Orthopaedic Surgery最新文献

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.

This study provides one of the most extensive long-term follow-up analyses of unplanned revisions following 3CO for spinal deformities, with a mean follow-up duration of 9.8 years, which has been underexplored in prior research. The findings provide critical data for preoperative discussions with patients and their families regarding the risks of unplanned reoperation. Additionally, the study highlights the need for long-term surveillance and proactive strategies to mitigate revision risks, particularly in patients undergoing multilevel 3CO.

Objective: Chronic exertional compartment syndrome (CECS) of the forearm is a rare and underdiagnosed condition that mainly affects young athletes. Minimally invasive endoscopic surgical treatment has been shown to reduce complication rates and allow for an expedited return to activity. Evidence on the outcomes of single-portal endoscopic fasciotomy for forearm CECS remains limited. The aim of this study was to describe the results of single-portal endoscopic-assisted fasciotomy in treating forearm CECS.

Methods: A total of 17 patients (21 forearms) diagnosed with forearm CECS and treated with single-portal endoscopic-assisted fasciotomy were included in this study. Intracompartmental pressure was preoperatively measured at rest, on exertion, and at 5 min postexertion. Additionally, pain intensity and physical function were evaluated using the visual analog scale (VAS) and the Disability of Arm, Shoulder, and Hand (DASH) questionnaire, respectively, before surgery and 4 weeks after surgery.

Results: Preoperative assessments revealed a mean intracompartmental pressure of 15.7 ± 1.5 mmHg at rest, 77.7 ± 3.8 mmHg on exertion, and 22.9 ± 2.3 mmHg at 5 min postexertion. The mean preoperative VAS score was 7.6 ± 1.1, which dropped to 0.1 ± 0.35 after surgery. The mean DASH score was 29.8 ± 3.0 preoperatively and 4.6 ± 2.4 postoperatively. Both VAS and DASH scores were significantly lower after surgery (paired t test, p < 0.001). No major adverse effects were reported. Patients returned to light cycling at an average of 10 ± 3.8 days and resumed usual daily activities within 18.2 ± 1.9 days on average.

Conclusions: Endoscopic compartment decompression through a single port proved to be an effective and safe surgical treatment technique in patients with forearm CECS, thus deserving serious consideration as a replacement for classic fasciotomy.

Level of evidence: III.

Objective: Intraoperative femoral condylar avulsion fractures during total knee arthroplasty (TKA) are rare but potentially lead to joint instability and poor outcomes if not properly managed. However, the necessity of using condylar-constrained prostheses in these cases remains controversial. This retrospective study examines the incidence, management approaches, and radiological outcomes of these fractures.

Methods: A total of 47 patients (11 males, 36 females; mean age 67.1 ± 7.0 years) with femoral condylar avulsion fractures were identified from 4290 TKAs performed between January 2008 and December 2022, matched with nonfracture patients at a 1:1 ratio by age, gender, and BMI. Intraoperative fractures were treated using cancellous bone screws or nonabsorbable sutures based on the size of the fracture fragment, without the insertion of condylar constrained prostheses. All patients underwent outpatient follow-up, with data collected on preoperative diagnosis, body mass index (BMI), knee range of motion (ROM), and type of prosthesis used. Key radiological indicators assessed included proximal tibia varus angle (PTVA), distal femoral valgus angle (DFVA), joint line congruence angle (JLCA), hip-knee-ankle angle (HKA), and preoperative subluxation status.

Results: The incidence of femoral condylar avulsion fracture in primary TKA was found to be 1.1%. Over a follow-up period of 1.5-3 years, no instability was noted in any patients. Significant differences were observed between fracture and nonfracture groups in PTVA (82.02 ± 3.39 vs. 85.32 ± 1.87, p = 0.01), DFVA (85.53 ± 2.73 vs. 87.51 ± 5.29, p = 0.02), and HKA (8.81 ± 3.30 vs. 6.53 ± 2.21, p = 0.01). However, the Knee Society Score (KSS) at last follow-up showed no statistical difference (p = 0.05).

Conclusion: Femoral condylar avulsion fractures during primary TKA may be linked to joint deformities. Fixation methods using cancellous bone screws or nonabsorbable sutures, combined with a hinged knee brace, resulted in favorable clinical and radiological outcomes, with no need for prosthesis modification.

Objectives: Femoral component rotation affects knee function and component survival in total knee arthroplasty (TKA). However, the presence of posterior femoral condylar cartilage leads to discrepancies in the femoral posterior condylar axis (PCA) between robotic-assisted TKA and manual TKA. The purpose of this study was to investigate the relationship between the discrepancy in thickness of the medial and lateral posterior femoral condylar cartilage and the discrepancy between robotic-assisted and manual rotation of the femoral component.

Methods: In the computed tomography (CT) modeling simulation section, we retrospectively reviewed a total of 18 preoperative knee CT scans of patients who underwent robotic-assisted TKA with different femoral prosthesis sizes between January 2022 and January 2023 to measure the mean posterior femoral condylar distance between femurs of different sizes. In the prospective clinical study section, we prospectively measured the cartilage thickness of the medial and lateral posterior condyles in 60 patients who underwent Mako-assisted TKA between October 2023 and December 2024.

Results: According to our mathematical model of the difference between robotic and manual femoral component rotation in the presence of different femoral sizes and differences in medial and lateral posterior condyle cartilage thicknesses, the maximum value of angular discrepancy of PCA was 4.02° and the minimum value was 1.13°. The average cartilage thickness difference between the medial and lateral posterior femoral condyles was 0.29 ± 0.97 mm (-2.00 to 2.10 mm). The mean difference in femoral component rotation between robotic and manual TKA was 0.35° ± 1.21° (-2.61° to 2.82°).

Conclusion: For most patients with posterior femoral condylar cartilage, the PCA determined by robotic-assisted surgery was greater than that determined manually. Therefore, when surgeons perform TKA with robotic assistance, it is important to be aware of this discrepancy in femoral component rotation to avoid complications such as poor component survival due to inadequate rotation of the femoral component.

Objective: The etiology of adjacent segment diseases and proximal junctional kyphosis has been related to biomechanical alterations after spinal operation. This study investigated the variation in pre- and postoperative range of motion in adjacent segments in patients with degenerative lumbar scoliosis (DLS) following posterior lumbar interbody fusion.

Patients and methods: Eight patients with symptomatic DLS were analyzed using a biplane radiographic imaging system while adopting different postures. Synchronized biplane radiographs from L1 to S1 and the motions of each vertebra were acquired pre- and postoperatively. Six degrees of freedom (DOF) of kinematic data were compared between different postoperative pelvic incidence-lumbar lordosis (PI-LL) groups (group A: PI-LL = -10°-~10°; group B: PI-LL = 10°-~20°).

Results: After surgery, the axial rotational movement (primary rotation) during flexion-extension, bending, and torsion in the first adjacent segment at L3-4 decreased significantly in three patients (8.14 ± 2.78 vs. 15.13 ± 6.71; 8.36 ± 5.59 vs. 9.08 ± 3.57; 5.07 ± 0.56 vs. 9.25 ± 5.06). At this level, the torsion around the crania-caudal (CC) axis during bending (1.48 ± 1.01 vs. 7.05 ± 5.84, p < 0.05) and flexion around the mediolateral (ML) axis and bending rotation around the anterioposterior (AP) axis during torsion decreased postoperatively (6.37 ± 6.01 vs. 13.83 ± 8.12, 4.53 ± 1.97 vs. 13.06 ± 6.65; p < 0.05, p < 0.05). After surgery, in the L1-2 segment, translation along the ML direction decreased during bending (3.69 ± 2.12 vs. 14.76 ± 7.99, p < 0.05). In the adjacent L5-S1 segment, primary flexed rotation around the ML axis increased in group B postoperatively during flexion-extension, but decreased in group A (6.08 ± 1.17 vs. -13.41 ± 2.99, p < 0.05). Coupled flexed rotation around the ML axis decreased and showed the opposite trend during bending (-10.76 ± 5.51 vs. 18.12 ± 39.83, p < 0.05).

Conclusions: Postoperative coupled motion at the adjacent segment decreased, which indicates an improved balance of the spinal order compared to before the surgery. However, primary motion changed according to the location of the upper instrumented vertebrae. Our results indicate that postoperative PI-LL values between 10° and 20° were associated with lower coupled motion and higher primary motion at L5-S1.

Objective: Intertrochanteric fractures (IF) in the elderly are often complicated by osteoporosis and high rates of fixation failure. Current treatment options have limitations in providing both stable fixation and early mobilization in this fragile population. This study aimed to introduce and evaluate a novel approach, the periprosthetic femoral fracture treatment concept (PFFtc), as a surgical strategy to guide hip arthroplasty in elderly IF patients.

Methods: A retrospective analysis was conducted on 209 elderly patients (mean age: 81.6 years; range: 70-93) with IF who underwent hip arthroplasty using the PFFtc protocol between March 2014 and August 2021, comprising 133 females and 76 males. All patients underwent treatment with the "PFFtc" and were subsequently followed up at intervals of 1 month, 3 months, 6 months, 1 year, 2 years, and annually thereafter. Clinical parameters such as ASA anesthesia grading, Visual Analogue Scale (VAS) scores, Harris Hip Scores (HHS), and Short-Form 36 (SF-36) outcomes were meticulously recorded. The subsidence of the femoral stem was assessed using Pelligrini's method, while mortality rates, postoperative complications, and patient's survival status post-discharge were systematically documented. Multivariate logistic regression analysis was performed to identify independent risk factors for postoperative complications.

Results: Over a mean follow-up of 38.5 ± 6.0 months, prosthesis subsidence averaged 2.2 mm and stabilized. No deaths occurred within 30 days postoperatively. The 1- and 2-year cumulative mortality rates were 4.3% and 11%, respectively. The most common complications included DVT and urinary tract infections. Logistic regression identified hypoproteinemia (OR = 2.38, p = 0.032) and heart disease (OR = 2.74, p = 0.012) as independent risk factors for postoperative complications. At final follow-up, the mean VAS was 1.1 ± 1.0, HHS was 89.4 ± 3.9, PCS was 53.2 ± 8.5, and MCS was 50.5 ± 6.7. Among surviving patients, 63.0% lived independently at home.

Conclusion: The PFFtc-guided arthroplasty approach appears to be a safe and effective option for managing IF in elderly patients. It provides stable fixation and functional recovery of prostheses and muscles and offers a promising alternative to traditional fixation strategies.

Objective: Incorporating the sagittal stable vertebra (SSV) in posterior spinal fusion (PSF) may reduce postoperative distal junctional kyphosis (DJK) in adolescent idiopathic scoliosis (AIS), but its determination varies across reference methods and may be affected by patient posture. This study aims to investigate the SSV determined by different sagittal reference lines in predicting the risk of DJK after PSF in AIS patients.

Methods: This retrospective cohort study evaluated AIS patients with Lenke Type 1 or 2 curves treated with PSF between January 2009 and July 2017. The inclusion or exclusion of SSV in PSF based on SSV determined by different reference lines was assessed for its association with the postoperative DJK. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and odds ratio were calculated.

Results: One hundred twenty-two patients (mean age at surgery: 15.1 ± 3.2 years) were included with the incidence of postoperative DJK 6.6%. PSF with the exclusion of SSV, defined by the vertebral level at which 50% of the vertebral body was anterior to the posterior sacral vertical line (PSVL), the midline between PSVL and the C7 plumb line (PSVL-C7PL Midline), and the line connecting the center point of the C7 vertebral body and the posterior superior corner of the sacrum (C7PSL), was significantly associated with the occurrence of postoperative DJK. Among the evaluated reference lines, PSVL demonstrated numerically higher sensitivity, NPV, odds ratio, and area under the curve (AUC), although these differences in AUC did not reach statistical significance.

Conclusions: Although there are concerns about whether standing posture affects the SSV determined by a specific reference line, this study demonstrates that PSVL might be an effective and convenient reference line for identifying SSV.

Objective: This study compared the intraoperative neurophysiological monitoring (IONM) data between patients with Marfan syndrome (MFS) scoliosis undergoing posterior spinal correction surgery and those with idiopathic scoliosis (IS).

Methods: Patients diagnosed with MFS who underwent posterior spinal correction surgery between January 2018 and December 2023 were reviewed. Patients with IS who underwent posterior spinal correction surgery were randomly selected as the control group. Motor-evoked potentials (MEPs) and somatosensory-evoked potentials (SEPs) were measured separately on the convex and concave sides of the main curve. We recorded IONM failure and asymmetrical SEPs waveforms. For each patient, we assessed the apical vertebral translation, Cobb angle of the main curve, curve pattern, deformity angular ratio (DAR), and global kyphosis. Independent-sample t-test and chi-square tests were conducted to compare differences between the IS and MFS groups.

Results: We included 238 girls with IS and 118 patients with MFS scoliosis (45 men and 73 women). The rates of MEPs and SEPs were 95.4% and 93.7% in girls with IS, and 92.4% and 89.8% in patients with MFS scoliosis, respectively. In the MFS group, the average N45 latency, P37 latency, and amplitude of SEPs were 49.5 ± 3.9 ms, 39.9 ± 3.5 ms, and 2.5 ± 1.4 μV on the convex side and 50.1 ± 4.0 ms, 39.9 ± 3.5 ms, and 2.4 ± 1.3 μV on the concave side, respectively. The MEP amplitude was 731.7 ± 734.3 μV on the concave side and 854.3 ± 778.2 μV on the convex side. Patients in the IS group had lower SEP-N45 and SEP-P37 latencies than the patients in the MFS group (p < 0.001). Asymmetrical SEPs were observed in 102 patients in the IS group and 52 patients in the MFS group, respectively (p = 0.879). IONM waveform failure was identified in 21 patients in the IS group and 17 patients in the MFS group, respectively (p = 0.108). IONM failure was more likely in patients with a larger C-DAR, S-DAR, T-DAR, and Cobb angle of the main curve preoperatively (p = 0.017, 0.005, 0.001, and 0.001, respectively).

Conclusions: In patients with MFS scoliosis, the success rates of MEPs and SEPs during posterior spinal fusion were 92.4% and 89.8%. Compared to MFS patients, those with IS demonstrated shorter SEP latencies, with similar MEP and SEP amplitudes. MFS patients with higher DAR values and larger Cobb angles of the main curve preoperatively were at a higher risk of IONM failure.