Orthopedic Research and Reviews最新文献

Background: Musculoskeletal (MSK) complaints are among the most common reasons for visits to primary care and outpatient clinics. While many cases are attributed to identifiable pathology, a significant proportion of patients present with persistent MSK symptoms despite normal physical examinations and imaging findings. These presentations pose diagnostic and management challenges and often result in patient frustration, clinician uncertainty, and overutilization of healthcare resources.

Objective: This narrative review aims to provide a comprehensive, evidence-informed, and practical framework for clinicians to evaluate and manage patients with MSK complaints in the absence of clear diagnostic abnormalities.

Methods: A targeted narrative review was performed using PubMed, MEDLINE, and major international clinical guidelines to identify relevant literature on the evaluation and management of musculoskeletal (MSK) pain without objective abnormalities. Evidence and expert consensus were synthesized into a biopsychosocial diagnostic and management framework specifically tailored for primary care and general outpatient settings.

Key findings: The review underscores the importance of empathetic communication, structured clinical assessment, and early exclusion of serious pathology. It presents a broad differential diagnosis encompassing mechanical, neuropathic, nociplastic, referred, and functional pain mechanisms. Management strategies are organized across key domains, including watchful follow-up, patient education, graded physical activity, stress and lifestyle management, psychosocial and occupational support, and functional goal setting. Pharmacologic therapy-such as short-term use of paracetamol or NSAIDs, and selected antidepressants for chronic nociplastic pain-should be considered cautiously and within a multidisciplinary, shared-decision framework. Opioid use is discouraged due to limited efficacy and high potential for harm.

Conclusion: Patients presenting with MSK complaints and normal diagnostic findings benefit most from a structured, individualized, and patient-centered approach that integrates clinical reasoning, effective communication, and functional rehabilitation. Applying this framework enables clinicians to address the multidimensional nature of such presentations while avoiding unnecessary investigations or interventions.

Introduction: Carpometacarpal (CMC) joint dislocations and fracture-dislocations are infrequent and often challenging to diagnose. Among these, dorsal fracture-dislocations involving the capitate and third metacarpal, as well as the hamate with the fourth and fifth metacarpals, represent an exceptionally rare subset. These injuries are typically the result of high-energy mechanisms, such as axial loading transmitted through a clenched fist striking a solid surface. Their subtle clinical signs and often inconspicuous radiographic findings, particularly in the context of polytrauma, contribute to a high rate of missed or delayed diagnoses. This paper aims to highlight the diagnostic challenges and management considerations of these rare dorsal CMC fracture-dislocations, emphasizing the importance of clinical suspicion and appropriate imaging in ensuring timely and effective treatment.

Case presentation: We report a rare case of dorsal fracture-dislocation involving the capitate-third metacarpal and hamate-fourth/ fifth metacarpal joints. The patient sustained the injury following blunt force trauma consistent with a clenched-fist mechanism. Definitive diagnosis was made following advanced imaging, which guided successful surgical management using open reduction and internal fixation of the hamate, capitate as well as the third and fourth CMC joints with excellent post-operative result and range of motion.

Conclusion: Dorsal fracture-dislocations of the capitate-third and hamate-fourth/fifth metacarpal joints are rare but potentially debilitating. Early recognition through careful clinical evaluation and targeted imaging is critical to prevent chronic pain, stiffness, and impaired hand function.

Introduction: Elbow ulnar collateral ligament (UCL) injuries can cause pain and decreased performance for the overhead athlete. Platelet-rich plasma (PRP) therapy is becoming more common to avoid surgery in partial UCL tears and improve return to play, but the literature is sparse regarding functional outcomes. This study aimed to characterize elbow UCL injuries among 5 collegiate baseball pitchers describe their return to play after PRP treatment, and compare dynamometry assessments before injury and after treatment.

Methods: Data from 5 Division 1 baseball pitchers who sustained low- to intermediate-grade UCL injuries determined by ultrasonography and/or magnetic resonance imaging were retrospectively reviewed. All athletes underwent one PRP injection, physical therapy, and a standardized return to play protocol as part of their treatment. Dynamometry measures were taken prior to injury (pre-season) as well as at the conclusion of the return-to-play protocol.

Results: Five consecutive baseball players with UCL injuries were evaluated. Pre-season dynamometry testing was performed on all players prior to the seasons and when they first arrived to the team. Players received PRP injections on average 36 days after their injury and started a standardized rehab program on average about 48 days after PRP. Players were cleared to full return to play at a mean 174 days post-injury. Follow-up examination at that time demonstrated full range of motion of the elbow without tenderness to palpation over the UCL for all athletes. All athletes were able to continue to play at the same level of competition as before the injury occurred without any complaints. No players had repeat injuries during the same or following seasons. Comparing pre-injury to clearance dynamometry, external rotation measures on average slightly decreased from 194 to 190 Newtons while grip strength increased from 586 to 646 Newtons, on average.

Conclusion: Successful return to play was possible in 5 collegiate baseball pitchers after nonoperative treatment including injection of PRP at a mean 174 days following injury. PRP treatment gives promising results in low and intermediate partial UCL injury. Performance metrics including external rotation and grip strength were consistent pre-injury and upon clearance.

A drop foot is characterized by the inability to lift the foot. If caused by common peroneal nerve (CPN) compression and conservative treatment is unsuccessful, a neurolysis may be considered. Studies suggest that a short period of time between start of symptoms and neurolysis is related to success. Aim of the present study is to report on 3 patients who underwent CPN neurolysis up to 72 months after the onset of a drop foot. The first patient was a 22-year-old female who sustained a painless left-sided drop foot after prolonged kneeling that was treated with a brace. One year later she developed severe anterolateral neuropathic lower leg pain not responding to medication. CPN neurolysis 14 months after the event resulted in complete pain relief and normal foot function that persists after two years of follow up. The second patient was a 58-year-old female with a 6-year history of chronic left-sided neuropathic lower leg pain and drop foot due to CPN damage following multiple knee surgeries. Three months after surgical CPN decompression, she reported pain relief and partial foot drop recovery. However, the painful drop foot recurred 5 months later, likely due to ongoing knee instability. Two years later, her situation is unchanged. The third patient was a 65-year-old male with spontaneous right-sided drop foot and severe neuropathic lower leg pain that had developed following intense walking for body weight reduction. As conservative treatment was unsuccessful, he chose to undergo CPN decompression 8 months later. Foot function recovered with total pain relief within the first 3 months postoperatively. Ten years later, he is still without symptoms. These cases illustrate that surgical decompression for drop foot may reduce symptoms, even in chronic cases. Neurolysis should be considered in selected cases, particularly if the drop foot is associated with unacceptable neuropathic pain.

Ankylosing spondylitis (AS) is a long-lasting autoimmune disorder marked by inflammatory processes affecting the spinal column and sacroiliac joints, alongside abnormal bone growth. This review aims to summarize the mechanisms underlying pathological new bone formation in AS, focusing on key cell types, molecular pathways, and their roles in disease progression. We will discuss the interplay between osteoblasts and osteoclasts, the cytokines and signaling pathways that influence new bone formation, and how recent research findings contribute to our understanding of this complex process. Through a comprehensive analysis of relevant literature, this review seeks to provide a theoretical foundation and direction for future therapeutic strategies.

Purpose: This report discusses a rare case of a vertebral artery that runs above the articular pillars of the cervical vertebrae.

Methods: A 19-year-old male patient presented after a fall due to paroxysmal dizziness and gait abnormalities, and underwent cervical computed tomography angiography (CTA) for preoperative assessment before posterior cervical surgery.

Results: Through cervical CTA imaging, we unexpectedly discovered two variant vertebral arteries positioned superficial to the articular pillars of the cervical vertebrae.

Conclusion: This rare case emphasizes the importance of vascular evaluation prior to cervical surgery. CTA imaging is necessary before patients requiring posterior cervical surgery. This unusual vertebral artery may have contributed to the patient's symptoms.

Background: The number of female doctors graduating from medical schools worldwide is increasing; however, orthopedic surgery remains one of the least gender-diverse surgical fields.

Objective: This scoping review aims to map the literature on the challenges faced by female orthopedic surgeons, categorize them into key domains, and identify essential gaps to guide future research and institutional reform.

Methods: A scoping review study design was employed, utilizing the Arksey and O'Malley framework. PubMed, Scopus, and Web of Science were searched for articles published between January 2000 and 2024. Papers that addressed challenges faced by female orthopedic residents and surgeons were included; of the studies screened, 92 met the inclusion criteria.

Results: Challenges were discussed in three main domains: female representation, the health and occupational risks, and the emotional environment. Approximately 23 challenges were identified. While the increase in female representation in orthopedic surgery more than doubled between 2000 and 2020, gender disparity persists. Musculoskeletal injuries were identified as the most common occupational health concern. Microaggressions were described in several forms: verbal comments, assumptions about skills, traditional role stereotypes, sexist language, and exclusion from informal networks.

Limitations: The study's limitations include unexplored multiple challenges due to the limited availability of data, such as unequal pay, patient preferences, and military orthopedic care. Most of the included studies were cross-sectional surveys, which limits generalizability and causal inference.

Conclusion: This review highlights the persistent gender-related challenges in the field of orthopedic surgery. Initiatives for mentorship and representation are in place and appear promising. Nonetheless, challenges related to occupational safety, well-being support, and leadership roles remain inadequately addressed. Future efforts must prioritize mentorship, ergonomic equipment design, strategies to address microaggressions, and institutional commitment to support female orthopedic surgeons.

Background: The bikini incision (BI) used in direct anterior approach total hip arthroplasty (DAA THA) theoretically improves scar aesthetics by utilizing the inguinal crease; however, current literature suggests its transverse orientation increases the risk of injury to the lateral femoral cutaneous nerve (LFCN). This study examines (1) patient and surgeon satisfaction with scar appearance and (2) differences in post-operative LFCN sensation between the vertical, traditional incision (TI) and the BI.

Questions/purposes: In this pilot study, the following questions were investigated: (1) Do BI patients experience increased scar satisfaction compared to TI patients? (2) Does the surgeon report greater satisfaction with BI scars compared to TI scars? (3) Do BI patients have a reduced incidence of LFCN sensory disturbance compared to TI patients?.

Patients and methods: Fifty-five patients (32 TI and 23 BI), at least 6 months post-DAA THA, were recruited from a high-volume, fellowship-trained reconstruction surgeon. 91% of the BI group was female, compared to 50% of the TI group. The Patient and Observer Scar Assessment Scale (POSAS) allowed patients to describe scar appearance and complications (eg, pain and itchiness) and enabled the surgeon to assess vascularity, pigmentation, thickness, relief, pliability, and surface area. Monofilament testing at superomedial, superolateral, inferomedial, and inferolateral quadrants of the anterior thigh assessed LFCN hypoesthesia.

Results: POSAS analysis demonstrated that (1) BI patients were significantly more satisfied with scar appearance than TI patients (p < 0.05), and (2) the surgeon was significantly more satisfied with BI scars than TI scars (p < 0.05). (3) Monofilament testing showed significantly more LFCN impairment in the inferomedial quadrant of the TI group (p < 0.0125).

Conclusion: This study demonstrates improved patient and surgeon satisfaction with the BI. Contrary to current beliefs, the BI better preserves LFCN innervation relative to the TI.

Treatment guidelines for open tibial fractures are well established in high-income countries, but their implementation in low-resource settings remains challenging. To date, only one African country has attempted to formulate national, consensus-based guidelines that cover key aspects such as antibiotic administration, initial stabilization, surgical debridement, wound management, and definitive fixation. This narrative review summarizes current principles for the initial management of open tibial shaft fractures and evaluates their relevance in the Southern African context, particularly in rural and resource-constrained environments. Given the limited availability of advanced imaging, specialized implants, and soft-tissue coverage expertise, clinicians must adapt existing protocols to local capacities. This review highlights areas where treatment recommendations from high-income settings may not be feasible and identifies practical considerations for applying initial management principles in Southern Africa. The need for context-specific, resource-appropriate guidelines is emphasized.

Objective: The incidence of total shoulder arthroplasty (TSA) in the United States continues to climb as an aging yet active population increases demand for the procedure. Due to promising clinical results out of Europe, improvement in prosthesis design, and wider acceptance of reverse total shoulder arthroplasty (rTSA), this study was designed to evaluate how rTSA and anatomical TSA (aTSA) utilization, patient selection, and length of stay have changed at a single institution.

Methods: This was a retrospective cohort study of patients from one hospital system between 2017 and 2023. Inclusion criteria included primary TSA cases using CPT codes. Exclusion criteria included hemiarthroplasty, revision arthroplasty, non-arthroplasty procedures. Primary arthroplasty procedures were separated into reverse or anatomic cohorts for analysis. Independent sample t-tests were used to compare continuous data between the first and last year of cohort data and to compare parameters between procedure types. Chi-square analysis was used for frequency-based data comparisons. Type-I error was set at α=0.05 for all analyses.

Results: From all 2774 shoulder arthroplasty cases identified, 2604 TSA cases were included in the final statistical analyses, 2114 of which were rTSA and 490 anatomic TSA. Comparison of arthroplasties in 2017 and 2023 revealed, rTSA increased from 115 surgery cases to 549, or 77.18% to 82.81% over the study period (p < 0.001). Anatomic TSA increased in total surgery cases from 29 to 111, (p = 0.655) and thus signifies an overall decrease in anatomic surgery utilization from 19.46% to 16.74%. Data showed an increase in average patient age for rTSA and decreased procedure time and length of stay for both groups.

Conclusion: rTSA utilization has surpassed and continues to increase relative to anatomic TSA. Peri-operative management of shoulder replacement has become more efficient with significantly decreased procedure time and decreased total hospital length of stay after primary TSA.