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

Introduction: Chronic infections and soft-tissue defects are serious complications after total hip arthroplasties (THAs) that may require hip disarticulation (HD). HD is a relatively high-risk procedure with poor long-term outcomes and survival. This is the first study to analyze the effect of an ipsilateral, pedicled vastus lateralis (VL) muscle flap in preventing HD in patients with recurrent complications after THA.

Methods: This retrospective case review analyzed the 6-month postoperative outcomes of 14 patients who underwent soft-tissue hip reconstruction with a VL muscle flap by a single surgeon.

Results: Most (86%) patients fully recovered after 6 months with preserved hip range of motion, no pain, and no weakness on ambulation. Two (14%) patients ultimately required HD despite introducing a VL flap.

Discussion: A VL muscle flap is an effective treatment of nonhealing THA and prophylactic intervention for patients at high risk for HD. The VL muscle is optimal because of its large size allowing reduction of soft-tissue dead space, its local anatomical location to the hip, and its exceptional vascularity. Additional prospective studies are necessary to determine the most appropriate population for this technique.

Background: Little is known about the effect of surgical approach on return to braking after total hip arthroplasty (THA), and few studies have investigated braking after THA with modern surgical techniques and rehabilitation protocols.

Methods: In a prospective comparative design, we enrolled 65 patients who received right-sided primary THA at our institution from April 2018 through March 2020, 34 with a direct anterior approach (DAA) and 31 with a posterior approach (PA). Braking tests measuring brake reaction time (BRT) and brake pedal depression (BPD) were administered to patients preoperatively and at 1, 2, and 4 weeks postoperatively using a realistic driving simulator. BRT and BPD were compared between groups and preoperatively versus postoperatively using mixed-effects models.

Results: Preoperative BRT averaged 638 msec in the DAA group and 604 msec in the PA group (P = 0.31). At 1 week postoperatively, the DAA group had significantly prolonged BRT compared with preoperatively (694 msec, P = 0.02). No significant difference was observed in the PA group (633 msec, P = 0.31). Both groups had returned to baseline by 2 weeks, and both had significantly faster BRT at 4 weeks compared with preoperatively (583 msec for DAA, P = 0.01; 537 msec for PA, P < 0.001). BPD was similar between groups, and there were no significant differences between preoperative and postoperative BPD at any time point.

Conclusions: With modern surgical techniques, BRT after right-sided THA returns to baseline levels approximately 2 weeks after surgery. There seems to be a quicker return to preoperative BRT observed in patients with a PA.

The primary objective of this review was to determine whether the attenuation of the postoperative inflammatory response (PIR) after total knee arthroplasty (TKA) leads to a notable improvement in clinical outcome scores. The secondary objective of this review was to determine the optimal approach in using inflammatory biomarkers, clinical inflammatory assessments, and imaging to quantify the PIR. A systematic literature search of eight major databases was conducted using a predetermined search strategy. C-reactive protein (CRP), interleukin-6 (IL-6), erythrocyte sedimentation rate (ESR), knee surface temperature (KST), and clinical outcome data were collected and graphically displayed. Eighty-six percent of the studies that reported a statistically significant decrease in inflammatory biomarkers in their treatment group demonstrated a concordant notable improvement in clinical outcome scores. Mean CRP, IL-6, ESR, and KST values peaked on postoperative day (POD) 2, POD1, POD7, and POD 1-3, respectively. The PIR is correlated with early pain and function recovery outcomes. Future studies comparing TKA surgical methodologies and perioperative protocols should assess PIR by incorporating inflammatory biomarkers, such as CRP and IL-6, and clinical inflammatory assessment adjuncts, to provide a more comprehensive comparison.

Supracondylar humerus fractures are common in the pediatric population, but flexion fractures are very rare in this population. The need for open reduction in these fractures is high and can be challenging for orthopaedic surgeons. In this article, we report a 9-year-old patient with bilateral flexion-type humeral fracture treated with closed reduction, which, to our knowledge, is the first report in the literature. We concluded that the first step in the treatment of flexion-type supracondylar fractures should be closed reduction with the help of an experienced assistant surgeon and that successful results can be obtained even in bilateral flexion-type fractures with appropriate treatment and follow-up.

Supracondylar humerus fractures are high-volume injuries in children; therefore, value-driven treatment has far-reaching implications for patients and families as well as healthcare systems. Children younger than 5 years can remodel posterior angulation. Most Type IIa fractures will maintain alignment after closed reduction. Many patients with surgical fractures can safely wait for nonemergent fixation. Outpatient surgery is associated with shorter surgical time, lower costs, and fewer return visits to the emergency department with no increase in adverse events. Type III fractures treated the following day do not have higher rates of open reduction, and patients with associated nerve injuries have no difference in recovery time compared with those treated more urgently. Pediatric-trained surgeons generally provide more efficient care (shorter surgical time and less after-hours surgery); however, their outcomes are equivalent to non-pediatric orthopaedic surgeons. Community hospitals have lower costs compared with teaching hospitals; therefore, transferring patients should be avoided when feasible. Postoperative care can be streamlined in uncomplicated cases to minimize radiographs, therapy referrals, and multiple visits. Splinting offers safer, lower cost immobilization over casting. With staffing shortages and an increasingly burdened healthcare system, it is imperative to maximize nonsurgical care, use outpatient facilities, and minimize postoperative requirements without negatively affecting patient outcomes.

Pseudotumors have been well documented to occur most frequently in metal-metal bearing total hip arthroplasties and less frequently in metal-polyethylene bearings. There are few cases in the literature of pseudotumors occurring in ceramic-ceramic articulations. We report a case of a large pelvic pseudotumor in a patient with a ceramic-ceramic bearing articulation in a 67-year-old man. In addition to the usual investigations, we did a detailed wear analysis of the ceramic implants and an examination of the soft tissues for particulate debris. The detailed wear analysis did show evidence of stripe wear; however, the volumetric wear was within the expected range. Synchrotron imaging identified strontium and zirconium debris arising from the ceramic surfaces. Although association does not mean causation, no other cause for the large pseudotumor could be identified and presumably represents an idiosyncratic reaction to ceramic debris.

Introduction: We aimed to use a national database to compare the 4-year revision surgery rates after rotator cuff repair (RCR) in patients with concomitant biceps tenodesis (BT) versus those without BT.

Methods: A retrospective cohort analysis was conducted using the PearlDiver database from 2015 to 2017. Patients undergoing primary open and arthroscopic RCR with and without BT were identified. Demographic variables, 90-day complications, and 2- and 4-year revision surgery rates were analyzed, and a multivariable logistic regression was conducted.

Results: Of the 131,155 patients undergoing RCR, 24,487 (18.7%) underwent concomitant BT and 106,668 (81.3%) did not. After controlling for comorbidities and demographics, patients with concomitant BT were associated with lower odds of all-cause revision (OR; P-value [0.77; P < 0.001]), revision BT (0.65; P < 0.001), revision RCR (0.72; P < 0.001), and shoulder arthroplasty (0.81; P = 0.001) within 4 years when compared with those without concomitant BT.

Discussion: In our analysis, patients undergoing primary RCR with concomitant BT had 35% reduced odds of revision BT and 23% reduced odds of any all-cause revision within 4 years when compared with those without concomitant BT. This suggests that tenodesis at the time of primary RCR may be associated with a reduction in the utilization of ipsilateral shoulder revision surgery rates.

Background: The main aim of this article was to propose a new concept of minimally invasive surgery for treating limb fractures, named as second to minimally invasive plates osteosynthesis (STMIPO).

Methods: We have described the STMIPO technique in a step-wise and standardized manner based on our findings from a study involving six patients treated at our institution. All patients with fracture achieved satisfactory outcomes.

Results: Ours clinical trials have shown that the STMIPO technique can be successfully applied in various limb fractures, including fibula fractures, tibial fractures, femur fractures, humerus fractures, ulna fractures, and radius fractures. All fracture patients achieved satisfactory outcomes.

Conclusion: As a new minimally invasive technology, the STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce with minimally invasive plates osteosynthesis (MIPO).

In the United States, rates of Mycobacterium tuberculosis infection have been declining for decades. Osteoarticular tuberculosis of the ankle is rarely observed. We present the case of a 65-year-old man who immigrated to the United States from India 24 years before the onset of symptoms. The patient initially reported atraumatic swelling and pain of the left ankle and foot and was treated for venous insufficiency. Later, the patient was referred to a nonsurgical orthopaedic clinic for additional workup and was found to have elevated inflammatory markers. MRI showed septic arthritis and osteomyelitis of the talus, distal tibia, and calcaneus. Joint aspiration revealed elevated white blood cell counts with predominately PMNs. The patient was then referred to an orthopaedic foot and ankle surgeon and underwent extensive irrigation and débridement. The patient was discharged on empiric antibiotics. Culture results from the original joint aspirate returned 14 days after surgery as positive for acid-fast bacillus, later identified as M tuberculosis by sequencing. Empiric antibiotics were discontinued, and the patient was started on appropriate antituberculotic therapy. This case report illustrates the challenge in the diagnosis of skeletal tuberculosis and the importance of including this condition on the differential for patients with atypical foot and ankle presentations.

Total knee arthroplasty (TKA) is evolving from mechanical alignment to more individualized alignment options in an attempt to improve patient satisfaction. Thirteen-year survival of kinematically aligned prostheses has recently been shown to be similar to mechanically aligned TKA, allaying concerns of long-term failure of this newer individualized technique. There is a complex inter-relationship of three-dimensional knee and limb alignment for a TKA. This article will review planning parameters necessary to individualize each knee, along with a discussion of how these parameters are related in three dimensions. Future use of computer software and machine learning has the potential to identify the ideal surgical plan for each patient. In the meantime, the material presented here can assist surgeons as newer individual alignment planning becomes a reality.