Orthopedics最新文献

Previously reported cases of cauda equina herniation primarily involve compression of the spinal cord caused by fracture fragments intruding into the spinal canal following traumatic spinal burst fractures or by dural tears occurring during spinal endoscopic surgery. Such cases can often be evaluated preoperatively or intraoperatively to facilitate the selection of an appropriate treatment plan. However, cauda equina herniation resulting from the use of a drainage tube following spinal endoscopic surgery has not yet been reported. In this article, we present a case of a 76-year-old male patient who experienced a dural tear resulting in cauda equina herniation due to the positioning of the drainage tube following an L4/5 lumbar unilateral biportal endoscopy procedure. This case highlights the importance of timely surgery following cauda equina herniation and provides guidance for intraoperative procedures and perioperative management of patients undergoing spinal endoscopic surgery.

Background: Anterior cruciate ligament (ACL) injury is a major risk factor for knee osteoarthritis (OA). Although ACL reconstruction (ACLR) restores stability, it does not reliably prevent OA. This study investigated the radiographic features of patients with knee OA more than 10 years after ACLR.

Materials and methods: Thirty patients (21 female and 9 male; mean age, 45.4 ± 12.0 years) who underwent ACLR more than 10 years ago (mean postoperative period, 14.5 ± 4.0 years) were included. Standing anteroposterior radiographs of ACLR and contralateral healthy knees were evaluated for Kellgren-Lawrence (KL) grade, osteophyte width at the medial and lateral tibial and femoral surfaces, and minimum joint space width (mJSW). Lower limb alignment was assessed using medial proximal tibial angle (MPTA) and joint line convergence angle (JLCA). Subgroup analyses were based on KL grade concordance and history of partial meniscectomy.

Results: KL grades were significantly higher in ACLR knees than in contralateral knees (P < .001). Osteophyte widths were greater in ACLR knees at medial tibia (2.1 ± 1.1 mm vs 0.5 ± 0.7 mm), lateral tibia (2.3 ± 2.3 mm vs 0.5 ± 0.7 mm), medial femur (2.0 ± 1.7 mm vs 0.1 ± 0.4 mm), and lateral femur (1.4 ± 2.3 mm vs 0.2 ± 0.5 mm); all P < .001. No significant differences were observed in mJSW (P = .904), MPTA (P = .232), or JLCA (P = .681). Subgroup analyses showed similar findings.

Conclusion: Enlarged osteophytes without joint space narrowing were observed in ACLR knees, suggesting a posttraumatic OA radiographic pattern distinct from that of primary OA.

Extrapulmonary tuberculosis is relatively rare, and osteoarticular tuberculosis involving the ankle joint is particularly uncommon. We report a 10.5-year-old, previously healthy male patient who initially presented to the trauma surgery department with a 2-month history of swelling, pain, and limited mobility of the left ankle following minor trauma. Blood tests, including tests to determine blood cell counts, C-reactive protein level, and the erythrocyte sedimentation rate, bacterial and fungal cultures, and T-cell spot tests for tuberculosis (T-SPOT.TB) were performed. B-ultrasound-guided aspiration of the infected area was carried out, which included two surgeries for extensive irrigation, debridement, and drainage. A pus sample was sent for routine bacterial culture and an acid-fast bacillus test, and the bone and soft tissue samples were sent for pathological biopsy and the detection of Mycobacterium tuberculosis by sequencing and rifampicin resistance analysis. The empirical antibiotic was administered for 1 week, followed by linezolid and rifampicin for anti-infection treatment. Ten days later, the T-SPOT.TB test result was positive. Gene sequencing detected the M. tuberculosis complex at "very low levels" with no detection of rifampicin resistance, and the pathological report revealed "chronic necrotizing granulomatous inflammation." After the diagnosis of M. tuberculosis infection was confirmed, the patient was started on appropriate antituberculosis therapy with the isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) regimen, and the function of the ankle joint was followed up in the outpatient clinic. This case serves as a reminder for clinicians to consider M. tuberculosis infection in children presenting with atypical ankle swelling and pain.

Background: There is limited data on perioperative management of patients with prior stroke undergoing total hip arthroplasty (THA). This study evaluates timing for THA following stroke. We assessed (1) complications at 90 days, 1 year, and 2 years; (2) timing of stroke and THA; and (3) risk factors for periprosthetic joint infection (PJI).

Materials and methods: We retrospectively analyzed a national database to identify 35,496 THA patients. Cohorts were stratified by time from stroke to surgery: no stroke (n = 20,000), stroke within 6 months (n = 5,535), 12 months (n = 3,165), 18 months (n = 2,614), 24 months (n = 2,168), and 30 months (n = 2,014). Complication rates were compared at 90 days, 1 year, and 2 years, and multivariate analysis identified risk for PJI.

Results: Stroke within 6 months of THA was associated with higher PJI revision rates at 90 days and 2 years (all P < .046). Stroke within 18 months increased PJI revision risk across all time points (all P < .047). Several risk factors were associated with this complication, including hypertension, obesity, and tobacco use. Stroke 6 to 18 months before THA was associated with higher rates of 90-day complications, including deep vein thrombosis, cardiac arrest, and surgical site infections. Patients with stroke prior to THA had significant risks of revision for PJI and aseptic revisions at 1 and 2 years, with risks depending on time between stroke and THA (all P < .002).

Conclusion: A history of stroke increases postoperative complications after THA, particularly PJI. We recommend patients defer THA for at least 18 months following a stroke to minimize risks.

Background: Despite integration of machine learning in electronic health record (EHR) systems, accurate prediction of case time continues to present variable outcomes. This study compared the accuracy of the EHR versus surgeons in predicting operating room (OR) times.

Materials and methods: A retrospective chart review examining orthopedic case times was conducted at a level 1 trauma center. OR durations were calculated, and the difference between predicted and actual times were compared between the EHR system and surgeons. A prediction within 30% of the actual case duration was considered correct. T test and analysis of variance (ANOVA) were used to compare prediction accuracy.

Results: The EHR-predicted OR time demonstrated a 77.9% accuracy, whereas surgeon-prediction demonstrated a 48.2% accuracy. EHR-predicted OR time resulted in a sum discrepancy of a 1,007-minute underestimation with an absolute difference of 9,941 minutes; surgeon-predicted OR time resulted in a sum discrepancy of 13,014-minute underestimation with an absolute difference of 15,850. minutes. ANOVA and t tests between surgeon-predicted case time and EHR-predicted time stratified by subspecialty demonstrated significant differences between spine-joint and spine-trauma. T tests comparing differences between single-procedure cases and multi-procedure cases for both EHR- and surgeon-predicted times demonstrated significantly increased discrepancies in multi-procedure cases.

Conclusion: Although performance varied, the EHR appears to more accurately predict operating time compared to surgeons. Notably, surgeons tend to underestimate operating time. These findings support the use of the EHR when scheduling cases to improve efficiency and maximize OR use.

Calcific tendinitis of the medial collateral ligament (MCL) is an exceedingly rare cause of knee pain. We report an exceptional case of massive, refractory MCL calcific tendinitis, with a unique presentation potentially linked to an underlying malignancy. A 61-year-old female patient presented with a 3-month history of persistent left medial knee pain, unresponsive to conservative therapy. Physical examination revealed medial joint line tenderness and limited range of motion. Imaging-including radiography, 3-dimensional computed tomography, and magnetic resonance imaging-demonstrated an unusually voluminous, strip-like calcific deposit within the proximal MCL. Notably, a concurrent lesion was identified in the left lung during the diagnostic workup and was subsequently confirmed as invasive lung adenocarcinoma. Given the failure of nonoperative measures and the large size of the calcification, open surgical excision was performed, leading to rapid and complete resolution of symptoms. This case highlights that massive, refractory calcific tendinitis may be a marker of systemic calcium dysregulation. The coexistence of invasive lung adenocarcinoma warrants consideration of an underlying systemic process, including potential metabolic dysregulation or paraneoplastic mechanisms that may contribute to periarticular calcification. We suggest that clinicians should evaluate for underlying metabolic and/or oncological disorders when atypical or massive periarticular calcifications are encountered. In such complex scenarios, open excision remains an effective definitive treatment if conservative measures fail.

Capitellar osteochondritis dissecans (OCD) is a painful and debilitating condition, most often seen in adolescent overhead athletes and gymnasts. Treatment options for unstable capitellar OCD lesions include fragment fixation, autologous chondrocyte implantation, osteochondral autograft, fragment debridement, and drilling of the lesion. While many current surgical techniques yield suboptimal outcomes, this case demonstrates a novel technique for treating an unstable capitellar OCD lesion with associated subchondral cyst in a 14-year-old female patient. This technique combines bioabsorbable pin fixation and allograft cartilage extracellular matrix with intraosseous bioplasty to restore the articular surface and subchondral support. A lateral approach to the elbow was used to create a reamed window in the capitellum, allowing access to the cystic defect. The osteochondral fragment was fixed with a poly-L-lactide acid pin, and the defect was backfilled using demineralized bone matrix mixed with bone marrow aspirate. The residual cartilage lesion was filled with extracellular matrix cartilage allograft. The graft was contained in the lateral window with fibrin glue. At 4-month follow-up, the patient displayed full elbow range of motion with no pain. At 6-year follow-up, magnetic resonance imaging showed a well-healed capitellum with normal contour and signal of the repaired cartilage. This case demonstrates a novel technique for treating OCD lesions of the capitellum with durable clinical and radiographic success.

Background: Management of severe distal tibia pilon fractures (AO/OTA 43-C3) in older adults is exceptionally challenging. Open reduction and internal fixation is associated with a high incidence of posttraumatic arthritis, whereas primary arthrodesis results in significant functional limitations. We investigated primary total ankle replacement (TAR) as a definitive, single-stage, motion-preserving solution.

Materials and methods: We retrospectively reviewed 29 older adult patients (age ≥60 years) treated with primary TAR since 2016 for comminuted pilon fractures. Inclusion required severe articular destruction (AO/OTA 43-C2/C3) but a reconstructable metaphyseal cortical shell. We evaluated surgical timing, adjunctive fixation, bone grafting, and clinical and radiographic outcomes. The primary outcome was the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score at ≥6 months.

Results: At 6 months post-surgery, the mean AOFAS score was 85.2 ± 7.5. Metaphyseal fracture union was achieved in all cases at an average of 17.4 ± 2.1 weeks. Postoperative alignment was excellent, with a mean medial distal tibial angle (MDTA) of 89.2° ± 1.8°. No deep infections, insert dislocations, or component overhang were observed. Three patients (10.3%) developed progressive valgus deformity, with MDTA increasing by an average of 3.4° at 1 year.

Conclusion: In this retrospective level IV series with short-term follow-up, primary TAR may be a feasible option for carefully selected older adult patients with comminuted pilon fractures and a preserved metaphyseal cortical shell, demonstrating encouraging early functional outcomes. Longer term follow-up is required to determine implant survivorship and revision risk.

Background: To our knowledge, there are no studies assessing associations between patients on preoperative estrogen replacement therapy (ERT) undergoing distal radius open reduction and internal fixation (DRORIF) and postoperative outcomes. Thus, the purpose of this study was to compare surgical and medical complications in patients on ERT undergoing DR-ORIF with a matched control cohort.

Materials and methods: The PearlDiver Mariner database was searched for female patients who took ERT within 3 months of the index procedure. Patients were matched 1:4 with non-ERT controls using propensity score matching. Complications were assessed at 90 days, 2 years, and 5 years. Statistical analyses were conducted using odds ratios (OR) with 95% confidence intervals (CI). Statistical significance was determined at a P value of <.05.

Results: The ERT cohort consisted of 1,815 ERT users, and the control cohort consisted of 7,247 patients. At 2 years, the ERT cohort was associated with a slightly greater incidence of malunion/nonunion (OR, 1.57; 95% CI, 1.13-2.18) but with no increased risk of revision surgery (OR, 1.10; 95% CI, 0.50-2.10). Similarly, at 5 years, the ERT cohort was associated with a slightly higher likelihood of a malunion/nonunion diagnosis (OR, 1.69; 95% CI, 1.24-2.30).

Conclusion: The current study suggests that patients on preoperative ERT had a slightly increased risk of malunion/nonunion at 2 years and 5 years after DR-ORIF. We did not find associations between increases in the risk of any other major or minor complications and the cohort of patients on preoperative ERT within 5 years postoperatively.

Background: Previous literature has suggested that bone-patellar tendon-bone (BPTB) autograft can be associated with more postoperative anterior knee pain compared to other graft types during anterior cruciate ligament reconstruction (ACLR). This study aimed to compare the differences between patients undergoing ACLR with either BPTB or hamstring (HT) autografts, focusing on 2-year follow-up patient-reported outcome measures (PROMs).

Materials and methods: A retrospective cohort study of a prospectively collected PROMs database was conducted for 411 patients who underwent primary ACLR between 2009 and 2021. Outcomes collected included 2-year Knee Injury and Osteoarthritis Outcome Score (KOOS), the KOOS pain subscale, and a Single Assessment Numeric Evaluation. Statistical analysis consisted of descriptive analyses (eg, counts, means, ranges), independent-sample t tests, chi-squared tests, as well as analysis of variance. The level of statistical significance was set at P ≤ .05.

Results: The 2-year improvement and final KOOS pain subscale from the preoperative baseline was not found to be significantly different between the groups (BPTB: 91.6 vs HT: 90.6; BPTB: 12.5 vs HT: 15.2, P = .065, P = .633, respectively). The baseline overall KOOS was higher in BPTB autograft cohort and the 2-year change in KOOS was higher in the HT autograft cohort when compared to other autograft cohort (68.2 vs 63.6, P < .001; 16.4 vs 19.7, P = .040, respectively). Overall KOOS at final follow-up did not differ between autografts (84.6 vs 83.0, P = .136, respectively).

Conclusion: ACLR with BPTB autograft was not found to be associated with worse knee pain scores compared to HT autograft at 2-year follow-up.