JBJS Reviews最新文献

» Midsubstance patellar tendon repairs are rare, technically demanding surgeries that are distinct from proximal and distal avulsions due to the challenges of tendon-to-tendon healing and zone of injury tissue quality.» Primary repair using the Krackow suturing technique remains the most widely used method, often combined with patellar and tibial-based fixation.» Protective constructs such as high-strength suture configurations or cerclage wire are employed to share load with the repair site and support healing and function.» Structural and biological augmentations, including autografts, allografts, synthetic ligaments, and collagen scaffolds, are increasingly used to reinforce the injured extensor mechanism, support repair, and enhance healing, particularly in high-risk or complex patients.» Postoperative rehabilitation protocols vary but generally include a period of immobilization in extension followed by progressive flexion, isometric quadriceps activation, and return to normal activity at 9 to 12 months and return to a preinjury level at 12 to 18 months.

Background: Sleep disturbances are common after total joint arthroplasty and can impair recovery, increase complications, and reduce patient satisfaction. Nonpharmacological interventions (NPIs) may offer safer alternatives to medications, but their effectiveness in improving postoperative sleep remains unclear. The aim of this study was to systematically evaluate the impact of NPIs on sleep outcomes following hip or knee arthroplasty.

Methods: We conducted a systematic review in November 2024 across PubMed, Scopus, Web of Science, and Embase for studies investigating NPIs related to sleep outcomes after hip or knee arthroplasty. Data extraction and quality assessment were performed independently using the National Institutes of Health tools. A meta-analysis was conducted on studies reporting Pittsburgh Sleep Quality Index scores, and the mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed by the Cochran Q statistic and the I2 test.

Results: Ten studies (n = 1,545; mean age 65.69 years, 54.43% female) were included. NPIs were categorized into nursing-based interventions, environmental controls, relaxation techniques, neuromodulation, and movement restriction. The pooled analysis of 6 studies (n = 760) showed that NPIs significantly improved sleep quality compared with controls (MD = -2.61; 95% CI -3.27 to -1.95; p < 0.00001; I2 = 86%). Subgroup analysis revealed the greatest benefit from nursing-based interventions (MD = -3.06; 95% CI -3.39 to -2.73; I2 = 30%), while environmental interventions showed a smaller but significant effect (MD = -1.58; 95% CI -2.75 to -0.40; I2 = 79%). Functional, psychological, and quality-of-life outcomes showed variable results across studies.

Conclusion: NPIs, particularly nursing-based interventions and environmental controls, appear effective in improving postoperative sleep after joint arthroplasty. However, heterogeneity and limited high-quality evidence warrant further randomized trials with standardized protocols and objective sleep measures.

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

Background: Historically, total knee arthroplasty (TKA) used resection and balancing techniques to target symmetric medial and lateral gaps throughout range of motion (ROM). With modern awareness on alternate alignment concepts, one area of ongoing debate is whether asymmetric medial and lateral compartment gaps improve outcomes. Proponents of an asymmetric looser lateral compartment gap philosophy postulate that this phenotype recreates native knee kinematics with lateral femoral condylar rollback pivoting through a tighter medial compartment during knee flexion. The purpose of this study was to compare patient-reported outcomes (PROs) and ROM with respect to symmetric or asymmetric gaps.

Methods: We performed a systematic review and random-effects meta-analysis of prospective and retrospective studies. We compiled all comparative studies reporting symmetric and asymmetric gaps, irrespective of directional or nondirectional gap asymmetry. However, we performed a meta-analysis only between a cohort of directional asymmetric gaps (looser lateral than medial gap) and symmetric gaps (equal medial and lateral gaps). Gaps were compared in flexion and extension. ROM and PROs were evaluated through standardized mean difference (SMD), with statistical significance defined by 95% confidence interval (CI).

Results: A total of 17 studies with 3,319 knees were included. Four studies reported nondirectional gap asymmetry, whereas 13 studies reported directional gap asymmetry, of which 8 shared common outcome variables and were therefore included in the meta-analysis. Analysis of gaps in flexion revealed significantly increased ROM favoring asymmetric looser lateral gaps over symmetric gaps (SMD -0.19, 95% CI -0.29 to -0.09). Analysis of gaps in extension also revealed increased ROM favoring asymmetric looser lateral gaps (SMD -0.10, 95% CI -0.36 to 0.16). Finally, the Forgotten Joint Score (FJS) favored looser lateral gaps in flexion over symmetric gaps (SMD -0.13, 95% CI -0.41 to 0.15). However, differences in the latter 2 were nonsignificant.

Conclusion: This is the first meta-analysis evaluating the postoperative outcomes as a function of symmetric vs. asymmetric mediolateral gaps. We report improved FJS and ROM favoring asymmetric looser lateral gaps in flexion.

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

» Inconsistent terminology and overlapping definitions for posterior distal tibia/ankle fractures (posterior malleolar, pilon-variant, posterior pilon) hinder standardized care and outcomes. This study critically evaluates classifications and treatments, proposing clear definitions based on fragment morphology, articular involvement, and biomechanics:» 1. Posterior malleolar fractures: Involve the non-weight-bearing posterior tibial margin, typically from rotational injuries. Nonoperative management suffices if the syndesmosis is stable (smaller fragments). In the case of an unstable syndesmosis, surgical fixation by a posterolateral (PL) approach is recommended for direct visualization, reduction, and stable fixation, although this may vary case by case.» 2. Posterior pilon-variant fractures: Intermediate severity, affecting the posteromedial (PM) tibia and partially compromising the weight-bearing surface. Characterized by large PM fragments. Fixation by a PM approach is recommended, promoting faster union and reducing neurovascular risk compared with PL, although this is ultimately up to the surgeon's preference.» 3. Posterior pilon fractures: Involve disruption of the weight-bearing articular surface with posterior plafond extension, resulting from high-energy axial compression (e.g., falls). Features include comminution, articular impaction, and potential involvement of posterior/medial columns, resembling classic pilon but posteriorly localized. Severe soft-tissue damage necessitates staged management: initial external fixation followed by definitive internal fixation. Addressing comminuted fragments requires a combined PL and PM approach. For a large fragment with no comminution, minimally invasive anterior cannulated screws can be used.» This taxonomy directly links fracture patterns to surgical urgency (nonoperative, single-stage, staged), fixation strategies (approach selection-PL, PM, or combined), and prognostic implications. By integrating anatomical precision with clinical practicality, the framework resolves current terminology disparities, enhances diagnostic reproducibility, and aims to improve outcomes for these complex injuries.

» Career transitions in orthopaedic surgery present meaningful opportunities for professional growth and personal fulfillment. Orthopaedic surgeons frequently navigate career shifts due to factors such as new professional or leadership opportunities, burnout, or workplace dissatisfaction. Notably, more than 50% of orthopaedic surgeons change jobs within their first 5 years of practice, underscoring the significance of strategic planning and thoughtful decision-making in these transitions.» To facilitate effective career changes, structured frameworks can guide surgeons through self-assessment, identification of strengths and interests, strategic delegation, and streamlining responsibilities.» Critical considerations before transition include recognizing the limitations of the current job situation, clarifying future career goals, and engaging trusted colleagues and mentors. Early and proactive communication, deliberate preparation, and iterative evaluation are essential practices that enhance the effectiveness of career transitions.» The purpose of this review was to explore when orthopaedic surgeons should contemplate career transitions, outline essential factors and critical questions for reflection, and propose structured strategies to support sustainable and successful career evolution.

Background: Rotator cuff repair is a common and effective method for treating rotator cuff tears (RCTs). At the same time, postoperative shoulder stiffness (PSS) remains a common adverse complication that may seriously affect patients' postoperative recovery and quality of life. Existing studies have reported inconsistent results on risk factors of PSS, and a systematic quantitative analysis is required. This study aims to identify the risk factors for PSS after RCT through a systematic review and meta-analysis and provide an evidence-based basis for clinical practice.

Methods: We searched PubMed, EMBASE, Cochrane, and Web of Science databases from their establishment date to November 2024. Cohort and case-control studies that met the criteria were included. Relevant risk factors and their effect sizes were extracted. Meta-analysis was performed using Stata/SE 17.0, and fixed-effect or random-effect models were selected and applied according to the level of heterogeneity. Subgroup analysis, sensitivity analysis, and publication bias assessment were also performed.

Results: Eighteen studies involving 63,565 patients were included, and 20 potential risk factors were analyzed. Among them, age (mean difference 0.23, 95% confidence interval [CI] 0.03-0.43, p = 0.027), female (odds ratio [OR] 1.99, 95% CI 1.69-2.32, p < 0.001), diabetes (OR 2.01, 95% CI 1.15-3.52, p = 0.015), thyroid disease (OR 1.32, 95% CI 1.09-1.59, p = 0.004), and workers' compensation insurance (OR 1.92, 95% CI 1.10-3.37, p = 0.022) were associated with PSS. Subgroup analyses indicated that female in non-Asian populations (OR 2.17, 95% CI 1.66-2.84, p < 0.001) and preoperative shoulder stiffness in patients with a follow-up of more than 3 months (OR 1.64, 95% CI 1.03-2.60, p = 0.035) were significantly associated with PSS.

Conclusion: PSS after RCT is affected by multiple factors. According to current evidence, advanced age, female, diabetes, thyroid disease, and workers' compensation insurance are high-risk factors. Clinical attention should be paid to comprehensive preoperative evaluation and individualized management strategies, especially to strengthen intervention during the perioperative period in high-risk groups.

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

» Reverse total shoulder arthroplasty (rTSA) has become the standard surgical treatment for rotator cuff arthropathy, offering reliable improvements in function and pain relief. However, postoperative shoulder pain remains a complex and clinically significant challenge.» The differential diagnosis of a painful rTSA includes infectious, mechanical, and neurological or immunological complications. Key etiologies include periprosthetic joint infection (0.5%-6.7% incidence, 13.8% of all complications), instability, aseptic loosening (glenoid loosening 2.3%, humeral loosening 1.4%), polyethylene wear, scapular notching (reported as high as 96%), postoperative fractures, neurologic injury (up to 3.6%), and metal hypersensitivity (prevalence of 10%-15% in the general population).» Diagnostic workup requires a structured approach combining clinical examination, radiographic analysis, serologic markers, advanced imaging, and intraoperative assessment when necessary. Several etiologies, particularly infection, metal allergy, and polyethylene wear, may present with overlapping symptoms, necessitating a systematic evaluation.» Management of the painful rTSA is diagnosis-specific and ranges from nonoperative interventions (physical therapy, benign neglect, nonsteroidal anti-inflammatory drugs, corticosteroids, or bracing) to surgical revision procedures such as debridement, component exchange, fracture fixation, or tendon lengthening.» Understanding the biomechanical principles of rTSA design, implant positioning, and soft tissue balance is critical for both prevention and treatment of postoperative pain. While biomechanical innovations have improved joint stability and the efficiency of surrounding soft tissue, the expanding use of rTSA continues to pose challenges for complication rates and long-term outcomes, necessitating clinical vigilance and individualized patient management strategies.

Background: Proximal humerus fractures (PHFs) are increasingly prevalent, particularly in the geriatric population, where they represent a significant burden both individually and societally. Vascular injury, though rare, can have profound implications for management and outcomes. The presence of these concomitant injuries has been shown to be associated with an increased length of hospital stay, total cost, and patient mortality underscoring the critical need for accurate identification of both osseous and vascular injuries to provide appropriate, comprehensive care. Despite extensive research, controversy remains regarding the optimal management of these injuries. Nonoperative management is suitable for fractures meeting specific criteria, while operative options vary based on fracture characteristics, patient factors, and surgeon expertise. The rise in reverse total shoulder arthroplasty (RSA) as a treatment of complex fracture patterns reflects evolving trends in clinical practice.

Clinical scenario: This report presents the case of a 76-year-old woman with a complex, 4-part PHF dislocation sustained secondary to a ground-level fall. On examination, she exhibited diminished radial nerve sensation with wrist extension weakness but was otherwise neurovascularly intact. Cross sectional imaging demonstrated significant medialization of an anterior fracture dislocation of the proximal humerus. Computed tomography angiography of the left upper extremity showed a markedly tortuous axillary artery with possible intimal injury, prompting a multidisciplinary approach.

Treatment approach: A shared decision-making model led to combination surgical case with vascular and orthopaedic surgery for subclavian artery exposure followed by RSA. Postoperatively, the patient recovered without complication, demonstrating the importance of an individualized, multidisciplinary strategy for managing complex PHF with associated vascular insult.

Conclusion: This case highlights the critical role of recognition of potential neurovascular injuries due to traumatic events and coordinated management of osseous and vascular injuries in complex PHF. We also describe a combined surgical approach and interdisciplinary coordination for PHF dislocations with concern for vascular compromise. Glenohumeral fracture dislocations are high-risk injuries where RSA offers predictable outcomes for complex fracture patterns but demands careful consideration in the setting of possible vascular trauma.