JBJS Reviews最新文献

» Patients with diabetes mellitus (DM) undergoing shoulder arthroplasty (SA) have a unique risk profile, which must be considered by clinicians.» The presence of DM as a comorbidity is associated with longer length of stay following SA, greater likelihood of nonhome discharge, and a higher rate of 90-day readmission.» Though the incidence is low, patients with DM are at an increased risk of serious postoperative cardiovascular complications, such as pulmonary embolism, venous thromboembolism, and myocardial infarction.» DM has generally been associated with increased risk of postoperative infection. The optimal hemoglobin A1c threshold in patients undergoing SA remains inconclusive. When extrapolating from lower limb arthroplasty, the literature indicates that this threshold is most likely in the range of 7.5% to 8%.» Patients with DM are more likely to require revision surgery after SA and report lower postoperative satisfaction.

Background: Iliopsoas injuries are a common cause of anterior hip and groin pain and can be successfully managed with conservative treatment. Corticosteroid and local anesthetic injections can also be offered in conjunction with nonoperative management. Given the variability in reported injection guidelines, composition, and techniques, the purpose of this study was to systematically review the literature to assess progression to surgery and patient outcomes following iliopsoas injections.

Methods: Four online databases (PubMed, Cochrane Library, MEDLINE, and Scopus) were searched for studies investigating the outcomes of iliopsoas injections from database inception until January 2024 in accordance with the Preferred Reporting Items for Systematic Meta-Analyses guidelines. Three reviewers screened titles, abstracts, and full-text articles independently and in duplicate. Recorded data included demographic data, patient-reported outcomes, complications, injection traits, and progression to surgery.

Results: Six articles were included in the review (follow-up time = 28.6 months). These studies included patients with iliopsoas bursitis, tendinopathy, and snapping hip. Five studies used the iliopsoas bursa as the injection target. All studies used local anesthetics in their injection formulations, with 5 also adding a corticosteroid. In 3 studies, the Numeric Rating Scale improved from preinjection (mean = 7.33) to postinjection (mean = 2.47). Three studies demonstrated an improvement in Harris Hip Score from a mean of 58.49 preinjection to 89.91 postinjection. Following injections, 28.9% (68/235) of patients progressed to surgery, with psoas tenotomy (38.3%, 26/68) being the most common procedure. There were no complications reported in all of the included studies.

Conclusion: This study demonstrates that iliopsoas injections are a clinically effective treatment of a variety of pathologies, including bursitis, tendinopathy, and snapping hip, and have a low rate of complications. Physicians should consider using iliopsoas injections in patients whose symptoms are refractory to conservative management, including physical therapy.

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

Background: Pediatric flexible flatfoot (FFF) is a common condition characterized by the collapse of the medial longitudinal arch, which can lead to pain and functional impairment in a subset of patients. Subtalar arthroereisis (AR) is a minimally invasive procedure that corrects FFF by limiting excessive pronation of the subtalar joint. Two main techniques exist: endosinotarsal AR, which involves placing an implant in the sinus tarsi, and exosinotarsal AR, which uses a screw external to the sinus tarsi. This systematic review and meta-analysis compares the clinical outcomes and complication rates of these 2 techniques.

Methods: A comprehensive literature search was conducted in Scopus, Web of Science, and PubMed. Only comparative clinical studies comparing endosinotarsal and exosinotarsal AR in pediatric patients with FFF were included.

Results: A total of 6 studies involving 791 feet were analyzed. The exosinotarsal group showed a statistically significant improvement in talocalcaneal (Kite) angle (mean difference = -1.14; p = 0.04), although the difference may not be clinically significant. Calcaneal pitch angle analysis revealed no significant difference, but sensitivity analysis favored the exosinotarsal technique when 1 study was excluded (mean difference = -2.21; p = 0.004). Postoperative pain was reported with higher rates in the exosinotarsal group, as well as screw breakage, while the endosinotarsal group had higher rates of implant dislocation.

Conclusion: Both techniques effectively treat pediatric FFF, but exosinotarsal AR may offer better structural correction. However, it may be associated with higher rates of pain that tend to recede after 6 months from the operation.

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

Background: Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of displaced proximal humerus fractures (PHFs) with reliable clinical improvement. However, the preferred techniques for humeral stem fixation are varied and may be influenced by patient and injury characteristics, including bone quality and fracture pattern. This systematic review and meta-analysis sought to determine the effect of humeral component cementing and bone grafting on tuberosity healing rates and functional outcomes after RSA for PHFs.

Methods: A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported on the use of cemented humeral stems and autograft bone. The primary outcome was the rate of greater tuberosity healing between the various techniques. Secondarily, the authors compared clinical outcomes including postoperative external rotation, forward elevation, abduction, Constant score, and the incidence of complications and revision surgery. Outcomes were compared based on the use of an uncemented press-fit stem, a fully cemented stem without bone graft, or a partially cemented stem with humeral head autograft (i.e., black and tan technique).

Results: Forty-eight studies reporting on 1,797 RSAs were included (mean patient age, 75 years; follow-up, 34 months; 81% female). Tuberosity healing was highest in the uncemented cohort, then the black and tan cohort, and lowest in the cemented cohort (80% vs. 70% vs. 61%, p = 0.006). No significant differences in postoperative range of motion, Constant score, complication rates, or revision rates were found.

Conclusion: Uncemented fixation with a press-fit stem was associated with superior greater tuberosity healing rates; however, functional outcomes and complications did not differ among techniques.

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

» Suture button fixation has emerged as an effective surgical construct in arthroscopic and open Latarjet and anterior glenoid reconstruction with free autograft bone with high rates of bone block healing.» Biomechanical data suggest that screw and suture button mechanical fixation constructs provide similar load to failure and stability for the Latarjet procedure.» Preliminary bone healing models have identified that flexible fixation may exhibit a higher degree of bone callus maturation, whereas rigid fixation results in excessive callus hyperplasia» Mechanical tensioner use provides consistent tensioning of suture button constructs and improves bone-to-bone healing rates when used for anterior glenoid reconstruction surgery.» Evidence is lacking regarding the reliability of bone-to-bone healing of allografts to native bone with use of suture button constructs.» Suture button fixation provides good short- and mid-term clinical outcomes for the arthroscopic Latarjet and anterior glenoid reconstruction with free autograft bone.

» Virtual reality (VR) is increasingly used across surgical specialties in training, offering a safe, immersive environment for skill development.» Studies show that VR significantly improves surgical performance making it an effective training tool for orthopaedic residents; however, effects may be more pronounced in junior trainees and may not be seen in senior trainees or attendings.» As VR technology evolves, it promises broader applications in surgical training, though further research is needed to establish its superiority over traditional methods.

» Advance care planning and palliative care can improve care for orthopedic patients.» The "surprise question" is a useful prognostication tool and trigger for palliative care referral.» Engage in routine advance care planning conversations.» Confirm code status before surgery.» Any surgeon can determine capacity and need for a surrogate decision maker.

Background: Modern nerve-to-nerve transfers are a significant advancement in peripheral nerve surgery. Nerve transfers involve transferring donor nerves or branches to recipient nerves close to the motor end unit, leading to earlier reinnervation and preservation of the musculotendinous units in proximal nerve injuries. After nerve reinnervation, function may be superior to traditional tendon transfer techniques in terms of strength and independent motion. Nerve transfer surgery has emerged as a promising treatment option for many cases of nerve injury that were previously expected to result in poor outcomes, such as proximal injuries, long nerve gaps, or unavailability of the proximal injured segment.

Methods: A review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Publications that focused on upper extremity nerve transfers were included, and functional motor and sensory recovery was analyzed. Technique reports, case reports, brachial plexus injuries, and reports on multiple nerve injuries were excluded.

Results: A total of 48 relevant articles were identified with search criteria, and we discuss functional outcomes on nerve transfers for ulnar nerve injury, musculocutaneous nerve injury, median nerve injury, and radial nerve injury that met inclusion criteria.

Conclusions: Nerve transfers are an option for restoring hand and forearm function in patients with peripheral nerve injuries adversely affecting their ability to function. The literature demonstrates positive functional outcomes after nerve transfer operations, and thus, the utility and variations have increased. We aim to provide an overview of the outcomes of current nerve transfer techniques for ulnar, radial, median, and musculocutaneous acquired/traumatic mononeuropathies in the hand and upper extremity.

Background: Intra-articular metastatic disease is a rare and unique manifestation of cancer metastasis, often originating from primary tumors such as lung adenocarcinoma, colorectal carcinoma, and malignant melanoma. The clinical symptoms frequently mimic chronic inflammatory arthritis, complicating diagnosis and treatment. This study aims to provide a comprehensive review of the incidence, clinical presentation, management strategies, and outcomes for patients with primary diagnosed cancers that metastasize to intra-articular locations, underscoring the specialized nature of this field.

Methods: We conducted a systematic search of PubMed, Medline, and Embase databases in July 2024, yielding 239 articles on intra-articular metastasis in cancer patients. Twenty-one studies met the inclusion criteria after screening. Five reviewers abstracted and analyzed data on patient demographics, metastatic details, diagnostic evidence, treatment modalities, and outcomes.

Results: The search yielded 239 articles, from which 21 studies met the inclusion criteria. The patient cohort is 24 cases with a mean age of 58.8 years. Of the 24 patients included, 18 (75%) were males and 6 (25%) were females. Colorectal carcinoma was the most frequent primary tumor (33.3%), followed by lung cancer (25%). The knees were predominantly affected by the metastases. Diagnostic modalities varied; magnetic resonance imaging, arthrocentesis, and biopsy were the most commonly used procedures. Treatment approaches were again varied and included chemotherapy, radiation therapy, and surgery in some instances.

Conclusion: Intra-articular metastases, though rare, present significant diagnostic and therapeutic challenges. The clinical manifestations often mimic inflammatory arthritis, complicating timely diagnosis. As underscored by this study, effective management requires a multidisciplinary approach tailored to the patient's primary cancer type and overall health status. This highlights the complexity of the disease and the need for collaborative care. Future research should focus on increasing awareness and early detection to improve patient outcomes.

Background: Hip resurfacing arthroplasty (HRA) offers numerous benefits over total hip replacements such as increased preservation of natural bone, improved range of motion, and lower dislocation risks. However, patient selection is crucial, with factors such as bone quality, activity level, and body mass index (BMI) playing significant roles. Obesity in particular poses challenges, potentially increasing mechanical load on the joint, complicating surgical techniques, and affecting both immediate and long-term outcomes. The aim of this systematic review was to evaluate outcomes of HRA in obese vs. nonobese patients to determine if obesity should be considered a contraindication to HRA or if similar treatment approaches can be applied.

Methods: A literature search was conducted using PubMed, Embase, and Scopus databases with specific search terms related to HRA and obesity. Articles were screened by title and abstract, followed by full-text review. Data extraction focused on demographic and study variables such as sex, age, BMI, complication and revision rates, and patient-reported outcomes. A meta-analysis was performed using a random-effects model to compare University of California Los Angeles (UCLA) scores, Harris hip scores, complication rates, and revision rates between obese and nonobese patients, with significance set at p < 0.05.

Results: From an initial pool of 39 articles, 4 met inclusion criteria, encompassing 1,385 patients. Analysis revealed a pooled mean age of 50.92 years and a complication rate of 9.83% in obese vs. 4.7% in nonobese patients. Revision rates were 1.15% for obese and 3.70% for nonobese patients. The difference in postoperative UCLA scores, complication rates, and revision rates were deemed not statistically significant.

Conclusion: The comparability in patient-reported outcomes, complication rates, and revision rates between obese and nonobese cohorts suggests that although heightened vigilance and tailored approaches may be warranted in obese patients, obesity alone should not preclude patients from undergoing HRA. These findings advocate for a more nuanced approach to patient selection, emphasizing individualized assessment over generalized BMI cutoffs. Future HRA research should focus on long-term follow-up and larger cohort studies to further validate these results.

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