Clinics in Orthopedic Surgery最新文献

Backgroud: Implants with different neck offsets for hip replacement surgery are now available from various implant manufacturers and have become a widely used option for achieving postoperative hip stability. This study aimed to compare the impact of neck offset on initial stem fixation and the mechanical effects of different stem lengths when using cementless stems.

Methods: We performed a finite element analysis using Mechanical Finder ver. 12.0. CAD models of the Profemur Preserve and Profemur TL cementless stems. Each stem was appropriately sized, and the von Mises stress was calculated. We defined micromotion as the relative displacement between the stem node and the surface of bone contact. The maximum micromotion values of these finite element models were compared under standing conditions.

Results: The stress per zone for both stems (Preserve and TL) was the highest in zone 5, followed by zones 3 and 4, which were almost in line with each other. The high offset (HIGH) stress was higher than the standard offset (STD) stress in each stem and zone. The micromotion of each stem was higher at each load in the following order: Preserve HIGH, Preserve STD, TL HIGH, and TL STD, with HIGH being higher than STD at each stem.

Conclusions: The choice of higher offset or shorter length stems induced higher micromotion at the interface to the bone in the early postoperative period. Therefore, surgeons should be more careful to get appropriate initial fixation using shorter stems with higher offset necks due to the relatively high incidence of loosening or fractures.

Background: The treatment of Kümmell disease (KD) is controversial. Corpectomy and reconstruction or osteotomy with long-level fusion was traditionally performed for the advanced KD. However, these procedures can be disadvantageous for elderly patients. Several alternative surgical procedures including transpedicular intravertebral cage augmentation (TPICA) or vertebroplasty (VP) combined with short-segment fixation (SSF) have been suggested to minimize the surgical burden. This study aimed to compare the outcomes of percutaneous TPICA plus SSF with VP plus SSF for advanced thoracolumbar (T11-L2) KD and to introduce our novel percutaneous TPICA technique using specially designed cannulated cage trials.

Methods: We devised specially designed cannulated cage trials to make the TPICA procedure safer and more reproducible, minimizing the risk of the pedicle medial wall violation. All consecutive patients who underwent percutaneous TPICA or VP combined with SSF for advanced thoracolumbar KD, from January 2021 to June 2022, with ≥ 1-year follow-up at a single institution, were included. Perioperative details, clinical outcomes (visual analog scale and Oswestry Disability Index), and radiological outcomes (anterior vertebral body compression percentage and vertebral kyphotic angle [VKA] of the fractured vertebra, and local Cobb angle [LCA]) were collected and compared between the groups.

Results: A total of 42 patients were enrolled, with 21 patients in each group. There were no patients with pedicle medial wall fracture in the TPICA group. Both procedures provided significantly favorable radiological outcomes compared to those preoperatively. No significant differences were observed in the changes over time in all radiological parameters between the groups. Loss of correction during the follow-up period was significantly smaller in patients with TPICA than in those with VP in VKA (median [interquartile range], 2.15 [0.30-2.80] vs. 2.90 [0.90-6.53]; p = 0.030) and LCA (2.70 ± 2.90 vs. 5.17 ± 4.40, p = 0.037).

Conclusions: Both procedures are minimally invasive and useful options for advanced KD, especially for elderly patients with high comorbidity. Our novel percutaneous TPICA technique using cannulated cage trials, being safer and more reproducible, may allow spine surgeons to easily perform TPICA.

Arthroscopic rotator cuff repair is the gold standard for treatment, but current techniques have shortcomings, especially for larger tears. Single-row repairs often fail to fully restore the footprint, leading to high retear rates. Although triple-row and double-row repairs show promise, concerns regarding retear persist. Biomechanical studies favor triple-row repair for better coverage and pressure distribution. Techniques such as linked double-row and double-pulley methods enhance strength. Secondary cuff failures near the musculotendinous junction are commonly caused by stress concentration. To address these challenges, novel methods have employed linked, knotless, and bridging constructs. Our approach, the double pulley-triple row, aims to minimize retears, especially at the musculotendinous junction, and provides uniform pressure distribution, which is particularly beneficial for large tears. The surgical steps involve standard arthroscopic procedures with specific instruments. Despite these challenges, our method combines proven techniques for optimized outcomes and promising improved results in rotator cuff repair.

Backgroud: Decreased acetabular version and posterior acetabular coverage of the femoral head have been regarded as the leading causes of sport-related posterior hip dislocation or subluxation. This study aimed to examine the posterior acetabular coverage of the femoral head in 21 patients who sustained posterior hip dislocation or subluxation during sport activities.

Methods: The anterior and posterior acetabular rims on 3-dimensional computed tomography (3D-CT) images were delineated on the normal side in these patients. Radiologic signs, including crossover and posterior wall signs, were examined. The fracture center level (FCL) of the posterior acetabular wall was identified on axial CT images of the injured hip and the level was marked on the normal side. The difference in the femoral head coverage by posterior and anterior acetabular rims was measured by measuring the horizontal distance between anterior and posterior acetabular rims at the FCL (posterior-anterior [P-A] index). The acetabular version was measured at the femoral head and FCL using axial CT images of the normal side. Femoral head coverage by the posterior acetabular wall on the normal side was measured using 3D-CT (areal coverage).

Results: The crossover and posterior wall signs were positive in 14 and 10 patients, respectively, in 3D-CT images. The FCL was evenly distributed in the proximal half of the posterior acetabular wall. Seven patients had a P-A index of ≤ 0, and all were positive for the crossover sign. The anterior acetabular rim was relatively prominent in these patients. The acetabular version was lower at the FCL than at the femoral head center (p < 0.001). The proximal half areal coverage of the posterior acetabular wall was significantly smaller than the whole areal coverage (p = 0.003).

Conclusions: Superior-posterior coverage of the femoral head by the posterior acetabular wall was insufficient in patients who sustained hip posterior dislocation or subluxation during sports activities.

Backgroud: Proximal humerus nails, frequently used for managing proximal humerus fractures, significantly enhance rotational stability and reinforce fractured fragments. Few research exists regarding the optimal number and positioning of distal screws. This study aimed to assess the stability of diverse screw configurations and scrutinize screw distribution and bone stress via finite element analysis.

Methods: The humerus intramedullary nail (Humerus Interlocking Nail System; TDM) underwent assessment using finite element analysis applied to a humerus model. Three groups were established based on varying distal screw numbers and locations: all 3 distal locking holes were used in group 1; 2 screws (dynamic hole and proximal static hole) in group 2, and 2 screws (dynamic hole and distal static hole) in group 3. Finite element analysis computed stress distribution within the implant and bone for each group. A 1-mm fracture gap was simulated at the surgical neck, and stress distributions were analyzed in both normal and osteoporotic bone models.

Results: Using two screws did not compromise rotational stability. Stress distribution analysis revealed stability across all groups without reaching failure strength. Group 3 exhibited a minor rise in component 11 (direct stress [force per unit area] acting on the positive and negative 1 faces in the 1-axis. direction) and component 22 (direct stress [force per unit area] acting on the positive and negative 2 faces in the 2-axis direction) stress, remaining below failure strength thresholds. Group 1 exhibited the lowest von Mises stress in the nail and screws, while groups 2 and 3 did not reach failure strength levels. Findings remained consistent in the osteoporotic model.

Conclusions: All 3 groups demonstrated rotational stability concerning stress distribution, indicating that using 2 screws for distal fixation does not adversely affect stability. This suggests the potential for saving surgical time and reducing radiation exposure without compromising stability.

Backgroud: Anterior dislocation in epilepsy patients is relatively severe, difficult to treat, and prone to recurrence. The purpose of this study was to compare the results of arthroscopic Bankart repair and the open Latarjet procedure in epilepsy patients who had anterior shoulder instability and to compare the results of the open Latarjet procedure in epilepsy and non-epileptic groups.

Methods: A total of 57 shoulders (34 dominant) in 55 patients (18-50 years, 45 men and 10 women) with anterior glenohumeral instability were included in the study and the average follow-up was 24 months. Out of 21 epilepsy patients (23 shoulders), 11 were treated with the open Latarjet procedure and 12 with arthroscopic Bankart repair. Additionally, comparisons were made between the 34 non-epileptic patients who underwent the open Latarjet procedure and the epilepsy patients who underwent the same procedure.

Results: In the epilepsy group, all 12 patients who underwent Bankart repair had on-track lesions, and all 11 patients who underwent the Latarjet procedure had off-track lesions. In the non-epilepsy group, all cases were off-track lesions. In the epilepsy group, there was no significant difference in the postoperative clinical outcome and recurrence rate between the Bankart repair and Latarjet procedure groups. In the Latarjet group, postoperative re-dislocation rate in the non-epilepsy patients was 14% (5/34 cases), compared to 45% (5/11 cases) in the epilepsy patients, 4 of which 4 occurred during seizures. It was 41% in the Bankart repair group for on-track lesions, which was similar to the recurrence rate after the Latarjet for off-track lesions in the epilepsy group.

Conclusions: After the Latarjet procedure, the functional outcomes in the epilepsy group were similar to those in the non-epilepsy group, except for the higher re-dislocation rate. With either of the surgical procedures, the re-dislocation rate secondary to seizures was very high. Despite the presence of on-track lesions, the Latarjet procedure would be more preferrable for anterior stabilization in epilepsy patients, in view of the high recurrence rate with arthroscopic Bankart repair.

Background: Developing and validating a modified parameter, the SYS-G angle (the angle between the lower endplate of the C2 and the upper endplate of C7 vertebrae), as a feasible substitute for the C2-C7 Cobb method in assessing cervical sagittal alignment and exploring its reference range through a large-scale retrospective study.

Methods: The visibility of the C6, C7 upper, and C7 lower endplates was graded and compared. Baseline data such as height, weight, body mass index (BMI), age, and sex were analyzed for their impact on the visibility of the C7 lower endplate. Values of C2-6 Cobb angle, SYS-G angle, and C2-7 Cobb angle were measured. The intra- and interobserver reliability, differences, and efficacy of evaluation on cervical lordosis of the parameters were compared, and the correlations among the parameters were analyzed. Furthermore, reference ranges for the SYS-G angle were established based on lateral cervical spine x-rays of 825 asymptomatic Chinese adults across different age groups and sexes.

Results: The visibility of the C7 lower endplates was significantly reduced compared to the C6 lower and C7 upper endplates. Age, weight, BMI, and male sex were identified as factors negatively influencing the visibility of the C7 lower endplate. Both intraobserver and interobserver reliability demonstrated excellence for all tested parameters. The linear regression model unveiled a stronger association of the SYS-G angle with the C2-7 Cobb angle compared to the C2-6 Cobb angle. Furthermore, the SYS-G angle exhibited excellent efficacy in evaluating cervical lordosis. Age displayed a positive correlation with the SYS-G angle, and across every age bracket from 20 to 69 years, men exhibited a higher mean SYS-G angle compared to women.

Conclusions: The visibility of the C7 lower endplate diminishes with increasing age, weight, BMI, and male sex. In cases where the C7 lower endplate is unclear, the SYS-G angle emerges as a reliable method for estimating cervical sagittal morphology. Reference ranges for the SYS-G angle were established across various age groups and sexes among asymptomatic Chinese adults, offering a valuable resource to guide therapeutic interventions for cervical spine disorders and deformities.

Background: Meniscal scaffold implantation has been introduced as a treatment for meniscal injuries, but there is still no clear consensus on its clinical impact, including its chondroprotective effect. This review aimed to assess the chondroprotective effects, clinical outcomes, and survivorship of meniscal scaffold implantation compared to meniscectomy, as well as among different types of scaffolds.

Methods: A comprehensive search strategy was performed on the databases of PubMed, Embase, Cochrane Library, and Google Scholar, encompassing articles published until June 1, 2024. Randomized controlled trials (RCT) and comparative studies published in English that reported results using collagen meniscal implant (CMI) and polyurethane meniscal scaffold for meniscal tear were included.

Results: A total of 421 studies were initially identified across databases, and a systematic review was conducted on 8 studies involving 596 patients. Among the 5 studies that addressed the chondroprotective effect, none found that meniscal scaffolds had a higher chondroprotective effect compared to meniscectomy. In studies comparing CMI and meniscectomy, the Lysholm score results showed a mean difference (MD) range between -5.90 and -4.40. In the case of visual analog scale score, the MD ranged from -1.0 to 1.0. In studies comparing polyurethane meniscal scaffolds and CMI, the Tegner score results showed an MD range of -2.0 to 0.4.

Conclusions: There was no superiority in chondroprotective effects for both CMI and polyurethane meniscal scaffolds compared to meniscectomy. Although meniscal scaffolds may provide improvements in clinical outcomes, no clinically relevant differences were observed in comparison to meniscectomy. There are no discernible differences between the 2 types of scaffolds.

Background: Hip fractures are a major health concern, especially among older adults. The conventional treatment for this condition involves surgery, but it carries the risk of excessive blood loss and complications. Tranexamic acid (TXA) has emerged as a possible solution for reducing bleeding during surgery. This study aims to evaluate the safety and efficacy of topical TXA compared to systemic TXA and a placebo in adult patients undergoing surgical treatment for hip fractures.

Methods: The literature was reviewed using 3 databases (PubMed, Scopus, and Google Scholar) for studies published up to November 2023. All randomized controlled trials (RCTs) assessing the effectiveness of topical TXA in hip fracture surgery were included for analysis. Two reviewers assessed the quality of studies independently using the Cochrane-recommended risk-of-bias tool. Statistical analysis was performed on Comprehensive Meta-Analysis Software (version 2.0).

Results: Nine RCTs with 1,024 patients assessed topical TXA in hip fracture surgery. Topical TXA significantly reduced hemoglobin loss (mean difference [MD], 1.004 g/dL; 95% CI, 0.096-1.911; p = 0.03) and transfused blood units (relative risk, 0.640; 95% CI, 0.487-0.841; p = 0.001) versus placebo, but there was no significant difference in hematocrit loss, total blood loss, deep vein thrombosis (DVT) rates, mortality, hospital stays, or surgery duration compared to placebo. Moreover, the meta-analysis revealed no significant differences between local and intravenous TXA administration in blood transfusion rates, total blood loss, incidence of DVT, and surgery duration. The results of the subgroup analysis that compared topical TXA to placebo in the arthroplasty group showed that TXA significantly reduced hemoglobin drop (MD, 1.500 g/dL; 95% CI, 0.324-2.676; p = 0.012) and total blood loss (MD, -322.3 mL; 95% CI, -566.6 to -78.0; p = 0.010).

Conclusions: The available evidence suggests that local TXA can significantly reduce hemoglobin loss and the number of transfused blood units without the risk of DVT compared to a placebo. Furthermore, local TXA demonstrated comparable effectiveness and safety to intravenous TXA following hip fracture surgery. Subgroup analysis revealed that topical TXA significantly decreased the hemoglobin drop and total blood loss in the arthroplasty group, as compared to the placebo.

Backgroud: Allografts are preferred in certain cases of revision anterior cruciate ligament reconstructions to avoid additional graft harvesting and to fill in enlarged tunnels. The clinical outcomes of quadriceps tendon-patellar bone allograft in revision anterior cruciate ligament reconstruction are not well-known. This study was performed to evaluate the clinical outcomes of revision anterior cruciate ligament reconstructions using quadriceps tendon-patellar bone allografts.

Methods: Patients who underwent revision anterior cruciate ligament reconstructions with quadriceps tendon-patellar bone allografts with a minimum follow-up of 2 years were retrospectively reviewed. Their mean follow-up length was 33.5 ± 19.5 months. Outcomes including clinical scores (Lysholm, International Knee Documentation Committee [IKDC], Tegner scale, and Knee injury and Osteoarthritis Outcome Score [KOOS]), knee stability (physical examinations and knee arthrometer), return to sports, and any associated complications were assessed. Degrees of graft synovialization were also evaluated using arthroscopy.

Results: A total of 38 patients were reviewed and their age at the time of surgery and follow-up length were 37.2 ± 12.5 years (range, 17-66 years) and 2.8 ± 1.6 years, respectively. All clinical scores including KOOS, IKDC, Lysholm, and Tegner scale significantly improved at 2 years after surgery and 92.1% of the patients returned to sports. The mean preoperative side-to-side difference in knee arthrometer decreased from 4.5 ± 2.3 mm before surgery to 2.6 ± 1.5 mm after surgery (p < 0.001). Graft synovialization was observed in 13 of 16 patients (81.3%) who underwent second-look arthroscopy. Complication rate was 10.5% (n = 4). All complications were graft re-rupture and occurred at an average of 18 months after revision surgery.

Conclusions: Quadriceps tendon-patellar bone allograft showed satisfactory clinical outcomes in revision anterior cruciate ligament reconstruction and thus could be a good alternative when autograft harvesting is not optimal.