Orthopaedic Surgery最新文献

Far lateral lumbar disc herniation (FLLDH) is a subtype of lumbar disc herniation marked by severe radicular and lower back pain, often accompanied by sensory and motor dysfunction. Microscopic tubular discectomy (MTD) is a contemporary minimally invasive approach for treating FLLDH, yet its superiority over conventional discectomy remains inconclusive. The purpose of this systematic review was to assess the effectiveness of MTD in improving pain and mobility for FLLDH patients. A secondary aim was to assess the safety of MTD. Primary outcome measures were patient-reported pain, assessed using a visual analog scale (VAS), patient-reported mobility, assessed using the Oswestry Disability Index (ODI), and scores on the Modified MacNab criteria clinical assessment. Secondary outcome measures were mean blood loss, operation duration, hospital stay, reherniation rate, reoperation rate, and any peri- or postoperative complications. MEDLINE, Embase, and Scopus were searched for empirical studies on MTD for FLLDH, reporting pain or mobility outcomes. Data extracted included study design, participant characteristics, pre- and postmean scores for pain and mobility, blood loss, operation time, hospitalization duration, reherniation rate, and complications. Articles were quality appraised using Joanna Briggs Institute (JBI) quality appraisal tools. Of 271 articles identified, 15 were included. Preoperative leg pain scores ranged from 5.5 to 8.6, and postoperative scores ranged from 1.2 to 3.8. For lower back pain, preoperative scores ranged from 2.4 to 7.6, with postoperative scores from 1 to 4.8. Seven studies assessed mobility using the ODI, reporting significant improvements; pre-operative scores ranged from 30.6 to 56.7, and postoperative scores ranged from 5.5 to 30.3. Seven studies used the Modified MacNab criteria, reporting excellent outcomes in 18.2%-71% of patients, good in 23%-54.5%, fair in 0%-18.2%, and poor in 0%-18%. Mean blood loss ranged from 30 to 70 mL, mean operation times from 43 to 126 min, and average hospital stays were, on average, ≤ 4 days. Reherniation was minimal, and the reoperation rate was low. Complications were rare, primarily transient neuropraxic symptoms. This review comprehensively synthesized empirical research on the effectiveness and safety of MTD for treating FLLDH. Overall, the findings indicate that MTD can reduce pain and improve mobility in patients with FLLDH, but limited sample sizes, variable follow-up periods, and a lack of controlled studies constrain definitive conclusions about MTD's superiority over other discectomy techniques. PROSPERO registration number: CRD42023443900.

Introduction: Patients with chronic obstructive pulmonary disease (COPD) and femoral neck fractures are at high risk for postoperative complications and mortality. One consideration to reduce risk is the type of anesthesia, although this has not been investigated. The purpose of this study was to compare 30-day complications between use of general and spinal anesthetic in patients with COPD and femoral neck fractures who underwent hip arthroplasty.

Methods: Patients with COPD treated with hip arthroplasty for femoral neck fractures were identified on the American College of Surgeons' National Surgical Quality Improvement Program (ACS-NSQIP) database between January 1, 2015 and December 31, 2020. Demographics, patient variables, and surgical variables were recorded. Patients were divided into cohorts based on general or spinal anesthetic. Propensity score matching was used to match the two groups. Thirty-day outcome measures were compared between groups using chi-squared test. Logistic regression was used to assess for risk factors for 30-day complications.

Results: Five thousand and forty patients with COPD were identified who underwent arthroplasty for femoral neck fracture-3800 with general anesthesia and 1240 patients with spinal anesthesia. The general anesthesia cohort had higher rates of diabetes (18.4% vs. 15.1%, p = 0.007), congestive heart failure (10.7% vs. 6.7%, p < 0.001), and chronic kidney disease requiring dialysis (2.6% vs. 1.5%. p = 0.019). After matching, the general anesthesia cohort had higher rates of mortality (8.4% vs. 5.8%, p = 0.042), nonhome discharge (85.5% vs. 79.2%, p < 0.001), and unplanned intubation (1.9% vs. 0.7%, p = 0.048). Logistic regression identified general anesthesia to be an independent risk factor for 30-day mortality (RR 1.514 [1.022-2.245]), nonhome discharge (1.626 [1.237-2.138]), and unplanned intubation (RR 1.488 [1.012-2.187]).

Conclusions: General anesthesia is an independent risk factor for 30-day mortality, nonhome discharge, and unplanned intubation in patients with COPD undergoing arthroplasty procedures for femoral neck fractures. If possible, spinal anesthetic should be considered as it may reduce the risk of complications in this patient population.

This scoping review summarizes the evidence regarding sociodemographic disparities in long-term ( $\ge$ 6 months postoperative) functional outcomes after total hip and knee arthroplasty (THA/TKA). Five databases were searched by a librarian. US-based original research articles that reported on long-term functional outcomes after THA/TKA by sex, race, ethnicity, socioeconomic status, and/or geography were included. Seventy-nine articles met inclusion criteria. Fifty-four articles reported on sex disparities, with 60% of post-THA and 51% of post-TKA outcomes finding that men had a better long-term functional outcome than women. Across the 34 articles and 72 outcomes that examined the variable of race or ethnicity, 63% of post-THA outcomes and 69% of post-TKA outcomes found White patients had better long-term function compared to minoritized patients. In the 24 articles and 47 outcomes that examined socioeconomic status (SES) in relation to long-term function, 63% of post-THA and 71% of post-TKA outcomes indicated higher SES was associated with better long-term function. Only 3 of the 79 studies looked at geography. None found significant disparities. The evidence from our sample shows that disparities in long-term functional outcomes post-THA/TKA likely exist for different racial, ethnic, and socioeconomic groups. There is a lack of data on smaller racial and ethnic minority populations, rural communities, and the way sociodemographic variables may interact with one another. Comparisons across studies were limited due to variation in the outcome measures used and length of follow-up. Additional research should identify patients at risk of decreased long-term function after THA/TKA and protocols to enhance their functional recovery.

Objectives: Total hip arthroplasty (THA) with Ceramic-on-Ceramic (CoC) components achieved excellent outcomes. However, the long-term outcomes of anatomic and tapered stems are controversial in clinical practice, and the difference in the survival rates between the tapered stems and anatomical stems over the long term remains unknown.

Methods: A retrospective cohort study was performed to evaluate the 11-year follow-up outcomes of anatomic and tapered femoral stems. Between January 2009 and December 2011, a total of 1438 patients with COC were included in this study initially. Among these hips, 30 patients (30 hips) experienced death, and 254 hips (17.6%) were lost to follow-up. Finally, a total of 591 hips with Corail stem and a total of 334 hips with Ribbed stems were included in this study. The outcomes were evaluated by the modified Harris hip score (mHHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a questionnaire assessing articular noises.

Results: For the Corail stem, the survival rate with aseptic loosening or revision of any component for any reason as the endpoint was 99.1% at 11 years. The survival rate with reoperation for any reason as the endpoint was 98.8% at 11 years. For the Ribbed stem, the survival rate with aseptic loosening or revision of any component for any reason as the endpoint was 98.8% at 11 years. In patients with the Corail stem, the preoperative modified Harris hip score (mHHS) score, with a mean of 43.8 points, significantly improved to a mean of 93.5 points at the final follow-up assessment (p < 0.001). In patients with the ribbed stem, the preoperative mHHS score, with a mean of 40.9 points, significantly improved to a mean of 92.8 points at the final follow-up assessment (p < 0.001) during the follow-up period. The incidence of squeaking and squaking in the Corail group was significantly higher than that in the ribbed group (squeaking: 22.7% vs. 6.9%; squaking: 17.4% vs. 4.2%). The incidence of postoperative thigh pain was 4% in patients with the Corail stem, significantly lower than that in patients with the ribbed stem (17.4% vs. 4%; p < 0.001).

Conclusion: In conclusion, CoC THA with Corail and Ribbed stems exhibits excellent clinical outcomes at the long-term follow-up. However, the incidence of postoperative thigh pain in the Ribbed group is significantly higher than that in the Corail group, while the incidence of squeaking was lower.

Objectives: Multiple imaging criteria are available for assessing fusion following anterior cervical discectomy and fusion (ACDF). In clinical trials, the 3-month postoperative follow-up serves as a critical timepoint for evaluating the efficacy of interventions on accelerating the fusion process. This study aims to determine how applying different fusion criteria influences the conclusions of a comparative analysis.

Methods: Patients aged 18 or older who underwent ACDF with allograft or beta-tricalcium phosphate artificial bone between C3 and C7 were reviewed from 1 April 2023 to 30 September 2023. Fusion rates between the two grafts at three-month follow-up were compared under different criteria. Fusion status was judged by CT or dynamic radiographs, or their combinations. Cut-offs of dynamic indicators included angle changes of 4°, 3°, and 2°, and interspinous motion of 3, 2, and 1 mm. Criteria were applied singly, combined in pairs, or combined in groups of three, leading to a total of 31 criteria. Student's t-test and Chi-squared test were employed, and Cohen's kappa coefficient and phi coefficient were calculated.

Results: Ninety-eight segments were included. Twenty-five criteria yielded higher fusion rates for artificial bone, with 7 out of 25 reaching statistical significance (p < 0.05). The remaining six criteria led to a reversed result, but none reached significance (p > 0.05). The agreement and correlation between CT and dynamic criteria were poor (kappa and phi < 0.200). In contrast, the agreement and correlation between two dynamic indicators were better, and even being close to moderate (kappa = 0.398, phi = 0.398) between 3° and 2 mm.

Conclusion: Changes in fusion criteria affected result significance but did not produce conflicting conclusions. There was a significant disagreement between the results under CT and dynamic radiographs criteria. Thresholds of 3° or 2 mm can be optimal choices for dynamic criteria.

Objective: Surgical management of cervical spinal fractures accompanying ankylosing spondylitis (ASCSF) is intractable in clinical practice. There is still debate about whether surgery by a single-anterior approach is enough for treating ASCSF. The purpose of this study is to summarize and share relevant experience and lessons from both our team and the literature.

Methods: Patients referred to our center for ASCSF following single-anterior surgery (from January 2008 to December 2020) were distinguished and enrolled. In addition, literature published from 2000 to 2021 on PubMed and Web of Science databases was systematically reviewed.

Results: A total of 63 patients (7 from our center and 56 from the literature) who underwent single-anterior surgery for treating ASCSF were brought into this study. The average follow-up time of patients in our center is 44 months. The average age of all patients was 58.6. C6/7 was the most commonly injured level (22 patients, 34.9%), and 44 patients (69.8%) experienced neurological impairment at admission. Most ASCSF patients have lordotic cervical alignment and minimal displacement of the fracture. A total of 8 patients died at an early stage after surgery. Apart from these 8 cases, the incidence rates of general complications and surgical complications were relatively 10.9% and 20.0% respectively. The incidence analysis revealed pneumonia (5.45%) as the predominant general complication, contrasting with implant failure (14.55%), which emerged as the most common surgical complication. Among the 8 cases (14.55%) demonstrating implant failure, radiographic analysis revealed preserved cervical lordosis in 4 patients (50%), kyphotic deformity in 1 patient (12.5%), while cervical alignment data were unavailable for the remaining 3 cases (37.5%). Moreover, 29 patients (52.7%) achieved improvement, and 18 patients (37.5%) maintained stable neurological function.

Conclusions: For most ASCSF patients with preserved lordotic alignment and minimal displacement, a single anterior surgery can achieve significant neurological improvement and result in a relatively lower incidence of complications. This provides a good basis for orthopedic physicians to handle cervical spine trauma patients with ankylosing spondylitis.

Objective: Glucocorticoid-induced osteonecrosis of the femoral head (GC-ONFH) represents a devastating complication of steroid therapy, primarily driven by osteoblast apoptosis and impaired osteogenesis. Although selenium (Se) is renowned for its potent bone-protective properties, its therapeutic potential, and specific mechanisms in GC-ONFH remain largely unexplored and thus require further investigation.

Methods: To assess the therapeutic effectiveness of oral selenium supplementation in GC-ONFH, a rat model of GC-ONFH was utilized. The rats were randomly allocated into three groups (n = 6 per group): (1) Control group, (2) Methylprednisolone sodium succinate (MPS) group, and (3) Se group. The intervention was carried out for 4 weeks. In vitro experiments utilized primary rat osteoblasts and MC3T3-E1 cells to elucidate the mechanisms through which selenium mitigates dexamethasone (DEX)-induced alterations in cell proliferation, apoptosis, and osteogenic differentiation. The assessments were conducted using micro-CT and histomorphometry, CCK-8 assays and flow cytometry, as well as RT-qPCR, Western blotting, and immunofluorescence.

Results: Selenium supplementation effectively prevented trabecular collapse and significantly reduced the number of empty lacunae in rats with GC-ONFH. Specifically, an optimal dose of 10 μmol Se successfully reversed the damage induced by DEX, including the restoration of cell proliferation, suppression of apoptosis, and rescue of osteogenic activity. Mechanistically, Se counteracts the DEX-induced suppression of phosphorylated phosphatidylinositol 3-kinase (p-PI3K), phosphorylated protein kinase B (p-AKT), and phosphorylated glycogen synthase kinase 3β (GSK3β) (p-GSK3β), thereby activating the PI3K/AKT/GSK3β signaling pathway, which promotes cell proliferation, inhibits apoptosis, and enhances osteogenesis in osteoblasts.

Conclusion: Selenium can activate the PI3K/AKT/GSK3β pathway, reverse DEX-induced hypoproliferation and apoptosis, restore osteogenic capacity, prevent trabecular collapse, and attenuate GC-ONFH in rat models. Our findings demonstrate that selenium supplementation can be regarded as a clinically applicable strategy for impeding the progression of GC-ONFH in at-risk patients.

Objective: Tumor-induced osteomalacia with the culprit tumor located in the knee joint is rare in clinical practice, and previous literature has only been seen in case reports, which pose great challenges to the clinical diagnosis and treatment of such patients. The purpose is to elucidate clinical characteristics and orthopedic surgical treatment experience of tumor-induced osteomalacia (TIO) with causative tumor located in the knee joint region.

Methods: Clinical data of all consecutive TIO patients with culprit tumors located in the knee joint region was retrospectively analyzed. All patients were surgically treated by an orthopedic bone and soft tissue tumor sub-professional team at Peking Union Medical College Hospital from January 2015 to January 2025. The clinical distribution feature and surgical effects were analyzed, and clinical practice experience was presented.

Results: All nine patients were included in this study. All patients exhibited varying degrees of bone pain and 100% (9/9) of the patients had limited mobility, often accompanied by difficulties in sitting up, walking, and weakness or fatigue. Approximately 44.4% (4/9) of the patients had significantly shorter height after initial symptoms appeared. All patients underwent a total of 10 operations to control the causative tumors in the knee joint region. Culprit tumors were located in the patella (one case), infrapatellar fat pad (three cases), suprapatellar capsule (one case), popliteal fossa (three cases), and the entire knee joint (one case), respectively. There was only one case of skeletal involvement, one case with involvement of bones and soft tissues, and seven cases with soft tissue causative tumors. All the patients had a gradual increase in blood phosphorus levels in the short term after the first orthopedic surgery, after a follow-up of 12 months to 10 years. During the follow-up, no patients experienced recurrence.

Conclusion: The causative tumor for TIO in the knee joint region is hidden and has diverse locations; however, there is no established orthopedic surgical intervention strategy for these rare entities in clinical practice. Due to the unique anatomical location and complex structure of the knee joint, orthopedic surgeons can adopt different surgical approaches to completely remove the causative tumor. For these patients, the prognosis is satisfactory after complete tumor resection, and the condition can be effectively improved. These findings may help to improve the clinical diagnosis and treatment level of orthopedic physicians for this rare entity.

Objectives: Obesity has an important impact on the future of total joint arthroplasty (TKA). We aimed to determine whether waist-to-hip ratio (WHR) is a useful measurement in predicting postoperative outcomes associated with obesity in patients undergoing primary TKA and compared the predictive value of WHR to that of body mass index (BMI).

Methods: Prospective data from patients undergoing unilateral primary TKA from February to May 2024 were analyzed, including BMI and WHR. Outcomes included complications, hospitalization details, and 12-month patient-reported function (University of California, Los Angeles [UCLA] activity scale, the Hospital for Special Surgery [HSS] score). Multivariable regression models were used to identify significant obesity-related predictors of outcomes.

Results: A total of 195 patients were included, with the mean BMI of 28.2 ± 5.2 kg/m² (range: 17.6-40.8) and the mean WHR of 1.03 ± 0.08 (range: 0.83-1.27). WHR was a significant predictor of wound complication (OR: 1.087, p = 0.016). Both WHR (OR: 1.153, p = 0.004) and BMI (OR: 1.058, p = 0.021) independently predicted systemic complications, with WHR explaining greater variance ( R ²  = 0.241 vs. 0.107 for BMI). For functional outcomes, higher WHR was associated with poorer UCLA activity scores (RR: 0.877, p = 0.012) and HSS function scores (RR: 0.921, p < 0.001), whereas BMI only showed significance for HSS function scores (RR: 0.960, p = 0.002). WHR again explained more variance in HSS function scores ( R ²  = 0.233 vs. 0.124). In contrast, neither WHR nor BMI correlated with surgical records, hospitalization days, or HSS pain scores (all p > 0.05).

Conclusions: The WHR demonstrates superior predictive value over BMI for perioperative complications and 12-month patient-reported functional outcomes following primary TKA. Preoperative WHR assessment may help surgeons improve risk stratification and better educate obese patients regarding postoperative expectations prior to elective TKA.

Objective: To evaluate the surgical efficacy of repeated vertebral column resection (Re-VCR) after instrumentation removal in congenital scoliosis (CS) patients previously undergoing primary posterior spinal correction with VCR, and to analyze complications pertinent to revision surgery.

Methods: In this retrospective cross-sectional study, a total of 16 CS patients who underwent Re-VCR following instrumentation removal between February 2013 and February 2022 were reviewed. Radiographic parameters were assessed pre- and post-primary operation, pre-removal, pre- and post-revision and at the last follow-up. Clinical data were also analyzed and recorded for each patient.

Results: The indications for instrumentation removal were infection, implant failure, patient and family request, and persistent pain. The Cobb angle of the main curve, global kyphosis (GK), coronal balance (CB) and sagittal vertical axis (SVA) significantly progressed after instrumentation removal. The average progression rates of scoliosis and kyphosis were 5.3° ± 4.0°/year and 10.0° ± 7.2°/year. Following revision surgery, the Cobb angle of the main curve, GK, CB showed significant improvement (t = 10.694, p < 0.001; Z = -3.516, p < 0.001; Z = -2.664, p = 0.008). For Re-VCR, the average extension of the fusion level was 2.9 ± 1.4 vertebrae proximally, 3.0 (2.0, 3.0) vertebrae distally and 5.4 ± 1.6 vertebrae in total. The average correction rates of the Cobb angle of the main curve and GK were 59.5% ± 23.4% and 53.7% ± 18.3% with no significant correction loss during follow-up (p > 0.05). Compared with pre-revision, the mean scores of pain, satisfaction, mental health and self-image on the Scoliosis Research Society-22 (SRS-22) questionnaire improved at different levels. Intra-revision complications included alert of neurophysiological monitoring and dural tear, while breakage of the distal L5 pedicle screw occurred in 1 (6.3%) patient 2 years after revision.

Conclusions: Severe progression of deformity and trunk imbalance was frequently observed following instrumentation removal. The removal of instrumentation is not routinely recommended, and revision surgery employing Re-VCR frequently necessitates an extension of the fusion level. Satisfactory radiographic and clinical outcomes following Re-VCR were effectively maintained throughout the follow-up period, but great caution should be exercised during Re-VCR.