Clinics in Orthopedic Surgery最新文献

Background: Vasovagal reactions (VVRs) are abnormal autonomic responses mediated by the vagus nerve. They can occur during or after interventional procedures and negatively impact patient care. The aim of this study was to evaluate the incidence of VVRs observed during nonoperative orthopedic interventions in outpatient clinics and to analyze the associated risk factors.

Methods: The data of 1,208 patients who underwent nonoperative orthopedic interventions at a single-center outpatient clinic between December 2023 and December 2024 were retrospectively analyzed. Patients were categorized into 2 groups based on the occurrence of VVR. The clinical data of both groups were analyzed to identify factors associated with VVRs.

Results: A total of 1,208 patients with a mean age of 54.7 years were included in the study. Among the 1,208 patients included, 51 cases of VVRs were reported (4.2%). The VVR group had a younger mean age (44.2 vs. 55.1 years, p < 0.001) and a higher proportion of females (74.5% vs. 59.2%, p = 0.029) compared to the non-VVR group. Mean visual analog scale (VAS) scores during intervention were higher in the VVR group (6.41 vs. 2.98, p < 0.001), and blood-injury-injection (BII) phobia was more common (39.2% vs. 1.8%, p < 0.001). Fasting time was longer in the VVR group (3.9 vs. 2.8 hours, p = 0.003). No significant differences were observed in hypertension, coronary artery disease, cerebrovascular disease, or asthma between groups (p > 0.05).

Conclusions: Younger age, female sex, higher VAS scores, BII phobia, and longer fasting times were the risk factors for VVRs associated with nonoperative orthopedic interventions.

Background: To investigate directional deviations between pilot holes and final pedicle screw trajectories in freehand placement and analyze risk factors for misplacement. While pedicle screws are widely used in thoracolumbosacral surgery, directional deviations between pilot holes and final screw trajectories remain understudied as potential risk factors for misplacement.

Methods: Thirty-three patients undergoing posterior fixation were prospectively enrolled. Inertial measurement units (IMUs) tracked the spatial positions of pedicle finders and screwdrivers via custom software. Surgeons (n = 6) were stratified into senior, middle, and junior groups. Analyzed variables included the use of tapping, surgeon experience, spinal deformity status, screw tip morphology, and surgical parameters.

Results: Among 198 implanted screws (6.00 ± 2.88/patient), all exhibited trajectory deviations (8.12° ± 3.47°). Tapping significantly reduced deviations (7.23° ± 3.23° vs. 8.87° ± 3.31°, p < 0.01). Senior surgeons achieved smaller deviations (7.34° ± 3.33°) than the middle group (8.60° ± 3.51°, p = 0.039) and junior group (8.68° ± 3.49°, p = 0.022). Multivariate analysis confirmed tapping (p = 0.001) and senior experience (p = 0.023) as protective factors. No significant associations emerged for spinal deformity (8.43° ± 3.73° vs. 7.97° ± 3.35°, p = 0.377), screw tip type (cylindrical, 8.43° ± 3.26° vs. tapered, 8.07 ± 3.51°; p = 0.637), obesity, or surgical position parameters.

Conclusions: Freehand pedicle screw placement consistently produces trajectory deviations from pilot holes, and surgeon experience and tapping are modifiable protective factors. The IMU-based tracking system enables quantitative surgical motion analysis, suggesting its utility for training optimization and technique standardization.

Backgroud: Advancing orthopedic care through large language models requires both multimodal processing capabilities for medical images and open-source deployment options for secure in-house operations, yet these remain underexplored in current literature. This study aims to benchmark open-source vision-language models (VLMs) against orthopedic residents using the Orthopedic In-Training Examination (OITE), assess domain-specific performance across orthopedic subspecialties, and investigate the relationship between model parameter size and performance.

Methods: Six open-source VLMs of varying sizes (Alibaba Qwen2.5-VL-72B-Instruct, Alibaba Qwen2.5-VL-32B-Instruct, Alibaba Qwen2.5-VL-7B-Instruct, Alibaba Qwen2.5-VL-3B-Instruct, Meta Llama-3.2-90B-Vision-Instruct, Meta Llama-3.2-11B-Vision-Instruct) were evaluated using the 2023 OITE (210 questions; 111 with images). Model performance was compared to resident scores from the 2023 OITE technical report. Pearson correlation coefficient was used to assess the association between model size and performance.

Results: The 2 largest open-source models, Qwen2.5-VL-72B and Llama-3.2-90B, demonstrated performance levels comparable to those of second-year orthopedic residents on the OITE examination. A mid-sized model, Qwen-32B, slightly outscored first-year residents. In contrast, small-sized models (under 11 billion parameters) performed worse than first-year residents. Qwen2.5-VL-72B performed best in foot & ankle and sports medicine topics, while Llama-3.2-90B was strongest in basic science and hand & wrist. All models had the most difficulty with spine and pediatric questions. Overall, model accuracy increased steadily with model size up to 72 billion parameters, but larger sizes showed little additional improvement.

Conclusions: Smaller models offer reduced accuracy in exchange for lower hardware requirements. Spine and pediatric domains remain consistently areas of underperformance across all models. Model selection should be based on domain-specific benchmark results to balance clinical needs with hardware limitations. While promising, open-source VLMs currently require further refinement and validation before they can be reliably applied in clinical or educational settings.

Backgroud: To evaluate the effects of steroid injection (SI) versus physical therapy and rehabilitation (PTR) on the functional results and sleep quality in patients with partial thickness supraspinatus tendon rupture (PTSR).

Methods: Patients who were diagnosed with PTSR were divided into 2 groups, SI and PTR. The SI group was treated with 1 mL betamethasone + 9 mL prilocaine injection, the PTR group was treated with deltoid muscle exercise. Short version of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire (QuickDASH) and Pittsburgh Sleep Quality Index (PSQI) of the SI group and PTR group were evaluated at baseline and at 1 month and 3 months after the procedure. There were 22 patients in the SI group and 25 patients in the PTR group.

Results: There was no statistically significant difference between QuickDASH scores at any timepoint in both groups. PSQI scores in the SI group were significantly lower at 1 month and 3 months after the procedure (p = 0.001, p = 0.006). A significant improvement was seen in both groups in QuickDASH (p = 0.001 and p = 0.011) and PSQI (p = 0.001 and p = 0.001) scores from baseline to 1 month after the procedure. A significant improvement was also seen in both groups in QuickDASH (p = 0.001 and p = 0.033) and PSQI (p = 0.001 and p = 0.001) scores from baseline to 3 months after the procedure.

Conclusions: Both SI and PTR treatment methods improved the patients' functional results and sleep quality. The SI group demonstrated earlier and greater improvement in sleep quality compared to the PTR group, while functional outcomes were similar between groups.

Background: Total ankle arthroplasty (TAA) is increasingly used as an alternative to ankle arthrodesis for patients with rheumatoid arthritis (RA), although its outcomes remain controversial. Using propensity score matching, this study compared clinical and radiographic outcomes of TAA for patients with RA and osteoarthritis (OA).

Methods: Eighteen patients with RA were selected from 21 eligible cases and matched-using propensity score matching based on 8 baseline variables-to 36 patients with OA from a pool of 386. All patients underwent mobile-bearing TAA and were followed up for a minimum of 2 years. Clinical outcomes were assessed using the Ankle Osteoarthritis Scale, American Orthopaedic Foot and Ankle Society ankle-hindfoot score, Short Form-36 Physical Component Summary, and a visual analog scale for pain. Radiographic outcomes and postoperative complications were also evaluated.

Results: At a mean follow-up of 7 years, both groups demonstrated improvement in all clinical outcome measures, with no significant differences between the RA and OA groups (p > 0.05). Radiographic outcomes, including postoperative tibiotalar angle, talar tilt angle, as well as the incidence values for periprosthetic osteolysis, implant subsidence, and aseptic loosening, were similar between groups. However, periprosthetic medial malleolar fractures occurred only in the RA group (3 cases, 16.7%; p = 0.033), and 2 cases of incision wound dehiscence were also observed in the RA group. No deep infections were reported in either group. Overall, reoperation rates did not differ significantly between groups.

Conclusions: Patients with RA who underwent TAA achieved clinical and radiographic outcomes comparable to those with OA. However, periprosthetic fractures and wound complications were more common in the RA group. Further studies with larger, matched cohorts and longer follow-up are needed to confirm these findings.

Background: When positioning the acetabular component for total hip arthroplasty (THA) in patients with sequelae of Legg-Calvé-Perthes disease (LCPD), elevating the center of rotation (COR) of the hip is often unavoidable. We aimed to compare the outcomes between the preserved and elevated COR groups in patients with sequelae of LCPD.

Methods: We enrolled 53 patients who underwent primary THA for sequelae of LCPD between 2006 and 2019. Patients were divided into 2 groups based on the postoperative COR position: 19 in the preserved COR group and 34 in the elevated COR group. The mean elevation of COR was 2.7 mm (range, 0-5.0 mm) in the preserved COR group and 8.1 mm (range, 6.0-12.0 mm) in the elevated COR group. Radiological outcomes, such as osteolysis and implant loosening, were evaluated. Additionally, reoperation, perioperative complications, limping gait, pelvic obliquity, and the modified Harris hip score (mHHS) were assessed.

Results: There were no significant differences in radiological or clinical outcomes between the 2 groups. Neither osteolysis nor implant loosening was observed, and no reoperations were required. Intraoperative periprosthetic femoral fractures occurred in 3 cases (6%), but no cases of sciatic nerve palsy were observed. Residual limping gait was noted in 10 patients (19%), and pelvic obliquity persisted in 8 patients (15%). At the last follow-up, the mean mHHS was 89.2.

Conclusions: The 5-17-year follow-up results of primary cementless THA in patients with sequelae of LCPD were satisfactory. Furthermore, a moderate elevation of the COR, with a mean of 8.1 mm (range, 6.0-12.0 mm), did not significantly affect the outcomes of THA in these patients. Therefore, a moderate elevation of the COR can be considered an acceptable option for patients undergoing THA with sequelae of LCPD.

Background: The optimal indications for superior capsular reconstruction (SCR) in cases of massive irreparable rotator cuff tears (RCTs) accompanied by degenerative arthritis remain controversial.

Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, searching PubMed, Embase (Elsevier), and Google Scholar. Studies were included if they documented Hamada grade and reported clinical and radiographic outcomes after SCR for irreparable RCTs. American Shoulder and Elbow Surgeons (ASES) score, visual analog scale for pain (pVAS), active range of motion, and acromiohumeral distance (AHD) were analyzed.

Results: In all 7 studies, there was no consistent trend observed regarding the influence of arthritis on the improvement of ASES scores, and none of the studies showed statistically significant correlations (p > 0.05). All 5 studies regarding pVAS showed a trend that the pVAS improvement after surgery decreased as the severity of arthritis increased (beta coefficient < 0). Out of the 7 studies regarding forward flexion (FF), 6 demonstrated a trend where the improvement after surgery decreased as the severity of arthritis increased (beta coefficient < 0). There was a tendency for the improvement in AHD to increase as the Hamada grade progressed.

Conclusions: There was no consistent trend observed regarding the impact of the severity of arthritis on the improvement of ASES score. However, there was a trend of decreasing improvement in pVAS and FF after surgery as arthritis progressed. SCR could be a viable option even in cases of Hamada grades 3 and 4.

Background: Tibiotalocalcaneal (TTC) arthrodesis is a viable salvage option for failed total ankle arthroplasty (TAA), but it is typically a complex procedure associated with a high complication rate. This study analyzed outcomes of salvage TTC arthrodesis using a retrograde intramedullary (IM) nail without subtalar joint preparation after failed TAA.

Methods: This study included 18 patients (18 ankles) who underwent TTC arthrodesis without subtalar joint preparation for failed TAA from July 2008 to March 2023 and were followed up for at least 2 years. Visual analog scale pain scores and Ankle Osteoarthritis Scale pain and disability scores were used to assess functional outcomes. Radiographic union, time to union, complications, and clinical success-defined as pain improvement without the need for revision surgery or amputation-were also evaluated.

Results: The mean follow-up duration after TTC arthrodesis was 79.8 months (range, 26-199 months). Tibiotalar joint union was achieved in 13 ankles (72.2%) at a mean of 7.5 months after TTC arthrodesis. Subtalar joint union was achieved in 7 ankles (38.9%). All functional scores improved significantly from preoperatively to the last follow-up. The overall clinical success rate was 83.3% (15 ankles).

Conclusions: TTC arthrodesis using a retrograde IM nail without subtalar joint preparation produced favorable outcomes in patients with failed TAA. No complications associated with the subtalar joint were observed in any patient during follow-up. Therefore, TTC arthrodesis using a retrograde IM nail without subtalar joint preparation may be a considerable salvage option for failed TAA.

Bony Bankart lesions present considerable challenges in shoulder surgery, particularly when large. While smaller lesions can often be treated effectively using the single-row technique, larger lesions require more complex approaches. Several arthroscopic techniques have been developed to manage these lesions. Although the double-row technique is effective, it has the disadvantage of placing suture material on the articular surface. In contrast, the transosseous technique permits adequate compression and surface contact without involving the articular surface; however, it is technically demanding and frequently requires specialized instruments. This technical note describes a simplified arthroscopic transosseous repair method for bony Bankart lesions using standard spinal needles and Kirschner wires, eliminating the need for specialized equipment while ensuring secure fixation and optimal surface contact.

Background: Although several reports have addressed tendinous mallet finger (TMF), they have not identified which method best informs surgeons about the extent of residual extension lag in these patients. We aimed to assess the association between sonographic classification of acute TMF and the degree of extension lag remaining at the final follow-up.

Methods: The inclusion criterion was acute TMF with symptom onset within 2 weeks. Thirty-eight patients (23 male and 15 female) participated, with a mean follow-up of 17.1 months (range, 12.3-23.5 months). Range of motion, including extension lag, was measured at both the initial presentation and the final follow-up. All patients were managed conservatively using a finger splint for a period exceeding 6 weeks. Ultrasonography was performed for all participants to assess the severity of terminal extensor tendon injury. Statistical analyses examined the relationship between sonographic type and extension lag at final follow-up.

Results: At initial presentation, the mean extension lag was 46.0°, which improved to 17.5° at the last follow-up. TMF cases were categorized into 3 sonographic types (hypo-echoic, thinned, and wavy) based on ultrasound characteristics. A significant difference in extension lag at final follow-up was observed among the TMF groups (p = 0.005). Patients with the wavy type had the greatest mean extension lag, whereas those with the hypo-echoic type had the least mean extension lag, with statistical significance.

Conclusions: Sonographic assessment of TMF can aid in predicting residual extension lag in patients with TMF undergoing conservative treatment with a finger splint.