JBJS Reviews最新文献

» High-tensile strength suture materials (HTSSMs) have significantly advanced the field of orthopaedic surgery by providing superior strength, enhanced handling characteristics, and improved durability compared with first-generation sutures.» These sutures are critical for ensuring repair integrity during the healing process of tendon-to-bone or tendon-to-tendon constructs.» While second-generation HTSSMs such as FiberWire, Orthocord, and Force Fiber offer higher tensile strength, better knot security, and reduced creep, their mechanical and biological properties vary, making it essential for surgeons to tailor their choice based on the tissue type, surgical technique, and patient-specific factors.» The incorporation of advanced materials such as ultra-high molecular weight polyethylene and innovative designs such as core-plus-braid configurations has further minimized risks of failure from abrasion, knot slippage, or tissue cut through.» Despite these advancements, challenges such as potential tissue irritation, granuloma formation, and suture cutout remain. Selecting the appropriate HTSSM involves balancing mechanical strength with handling properties and biological responses.» Flat sutures distribute load more evenly and are less prone to tissue cutout, making them ideal for delicate tissues, while round sutures offer better abrasion resistance in high-stress repairs.» In addition, understanding key properties such as stiffness, creep, and knot security can help optimize outcomes and minimize complications.» Surgeons should remain vigilant about the trade-offs associated with material coatings and knot volume, as these factors can influence both repair success and postoperative tissue health.

» Obesity is a public health concern, with 41.9% of the US population classified as obese. Obesity increases the risk of chronic disease, type II diabetes, cardiovascular diseases, etc., leading to increased morbidity and mortality. Obesity has been identified as an independent risk factor of postoperative complications, including infection and impaired wound healing, following elective surgery. In total joint arthroplasty, it has been well elucidated that obese patients are predisposed to higher rates of postoperative complications, longer hospital stays, and increased cost of stay.» Obesity is influenced by the interplay between many societal, behavioral, and socioeconomic factors and requires a multidisciplinary approach to treatment. The patient's care team should be well versed in nutritional counseling, behavioral health counseling, medication management, and surgery to allow for a comprehensive approach.» Orthopaedic surgeons, dietitians, nutritionists, weight-loss physicians, and bariatric surgeons all play a critical role in treating this patient population. This review highlights the roles of these practitioners in developing an interdisciplinary framework to help patients with hip and knee arthritis lose weight before joint replacement surgery. Not only will this afford more patients the quality-of-life benefits that come with a hip or knee replacement but will also serve to decrease the complication rates associated with this patient cohort.» The aim of this review was to educate orthopaedic surgeons on various strategies that can be used to best optimize these patients for successful joint replacement surgery.

Background: Intertrochanteric fractures in the elderly present significant management challenges, with intramedullary (IM) nails increasingly used for fixation. However, the optimal implant type remains debated. Third-generation IM nails, including proximal femoral nail antirotation (PFNA), Gamma 3 (G3), and Intertan (IT), feature helical blades, single lag screws, and dual integrated lag screws, respectively. This meta-analysis evaluates functional outcomes, healing status, and complication rates of intertrochanteric fractures treated with these devices.

Methods: A systematic review and meta-analysis were conducted using PubMed, Embase, CENTRAL, and Google Scholar until November 2024. Randomized controlled trials (RCTs) and observational comparative studies involving patients older than 65 years were included. Outcomes assessed functional scores, healing status, and complications.

Results: Twenty-four studies (6 RCTs, 5 prospective cohort studies, and 13 retrospective cohort studies) involving 2,999 patients were analyzed. The G3, IT, and PFNA groups included 617, 1,124, and 1,258 patients, respectively. Results showed similar functional recovery across devices. Perioperative parameters favored PFNA, while IT demonstrated lower complication and revision rates. No outcomes favored G3, suggesting it is interchangeable with other devices. PFNA was easier to use and required shorter operation times but had higher cutout and revision rates. IT, despite longer operation times, promoted faster fracture healing and had fewer complications. G3 did not outperform other devices in any measured outcome.

Conclusion: PFNA, G3, and IT provide comparable functional outcomes and overall complication rates, making device selection largely dependent on surgeon preference. However, IT may be the superior choice for complex fractures requiring more excellent stability due to its lower complication and revision rates. This analysis highlights the importance of tailoring implant selection to individual patient needs and fracture complexity.

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

» The incidence of postoperative foot drop after spine surgery is estimated at 3.33%, with higher rates reported in complex procedures such as high-grade spondylolisthesis correction (up to 30%). Risk factors include disc-space distraction, deformity corrections, prolonged surgery, and advanced patient age.» The primary mechanisms of postoperative foot drop include direct nerve trauma, stretch injuries from retraction or distraction, compression from hematomas or implants, and ischemic damage because of disrupted blood flow.» Preoperative counseling, intraoperative precision, appropriate disc space distraction, and careful nerve retraction are key to mitigating the risk of foot drop, with ongoing research needed to standardize preventive and management guidelines.» Treatment strategies are tailored to the underlying cause, ranging from conservative options (physical therapy, ankle-foot orthoses, and functional electrical stimulation) to surgical interventions (hematoma evacuation, implant removal, neurolysis, nerve transfer, and tendon transfer), although outcomes are highly variable.

Background: Cervical spondylotic myelopathy (CSM) is a common cause of progressive neurological decline in elderly patients, often necessitating surgical decompression. Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are commonly used procedures. However, there is no consensus on the superior approach, particularly in cases involving 2-level CSM.

Methods: A systematic review and meta-analysis were conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. PubMed, Cochrane, Scopus, and Embase databases were searched for studies comparing perioperative, clinical, and radiological outcomes of ACDF and ACCF in 2-level CSM. Fourteen studies with 4,449 patients (ACDF: 2,265, ACCF: 2,184) met the inclusion criteria. Outcomes analyzed included operating (OR) time, blood loss, hospital stay, patient-reported outcomes (Neck Disability Index [NDI], Visual Analog Scale [VAS], modified Japanese Orthopaedic Association [mJOA], Odom criteria), radiological parameters, complications, and fusion rates. Statistical analysis was performed using Review Manager 5.4, with heterogeneity assessed using I2 statistics.

Results: ACDF was associated with significantly shorter OR time, reduced blood loss, shorter hospital stays, and lower overall complication rates compared with ACCF. Both procedures showed comparable improvements in NDI, VAS, and mJOA scores. ACDF demonstrated superior postoperative cervical alignment, with greater improvements in global and segmental lordosis. Complication rates, including implant-related issues, were higher in the ACCF group, while reoperation and fusion rates were similar.

Conclusion: Both ACDF and ACCF significantly improve functional outcomes in 2-level CSM. However, ACDF demonstrated advantages in perioperative outcomes, complications, and cervical alignment. While ACDF is associated with shorter OR time and fewer complications, ACCF may be necessary in cases with extensive disk herniation or other pathologies requiring direct decompression posterior to the vertebral body. Surgical decisions should be individualized based on patient-specific pathology.

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

Purpose: The purpose of this study was to systematically review the literature to assess surgical complications following surgical management of olecranon fractures.

Methods: A literature search of MEDLINE, Embase, and the Cochrane Library was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Clinical studies reporting complications following olecranon fracture management were included. The complication profile of plate fixation (PF), screw fixation, and tension band wiring (TBW) was recorded. Implant removal rates were considered independent of complication rates.

Results: Eighty-six studies were included in the analysis, with 5,161 patients who underwent an olecranon fracture treatment with an average age of 50.2 years (range, 7.4-88.8) and an average follow-up of 30.8 months (range, 3-218). The majority of studies used PF (58.1%). Screw fixation had higher implant complications than PF (5.9% vs 3.0%, p < 0.001), and PF had the highest percentage of musculoskeletal complications (3.6%, p <0.001) and wound complications (4.8%, p = 0.048). Nerve complications were similar among the 3 surgical options (p = 0.233). PF had the lowest complication rate (12.6%, p < 0.001), while screw fixation had the lowest reoperation (8.6%, p < 0.001) and implant removal rates (6.2%, p < 0.001). The overall complication rate for TBW was 18.4%, with loss of reduction being the most common complications occurring in 2.8% of patients.

Conclusion: PF demonstrated lower overall complications compared with screw fixation, with increased rates of symptomatic implants requiring removal which contributed to higher reoperation rates. TBW demonstrated an inferior complication profile compared with both modern fixation options. Further research should expand on the limited comparative studies between screw and PF.

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

» Multifactorial Pathogenesis: Legg-Calvé-Perthes disease (LCPD) may result from a complex interplay of genetic, epigenetic, and environmental factors, culminating in avascular necrosis of the femoral head in children aged 4 to 10 years.» Genetic Contributions: Mutations in COL2A1 weaken cartilage integrity, and polymorphisms in IL6 drive inflammatory responses, exacerbating bone resorption and necrosis.» Role of Epigenetics: Epigenetic mechanisms, such as altered DNA methylation and miRNA dysregulation, may modulate disease progression by linking genetic susceptibility to environmental influences.» Environmental Amplifiers: Key environmental risk factors, including maternal smoking, low birth weight, and socioeconomic deprivation, may exacerbate the genetic and epigenetic predisposition to LCPD.» Future Directions: Advancements in genetic screening and epigenetic therapies, such as miRNA modulators and DNA methylation inhibitors, combined with preventive measures like improved prenatal care and reduced smoke exposure, may offer promising avenues for optimizing outcomes in LCPD.

» Medicare reimbursement: Physician payments have declined 29% since 2001, straining practice sustainability. Proposed legislation (H.R. 2474) could align payments with inflation, although concerns persist about its fiscal impact on Medicare.» Medicare advantage: These plans provide benefits such as cost caps and premium-free options for patients, but increase administrative burdens, delay care, and restrict provider networks for physicians.» Prior authorization: Intended to ensure appropriate care and control costs, prior authorization frequently delays treatment, raises administrative workloads, and contributes to physician burnout. Proposed reforms aim to balance efficiency and oversight.» Noncompete clauses: Advocates argue noncompete clauses protect healthcare investments, but critics highlight their role in limiting physician mobility, disrupting patient care, and reducing competition. Legal challenges to a federal ban add uncertainty.» Physician-owned hospitals: Supporters emphasize physician-owned hospitals' high-quality care and competitive benefits, whereas detractors warn of risks such as conflicts of interest, inequities in patient access, and strain on community hospitals.» Advancing nonopioid pain management: Nonopioid strategies reduce dependency risks and improve recovery but may require additional resources and upfront costs. Policies such as the Non-Opioids Prevent Addiction in the Nation Act aim to incentivize their use.

» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.

» Osteotomy is an effective treatment strategy for young, active patients with symptomatic valgus malalignment of the knee that has been unresponsive to conservative management.» Osteotomies are also indicated to support joint preservation procedures, such as lateral meniscus allograft transplantation and/or cartilage restoration to the lateral compartment, in the valgus malaligned patient, even if the malalignment is subtle.» Techniques to correct valgus include lateral opening wedge distal femoral osteotomy (LOWDFO), medial closing wedge distal femoral osteotomy (MCWDFO), lateral opening wedge high tibial osteotomy (LOWHTO), or medial closing wedge high tibial osteotomy (MCWHTO). The specific technique chosen depends on surgeon preference, concomitant procedures, and deformity location (femoral, tibial, or both).» Each approach comes with its own advantages and disadvantages. LOWDFO offers easier correction for larger deformities but has a higher risk of nonunion, while MCWDFO facilitates faster time to union but is more technically demanding. For those with a tibial-based deformity, LOWHTO carries a higher risk of nonunion, MCWHTO may lead to medial collateral ligament laxity or patella baja, and both may cause alterations of the tibial slope and may be limited as an isolated procedure in severe deformity correction.» Irrespective of the surgical approach, the outcomes of these procedures are generally favorable, improving patient-reported outcomes and potentially delaying the need for total knee arthroplasty. However, it is crucial to carefully select the appropriate procedure based on the patient's anatomy and the specificities of their valgus deformity to ensure the best possible results.