Hss Journal最新文献

Piriformis syndrome (PS) is a sciatic nerve entrapment condition caused by compression by the piriformis muscle, often presenting with symptoms that mimic lumbar radiculopathy and gluteal and buttock pain. This narrative review explores its diagnostic challenges and highlights the role of advanced imaging techniques in improving diagnostic accuracy. Literature suggests that PS may account for 5% to 8% of low back pain cases, frequently manifesting as buttock pain exacerbated by sitting or hip motion. Traditional imaging often fails to detect PS due to nonspecific findings, but magnetic resonance neurography can reveal sciatic nerve inflammation. A multimodal approach combining clinical assessment with targeted imaging enhances diagnostic precision and guides effective management of PS.

Background: Anterior cruciate ligament (ACL) tears are common and often devastating injuries among elite athletes. While interest in ACL preservation has highlighted the importance of ACL tear location to treatment decision-making, there is limited data on ACL tear location in elite athletes.

Purpose: We sought to describe the distribution of ACL tear location among National Football League (NFL) athletes and test the hypothesis that tear location is associated with injury mechanism.

Methods: Using a dataset from a study published in 2023, we identified 191 players with magnetic resonance imaging (MRI) of acute ACL tears occurring in NFL practice or games from 2015 to 2019; these were reviewed by 2 musculoskeletal radiologists. Data from these MRIs were linked to each player's electronic medical record data, and injuries from 2018 to 2019 were linked with available video to assess for an association between tear location and mechanism of injury in 73 of those players.

Results: Overall, 3% of tears were type I, 20% type II, 74% type III, 2% type IV, and <1% type V. For noncontact injuries, 71% were type III and 29% type II. Among indirect contact injuries, 78% were type III, 13% type II, 4% type IV, and 4% type V. In direct contact injuries, tears were 73% type III, 13% type II, and 13% type IV.

Conclusion: This retrospective review of MRI and video data of ACL tears in NFL players found that mid-substance tears were the most common. There was a higher proportion of type III tears and a lower proportion of type I tears compared to prior studies, suggesting these athletes may be less amenable to preservation techniques.

Level of evidence: Level IV: cross-sectional study.

Background: Decreasing wound healing complications is important for total joint arthroplasty. 2-Octyl cyanoacrylate with polymer mesh tape (2OPMT) is a skin closure system that works by combining a liquid adhesive with a polymer mesh to form a waterproof microbial barrier over surgical wounds. However, allergic contact dermatitis (ACD) has been a reported complication of 2OPMT use, with an incidence ranging from 0.5% to 2.5%.

Purpose: We sought to report our results of 2OPMT with primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and determine the incidence of ACD.

Methods: We conducted a single-institution, single-surgeon retrospective cohort study of 185 TKA and 154 THA patients who underwent procedures at a tertiary referral institution from October 2021 to November 2023.

Results: Overall incidence of ACD associated with 2OPMT was 3.8% (13/339). Incidence of ACD in TKA was 3.8% (7/185) and in THA it was 3.9% (6/154). All skin reactions were recognized at the first postoperative visit and treated with a combination of topical and/or oral steroids and oral antihistamines. All ACD reactions resolved by the second postoperative visit, and none of these patients developed a surgical site infection or a periprosthetic joint infection.

Conclusions: We found an ACD incidence of 3.8% with 2OPMT use in TKA and THA. This is similar to other studies reporting on ACD in TKA and THA. While it can be treated with routine use of steroids, antihistamines, and antibiotics, ACD is uncomfortable for patients and presents them with a concerning clinical appearance that requires additional treatment.

Level of evidence: Level III: retrospective cohort study.

Background: The most common cancer in women worldwide, breast cancer most often metastasizes to the bone. Improved chemo- and radiotherapies and novel molecular therapies have prolonged survival in women with osseous metastatic breast cancer, but spinal metastases often cause cord compression that degrades their functional independence.

Purpose: In women with breast cancer metastasized to the spine, we sought to (1) identify independent predictors of a functional deficit 3 months after surgical management and (2) assess the utility of existing metrics at highlighting patients at risk of a postoperative functional deficit.

Methods: We performed a single-institution, retrospective analysis of 92 patients meeting our inclusion criteria between 2004 and 2021. Patients were classified by 3-month postoperative Eastern Cooperative Oncology Group (ECOG) scores into good/independent (ECOG 0 to 2) and poor/dependent (ECOG 3 to 5) functional outcome groups. Univariate and multivariate analyses were performed to identify patient and tumor factors associated with good vs. poor 3-month ECOG scores.

Results: Preoperative use of selective estrogen receptor modulators (SERMs) was significantly associated with good postoperative functional outcomes. Poor preoperative function, the presence of visceral metastases at the time of surgery, and triple-negative primary or metastatic tumor status were independently associated with poor 3-month postoperative function. Host characteristics, sociodemographic factors, and indicators of surgical complexity, including estimated blood loss, front/back surgery, and corpectomy reconstruction, were not associated with 3-month ECOG score. A multivariate model including these significant univariate associations and normalized for patient demographics identified preoperative SERM use, poor preoperative function (ECOG score), and triple-negative primary or metastatic tumor status as independently associated with functional status 3 months after surgery.

Conclusions: Our retrospective analysis found that preoperative SERM use was significantly associated with improved postoperative functional outcomes, while poor preoperative function and triple-negative tumor status were significantly associated with poor function 3 months after surgery. These factors may serve as indicators of function and independence after surgery for patients with metastatic breast cancer to the spine.

Level of evidence: Level IV: Prognostic Study.

Background: Studies have shown that various types of spine surgery can be a contributing factor in bone loss, but the influence of lateral lumbar interbody fusion (LIF) on postoperative bone loss remains unclear.

Purpose: We sought to investigate the influence of spine surgery, measured by quantitative computed tomography (QCT), on the adjacent vertebrae, and to evaluate the bone loss between stand-alone LIF (SA-LIF) and LIF supplemented with posterior pedicle screw-rod fixation (360° constructs).

Methods: We conducted a retrospective review of the records of patients who underwent SA-LIF and 360° constructs between 2016 and 2024. Inclusion criteria were (1) the interval between surgery and the secondary CT was 2 to 12 months; (2) the interval between the preoperative and postoperative CT was a minimum of 2 months; (3) the patient did not undergo additional spine surgery between those 2 CT scans; and (4) volumetric bone mineral density (vBMD) measurements of 1 level above the upper vertebra (UV+1) were possible in all cases. We excluded levels with a corpectomy, planned staged surgery, more than 4 levels of fusion, and poor QCT imaging quality. Postoperative changes in vBMD in the vertebrae at UV+1, UV+2, and 1 level below the lower vertebra (LV-1) were measured. Pre- and postoperative vBMDs were compared. Postoperative vBMD changes were also compared between the 2 groups.

Results: Out of 191 patients who underwent the anterior or lateral interbody fusion in the specified time period, 72 patients met our inclusion criteria (36 SA-LIF; 63.3 ± 15.1 years, 36 360° constructs; 58.6 ± 11.3 years). UV+1 and UV+2 showed significant decreases in the SA-LIF group, and UV+2 and LV-1 decreased significantly in the 360° group. In the ANCOVA adjusted for age, the percent change in vBMD at each adjacent level showed no significant difference between the 2 groups.

Conclusion: Both SA-LIF and 360°construct surgeries negatively affected the postoperative vBMD values at adjacent levels. There was no statistically significant difference in bone loss between the 2 groups, suggesting that additional surgical invasiveness caused by screw insertion may not affect the severity of postoperative bone loss.

Level of evidence: Level III: retrospective cohort study.

Background: Gaining operative proficiency requires adequate case volume during orthopedic residency training. Numerous surgical fields have demonstrated that male residents report higher case volume than female residents. In general surgery, racially/ethnically underrepresented in medicine residents report lower case volume than White residents.

Purpose: We sought to evaluate differences in case volume between male and female orthopedic surgery residents and between White residents and those of other races and ethnicities at a single orthopedic residency.

Methods: Accreditation Council for Graduate Medical Education case logs were reviewed for orthopedic residents from 2010 to 2023 at a single institution. Overall residency case volume and volume by post-graduate year (PGY) were compared between men and women and between White and "other race" residents.

Results: Of 111 residents included, 80.2% self-reported as men, 19.8% as women, 61.3% as White, non-Hispanic, and 32.4% as any other race (for 6.3%, race/ethnicity was unavailable). Overall, women logged a mean of 1865.6 cases while men logged a mean of 1861.0 cases, showing no difference based on gender. At the PGY-4 level, women logged more cases than men, with a mean of 430.3 for women versus 370.0 for men. There was no difference in overall case volume between White residents and those of "other" race/ethnicity, nor were there race/ethnicity-based differences by PGY level.

Conclusion: In contrast to prior studies, our retrospective single-institution review found no difference in overall case volume for orthopedic residents based on their self-reported gender or race/ethnicity. Institutions and the specialty at large should continue to create equitable surgical opportunities for orthopedic trainees, while future research should assess autonomy within cases.

Background: Total shoulder arthroplasty (TSA) is an effective treatment for advanced osteonecrosis (ON) of the humeral head, a condition involving vascular disruption and bone necrosis. However, systemic comorbidities in ON patients may impact postoperative outcomes.

Purposes: We sought to evaluate health care utilization, systemic complications, and implant-related outcomes in TSA patients with and without ON.

Methods: Using the TriNetX research database, we identified patients who underwent TSA between December 9, 2002, and December 9, 2022. Two cohorts were created: The TSA + ON cohort included patients with any ON diagnosis of the humerus within 1 year leading to their TSA, and the TSA-only cohort excluded patients with ON of the humerus within the same timeframe. Propensity score matching was used to balance comorbidities. Outcomes-including emergency department (ED) visits, readmissions, adverse events, and prosthetic complications-were assessed at 30th day, 90th day, and 1st year. The Benjamini-Hochberg method was applied to control the false discovery rate.

Results: The query identified 1281 patients with ON and 71 201 patients without ON who underwent primary TSA. After matching, each group consisted of 1218 patients. There were no significant differences in ED visits or readmissions between cohorts after correction. Systemic complications were similar, except for acute kidney injury at the 90th day, which was more frequent in the TSA + ON group. No other adverse events reached significance. Implant-related outcomes, including prosthetic joint infection and revision, were comparable.

Conclusion: The findings of this retrospective cohort database study suggest that TSA may be safe and effective in ON patients, with similar implant outcomes to non-ON patients. However, the increased rate of acute kidney injury we found at the 90thday in the TSA + ON cohort suggests the need for closer perioperative renal monitoring and supports individualized risk stratification to improve outcomes in this population.

Level of evidence: Level III: retrospective cohort database study.

Background: Robotic assistance is becoming increasingly popular among surgeons performing total hip arthroplasty (THA). The impact of robotic assistance on the assessment of intraoperative stability and acetabular liner selection is not well described.

Purpose: We sought to compare the incidence of intraoperative conversion from a neutral liner to a non-neutral liner in patients undergoing either robotic-assisted THA or manual THA.

Methods: We conducted a retrospective cohort study of patients who underwent primary THAs at our institution between January 1, 2018 and June 30, 2022. Partial hip arthroplasties, simultaneous bilateral hip arthroplasties, revision surgeries, and navigation-guided THAs were excluded. We identified 9614 primary THAs performed on 8807 patients; of these, 3875 were robotic-assisted THAs and 5739 were manual THAs. Liners were subcategorized into implanted versus wasted and neutral versus non-neutral (eg, elevated, lipped, lateralized, face changing, true constrained, and dual mobility). The primary outcome was the rate of intraoperative conversion from a neutral to non-neutral liner, defined as a wasted neutral liner followed by the implantation of a non-neutral liner.

Results: Neutral liners were more frequently used in robotic-assisted THA than in manual THA (71% vs 42%, respectively), whereas elevated or lipped liners were more commonly used in manual THA than in robotic-assisted THA (34% vs 26%, respectively). After controlling for patient demographics and surgical variables, robotic-assisted THA had lower odds of conversion from a wasted neutral to an implanted non-neutral liner compared to manual THA.

Conclusion: Robotic-assisted THA is associated with a decreased rate of intraoperative liner conversion from a neutral to a non-neutral liner, suggesting that robotic assistance may provide greater stability during intraoperative assessments of implant placement.

Level of evidence: Level III: retrospective cohort study.

In the treatment of osteoarthritis and soft tissue injury, early basic science and clinical data have been promising for the use of autologous blood formulations. This review article explores autologous conditioned serum, alpha-2-macroglobulin, and autologous protein solution, which function via overlapping but distinct mechanisms to reduce inflammation, counteract catabolism, and improve joint homeostasis. The ideal timing and quantity of dosing are largely unknown and may vary based on indication. Additional high-quality clinical trials are necessary to define the efficacy of these interventions on both long-term symptomatic improvement and mitigation of osteoarthritic disease progression.