Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews最新文献

Introduction: Musculoskeletal complications associated with end-stage renal disease (ESRD) are known to predispose patients to an increased risk of hip fractures. The aging population and the effects of treatments pose challenges to advancements in bone health management. This study is one of the largest to date, examining patient demographics and temporal trends among ESRDpatients with hip fractures.

Methods: A retrospective analysis of data from the United States Renal Data System, spanning 1977 to 2012, was conducted. Two cohorts of 115,386 sex-matched and age-matched patients with ESRD were studied: those with hip fractures and patients without hip fractures. Statistical significance was determined by a P value <0.05. Clinical significance was assessed using effect size (ES).

Results: The incidence of hip fractures among patients with ESRD increased by 3,369% between 1977 and 2007, followed by an 11% decrease from 2007 to 2012. ESRD patients with hip fractures were significantly more likely to be White (77.7% vs. 76.1%; P < 0.001, ES: 0.02) and older (71.6 vs. 71.2, P < 0.001; ES: 0.03). No difference in sex was observed between cohorts: male (47.0% vs. 47.0%) and female (53.0% vs. 53.0%).

Discussion: The temporal trend reflects current ESRD literature but contrasts with trends seen in the general population, partly because of the increased lifespan of these patients and thus longer dialysis, a known risk factor of fractures. Our data support current literature that White race is an independent risk factor of hip fractures, which may be due to genetic variations in vitamin D, FGF-23 metabolism, and bioavailability. The earlier onset of hip fractures in patients with ESRD may offset the effect of menopause-driven fractures observed in the general population.

Introduction: The Moberg volar advancement flap was classically described for covering thumb defects following traumatic fingertip amputations. However, its use in the lesser digits has been rarely reported. This study aims to evaluate the clinical outcomes of a modified volar advancement flap for fingertip amputations in lesser digits.

Methods: A single-center retrospective review was conducted on patients who underwent a modified volar advancement flap for fingertip amputation reconstruction of the lesser digits between 2015 and 2021. Patients who had flaps performed for the thumb, nontraumatic causes (eg, infection or gangrene), or who defaulted on postoperative rehabilitation and follow-up were excluded.

Results: Eighteen patients met the inclusion criteria for analysis, with a mean follow-up duration of 6 months. Protective sensation was achieved in 75% of patients, whereas 43.8% regained normal sensation. The mean QuickDASH score was 4.22 ± 5.97 (range 0 to 18.18). Common complications included hypersensitivity (61.1%), infection (11.1%), wound dehiscence (11.1%), and fixed flexion deformity of the distal interphalangeal joint (7.1%). No cases of flap necrosis or dorsal skin necrosis were observed.

Conclusion: The modified volar advancement flap remains a feasible option for reconstructing fingertip amputations, even in the lesser digits. This technique does not require microsurgical expertise and can be safely performed by general orthopaedic surgeons.

We report a case of a 9-year, 10-month-old female patient who ultimately required a revision vertebral column resection to manage a progressive congenital kyphoscoliosis complicated by postoperative surgical site infection, decubiti and implant exposure, proximal junctional kyphosis, and pseudarthrosis. Definitive surgery consisted of T4-L4 posterior spinal fusion and revision vertebral column resection with a pedicled rib vascular bone graft. At 3-year follow-up, the patient was fully recovered with return to full noncontact activities. The purpose of this case report is to describe the use of a rib vascular bone graft to increase the likelihood of arthrodesis for a complex pediatric spinal fusion patient with deficient posterior elements and multiple failed surgeries.

A number of children with abnormal tone are implanted with pumps that deliver baclofen to the intrathecal space through an attached catheter. These pumps contain a catheter access port that allows for withdrawal or introduction of fluids to the intrathecal space. Patients treated with baclofen pumps often also present with neuromuscular scoliosis or other conditions that require extensive surgery and perioperative analgesia. In this article, we describe cases in which intrathecal morphine (Duramorph) was delivered through implanted baclofen pumps to manage perioperative pain. We demonstrate that baclofen pumps can be used to deliver intrathecal morphine for effective perioperative analgesia with minimal risk of complications such as respiratory depression, pruritis, and nausea/vomiting. We also highlight steps which must be taken to ensure safety when using this technique.

Introduction: Interspinous process devices (IPDs) are a lesser invasive treatment option for lumbar spinal stenosis (LSS). The utility of IPDs has been debated, and no recent, large-scale representative database studies have examined utilization and revision surgery trends of IPDs.

Methods: Patients with LSS undergoing IPD placement were identified from the 2017-2022 M170Ortho PearlDiver Database and stratified by direct lumbar decompression usage and levels treated. Yearly IPD utilization of the study populations was tracked, and notable changes in usage were identified. Provider specialties placing IPDs were assessed. Kaplan-Meier survival analyses followed 3-year subsequent lumbar operation rates.

Results: A total of 10,422 patients with LSS undergoing IPD placements were identified, with a significant utilization increase from 2017 to 2020 (P = 0.027) and decrease from 2020 to 2022 (P = 0.039). These were done without direct decompression for 6183 (59.3%) and with direct decompression for 4239 (40.7%), with greater proportion performed without decompression over the years (P = 0.032). One-level procedures were 6,723 (64.5%) and two-level procedures were 3,699 (35.5%), with similar proportions over the years. Orthopaedic/neurologic surgeon utilization decreased, with pain specialists becoming the predominant providers using IPDs. Overall 3-year revision surgery rate was 12.0%, and no differences existed in revision surgery rates by decompression usage (P = 0.2) or levels treated (P = 0.3).

Discussion: This study is first to report on the notable IPD utilization decrease from 2020 to 2022 after strong adoption from 2017 to 2020. This aligned with an increasing proportion placed without decompression and by pain specialists, with no revision surgery rate differences. Although the reason for this change over time is unclear, this study reports shifting physician practices with IPDs.

An 11-year-old girl sustained an irreducible anterior radial head dislocation associated with a Salter-Harris type II proximal radial physeal injury and a volar annular ligament avulsion fracture after falling on an outstretched hand. Closed reduction was unsuccessful. During open reduction, the annular ligament was found interposed within the radiocapitellar joint, avulsed with a small bony fragment from the volar aspect of the radial notch. After ligament release, the radial head remained unstable, requiring anatomical repair using a pullout suture technique. At 1-year follow-up, the patient exhibited excellent functional recovery and a Mayo Elbow Performance Score of 100. Volar annular ligament avulsion fractures are exceedingly rare and may contribute to irreducibility in pediatric anterior radial head dislocations. Recognition of this interposition pattern is essential for planning surgical management. Anatomical repair through pullout technique can restore joint stability and function.

Objective: To evaluate the effects of adductor canal block (ACB) on motor and sensory functions following total knee arthroplasty. Motor function was quantified using median frequency of surface electromyography, whereas sensory function was assessed through pain scores, cutaneous sensation, and morphine consumption in patients with and without ACB.

Methods: This randomized controlled trial enrolled 25 total knee arthroplasty patients allocated to either ACB or non-ACB groups. Measurements included median frequency of rectus femoris and vastus medialis muscles during standardized 2-minute leg extension tasks, visual analog scale pain scores, morphine consumption, and cutaneous sensory function on postoperative days 1 to 4.

Results: No notable differences were detected between the groups regarding median frequency of rectus femoris and vastus medialis, visual analog scale pain scores, or morphine consumption across all postoperative days. These findings suggest that ACB did not compromise postoperative quadriceps muscle strength or pain control. However, cutaneous sensory recovery occurred on postoperative day 1 for all non-ACB subjects, whereas sensory recovery was delayed in the ACB group.

Conclusion: ACB preserves quadriceps strength while effectively managing pain after TKA, although temporary sensory deficits should be anticipated during early mobility.

Trial registration: Clinical Trials Registry and institutional ethical approval, March 2021.

Objectives: To evaluate the validity of Early Appropriate Care (EAC) criteria for managing unstable fractures of the spine, femur, and pelvis using a large database of patients.

Methods: Those ≥18 years old with spine, pelvis, or femur fractures presenting to the emergency department with hemodynamic instability requiring resuscitation were included. Polytrauma patients with other significant injuries were excluded. Complications in the immediate (7, 14, and 30 days) and intermediate (90, 180, and 365 days) postoperative period were evaluated.

Results: A total of 4115 adult orthopaedic trauma patients met EAC resuscitation criteria: 2,783 patients (68%) underwent definitive fixation within 48 hours and 1,332 (32%) after 48 hours. After propensity matching, both cohorts consisted of 1,317 patients with similar demographics and medical comorbidities. Patients who underwent definitive fixation within 48 hours were at lower risk of deep vein thrombosis, pulmonary embolism, deep infection, sepsis, and death in the intermediate postoperative period (P < 0.05 for all).

Conclusion: EAC of spine, pelvis, or femur fractures following adequate resuscitation is associated with lower rates of deep vein thrombosis, pulmonary embolism, sepsis, and death in the early and intermediate postoperative period. Age-stratified analysis found younger cohorts were less likely to have myocardial infarction or stroke, along with lower mortality rates across multiple time points. These data highlight the importance of early definitive fixation of adequately resuscitated orthopaedic trauma patients, validating the findings of previous studies through a large, international database.

Introduction: Although several studies observe and report the incidence of heterotopic ossification (HO) following total hip arthroplasty, to our knowledge, no study has characterized HO around femoral endoprostheses for reconstruction in cases of tumor resection or massive bone loss.

Methods: A grading system for HO around a femoral endoprosthesis was developed based on the Brooker Classification System. We then retrospectively reviewed all patients who underwent primary femoral endoprosthetic reconstruction (proximal, distal, or total) between 2010 and 2017 with minimum 6-month follow-up at a single institution. Radiographs from the most recent follow-up were used to classify the pattern of HO using the defined classification system. Intra- and interrater reliabilities of the classification system were determined. Electronic medical records were reviewed for patient demographics and further information on treatment.

Results: Forty-one femoral endoprostheses in 41 patients were included (22 proximal, 15 distal, and four total femur arthroplasties). Mean age at surgery was 53 ± 23 years (range 9 to 91 years), and 22 were female (54%). Inter- and intrarater agreement for HO classification was 87% (κ = 0.82) and 91% (κ = 0.88), respectively. In total, an 83% incidence of HO was found after femoral endoprosthetic arthroplasty. All proximal femur arthroplasties and 66.7% of distal femoral arthroplasties exhibited some degree of HO. Patients with HO were markedly older than those without (57 ± 21 vs. 30 ± 19; P = 0.003).

Discussion: The proposed classification system has high reproducibility and agreement. Our data suggest that HO is very common after femoral endoprosthetic reconstruction and is more predominant around the hip compared with the knee. Most HO was noted around the diaphyseal stem of the prosthesis and away from the joint.

Dysplasia epiphysealis hemimelica, also known as Trevor disease, is a rare and intriguing developmental disorder characterized by asymmetric cartilage overgrowth at the epiphyses, predominantly affecting long bones. We present a case of an 8-year-old girl with dysplasia epiphysealis hemimelica involving the carpal bones which is a highly unusual site in the upper limb. The patient underwent successful surgical excision of the symptomatic wrist mass, leading to notable functional improvement, albeit with mild residual extension limitation. This case highlights the critical role of advanced imaging in accurate diagnosis and surgical planning. Although conservative management remains the standard, timely surgical intervention may be necessary to alleviate symptoms and restore function in cases with notable impairment.