Annals of Joint最新文献

Background and objective: Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice.

Methods: PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design.

Key content and findings: Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs.

Conclusions: The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Background: Long-term exposure to weightlessness can result in bone and muscle degradation, significantly impacting musculoskeletal function. Recent studies have also indicated damage to articular cartilage due to weightlessness. This study aims to observe the effects of simulated weightlessness on the cartilage microstructure of the quadriceps muscle and the muscular knee joint in rats.

Methods: A total of 30 rats were used in this study, of which 20 rats were subjected to simulated weightlessness by tail suspension, which may be suitable for clinical long-term bedridden patients. At 14 and 28 days, the microscopic morphology of knee cartilage and quadriceps femoris muscle was observed by transmission electron microscopy, and the collagen and water content of cartilage was evaluated by magnetic resonance imaging. The mitochondrial activity of knee muscle and the levels of inflammatory factors in synovial fluid were detected by enzyme-linked immunosorbent assay (ELISA). Biomechanical and histological evaluation of cartilage was performed.

Results: On day 14, T2 mapping revealed no significant loading effect. However, transmission electron microscopy revealed altered mitochondrial inner membrane structure in cartilage, with vacuolization, disrupted endoplasmic reticulum, alongside mitochondrial ultrastructural damage in muscle. ELISA results showed that a large number of mitochondria in muscle were inactivated, and the levels of inflammatory factors in synovial fluid were increased. The staining results showed slight fracture of the cartilage surface and the type II collagen-positive cells were reduced. Nanoindentation showed that the cartilage microsurface was uneven, and the elastic modulus and hardness were decreased. On day 28, T2 mapping analysis indicated increased cartilage T2 values. Transmission electron microscopy showed alterations in the structure of the mitochondrial inner membrane in cartilage, severe vacuolization, disrupted endoplasmic reticulum, and substantial mitochondrial damage in muscle tissue. Muscle mitochondrial activity was markedly decreased, inflammatory factors levels were elevated, and the cartilage surface exhibited severe damage. The type II collagen positive cells were further reduced, the micro-surface of cartilage was uneven, and the elastic modulus and hardness were significantly decreased.

Conclusions: The weightless environment resulted in the damage of endoplasmic reticulum and mitochondria of cartilage, mitochondrial damage of quadriceps muscle, inactivation of muscle mitochondria (P=0.01), increased intra-articular inflammation (P=0.01), decreased elastic modulus and hardness (P=0.03), and damaged cartilage surface, which aggravated cartilage degeneration.

Background and objective: Anterior cruciate ligament reconstruction (ACLR) failures occur for various reasons including residual laxity, untreated concomitant injuries, poor graft quality, and high tibial slope. Various additional procedures can help to decrease revision ACLR failures including anterolateral complex (ALC) procedures and slope-reducing osteotomies for patients with high tibial slopes. This narrative review aims to review the literature on the roles of ALC augmentation procedures and slope-reducing osteotomies in the setting of patients undergoing revision ACLRs.

Methods: A narrative review of relevant literature was performed in July 2024. Studies about anterolateral complex reconstructions and slope-reducing osteotomies in revision ACLRs were included.

Key content and findings: The literature reported that lateral extra-articular tenodesis (LET) and anterolateral ligament reconstructions (ALLR) can be used in revision ACLR cases to significantly reduce clinical knee laxity and the risk of repeated graft failure. There is not currently a strong opinion on which ALC procedure is superior. There are reported slight differences in lateral knee pain and knee stiffness, but both similarly significantly improve clinical and functional outcomes. In revision ACLR cases that also have a high posterior tibial slope (PTS), a slope-reducing tibial osteotomy is warranted. An anterior closing wedge proximal tibial osteotomy (ACW-PTO) significantly reduces anterior tibial translation and graft failure. There is concern about the changes to patellar height, but the literature has found that such changes are either slight or absent by 6 months postoperatively.

Conclusions: The risk of ACLR failure is increased by risk factors like high tibial slope, preoperative knee laxity, and prior ACLR rupture. Anterolateral complex procedures and slope-reducing osteotomies may be used to address these specific concerns and reduce the risk of graft rupture. For revision ACLR cases with lower PTS, augmentation with a LET or an ALLR to reduce the risk of graft failure and improve rotational stability may be warranted. In the setting of a revision ACLR in patients with a high PTS of ≥12°, a concomitant ACW-PTO and ALC procedure should be considered to decrease the risk of an ACLR graft failure.

Background and objective: Diagnosing chronic lateral ankle instability (CLAI) involves a comprehensive evaluation encompassing medical history, physical findings, and imaging examination. The optimal method of diagnosis of CLAI remains controversial. Therefore, the objective of this review was to summarize the current literatures regarding recent evolution and technical improvement of diagnostic methods for CLAI.

Methods: A literature regarding the diagnosis of CLAI was reviewed on PubMed, including articles written in English until May 2024.

Key content and findings: In the manual examination for the diagnosis of CLAI, the anterior drawer test is the standard evaluation for lateral ligament insufficiency. The anterolateral drawer test, meanwhile, which focuses more on lateral instability biomechanically, has also been performed. Ultrasonography is a point-of-care tool that is less invasive than stress radiography and can dynamically assess ligament integrity, making the diagnosis of CLAI more accurate and convenient. Magnetic resonance imaging (MRI) is a useful modality that allows extensive preoperative evaluation of ligamentous properties and associated osteochondral damage, and it is essential in the preoperative diagnosis of CLAI.

Conclusions: A combination of physical examination and imaging studies is especially important to more accurately diagnose CLAI. Future research should focus on standardizing testing and measurement methods to objectively define CLAI.

Angiotensin II receptor blockers (ARBs) are commonly prescribed for hypertension and heart failure, and have well-described antifibrotic properties throughout medical literature. The etiology and pathogenesis of fibrosis is biologically complex with a multitude of factors playing a role in the process. Consequently, pathologic fibrosis may be significant within orthopaedics contributing to post-operative stiffness and, ultimately, negative patient outcomes. The pharmacology of ARBs has been described to combat fibrosis in preclinical settings, while the literature of ARBs antifibrotic properties in relation to orthopaedics remains scarce. However, fibrosis is one of the primary factors contributing to tissue healing and functional recovery in the field of orthopaedic surgery. Fibrosis has specifically been described in relation to shoulder surgery, knee arthroplasty and hip arthroscopy. As such, outcomes of various orthopaedic surgeries are dependent upon a balance between tissue healing and stiffness, both of which may be mediated by a fibrotic response. Importantly, ARBs have recently emerged as a potential therapy to combat fibrosis-mediated stiffness in orthopaedic surgery patients. Thus, the following review article seeks to highlight the basic and clinical science of ARBs with emphasis on their implications and indications for orthopaedic surgery and musculoskeletal medicine.

Background: Syndesmotic ankle fractures occur when there is damage to the syndesmosis complex, resulting in severe pain and instability. Treatment methods include static fixation, dynamic fixation, and fibular nailing. This systematic review and meta-analysis aims to compare the outcomes of these surgical interventions for syndesmotic ankle fractures.

Methods: PubMed and Embase were searched up until April 2024 for comparison studies that included at least two of the treatment methods and relevant functional outcomes and complication metrics. Review Manager 5.4 was used for statistical analyses, and a P value ≤0.05 was considered statistically significant. Risk of bias was assessed with Review Manager 5.4. and the Newcastle-Ottawa scale.

Results: Nineteen studies with a total of 1,182 patients met the inclusion criteria. Compared to static fixation, dynamic fixation had a significantly higher Olerud-Molander Ankle Score (OMAS) at both 1-year [standardized mean difference (SMD) =0.43; 95% confidence interval (CI): 0.22 to 0.65; P<0.05] and 2-year post-operation (SMD =0.76; 95% CI: 0.33 to 1.20; P<0.05). Dynamic fixation had a significantly lower reoperation rate than static fixation [risk ratio (RR) =0.55; 95% CI: 0.36 to 0.83; P=0.004]. Compared to static fixation, fibular nail had a significantly higher OMAS at 1-year post-operation (SMD =0.28; 95% CI: 0.03 to 0.53; P=0.03). Fibular nails had significantly lower infection (RR =0.12; 95% CI: 0.04 to 0.37; P<0.05) and reoperation rates (RR =0.22; 95% CI: 0.06 to 0.86; P=0.03) than static fixation. Compared to fibular nail, dynamic fixation had a significantly higher OMAS at both 1-year (SMD =1.07; 95% CI: 0.83 to 1.31; P<0.05) and 2-year post-operation (SMD =1.03; 95% CI: 0.60 to 1.47; P<0.05). Dynamic fixation had a significantly higher reoperation rate compared to fibular nail (RR =20.41; 95% CI: 2.81 to 148.21; P=0.003).

Conclusions: Dynamic fixation seems to be the superior treatment method, displaying better outcomes than static fixation and fibular nailing, with the fibular nail proving to be a viable alternative. Dynamic fixation should be the first choice of treatment for those with syndesmotic ankle fractures due to its clinical advantages compared to static fixation and fibular nailing.

Level of evidence: 3.

The peroneus muscles, consisting of the peroneus longus (PL) and peroneus brevis (PB) tendons, are vulnerable to injury at anatomically specific sites or within tendon sheaths. Peroneal tendon dislocation (PTD) is often misdiagnosed as a lateral ankle sprain as it occurs at a lower frequency than a lateral ankle sprain. Anatomical variations in the retromalleolar groove, soft tissue overstuffing, and presence of accessory peroneal muscles contribute to the etiology of PTD. PTD has been classified into four types based on injury patterns involving the superior peroneal retinaculum (SPR) and fibrocartilaginous ridge. Diagnosis involves recognizing tender points and using imaging including magnetic resonance imaging (MRI) and ultrasonography. Conservative treatments, including below-knee plaster casts, have varying success rates, and some patients progress to recurrent PTD (RPTD), prompting consideration of surgical interventions. Diagnosis is easy in patients with RPTD who can reproduce the dislocation by themselves; however, in many cases, this is not possible. In such cases, ultrasonography after intrasheath injection is effective in confirming the presence of a pseudo-pouch. RPTD can be diagnosed if a pseudo-pouch is identified during ultrasonography. Surgical approaches such as osteotomy, soft tissue procedures, and groove deepening techniques are used to stabilize the peroneal tendons. Soft tissue procedures, especially SPR reattachment, have emerged as a preferred option, demonstrating outcomes comparable to those of osteotomy, with fewer complications. Intrasheath subluxation, a unique PTD subtype, is diagnosed using ultrasonography. In this type of subluxation, no damage to the SPR is observed, and the positions of the PL and PB tendons are interchanged. Surgical intervention may involve excision of the synovium and SPR repair. In cases of PTD complicated by a longitudinal rupture of the PB tendon, suturing of the torn area or tubularization of the remaining tendon for partial resection of the degenerated tendon can be performed. The purpose of this article is to describe the methods for diagnoses and management of PTD.