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Long-Term Outcome After Pectoralis Major Transfer for Irreparable Anterosuperior Rotator Cuff Tears 胸大肌转移治疗不可修复的前上肩袖撕裂后的远期疗效
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00485
P. Moroder, E. Schulz, Marian Mitterer, F. Plachel, H. Resch, Stefan Lederer
Background: Promising short-term outcomes after pectoralis major tendon transfer for the treatment of an irreparable anterosuperior rotator cuff tear have been reported. The purpose of this study was to evaluate the long-term outcome. Methods: Twenty-seven consecutive patients with irreparable anterosuperior rotator cuff tears without advanced cuff arthropathy or advanced humeral head migration were treated with a partial subcoracoid pectoralis major tendon transfer between 2004 and 2005. At an average of 10 years (range, 9 to 11 years) postoperatively, 22 patients (82%) with an average age of 62 years (range, 42 to 74 years) at the time of surgery had a long-term follow-up examination that included the pain score, strength and range-of-motion assessment, Constant score, Simple Shoulder Test (SST), as well as radiographic and ultrasonographic imaging. The long-term results were compared with the preoperative findings as well as the short-term results that were collected from a previous evaluation. Results: The adjusted Constant score increased from 54% to 87% at the short-term follow-up (p < 0.001) and remained improved at the long-term follow-up, with a mean score of 83% (p = 0.001). While the significant improvement of the pain level at the short-term follow-up was maintained at the time of final follow-up (p = 0.001), the increase in strength returned to the preoperative level (p = 0.178), and the improvement in range of motion diminished again over time despite remaining significantly improved (p = 0.029), especially with regard to internal rotation (p < 0.001). At the long-term follow-up, 77% of the patients were very satisfied with the procedure. A third of the patients had no progression of cuff arthropathy, a third had progression by 1 grade, and a third had progression by ≥2 grades. At the time of final follow-up, 1 patient (5%) had undergone revision surgery to reverse shoulder arthroplasty. Conclusions: Pectoralis major tendon transfer for the treatment of irreparable anterosuperior rotator cuff tears results in a significant clinical improvement even 10 years after surgery, especially with respect to pain and internal rotation. Despite long-term radiographic progression of cuff arthropathy, patient satisfaction remains high over time, with a low rate of salvage with reverse shoulder arthroplasty. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
背景:胸大肌肌腱转移治疗不可修复的前上肩袖撕裂的短期疗效有报道。本研究的目的是评估长期结果。方法:2004 ~ 2005年,对27例无严重肩袖关节病变或肱骨头移位的不可恢复性肩上袖撕裂患者行部分喙下胸大肌肌腱转移术。术后平均10年(范围,9 - 11年),22例(82%)平均年龄62岁(范围,42 - 74岁)的患者接受了长期随访检查,包括疼痛评分、力量和活动范围评估、恒定评分、简单肩关节测试(SST)以及x线和超声成像。将长期结果与术前结果以及从先前评估中收集的短期结果进行比较。结果:调整后的Constant评分在短期随访时由54%上升至87% (p < 0.001),在长期随访时仍有改善,平均评分为83% (p = 0.001)。虽然在短期随访时疼痛水平的显著改善在最后随访时保持不变(p = 0.001),但强度的增加恢复到术前水平(p = 0.178),活动范围的改善随着时间的推移再次减弱,尽管仍有显著改善(p = 0.029),特别是关于内旋(p < 0.001)。在长期随访中,77%的患者对手术非常满意。三分之一的患者没有袖套关节病变进展,三分之一的患者进展1级,三分之一的患者进展≥2级。在最后随访时,1例患者(5%)接受了翻修手术以逆转肩关节置换术。结论:胸大肌肌腱转移治疗不可修复的前上肩袖撕裂,即使在手术后10年仍有显著的临床改善,特别是在疼痛和内旋方面。尽管袖带关节病的长期影像学进展,但随着时间的推移,患者的满意度仍然很高,反向肩关节置换术的挽回率很低。证据等级:治疗性IV级。完整的证据等级描述见作者指南。
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引用次数: 50
Patient and Radiographic Factors Help to Predict Metal-on-Metal Hip Resurfacings with Evidence of a Pseudotumor 患者和影像学因素有助于预测假肿瘤的金属对金属髋关节表面置换术
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00212
G. Matharu, O. Blanshard, K. Dhaliwal, A. Judge, D. Murray, H. Pandit
Background: The role of radiographs in the follow-up of patients with metal-on-metal hip resurfacing (MoMHR) implants is unclear. We investigated whether a combination of patient and radiographic factors predicted MoMHRs with evidence of a pseudotumor. Methods: We performed a retrospective single-center case-control study of 384 MoMHRs. The pseudotumor group of 130 hips all had evidence of a symptomatic pseudotumor on cross-sectional imaging, with the diagnosis confirmed at revision. The nonpseudotumor group of 254 hips (a subgroup of these hips were previously reported on) all had normal findings on cross-sectional imaging. Radiographs taken immediately prior to revision were assessed in the pseudotumor group and were compared with radiographs taken at the time of normal cross-sectional imaging in the nonpseudotumor group. Two blinded independent observers analyzed the radiographs for signs of failure, with excellent interobserver agreement. Logistic regression modeling identified the patient and radiographic predictors of revision for pseudotumor. Results: Hips with a pseudotumor more commonly had abnormal findings on radiographs compared to hips without a pseudotumor (80.0% compared with 63.4%; p = 0.001). Patient and radiographic factors predictive of revision for pseudotumor in the multivariable model were female sex (odds ratio [OR], 3.14; 95% confidence interval [CI], 1.85 to 5.35; p < 0.001), high inclination (OR, 1.04 per degree; 95% CI, 1.01 to 1.07 per degree; p = 0.006), acetabular osteolysis (OR, 5.06; 95% CI, 2.14 to 12.0; p < 0.001), femoral osteolysis (OR, 17.8; 95% CI, 5.09 to 62.2; p < 0.001), and acetabular loosening (OR, 3.35; 95% CI, 1.34 to 8.35; p = 0.009). Factors predictive of not having a pseudotumor were anteversion of ≥5° (5° to <10°: OR, 0.31; 95% CI, 0.12 to 0.77; p = 0.012; and ≥10°: OR, 0.32; 95% CI, 0.15 to 0.70; p = 0.004) and heterotopic ossification (OR, 0.19; 95% CI, 0.05 to 0.72; p = 0.015). The final multivariable model was well calibrated (p = 0.589), with good discriminatory ability (area under the curve = 0.801; sensitivity = 74.4%; specificity = 71.7%). Conclusions: A combination of patient and radiographic factors provided useful information for distinguishing between MoMHRs with and without evidence of a pseudotumor. Surgeons may wish to consider these specific patient and radiographic factors before proceeding with cross-sectional imaging. Radiographs are important when assessing patients with MoMHR implants and should be included in all follow-up protocols. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景:x线片在金属对金属髋关节置换术(MoMHR)患者随访中的作用尚不清楚。我们研究了患者和影像学因素的结合是否能预测有假性肿瘤证据的momhr。方法:我们对384例momhr进行回顾性单中心病例对照研究。假瘤组130髋在横断面成像上均有症状性假瘤的证据,在翻修时确诊。非假瘤组254髋(这些髋的一个亚组先前已报道)在横断面成像中均显示正常。假肿瘤组评估了翻修前立即拍摄的x线片,并与非假肿瘤组正常横断面成像时拍摄的x线片进行了比较。两名独立的盲法观察者分析了x线片上的失败迹象,观察者之间的意见非常一致。逻辑回归模型确定了患者和放射学对假肿瘤修正的预测因素。结果:与没有假肿瘤的髋关节相比,假肿瘤髋关节在x线片上的异常表现更为常见(80.0%比63.4%;P = 0.001)。在多变量模型中,预测假性肿瘤修正的患者和影像学因素为女性(优势比[OR], 3.14;95%置信区间[CI], 1.85 ~ 5.35;p < 0.001),高倾角(OR, 1.04 /度;95% CI, 1.01 ~ 1.07 /度;p = 0.006),髋臼骨溶解(OR, 5.06;95% CI, 2.14 ~ 12.0;p < 0.001),股骨骨溶解(OR, 17.8;95% CI, 5.09 ~ 62.2;p < 0.001),髋臼松动(OR, 3.35;95% CI, 1.34 ~ 8.35;P = 0.009)。预测无假瘤的因素为≥5°前倾(5°至<10°:OR, 0.31;95% CI, 0.12 ~ 0.77;P = 0.012;≥10°:OR为0.32;95% CI, 0.15 ~ 0.70;p = 0.004)和异位骨化(OR, 0.19;95% CI, 0.05 ~ 0.72;P = 0.015)。最终的多变量模型校正良好(p = 0.589),具有良好的判别能力(曲线下面积= 0.801;灵敏度= 74.4%;特异性= 71.7%)。结论:患者和影像学因素的结合为区分有和没有假性肿瘤证据的momhr提供了有用的信息。外科医生可能希望在进行横断面成像之前考虑这些特定的患者和放射学因素。在评估植入MoMHR的患者时,x线照片很重要,并应纳入所有随访方案。证据等级:诊断级III。有关证据水平的完整描述,请参见作者说明。
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引用次数: 13
Histological Evidence of Muscle Degeneration in Advanced Human Rotator Cuff Disease 晚期人类肩袖疾病中肌肉退变的组织学证据
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00335
M. Gibbons, Anshu Singh, O. Anakwenze, Timothy Cheng, M. Pomerantz, S. Schenk, A. Engler, S. Ward
Background: Cellular remodeling in rotator cuff muscles following a massive rotator cuff tear is poorly understood. The aim of the current study was to provide histological evidence to elucidate the mode of muscle loss in advanced human rotator cuff disease and to assess tissue-level changes in relation to findings on noninvasive imaging. Methods: Rotator cuff muscle biopsy samples were taken from the scapular fossae from 23 consecutive patients undergoing reverse total shoulder arthroplasty in order to evaluate muscle composition in severe rotator cuff disease. Markers of vascularity; inflammation; fat distribution; and muscle atrophy, degeneration, and regeneration were quantified. Results: The samples primarily consisted of dense, organized connective tissue (48.2% ± 19.1%) and disorganized, loose connective tissue (36.9% ± 15.9%), with substantially smaller fractions of muscle (10.4% ± 22.0%) and fat (6.5% ± 11.6%). Only 25.8% of the biopsy pool contained any muscle fibers at all. Increased inflammatory cell counts (111.3 ± 81.5 macrophages/mm2) and increased vascularization (66.6 ± 38.0 vessels/mm2) were observed across biopsies. Muscle fiber degeneration was observed in 90.0% ± 15.6% of observable muscle fascicles, and the percentage of centrally nucleated muscle fibers was pathologically elevated (11.3% ± 6.3%). Fat accumulation was noted in both perifascicular (60.7% ± 41.4%) and intrafascicular (42.2% ± 33.6%) spaces, with evidence that lipid may replace contractile elements without altering muscle organization. Conclusions: Dramatic degeneration and inflammation of the rotator cuff muscles are characteristics of the most chronic and severe rotator cuff disease states, suggesting that muscle loss is more complicated than, and distinct from, the simple atrophy found in less severe cases. Clinical Relevance: In order to address degenerative muscle loss, alternative therapeutic approaches directed at muscle regeneration must be considered if muscle function is to be restored in late-stage rotator cuff disease.
背景:大量肩袖撕裂后肩袖肌肉的细胞重塑尚不清楚。本研究的目的是提供组织学证据来阐明晚期人类肩袖疾病中肌肉损失的模式,并评估与无创成像结果相关的组织水平变化。方法:对23例连续行逆行全肩关节置换术患者的肩胛窝进行肩袖肌肉活检,以评估严重肩袖疾病患者的肌肉组成。血管特征;炎症;脂肪分布;定量观察肌肉萎缩、退化和再生情况。结果:样本主要由致密、有组织的结缔组织(48.2%±19.1%)和松散、无组织的结缔组织(36.9%±15.9%)组成,肌肉(10.4%±22.0%)和脂肪(6.5%±11.6%)的比例较小。只有25.8%的活检池含有任何肌纤维。活检观察到炎症细胞计数增加(111.3±81.5个巨噬细胞/mm2),血管化增加(66.6±38.0个血管/mm2)。90.0%±15.6%的可观察肌束出现肌纤维变性,中央有核肌纤维病理增高(11.3%±6.3%)。血管束周(60.7%±41.4%)和血管束内(42.2%±33.6%)均有脂肪堆积,这表明脂质可以在不改变肌肉组织的情况下取代收缩因子。结论:肩袖肌肉的急剧退化和炎症是大多数慢性和严重的肩袖疾病状态的特征,表明肌肉损失比在不太严重的病例中发现的简单萎缩更复杂,并且不同。临床相关性:为了解决退行性肌肉损失,如果要恢复晚期肩袖疾病的肌肉功能,必须考虑针对肌肉再生的替代治疗方法。
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引用次数: 61
Intra-Articular Vancomycin Powder Eliminates Methicillin-Resistant S. aureus in a Rat Model of a Contaminated Intra-Articular Implant 关节内万古霉素粉末消除受污染关节内植入物大鼠模型中的耐甲氧西林金黄色葡萄球菌
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00127
A. Edelstein, Joseph A. Weiner, Ralph W. Cook, Danielle S. Chun, Emily J. Monroe, Sean M. Mitchell, Abhishek Kannan, W. K. Hsu, S. Stulberg, E. Hsu
Background: Periprosthetic joint infection following hip and knee arthroplasty leads to poor outcomes and exorbitant costs. Topical vancomycin powder has been shown to decrease infection in many procedures such as spine surgery. The role of vancomycin powder in the setting of total joint arthroplasty remains undefined. Our aim was to evaluate the efficacy of intra-articular vancomycin powder in preventing infection in a rat model of a contaminated intra-articular implant. Methods: Thirty-two female Sprague-Dawley rats underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. The knee joint was also inoculated with 1.5 × 107 colony forming units (CFU)/mL of methicillin-resistant Staphylococcus aureus (MRSA). Four treatment groups were studied: (1) no antibiotics (control), (2) preoperative systemic vancomycin, (3) intra-articular vancomycin powder, and (4) both systemic vancomycin and intra-articular vancomycin powder. The animals were killed on postoperative day 6, and distal femoral bone, joint capsule, and the implanted wire were harvested for bacteriologic analysis. Statistical analyses were performed using Wilcoxon rank sum and Fisher exact tests. Results: There were no postoperative deaths, wound complications, signs of vancomycin-related toxicity, or signs of systemic illness in any of the treatment groups. There were significantly fewer positive cultures in the group that received vancomycin powder in combination with systemic vancomycin compared with the group that received systemic vancomycin alone (bone: 0% versus 75% of 8, p = 0.007; Kirschner wire: 0% versus 63% of 8, p = 0.026; whole animal: 0% versus 88% of 8, p = 0.01). Only animals that received both vancomycin powder and systemic vancomycin showed evidence of complete elimination of bacterial contamination. Conclusions: In a rat model of a contaminated intra-articular implant, use of intra-articular vancomycin powder in combination with systemic vancomycin completely eliminated MRSA bacterial contamination. Animals treated with systemic vancomycin alone had persistent MRSA contamination. Clinical Relevance: This animal study presents data suggesting that the use of intra-articular vancomycin powder for reducing the risk of periprosthetic joint infections should be investigated further in clinical studies.
背景:髋关节和膝关节置换术后假体周围关节感染导致预后不佳和费用过高。局部万古霉素粉末已被证明在许多程序中减少感染,如脊柱手术。万古霉素粉末在全关节置换术中的作用尚不明确。我们的目的是评估万古霉素粉在关节内植入物污染大鼠模型中预防感染的功效。方法:32只雌性Sprague-Dawley大鼠行膝关节切开术,植入具有1 mm关节内连通的股骨髓内丝。膝关节同时接种1.5 × 107菌落形成单位(CFU)/mL耐甲氧西林金黄色葡萄球菌(MRSA)。分为4个治疗组:(1)不使用抗生素(对照组),(2)术前全身使用万古霉素,(3)关节内使用万古霉素散,(4)全身使用万古霉素和关节内使用万古霉素散。术后第6天处死动物,收集股骨远端骨、关节囊和植入金属丝进行细菌学分析。采用Wilcoxon秩和和和Fisher精确检验进行统计分析。结果:所有治疗组均无术后死亡、伤口并发症、万古霉素相关毒性体征或全身性疾病体征。万古霉素粉联合全身性万古霉素组的阳性培养明显少于单独全身性万古霉素组(骨:0% vs 75%, p = 0.007;克氏针:0% vs 63%, p = 0.026;全动物:0% vs . 88% (p = 0.01)。只有同时接受万古霉素粉末和全身万古霉素的动物显示出细菌污染完全消除的证据。结论:在关节内植入物污染的大鼠模型中,关节内万古霉素粉剂联合全身万古霉素完全消除了MRSA细菌污染。用全身万古霉素单独治疗的动物有持续的MRSA污染。临床意义:本动物研究的数据表明,关节内万古霉素粉剂用于降低假体周围关节感染的风险应在临床研究中进一步研究。
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引用次数: 42
A Prospective Study of Four Total Ankle Arthroplasty Implants by Non-Designer Investigators 由非设计人员进行的四种全踝关节置换术植入物的前瞻性研究
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00097
T. Lefrancois, A. Younger, K. Wing, M. Penner, P. Dryden, H. Wong, T. Daniels, M. Glazebrook
Background: There are several types of prostheses available to surgeons when performing a total ankle arthroplasty (TAA). The main objective of this study was to summarize the clinical and functional outcomes of 4 TAA prostheses: the Hintegra implant (Integra LifeSciences), the Agility implant (DePuy), the Mobility implant (DePuy), and the Scandinavian Total Ankle Replacement (STAR) implant (Small Bone Innovations [SBi]). Methods: Patients were prospectively recruited. A total of 451 TAAs with a mean follow-up (and standard deviation) of 4.5 ± 2.0 years were included. Patients were assessed annually and completed self-reported outcome measures at these visits. Complications and revisions were reported at the time of incident. Mean improvements are reported by prosthesis. Linear mixed-effects models were used to obtain adjusted comparisons of scores across prostheses. Survivorship curves were generated by prosthesis and type of complication. Results: Mean improvement in the Ankle Osteoarthritis Scale (AOS) total score was less among patients with the Mobility implant (19.5; 95% confidence interval [CI], 15 to 24) than it was among patients with the Agility implant (29.1; 95% CI, 24 to 34), Hintegra implant (29.7; 95% CI, 27 to 33), and STAR implant (28.5; 95% CI, 23 to 34). Patients in the Mobility group also had less mean improvement in the AOS pain score (21.3; 95% CI, 17 to 26) compared with patients in the Hintegra (29.0; 95% CI, 26 to 32), Agility (29.8; 95% CI, 25 to 35), and STAR (29.1; 95% CI, 23 to 35) groups. The Mobility group also had less mean improvement in the AOS disability score (17.3; 95% CI, 12 to 23) compared with the Hintegra (30.4; 95% CI, 27 to 34), Agility (28.8; 95% CI, 23 to 34), and STAR (27.8; 95% CI, 21 to 34) groups. Survival results among the 4 prostheses are reported. Conclusions: This study demonstrated acceptable outcomes of 4 modern TAA prostheses. Outcome results from patient-reported scores were comparable between at least 3 of the 4 prostheses (the Hintegra, STAR, and Agility implants). The rates of complications and revisions found in this study are within the limits reported in the literature for similar prostheses and methods of reporting. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
背景:在进行全踝关节置换术(TAA)时,有几种类型的假体可供外科医生使用。本研究的主要目的是总结4种TAA假体的临床和功能结果:Hintegra假体(Integra LifeSciences)、Agility假体(DePuy)、Mobility假体(DePuy)和Scandinavian全踝关节置换术(STAR)假体(Small Bone Innovations [SBi])。方法:前瞻性招募患者。共纳入451例taa,平均随访时间(及标准差)为4.5±2.0年。每年对患者进行评估,并在这些访问中完成自我报告的结果测量。在事件发生时报告了并发症和修复。据报道,假体的平均改善。线性混合效应模型用于获得假体间调整后的评分比较。根据假体和并发症类型生成生存曲线。结果:踝关节骨性关节炎量表(AOS)总分的平均改善程度在植入移动性植入物的患者中较低(19.5;95%可信区间[CI], 15至24),比使用Agility植入物的患者(29.1;95% CI, 24 ~ 34), Hintegra种植体(29.7;95% CI, 27 ~ 33), STAR植入物(28.5;95% CI, 23 ~ 34)。运动组患者在AOS疼痛评分上的平均改善也较小(21.3;95% CI, 17 - 26)与Hintegra患者相比(29.0;95% CI, 26 - 32),敏捷性(29.8;95% CI, 25 ~ 35), STAR (29.1;95% CI, 23 ~ 35)组。运动组在AOS残疾评分上的平均改善也较小(17.3;95% CI, 12 ~ 23),与Hintegra (30.4;95% CI, 27 - 34),敏捷性(28.8;95% CI, 23 - 34), STAR (27.8;95% CI, 21 ~ 34)组。报道了4个假体的存活情况。结论:本研究显示4例现代TAA假体预后良好。4种假体中至少3种(Hintegra、STAR和Agility假体)患者报告的评分结果具有可比性。在本研究中发现的并发症和修改率在类似假体和报道方法的文献报道的范围内。证据等级:治疗性II级。有关证据水平的完整描述,请参见作者说明。
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引用次数: 53
Early Results of Acetabular Reconstruction After Wide Periacetabular Oncologic Resection 髋臼周围肿瘤切除术后髋臼重建的早期结果
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00803
M. Abdel, P. von Roth, K. Perry, P. Rose, D. Lewallen, F. Sim
Background: Reliable acetabular fixation in total hip arthroplasty following periacetabular resections is challenging. Tantalum components have been successfully implemented for difficult revision arthroplasties, but, to our knowledge, have not been reported for acetabular reconstruction following oncologic periacetabular resection. The primary purpose of the current study was to determine the early clinical outcomes, complications, and radiographic findings for acetabular reconstruction after oncologic periacetabular resection. In addition, a novel classification scheme for primary periacetabular resections and reconstructions is presented. Methods: We reviewed 10 consecutive patients treated with tantalum acetabular reconstruction following periacetabular resection. All patients had a primary acetabular malignancy including chondrosarcoma (n = 7) and osteosarcoma (n = 3). The cohort included 6 males (60%). The mean age was 54 years (range, 30 to 73 years). The mean follow-up was 59 months (range, 8 to 113 months). Results: At the most recent follow-up, 9 patients were alive and 1 had died of the respective disease. All patients obtained full ambulatory status with the use of gait aids. Postoperative complications included dislocation (n = 3), wound-healing disturbance (n = 1), and deep venous thrombosis (n = 1). Two patients underwent reoperations for recurrent dislocations. The mean postoperative Harris hip score was 75 points (range, 49 to 92 points). Conclusions: Preliminary results of tantalum reconstruction following periacetabular resections provide reasonable improvement in early clinical outcomes and stable fixation in situations with massive bone loss and compromised bone quality. As expected due to the lack of a functioning abductor mechanism from the wide oncologic resection, early dislocations remain a concern. As such, we now consider the primary use of increasing constraint, but it must be balanced with the often compromised host bone. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
背景:髋臼周围切除术后全髋关节置换术中可靠的髋臼固定是具有挑战性的。钽假体已成功应用于困难的翻修性关节置换术,但据我们所知,尚未有关于肿瘤髋臼周围切除术后髋臼重建的报道。本研究的主要目的是确定肿瘤髋臼周围切除术后髋臼重建的早期临床结果、并发症和影像学表现。此外,一种新的分类方案,初步髋臼周围切除和重建提出。方法:我们回顾了10例髋臼周围切除术后行钽重建的患者。所有患者均患有原发性髋臼恶性肿瘤,包括软骨肉瘤(n = 7)和骨肉瘤(n = 3)。该队列包括6名男性(60%)。平均年龄54岁(30 ~ 73岁)。平均随访59个月(8 ~ 113个月)。结果:在最近一次随访中,9例患者存活,1例患者死于相应疾病。所有患者在使用步态辅助工具后均可完全走动。术后并发症包括脱位3例,创面愈合障碍1例,深静脉血栓形成1例。2例患者因脱位复发再次手术。术后Harris髋关节平均评分为75分(范围49 ~ 92分)。结论:髋臼周围切除术后钽重建的初步结果可以合理地改善早期临床结果,并稳定固定大量骨丢失和骨质量受损的情况。正如预期的那样,由于广泛肿瘤切除缺乏功能性外展肌机制,早期脱位仍然是一个问题。因此,我们现在考虑增加约束的主要用途,但它必须与经常受损的宿主骨平衡。证据等级:治疗性IV级。完整的证据等级描述见作者指南。
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引用次数: 22
Increased Mortality in Elderly Patients with Sarcopenia and Acetabular Fractures 老年骨骼肌减少症和髋臼骨折患者死亡率增高
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00734
M. Deren, Jacob M. Babu, Eric M. Cohen, J. Machan, C. Born, R. Hayda
Background: Sarcopenia is a condition of clinically relevant loss of muscle mass and function. Acetabular fractures in elderly patients are common and difficult to treat. This study aimed to determine if sarcopenia is common in elderly patients with acetabular fractures and correlates with lower-energy mechanisms of injury, higher rates of complications, and higher mortality than patients with normal muscle mass. Methods: The Rhode Island Hospital Trauma Database was queried for patients who were ≥60 years of age from 2005 to 2014 using the International Classification of Diseases, Ninth Revision, code for closed acetabular fracture, 808.0. Charts were retrospectively reviewed for demographic data, operative intervention, mechanism of injury, mortality, comorbidities, and other factors. Computed tomography (CT) was used to determine the muscle cross-sectional area and to calculate the skeletal muscle index. Results: The database revealed 192 patients coded for acetabular fracture; of these, 181 were correctly diagnosed. Ninety-nine patients had recorded body mass index (BMI) and adequate CT scans to measure the skeletal muscle index. Forty-two patients (42.4%) had sarcopenia, and 57 patients (57.6%) did not have sarcopenia. There were no significant differences in demographic characteristics between the groups with the exception of BMI and sex. BMI was higher in patients who did not have sarcopenia (31.7 kg/m2) than it was in patients with sarcopenia (23.6 kg/m2) (p < 0.001). Male sex was significantly greater (p = 0.0104) in patients with sarcopenia at 76.2% (32 of 42 patients) than in patients without sarcopenia at 50.9% (29 of 57 patients). Fractures in patients without sarcopenia were associated with a higher-energy mechanism of injury in 78.9% of cases compared with 52.4% of cases of patients with sarcopenia (p = 0.005). Sarcopenia was significantly associated (p = 0.0419) with increased 1-year mortality (28.6%) compared with the absence of sarcopenia (12.3%). This association was even stronger if in-hospital mortality was excluded (p = 0.00074). Finally, anterior column fractures were more likely (p = 0.017) to be sustained by patients with sarcopenia at 47.6% (20 patients) than by patients who did not have sarcopenia at 24.6% (14 patients). Conclusions: Sarcopenia is common in elderly patients with acetabular fractures and is associated with lower-energy mechanisms, anterior column fractures, and higher risk of 1-year mortality. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景:肌肉减少症是一种临床相关的肌肉质量和功能损失。老年患者髋臼骨折是一种常见且难以治疗的疾病。本研究旨在确定老年髋臼骨折患者中肌肉减少症是否常见,并且与低能量损伤机制、高并发症发生率以及比正常肌肉质量患者高死亡率相关。方法:采用国际疾病分类第九版,闭合性髋臼骨折编码808.0,查询罗德岛医院创伤数据库2005 - 2014年年龄≥60岁的患者。回顾性回顾图表,统计数据、手术干预、损伤机制、死亡率、合并症和其他因素。采用计算机断层扫描(CT)测定肌肉横截面积,计算骨骼肌指数。结果:数据库中有192例髋臼骨折患者;其中,181人被正确诊断。99名患者记录了身体质量指数(BMI)和足够的CT扫描来测量骨骼肌指数。42例(42.4%)患者有肌肉减少症,57例(57.6%)患者没有肌肉减少症。除BMI和性别外,两组人口统计学特征无显著差异。无肌少症患者的BMI (31.7 kg/m2)高于肌少症患者(23.6 kg/m2) (p < 0.001)。男性在肌肉减少症患者中的比例为76.2%(42例患者中32例),显著高于非肌肉减少症患者的50.9%(57例患者中29例)(p = 0.0104)。无肌少症患者的骨折与高能量损伤机制相关的比例为78.9%,而有肌少症患者的这一比例为52.4% (p = 0.005)。与肌少症不存在(12.3%)相比,肌少症与1年死亡率(28.6%)显著相关(p = 0.0419)。如果排除住院死亡率,这种关联甚至更强(p = 0.00074)。最后,有肌肉减少症的患者有47.6%(20例)比没有肌肉减少症的患者有24.6%(14例)更有可能维持前柱骨折(p = 0.017)。结论:骨骼肌减少症在老年髋臼骨折患者中很常见,并与低能机制、前柱骨折和较高的1年死亡率相关。证据等级:预后III级。有关证据水平的完整描述,请参见作者说明。
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引用次数: 63
Outcome After Combined Pelvic and Femoral Osteotomies in Patients with Legg-Calvé-Perthes Disease 腿骨-脚骨- perthes病联合骨盆和股骨截骨术的疗效
Pub Date : 2017-02-01 DOI: 10.2106/JBJS.16.00255
N. Mosow, E. Vettorazzi, S. Breyer, S. Breyer, K. Ridderbusch, K. Ridderbusch, R. Stücker, R. Stücker, M. Rupprecht, M. Rupprecht
Background: The aim of this study was to evaluate the outcome at skeletal maturity of combined pelvic and femoral varus osteotomies in children with Legg-Calvé-Perthes (LCP) disease. Methods: From January 1998 to December 2009, 69 patients with LCP disease underwent combined osteotomies at our institution. Fifty-two children (19 girls and 33 boys) met the inclusion criteria and were enrolled in the study. The LCP disease was classified and the cases of all patients were reviewed at skeletal maturity. The mean age (and standard deviation) at the time of diagnosis was 6.9 ± 2.4 years, and the mean age at the time of surgery was 7.9 ± 2.3 years. The mean time to follow-up was 10.8 ± 3.5 years. The final follow-up radiographs were assessed according to the Stulberg classification and the sphericity deviation score. Results: The mean Harris hip score at the time of follow-up was 90 ± 13.2. According to the Harris hip score grading system, 37 patients (71%) had an excellent outcome; 8 patients (15%), a good result; 3 patients (6%), a fair result; and 4 patients (8%), a poor result. Seven patients (13%) were classified as having a Stulberg class-I hip; 20 (38%), a class-II hip; 15 (29%), a class-III hip; 6 (12%), a class-IV hip; and 4 (8%), a class-V hip. The mean sphericity deviation score was 24.4 ± 14.4 at skeletal maturity. There was a strong relationship between a younger age at diagnosis and better functional and radiographic outcomes. Conclusions: In the absence of a randomized study design, conclusions have to be drawn with caution. Combined pelvic and femoral osteotomies in these children with LCP disease did not result in better functional or radiographic outcomes compared with the historic results of Salter osteotomy or proximal femoral osteotomy alone. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
背景:本研究的目的是评估患有legg - calv - perthes (LCP)病的儿童骨盆和股内翻联合截骨术的骨骼成熟结果。方法:1998年1月至2009年12月,本院69例LCP患者行联合截骨术。52名儿童(19名女孩和33名男孩)符合纳入标准并被纳入研究。对LCP疾病进行分类,并在骨骼成熟时对所有患者的病例进行回顾。诊断时的平均年龄(及标准差)为6.9±2.4岁,手术时的平均年龄为7.9±2.3岁。平均随访时间为10.8±3.5年。根据Stulberg分级和球度偏差评分对最终随访x线片进行评估。结果:随访时Harris髋关节平均评分为90±13.2。根据Harris髋关节评分系统,37例(71%)患者预后良好;8例(15%),效果良好;3例(6%),结果尚可;4例(8%),预后较差。7名患者(13%)被归类为Stulberg i级髋关节;20例(38%)为ii类髋关节;15例(29%),iii类髋关节;6例(12%),iv类髋关节;4 (8%), v类髋关节。骨骼成熟时的平均球度偏差评分为24.4±14.4。较年轻的诊断年龄与较好的功能和影像学结果之间有很强的关系。结论:在缺乏随机研究设计的情况下,必须谨慎得出结论。与Salter截骨术或股骨近端截骨术相比,这些LCP患儿联合骨盆和股骨截骨术的功能或影像学结果并不好。证据等级:治疗性IV级。完整的证据等级描述见作者指南。
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引用次数: 19
Plate Fixation Compared with Nonoperative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter Randomized Controlled Trial 钢板固定与非手术治疗移位型锁骨中轴骨折的比较:一项多中心随机对照试验
Pub Date : 2017-01-18 DOI: 10.2106/JBJS.15.01394
S. Woltz, Sylvia A. Stegeman, P. Krijnen, B. V. van Dijkman, T. P. van Thiel, N. Schep, P. A. de Rijcke, J. Frölke, I. Schipper
Background: The use of operative treatment for clavicular fractures is increasing, despite varying results in previous studies. The aim of this study was to compare plate fixation and nonoperative treatment for displaced midshaft clavicular fractures with respect to nonunion, adverse events, and shoulder function. Methods: In this multicenter, prospective, randomized controlled trial, patients between 18 and 60 years old with a displaced midshaft clavicular fracture were randomized between nonoperative treatment and open reduction with internal plate fixation. The primary outcome was evidence of nonunion at 1 year. Other outcomes were secondary operations, arm function as measured with the Constant shoulder score and Disabilities of the Arm, Shoulder and Hand (DASH) score, pain, cosmetic results, and general health status. Outcomes were recorded at 6 weeks, 3 months, and 1 year following trauma. Results: One hundred and sixty patients were randomized. The rate of nonunion was significantly higher in the nonoperatively treated group than in the operatively treated group (23.1% compared with 2.4%; p < 0.0001), as was the rate of nonunion for which secondary plate fixation was performed (12.9% compared with 1.2%; p = 0.006). The rate of secondary operations was 27.4% in the operatively treated group (16.7% for elective plate removal) and 17.1% in the nonoperatively treated group (p = 0.18). Nineteen percent of the patients in the operatively treated group had persistent loss of sensation around the scar. No difference was found between the groups with respect to the Constant and DASH scores at all time points. Conclusions: For patients with a diaphyseal fracture of the clavicle displaced at least 1 shaft width, plate fixation improves the chances that the bone will heal; however, the rate of patients who need a second operation is considerable. In addition, the procedure does not improve shoulder function or general symptoms, and it does not decrease limitations compared with nonoperative treatment in a sling. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
背景:锁骨骨折的手术治疗越来越多,尽管以往的研究结果不一。本研究的目的是比较钢板固定和非手术治疗移位的锁骨中轴骨折的不愈合、不良事件和肩关节功能。方法:在这项多中心、前瞻性、随机对照试验中,年龄在18 - 60岁的锁骨中轴移位骨折患者被随机分为非手术治疗和切开复位内钢板固定两组。主要结局是1年时骨不连的证据。其他结果包括二次手术、手臂功能(用肩部评分和手臂、肩膀和手的残疾(DASH)评分测量)、疼痛、美容结果和一般健康状况。分别在创伤后6周、3个月和1年记录结果。结果:随机选取160例患者。非手术治疗组骨不愈合率明显高于手术治疗组(23.1%比2.4%;P < 0.0001),采用二次钢板固定治疗的骨不连率(12.9%与1.2%;P = 0.006)。手术治疗组的二次手术发生率为27.4%(择期钢板取出组为16.7%),非手术治疗组为17.1% (p = 0.18)。手术治疗组中19%的患者疤痕周围持续失去知觉。各组之间在各时间点的Constant和DASH评分均无差异。结论:对于移位至少1轴宽的锁骨骨干骨折患者,钢板固定可提高骨愈合的机会;然而,需要第二次手术的患者比例相当高。此外,该手术不能改善肩功能或一般症状,与非手术吊带治疗相比,也不能减少局限性。证据水平:治疗性i级。参见《作者说明》获得证据水平的完整描述。
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引用次数: 123
Quality of Life in Bilateral Vs. Unilateral End-Stage Ankle Arthritis and Outcomes of Bilateral Vs. Unilateral Total Ankle Replacement 双侧与单侧终末期踝关节关节炎患者的生活质量及双侧与单侧全踝关节置换术的预后
Pub Date : 2017-01-18 DOI: 10.2106/JBJS.16.00398
S. Desai, M. Glazebrook, M. Penner, K. Wing, A. Younger, Ellie B. Pinsker, T. Daniels
Background: We performed a retrospective cohort study to compare preoperative health-related quality of life (HRQoL) between patients with bilateral and those with unilateral end-stage ankle arthritis. We also compared midterm outcomes in a subgroup of patients who had undergone staged bilateral total ankle replacement (TAR) with the outcomes in the group treated with unilateral TAR. Methods: The HRQoL before surgical treatment was compared between 53 patients with bilateral end-stage ankle arthritis identified from the Canadian Orthopaedic Foot and Ankle Society Prospective Ankle Reconstruction Database and 106 patients with unilateral arthritis selected from the same database. Short Form-36 (SF-36) and American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM) scores were used to assess preoperative HRQoL. Midterm outcomes (implant survival, HRQoL, and reoperation and revision rates) were compared between 37 patients who had undergone staged bilateral TAR and 106 patients treated with unilateral TAR; all patients were followed for at least 2 years. Results: Preoperatively, patients with unilateral disease had a higher prevalence of posttraumatic arthritis, whereas patients with bilateral disease had a higher prevalence of primary and secondary arthritis (p < 0.001). The mean preoperative SF-36 physical component summary (PCS) score in the unilateral group was higher than that in the bilateral group (p < 0.002). The mean postoperative follow-up (and standard deviation) was 5.0 ± 2.0 years in the bilateral TAR group and 4.0 ± 1.8 years in the unilateral TAR group. The patients who underwent either unilateral or staged bilateral TAR demonstrated improved SF-36 PCS scores between the preoperative and postoperative evaluations (p < 0.001). The postoperative SF-36 PCS scores were similar between the patients with unilateral TAR and those with bilateral TAR (p = 0.70). Six ankles (6%) in the unilateral cohort and 6 ankles (8%) in the bilateral cohort required revision of the metal component (p = 0.52). The mean implant survival time was 10.9 years (95% confidence interval [CI] = 10.1 to 11.7 years) in the bilateral cohort and 9.2 years (95% CI = 8.5 to 9.8 years) in the unilateral cohort (p = 0.60). Conclusions: Preoperative SF-36 scores demonstrated that bilateral end-stage ankle arthritis is a more debilitating condition than unilateral arthritis. Patients who underwent staged bilateral TAR benefited as much as patients who underwent unilateral TAR, despite having a worse preoperative health status. Metal component revision rates and implant survival were similar between the 2 groups. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
背景:我们进行了一项回顾性队列研究,比较双侧和单侧终末期踝关节关节炎患者术前健康相关生活质量(HRQoL)。我们还比较了分阶段双侧全踝关节置换术(TAR)患者亚组与单侧全踝关节置换术患者亚组的中期结果。方法:比较来自加拿大骨科足踝协会前瞻性踝关节重建数据库的53例双侧终末期踝关节患者和来自同一数据库的106例单侧关节炎患者手术前的HRQoL。采用Short Form-36 (SF-36)和American Academy of Orthopaedic Surgeons Foot and Ankle Module (AAOS-FAM)评分评估术前HRQoL。中期结果(种植体存活、HRQoL、再手术和翻修率)比较了37例分阶段双侧TAR患者和106例单侧TAR患者;所有患者随访至少2年。结果:术前单侧病变患者创伤后关节炎患病率较高,而双侧病变患者原发性和继发性关节炎患病率较高(p < 0.001)。单侧组术前SF-36 physical component summary (PCS)评分平均值高于双侧组(p < 0.002)。双侧TAR组术后平均随访时间(及标准差)为5.0±2.0年,单侧TAR组为4.0±1.8年。接受单侧或分阶段双侧TAR的患者在术前和术后的sf - 36pcs评分均有改善(p < 0.001)。单侧TAR患者与双侧TAR患者术后sf - 36pcs评分相似(p = 0.70)。单侧队列中6个踝关节(6%)和双侧队列中6个踝关节(8%)需要修改金属组件(p = 0.52)。双侧队列的平均种植体生存时间为10.9年(95%可信区间[CI] = 10.1 ~ 11.7年),单侧队列的平均种植体生存时间为9.2年(95% CI = 8.5 ~ 9.8年)(p = 0.60)。结论:术前SF-36评分表明,双侧终末期踝关节关节炎比单侧关节炎更使人衰弱。尽管术前健康状况较差,但接受分阶段双侧TAR治疗的患者与接受单侧TAR治疗的患者受益程度相同。两组间金属假体修复率和种植体存活率相似。证据等级:治疗性III级。有关证据水平的完整描述,请参见作者说明。
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引用次数: 13
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The Journal of Bone and Joint Surgery
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