95 % CI: 0.24-3.64, p = 0.03) in observational studies. In interventional studies, similar trends were observed for pivot-shift test (RR: 0.60; 95 % CI: 0.32-1.10, p = 0.10) and Lysholm score (MD: 0.81; 95 % CI: -1.48-3.10, p = 0.49), but these differences were not statistically significant. No statistically significant differences were found for other outcomes in either study category.

Conclusions: Interventional studies found no significant differences between anatomical SB and DB ACL reconstruction. Observational studies suggested fewer pivot-shift and slightly higher Lysholm scores with DB; however, these findings were susceptible to bias, showed limited clinical relevance, and lacked consistent replication, suggesting that the evidence remains inconclusive.

Background: The prognostic impact of pathologic fractures in patients with bone metastases remains controversial. In this study, we focused on pathologic femoral fractures, which are among the most common and are associated with significant morbidity.

Methods: We retrospectively reviewed cases of pathologic femoral fractures treated at our department between 2008 and 2020. A control group was selected from patients with metastatic bone tumors without pathologic femoral fractures during the same period. The two groups were matched 1:1 using propensity score matching based on age, new Katagiri score, primary cancer type, and TNM stage classification to eliminate selection bias.

Results: The pathologic femoral fracture group consisted of 75 patients (mean age, 67 years), and surgery was performed in 66 patients (tumor prostheses, n = 41; hip hemiarthroplasties, n = 9; internal fixations, n = 15; hip disarticulation, n = 1). Nine patients did not undergo surgery because of poor general condition and/or poor prognosis. The control group consisted of 678 patients (mean age, 66 years). The 5-year overall survival rate before propensity score matching was 28 % in both groups (p = 0.53). In the propensity score matching analysis (n = 53 patients per group) using the post-fracture performance status in the new Katagiri score, the survival hazard ratio associated with the pathologic fracture was 0.79 (95 % confidence interval: 0.5-1.3, p = 0.38). Since it has not been established whether performance status in the new Katagiri score is assessed in the pre- or post-fracture status, the score was re-evaluated based on pre-fracture performance status. After matching 59 patients per group, the survival hazard ratio was 0.97 (95 % confidence interval: 0.6-1.6, p = 0.91).

Conclusions: The results of this study suggest that, with appropriate treatment, femoral pathologic fractures may not significantly impact the prognosis of patients with metastatic bone tumors. This highlights the importance of providing appropriate management for pathologic femoral fractures.

Background: Primary spine tumors are rare but can cause pain and neurological symptoms, occasionally requiring surgery. Previous national database studies have primarily focused on malignant spine tumors; however, data on primary intermediate spine tumors (PISTs) and primary benign spine tumors (PBSTs) remain limited. Therefore, we aimed to describe the demographic, clinical, and surgical characteristics of PISTs and PBSTs using the Bone and Soft Tissue Tumor (BSTT) Registry of the Japanese Orthopaedic Association.

Methods: We analyzed 908 cases of PISTs (n = 118) and PBSTs (n = 790) from the BSTT Registry (2006-2019). We evaluated and stratified the clinical, anatomical, and histological characteristics according to tumor grade, patient age, tumor location, and histological subtype. Surgical data were evaluated using procedure and margin status.

Results: Hemangiomas were the most common tumors (48.2 %), followed by giant cell tumor of bone (9.5 %) and Langerhans cell histiocytosis (7.0 %). PISTs were significantly more common in younger patients (p < 0.001), whereas PBSTs showed a bimodal age distribution. The lumbar spine was the most frequently affected site, with no significant difference between patients with PISTs and those with PBSTs (p = 0.521). Imaging-based diagnoses were frequent in patients with PBSTs (p < 0.001). Surgery was performed in 23.2 % of all cases and 63.6 % of patients with PISTs (p < 0.001). Resection was the most common procedure (63.5 %), and intralesional margins predominated (49.3 %), with margin status significantly differing according to tumor grade (p = 0.042).

Conclusions: This nationwide registry study provides the largest dataset of PISTs and PBSTs to date, including 908 cases and 22 histological subtypes. Our findings highlight age- and location-specific tumor trends and offer valuable insights into real-world diagnostic and surgical practices. These results support future research and demonstrate the value of large-scale registry data for rare spinal tumors.