JBJS Reviews最新文献

» Tibial fixation remains the biomechanically weaker site in ACL reconstruction due to lower bone density and directional loading forces, making fixation choice critical for graft stability.» Interference screws provide aperture fixation close to the joint line but are limited by graft slippage, tunnel widening, and progressive loss of tension over time.» Suspensory devices engage cortical bone and reduce graft damage during insertion; when supplemented with backup fixation, such as knotless suture anchors, they demonstrate greater fixation strength and reduced graft micromotion.» Internal suture augmentation offers promising biomechanical and early clinical benefits by protecting the graft during the vulnerable early healing period, especially in young athletes and revision cases, though long-term effects remain under investigation.» Fixation strategy should be individualized, balancing graft choice, bone quality, and rehabilitation demands to optimize outcomes and reduce risk of failure.

Background: Total ankle arthroplasty (TAA) provides pain relief and motion preservation for end-stage ankle arthritis, yet outcomes and utilization vary widely. Social determinants of health (SDOHs) such as socioeconomic, demographic, and behavioral factors may contribute to these disparities, but their influence on TAA has not been systematically evaluated.

Methods: A systematic review was registered on PROSPERO (CRD420251156933) and performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PROGRESS-Plus framework to identify studies examining the impact of SDOH on TAA utilization and outcomes. PubMed, Embase, and Scopus were searched through 2025. Study quality was assessed with the Risk Of Bias In Nonrandomized Studies of Interventions tool, and certainty of evidence for each domain was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation framework. Data were synthesized narratively with random-effects meta-analysis where feasible.

Results: Forty-four studies including more than 200,000 patients were analyzed. Social determinants were found to influence both access to TAA and postoperative outcomes. Men demonstrated slightly better postoperative function, whereas women reported more pain and higher rates of nonhome discharge. Older patients experienced more perioperative complications but achieved similar long-term implant survival compared with younger cohorts. Patients from minority racial and ethnic groups had higher complication rates and were less likely to receive TAA compared with arthrodesis. Lower income, public insurance, and treatment in rural or lower-volume hospitals were consistently linked with reduced access to TAA, longer hospital stays, and greater healthcare costs. Behavioral factors such as smoking and preoperative opioid use were strongly associated with wound complications, prolonged hospitalization, and poorer recovery.

Conclusion: SDOH significantly shape access to surgery, complication risk, and recovery after TAA. Recognition of these influences and targeted strategies such as preoperative optimization, equitable referral pathways, and improved access to rehabilitation may help reduce disparities and improve outcomes in ankle arthroplasty.

Level of evidence: Level III, systematic review of predominantly Level III studies.

Background: The lack of a gold standard in tarsal tunnel syndrome (TTS) diagnosis leads to diagnostic inconsistencies and variation in patient selection for treatment. Therefore, the aim of this review is to summarize the diagnostic criteria used in current studies on TTS based upon this best-evidence synthesis.

Methods: Three databases were searched to identify all studies on TTS. Studies were included when they included (1) diagnosis or treatment of TTS as the primary focus, (2) a description of the diagnosis of TTS, (3) an original data set of TTS cases, and (4) a minimum of 10 adult patients diagnosed with TTS. A best-evidence synthesis was used to summarize the results.

Results: In total, 4,213 patients were represented in 82 included studies. Among the varying diagnostic methods employed, aside from clinical symptoms, provocative testing was most often used (in 94% of studies, mandatory for diagnosis in 41% of studies) with the Tinel sign being the most prevalent (used in 89% of studies). Sensitivities of provocative tests, electrodiagnostic, and ultrasound measurements showed significant variability.

Conclusion: We provided an overview of the diagnostic tools and workups reported in the literature on TTS. Our findings show that the lack of a standardized diagnostic approach results in considerable variability in clinical practice. Alongside typical clinical symptoms, the Tinel sign is the most frequently used diagnostic test. The varying sensitivities reported in literature underscore the need for evidence-based diagnostic guidelines on TTS diagnosis.

Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

» Proximal humeral malunions: Arthroscopic techniques are effective for mild malunions, osteotomy is suitable for more significant deformities, and shoulder arthroplasty is ideal for cases with severe damage or nonviable humeral heads.» Humeral shaft malunions: Rotational and angled deformities should be addressed with an osteotomy, though malunions are generally well tolerated and more likely to be cosmetic deformities.» Distal humerus malunions are complex, but corrective osteotomy or arthroplasty can improve function and pain, especially with 3-dimensional imaging enhancing surgical accuracy.

» Anterior cruciate ligament (ACL) tears are one of the most common severe injuries in sports medicine, with notable differences in incidence and outcomes between male and female athletes.» While anatomical, biomechanical, and hormonal sex-specific factors such as quadriceps angle, posterior tibial slope, and cyclic hormonal variation have been extensively evaluated, the influence of psychological and societal factors, including fear of reinjury, access to training, and disparities in access to care, remains less well understood.» This review aims to provide a comprehensive overview of intrinsic (anatomic, biomechanical, and hormonal) and extrinsic (psychological, social, and environmental) factors contributing to sex-based differences in ACL injury risk. In doing so, we seek to highlight both the breadth of current understanding and the relative lack of research addressing external, sex-based influences on injury incidence and recovery.» Recognizing sex-based differences in ACL injury risk, treatment, and recovery should guide the development of individualized prevention and rehabilitation strategies to optimize outcomes for all athletes.

» Based on the available evidence, there are numerous strategies that may reduce infection risk in primary shoulder arthroplasty. Preoperatively, optimization of iron deficiency anemia and smoking cessation are associated with lower rates of periprosthetic joint infection and perioperative complications. In addition, risk of infection may be mitigated by deferring shoulder arthroplasty for at least three months following a corticosteroid injection. Management of biologic and targeted immunosuppressive therapies should be coordinated with medical specialists and tailored to the specific agent's pharmacokinetics and surgical risk.» Preoperative skin preparation with agents such as benzoyl peroxide or chlorhexidine gluconate may decrease bacterial colonization. Antibiotic prophylaxis with a single preoperative dose of cefazolin administered within one hour of incision reduces infection risk, and in patients with true beta-lactam allergy, fully infused vancomycin prior to incision is an effective alternative. Intraoperatively, measures such as dilute betadine lavage, vancomycin powder, chlorhexidine wash, and antibiotic irrigation can reduce bacterial contamination. Additional intraoperative techniques including electrocautery after skin incision may further decrease bacterial burden, although higher level evidence for these latter interventions remains limited or conflicting.

Background: Fibrosis is a prevalent impediment to musculoskeletal healing, which contributes to poor outcomes across orthopaedic procedures and remains largely underaddressed in orthopaedic care.

Purpose: To review the effects of losartan on fibrosis across musculoskeletal tissues, and to evaluate its mechanistic rationale, preclinical outcomes, delivery strategies, and translational potential in orthopaedic practice.

Content summary: Losartan inhibits transforming growth factor beta 1 signaling by antagonizing the angiotensin II type 1 receptor, thereby reducing myofibroblast activity, limiting extracellular matrix deposition, and preserving regenerative cell populations across musculoskeletal tissues. Preclinical models demonstrate histological and mechanical improvements in models of cartilage injury, joint capsule fibrosis, tendon-bone healing, and skeletal muscle regeneration. Therapeutic efficacy is strongly influenced by timing, delivery route, and the microenvironment of the injury. Biomaterial innovations such as nanofiber scaffolds and injectable angiotensin II receptor blocker (ARB) hydrogels may enhance delivery. Further studies stratifying outcomes by age and sex are warranted. Ongoing clinical trials are evaluating losartan for arthrofibrosis, skeletal muscle disorders, and comparative antifibrotic efficacy among ARBs.

Conclusion: Losartan offers a mechanistically targeted, clinically familiar antifibrotic therapy with strong potential to improve surgical and rehabilitative outcomes in orthopaedics.

Background: Administering recombinant human growth hormone (rHGH) in a medically directed fashion has emerged as an investigational therapeutic intervention in clinical research to improve orthopaedic and sports medicine-related outcomes. Literature suggests that rHGH administration may improve athletic performance and influence osteoporosis and hip fracture outcomes. The purpose of this systematic review is to examine dosage regimens, identify adverse events, and summarize published peer-reviewed data of clinical outcomes where rHGH has been used in orthopaedic surgery human clinical studies to identify potential patient population targets, gaps in knowledge, and risks of use.

Methods: Three databases (Embase, PubMed, and MEDLINE) were searched using search terms including but not limited to "human growth hormone," "muscle strength," and "bone healing." Duplicate studies were removed and were subsequently screened first by title and abstract, followed by full-text. The reference lists of included studies were also evaluated with title screen. Data were abstracted and underwent pooled analysis, including meta-analysis where possible.

Results: The initial search produced 2,047 unique studies. A total of 22 studies with moderate methodological quality were included, which comprised 1,157 total patients, with a mean age of 54.3 years and a mean daily rHGH dose of 1.49 mg/d. Administration of rHGH led to a dose-dependent increase in serum insulin-like growth factor 1 (mean increase +133.2%). Lean body mass increased in 15 of the 23 studies (mean difference of +3.63% vs. placebo). Leg extension strength increased for rHGH administration vs. placebo (mean difference +3.17%). The most common adverse events in GH patients were peripheral edema (odds ratio [OR] = 3.03), carpal tunnel symptoms (OR = 3.85), and arthralgias (OR = 2.94).

Conclusion: rHGH administration led to improvements in clinical outcomes; however, the noteworthy side effects should also be taken into consideration when designing a treatment regimen for orthopaedic-related pathologies.

Level of evidence: Therapeutic Level II, systematic review of Level I and II studies. See Instructions for Authors for a complete description of levels of evidence.

» Ramp lesions occur in up to 40% of anterior cruciate ligament (ACL) injuries and are easily missed without systematic posteromedial inspection.» Magnetic resonance imaging has 70% sensitivity; arthroscopic probing using the posteromedial portal remains the diagnostic gold standard.» Unstable ramp lesions require repair; stable lesions may heal spontaneously with ACL reconstruction.» Repair restores knee stability and yields excellent outcomes comparable with isolated ACL reconstruction.» Return-to-sport rates exceed 80%, with rehabilitation mirroring standard ACL reconstruction protocols.

Background: The management of periprosthetic femoral fractures (PFFs) around polished taper-slip (PTS) cemented femoral stems in total hip arthroplasty has seen a recent shift in practice from revision to open reduction and internal fixation (ORIF). While ORIF is the accepted standard for stable uncemented stems, evidence guiding optimal management of PFF around cemented stems remains inconclusive. This metanalysis aimed to compare the outcomes of ORIF vs. revision in patients with Vancouver B2 PFFs around cemented PTS femoral stems.

Methods: We systematically searched MEDLINE, Embase, CENTRAL, Scopus, and ClinicalTrials.gov from inception to May 2025, for studies comparing ORIF with revision arthroplasty in adults with Vancouver type B2 PFFs around cemented PTS stem. None of the included studies were randomized control trials (RCTs). The outcomes were 5-year implant survival, 2-year reoperation rate, 1-year mortality, infection, aseptic loosening, nonunion, and operative time.

Results: Eight studies involving 675 patients (318 ORIF, 357 revision) met eligibility criteria. The mean age was 82.2 years, and the mean follow-up was 2.8 years. Two-year reoperation was significantly lower with ORIF (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.14-0.53, p < 0.001). Operative time was significantly shorter in the ORIF group (mean difference -42.28 minutes, 95% CI -71.27 to -13.29; p < 0.001). No significant differences were observed in 5-year implant survival (OR 0.64, 95% CI 0.26-1.60) or 1-year mortality (OR 2.05, 95% CI 0.71-5.89). Postoperative infection, aseptic loosening, and nonunion rates were also similar. Risk of bias was moderate overall.

Conclusion: For patients with Vancouver B2 PFFs around cemented PTS femoral stems, ORIF was associated with a significantly lower 2-year reoperation rate and shorter operative time compared with revision, while other outcomes were similar. These findings indicate comparable overall performance between ORIF and revision; however, given the heterogeneity and potential selection bias, uncertainty remains high, supporting the need for an RCT to evaluate both options.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.