Orthopaedic Surgery最新文献

Background: Osteonecrosis of the femoral head (ONFH) is a progressive and disabling disease that commonly affects young and middle-aged adults. Without timely treatment, it often progresses to femoral head collapse and hip dysfunction, ultimately requiring total hip arthroplasty. Although core decompression (CD) and superselective intra-arterial perfusion have been applied clinically, their long-term efficacy as monotherapy remains limited, and the clinical value of combining these approaches has not been fully clarified.

Objectives: This study aimed to evaluate the clinical efficacy of CD combined with superselective intra-arterial perfusion in the treatment of ONFH, and to identify key prognostic factors influencing therapeutic outcomes.

Methods: This study enrolled 145 patients in the CD group, 123 in the SIAE group, and 89 in the combined group. Preoperative baseline characteristics, postoperative Harris Hip Scores (HHS), Visual Analog Scale (VAS) scores, MRI-derived collapse rates, and complication rates were compared. Patients were stratified into effective and non-effective groups to analyze risk factors. Receiver operating characteristic (ROC) curves assessed predictive performance.

Results: Baseline characteristics, including sex, age, body mass index (BMI), Association Research Circulation Osseous (ARCO) staging, etiology, and lesion location, showed no intergroup differences. The combined group exhibited superior postoperative HHS improvement, VAS reduction, and collapse rate mitigation compared to monotherapy groups. Complication rates were lowest in the combined group (2.2%) versus CD (7.6%) and SIAE (12.2%) groups. The combined group had the highest efficacy rate, with non-traumatic etiology and marginal necrosis predominating in the effective group. Logistic regression identified surgical approach, BMI, etiology, and lesion location as independent predictors of efficacy. Surgical approach demonstrated the highest predictive power (area under the curve (AUC) = 0.7838, sensitivity 83.75%, specificity 60.41%), while the constant term achieved optimal performance (AUC = 0.8549).

Conclusion: CD combined with SIAE significantly enhances clinical outcomes, alleviates pain, reduces collapse rates, and minimizes complications in ONFH. Surgical approach, BMI, etiology, and lesion location critically influence efficacy. The combined strategy represents a superior intervention with promising clinical applicability.

Objective: The posterior minimally invasive approaches for odontoid fractures include the midline nuchal ligament approach (MNLA) and the paramedian muscle-splitting approach (PMSA). However comparative data on their anatomical characteristics and clinical efficacy remain scarce to date. The objective of this study is to determine the differences in anatomy and clinical outcomes between the MNLA and the PMSA for reduction and temporary internal fixation of odontoid fractures.

Methods: This retrospective analysis focused on 31 patients with odontoid fractures from February 2021 to December 2023. Among them,16 patients underwent PMSA and 15 patients underwent MNLA. Various parameters were compared between the two groups, including operation time, intraoperative blood loss, postoperative complications, edema rates of cervical posterior muscles, the range of motion in rotation of C1-C2, patient satisfaction, Visual Analogue Scale score for neck pain, axial symptom scores, and neck disability index. Additionally, an anatomical study was performed; the PMSA and the MNLA were simulated on six fresh cadaveric specimens to compare the anatomical differences in surgical exposure between the two approaches.

Results: In the clinical study, both groups successfully achieved fracture healing. Compared with the PMSA group, the MNLA group had several advantages, including shorter operative times, lower intraoperative blood loss, and a lower edema rate of posterior cervical muscles. However, similar results were observed between the two groups in terms of the range of motion in rotation of C1-C2, patient satisfaction, Visual Analogue Scale score for neck pain, axial symptom scores, and neck disability index at the last follow-up. In the cadaveric study, we found the trapezius-splenius capitis interface and the course of the greater occipital nerve (GON) varied significantly and the GON was present in the surgical field in 2 of 6 specimens in the PMSA, which brought difficulties for the surgical operation. In contrast, the MNLA, using the spinous process of C2 and the obliquus capitis inferior (OCI) as anatomical landmarks, provided a simpler surgical procedure and easier exposure.

Conclusion: Both the MNLA and the PMSA demonstrated favorable clinical outcomes for the treatment of odontoid fractures. However, compared with the PMSA, the MNLA, using the spinous process of C2 and the OCI as anatomical landmarks, offers advantages of the stability of the surgical procedure, easy exposure, and reduced iatrogenic damage to the cervical posterior muscles and GON.

Background: Craniovertebral junction anomalies (CVJAs), including conditions such as basilar invagination and atlantoaxial dislocation, frequently result in progressive neurological deterioration. Traditional surgical approaches-whether anterior, posterior, or combined-may prove inadequate for revision cases characterized by persistent ventral compression. This study evaluates the efficacy of anterior transoral odontoid reduction combined with clivocervical fusion for managing complex CVJAs requiring revision surgery.

Methods: A 56-year-old female patient presented with recurrent symptoms following prior posterior occipitocervical fusion. She underwent revision surgery involving anterior transoral odontoid reduction combined with clivocervical fusion. Postoperative rehabilitation, imaging studies (CT, MRI, and CTA), and neurological function assessed via the JOA score were evaluated at 3-, 6-, and 12-month follow-up intervals.

Results: Postoperative imaging demonstrated significant improvements: the clivo-axial angle improved to 146.1° from 135.5°, the odontoid tip descended caudally by 4.33 mm, and spinal cord compression resolved. Neurological function improved, with stable fixation, successful fusion, and no complications. Long-term follow-up confirmed sustained radiographic stability and neurological recovery.

Conclusion: Anterior transoral odontoid reduction combined with clivocervical fusion effectively addresses persistent ventral compression in revision CVJAs cases. This technique achieves neural decompression, biomechanical stability, and functional recovery, offering a promising option for complex cases with failed initial posterior fixation.

Objective: This study aimed to analyze the bone mineral density (BMD) in various body regions, investigate the effects of age and sex on BMD, and characterize BMD variations among different lumbar segments (L1-L4). Thereby uncovering patterns of regional bone loss, quantifying heterogeneity risks, and dynamically tracking individual trajectories.

Methods: BMD was measured using dual-energy x-ray absorptiometry (DXA). Patients were stratified to analyze the effects of age and sex on BMD at the following sites: lumbar spine (L1-L4); femur: Ward's triangle, greater trochanter, femoral shaft, femoral neck, upper femoral neck, and lower femoral neck; and head, ribs, and pelvis. Subgroup analyses were conducted based on age, BMD Z-scores, BMD T-scores, and body mass index (BMI) to compare lumbar segmental BMD (L1-L4) between the sexes. The study conducted from 2019 to 2024 included lumbar spine data from 20,199 patients; femur data from 23,218 patients; and head, ribs, and pelvis data from 1288 patients.

Results: In males, the BMD at the femoral Ward's triangle, femoral shaft, and femoral neck (including the upper and lower regions) began to decline from 45 to 49 years of age. The BMD of the femoral greater trochanter decreased at 50-54 years of age. The head BMD in males decreased at 55-59 years of age. The rib BMD showed no significant age-related changes, though the pelvic BMD decreased at 60-64 years. In females, the head, femoral greater trochanter, and femoral shaft BMD decreased at 45-49 years of age. In male patients aged 50-89 years and female patients aged 40-89 years, male and female patients in the Z > -2.0 group, male and female patients in the BMD T-score stratification groups, male patients with a BMI < 30 kg/m², the BMDs of L1 and L2 were significantly lower than those of L3 and L4 among different age groups. The BMD of L1/L2 was significantly lower than that of L3/L4 in all female patients, regardless of BMI group.

Conclusion: The BMDs of several body regions are associated with age and sex, with variations in the rate of change, age at first change, and age-related trends depending on the anatomical site and sex. Heterogeneity exists among the lumbar segments, as the BMDs of L1 and L2 are generally significantly lower than those of L3 and L4; however, this trend varies in specific subgroups.

Purpose: Combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries are common and present challenges in management. While ACL reconstruction has been established, the optimal approach for combined ACL and MCL injuries remains debatable owing to the varying severity and chronicity of MCL injuries. This study aimed to describe a novel surgical technique for chronic ACL and grade III MCL injuries and assess whether simultaneous ACL and MCL reconstruction improves chronic MCL instability.

Methods: A total of 41 patients diagnosed with combined ACL and MCL injuries were included in the study. Twenty-five patients were allocated into the simple ACL reconstruction (SAR) group while 16 patients were allocated into the simultaneous ACL and MCL reconstruction (SAMR) group according to MCL injury severity. The surgical technique utilized a single ipsilateral hamstring autograft for both ACL and MCL reconstruction. Clinical assessments, including range of motion (ROM), functional score, Lachman test, and valgus instability, were conducted before and after surgery. Postoperative magnetic resonance imaging (MRI) was used to evaluate graft quality.

Results: Postoperative outcomes revealed significant improvements in ROM, functional scores, Lachman test, and valgus instability in both groups. There were no significant differences between the SAR and SAMR groups, suggesting that patients with combined ACL rupture and severe MCL injuries can achieve similar stability outcomes as those with ACL rupture and mild MCL injuries. The MRI results revealed high-quality grafts in both groups.

Conclusion: This study introduces a novel technique using simple hamstring autografts for simultaneous ACL and MCL reconstruction, and this surgical technique can achieve knee stability comparable to that of low-grade MCL injuries and can be used for single ACL reconstruction. Further research with larger sample sizes and long-term follow-up is needed to confirm these findings.

Thoracolumbar fractures are a prevalent clinical disease, with several surgical techniques, including traditional freehand pedicle screw fixation (TFPSF), conventional fluoroscopy (C-arm) percutaneous pedicle screw fixation (CPPSF), O-arm-assisted percutaneous pedicle screw fixation (OPPSF), and robot-assisted percutaneous pedicle screw fixation (RPPSF), being currently applied. However, a comprehensive comparison of their relative efficacy across multiple perioperative and functional outcomes is lacking, leading to uncertainty in optimal technique selection. This network meta-analysis (NMA) evaluates and compares the clinical efficacy of these four surgical techniques to identify the most effective intervention and guide clinical decision-making. Researchers independently searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science for studies published before September 20, 2024. Studies were selected based on stringent eligibility criteria. Randomized controlled trials (RCTs) were assessed using RoB 2.0, while cohort studies were evaluated with the Newcastle-Ottawa Scale (NOS). After data extraction, Bayesian network analysis was executed using R 4.2.2 and Stata 16.0. Nineteen studies were included, encompassing 1344 patients with thoracolumbar fractures. For screw accuracy, OPPSF ranked highest (SUCRA = 92.7%), significantly outperforming TFPSF (RR 1.12; 95% credible intervals [CrI] [1.04, 1.23]) and CPPSF (RR 1.12; 95% CrI [1.04, 1.22]), with RPPSF also surpassing both. OPPSF showed superior intraoperative blood loss reduction (SUCRA = 79.8%) while TFPSF had significantly more bleeding than others. For hospitalization, RPPSF ranked highest (SUCRA = 65.0%) but CPPSF significantly shortened stays versus TFPSF (MD -2.24; 95% CrI [-4.48, -0.03]). CPPSF also showed better pain control (SUCRA = 77.9%) with significantly lower VAS scores versus TFPSF (MD -1.02; 95% CrI [-1.71, -0.37]). RPPSF demonstrated the lowest complication risk (SUCRA = 94.9%), with both CPPSF and RPPSF showing significant reductions versus TFPSF. Additionally, although CPPSF ranked first in SUCRA for both operative time (SUCRA = 81.6%) and Cobb angle (SUCRA = 72.4%), the pairwise comparisons did not demonstrate statistical significance, necessitating cautious interpretation. In summary, OPPSF tends to demonstrate superior precision and blood loss control, CPPSF may optimize rehabilitation efficiency, while RPPSF appears to be the safest technique. Technique selection should balance clinical outcomes, economic feasibility, and patient-specific priorities.

Objectives: The prevertebral fascia (PVF), which constitutes part of the deep layer of the deep cervical fascia, is routinely incised during anterior cervical discectomy and fusion (ACDF) surgery. Suturing the PVF could serve as an optimal barrier between the surface of the fusion device and the posterior esophagus and may alleviate postoperative dysphagia. Thus, this retrospective study was aimed to (1) evaluate the impact of prevertebral fascia (PVF) suturing and (2) perform a multivariate analysis of relevant risk factors for postoperative dysphagia following anterior cervical discectomy and fusion (ACDF).

Methods: A total of 197 patients who underwent ACDF and had at least 1 year of follow-up between June 2020 and February 2024 were retrospectively reviewed. To compare baseline data and incidence of dysphagia, the patients were divided into two groups on the basis of whether they had undergone PVF suturing during the operation (suture group, N = 83; nonsuture group, N = 114). The incidence and severity of dysphagia were evaluated using the Bazaz grading system. The patients were further categorized into a dysphagia group (N = 56) and a nondysphagia group (N = 141) to conduct a multivariate analysis of dysphagia.

Results: Compared with the nonsuture group, the suture group presented a significantly lower incidence and severity of dysphagia at 1 week, 1 month, and 3 months postoperatively (p < 0.05). A binary logistic regression analysis revealed that advanced age (odds ratio [OR], 1.034; 95% confidence interval [95% CI, 1.006-1.063]), greater ΔC_2-7A (OR, 1.141; 95% CI, 1.056-1.232), minor ΔTS-CL (OR, 0.890; 95% CI, 0.842-0.941), and nonsutured PVF (OR, 0.329; 95% CI, 0.146-0.740) were significantly associated with higher rates of dysphagia (p < 0.05).

Conclusion: Suturing of the PVF during ACDF can significantly decrease the incidence and severity of transient postoperative dysphagia in patients. The incidence of postoperative dysphagia is also significantly associated with advanced age, greater ΔC_2-7A, and minor ΔTS-CL.

Objective: It is unclear whether a hip with a developmental dysplasia deformity can remain functional and free of osteoarthritis (OA) throughout life. This study aims to determine the percentage of Chinese older adults without severe OA who meet the diagnostic criteria for DDH and BDDH. Additionally, this study seeks to explore hip morphology in this population.

Methods: Data from 808 consecutive patients with recent unilateral femoral neck fractures, collected between January 2022 and October 2024, were retrospectively analyzed. A total of 493 patients (493 hips) were included in the analysis. For imaging evaluation, the following parameters of the contralateral (unfractured) hip were measured: LCEA, Tönnis angle, Sharp's angle, femoral head eminence index (FHEI), and femoral head lateralization. Categorical variables were expressed as numbers and percentages. Continuous variables were presented as mean ± SD if normally distributed; otherwise, they were reported as median (Q1, Q3). The Pearson chi-square test, likelihood ratio chi-square test, or Fisher's exact test was used to compare categorical variables. An independent-samples t-test or Mann-Whitney U test was used to compare continuous variables in the group analysis. For parameter comparisons between multiple groups, use ANOVA with post hoc analysis.

Results: In this study, 7.1% of individuals aged over 60 years with unilateral femoral neck fractures exhibited imaging results consistent with DDH, while 13.2% had results consistent with BDDH. Patients with DDH and BDDH were at a higher risk of developing mild OA compared to individuals with normal acetabular coverage. However, not all individuals with DDH or BDDH develop OA. Only the Tönnis angle was significantly associated with mild OA, indicating a 7.8% increase in OA risk for each 1° increase in the Tönnis angle. Significant differences were observed in the Tönnis angle (5.0 ± 3.9 vs. 11.5 ± 4.1 vs. 17.5 ± 4.1, p < 0.001), Sharp's angle (38.2 ± 2.9 vs. 41.7 ± 2.5 vs. 44.0 ± 2.5, p < 0.001), femoral head lateralization (7.8 ± 2.7 vs. 9.3 ± 2.6 vs. 10.3 ± 2.8, p < 0.001), and FHEI (17 ± 4 vs. 25 ± 3 vs. 30 ± 4, p < 0.001) between the normal group and both the DDH and BDDH groups.

Conclusion: The prevalence of DDH imaging abnormalities is notable among Chinese older adults without severe OA. Individuals with DDH and BDDH are more likely to exhibit mild OA symptoms, although not all develop OA. Using multiple imaging parameters in addition to LCEA facilitates characterizing hip morphology in asymptomatic individuals with DDH.

Objective: In total hip arthroplasty, the femoral component design requires a trade-off between initial stability and stress shielding. We designed the new bionic hip arthroplasty (BHA) prosthesis with compression and tension screws to mimic compression and tension trabeculae for bionic reconstruction. This prosthesis is designed to reduce stress shielding by mimicking physiological load transfer while ensuring sufficient initial stability for successful bone integration. This study aimed to biomechanically evaluate the initial stability and migration pattern of the BHA prosthesis under dynamic and static loading conditions.

Methods: The BHA prostheses were implanted into ten Sawbones fourth-generation composite non-osteoporotic femurs. In dynamic fatigue testing, the irreversible displacements and migration patterns in vertical and rotational directions were analyzed after 1,000,000 loading cycles. In static failure testing, the failure load of the BHA implanted model was analyzed.

Results: In dynamic fatigue testing, the irreversible subsidence displacement of the BHA prosthesis was (0.3683 ± 0.1046) mm and the irreversible retroversion displacement was (0.0328 ± 0.0157)°. The irreversible displacements in both vertical and rotational directions stabilized at 100,000 loading cycles. In static failure testing, the failure load of the BHA implanted model was (4485 ± 702) N.

Conclusions: The irreversible subsidence displacement of the BHA prosthesis was below the interface failure threshold of 1.5 mm, and secondary fixation was accomplished at 100,000 loading cycles. The average failure load was approximately 6.4 times body weight, much higher than the daily load range of hip joints. The BHA prosthesis suggests potential for adequate axial initial stability to facilitate bone ingrowth, which is expected to reduce revision rates in patients.

Objective: Hyperuricemia, characterized by elevated serum uric acid levels without acute gout symptoms, may influence postoperative outcomes after total knee arthroplasty (TKA). This study aimed to evaluate the impact of hyperuricemia on postoperative inflammatory responses, complications, and mid-term functional outcomes in patients undergoing primary TKA.

Methods: This was a retrospective cohort study. We identified all patients who had undergone primary TKA from April 1, 2015, to March 30, 2016. Patients were grouped by uric acid level. The knee society score (KSS) and hospital for special surgery knee score (HSS) before the surgery and 6 years after the surgery were recorded. Statistical analyses included t-tests, chi-square tests, and regression analyses to assess the influences of uric acid levels on C-reactive protein (CRP) levels, body temperature, functional scores, and local inflammatory response. The influence of the uric acid level on the local inflammatory response was also analyzed.

Results: Of the 614 patients, 140 had hyperuricemia, and 474 had normal uric acid levels. The hyperuricemia group had a higher unplanned readmission rate (11.4% vs. 5.7%, p < 0.05) and longer hospital stay (10.75 vs. 9.54 days, p = 0.002). CRP levels were significantly greater in the hyperuricemia group (OR = 34.64, 95% CI: 27.99-41.30, p < 0.001), and the incidence of the local inflammatory response was greater (42.1% vs. 9.5%, p < 0.01). The diagnostic accuracy for uric acid in the local inflammatory response was 0.742 (AUC). Improvements in the KSS clinical score (p < 0.01), KSS functional score (p < 0.01), and HSS score (p < 0.01) were lower in the hyperuricemia group.

Conclusions: Hyperuricemia is associated with significantly elevated postoperative CRP levels, a higher unplanned readmission rate, and substantially poorer mid-term functional outcomes after TKA. These patients also demonstrate increased inflammatory complications. These findings support preoperative uric acid screening to identify high-risk patients for targeted management.

Clinical relevance: Level III.

Trial registration: ClinicalTrials.gov identifier: NCT05476367.