Clinics in Orthopedic Surgery最新文献

Background: The nonunion rate for atypical femoral fractures (AFF) is known to be higher than that for typical fractures of the femur. We performed a meta-analysis to determine the incidence of nonunion necessitating reoperation following fixation for AFF and compare the rates according to the fracture site (subtrochanter or midshaft).

Methods: A total of 742 AFFs from 29 studies were included. A proportion meta-analysis utilizing a random-effects model was conducted to estimate the prevalence of nonunion. The outcomes were the incidence of reoperations that included osteosynthesis. To determine the association of nonunion with patient mean age or average duration of bisphosphonate use, meta-regression analysis was done.

Results: In proportion meta-analysis, the estimated pooled prevalence of nonunion was 7% (95% confidence interval [CI], 5%-10%) from all studies. There was a significant difference in nonunion rate between the 2 groups (I² = 34.4%, p = 0.02); the estimated prevalence of nonunion was 15% (95% CI, 10%-20%) in subtrochanteric AFFs and 4% (95% CI, 2%-6%) in midshaft AFFs. From meta-regression analysis, significant correlations were identified between nonunion rate and patient mean age (coefficient: -0.0071, p = 0.010), but not in the average duration of bisphosphonate use (coefficient: -0.0024, p = 0.744).

Conclusions: A notable disparity existed in the nonunion rate among subtrochanteric AFFs and midshaft AFFs group. Therefore, it is critical for orthopedic surgeons to consider the complexity and challenges associated with AFF and to estimate the proper possibility of nonunion according to the fracture site.

Background: Periprosthetic osteolysis is a prevalent complication following total ankle arthroplasty (TAA), implicating various cytokines in osteoclastogenesis as pivotal in this process. This study aimed to evaluate the relationship between osteolysis and the concentrations of osteoclastogenesis-related cytokines in synovial fluid and investigate its clinical value following TAA.

Methods: Synovial fluid samples from 23 ankles that underwent revision surgery for osteolysis following TAA were analyzed as the osteolysis group. As a control group, we included synovial fluid samples obtained from 23 ankles during primary TAA for osteoarthritis. The receptor activator of nuclear factor-κB ligand (RANKL)/osteoprotegerin (OPG) ratio in these samples was quantified using sandwich enzyme-linked immunosorbent assay techniques, and a bead-based multiplex immunoassay facilitated the detection of specific osteoclastogenesis-related cytokines.

Results: RANKL levels averaged 487.9 pg/mL in 14 of 23 patients in the osteolysis group, with no detection in the control group's synovial fluid. Conversely, a significant reduction in OPG levels was observed in the osteolysis group (p = 0.002), resulting in a markedly higher mean RANKL/OPG ratio (0.23) relative to controls (p = 0.020). Moreover, the osteolysis group had increased concentrations of various osteoclastogenesis-related cytokines (tumor necrosis factor-α, interleukin [IL]-1β, IL-6, IL-8, IP-10, and monocyte chemotactic protein-1) in the synovial fluid relative to the control group.

Conclusions: Our results demonstrated that periprosthetic osteolysis was associated with osteoclastogenesis activation through an elevated RANKL/OPG ratio following TAA. We assume that RANKL and other osteoclastogenesis-related cytokines in the synovial fluid have clinical value as a potential marker for the development and progression of osteolysis following TAA.

Background: The hamstring autograft can be harvested using various skin incisions, such as vertical, transverse, and oblique incisions, and from different localizations, including anteromedial and posteromedial harvest sites. The aim of this study was to compare studies on the anteromedial and posteromedial approaches for hamstring autograft harvest in terms of clinical outcomes, saphenous nerve injury, infection, operative time, graft length, incision length, range of motion, and patient satisfaction.

Methods: Following the 2020 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, a search was conducted in PubMed and Scopus, focusing on studies comparing anteromedial and posterior approaches for hamstring harvest. This study was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42023450249). Methodological quality was evaluated using the Modified Coleman Methodology Score. Odds ratios (ORs) and mean differences (MDs) quantified dichotomous and continuous outcomes, respectively.

Results: Five articles, involving 405 knees, underwent analysis. Four studies were level 3 evidence, while 1 was level 1. The anteromedial hamstring harvest showed higher rates of saphenous nerve injury (OR, 9.77; 95% confidence interval [CI], 2.19-43.65; p = 0.003) and longer operative times, with an MD of about 13 minutes (MD, 13.33; 95% CI, 0.68-25.97; p = 0.04), compared to the posteromedial approach. The anteromedial method yielded a longer semitendinosus graft, with an MD of about 17 mm (MD, 17.57; 95% CI, 7.17-27.98; p = 0.0009). However, no significant differences existed in range of motion, flexion contracture, unintentional graft harvest, infection rates, and patient-reported outcomes. Notably, the posteromedial group reported higher cosmetic satisfaction, with 92% being very satisfied, compared to the anteromedial group with 80% (p = 0.005). However, overall satisfaction levels were similar between the 2 groups (p = 0.35), with a very satisfied rate of 72% for the anteromedial group and 78% for the posteromedial group.

Conclusions: The anteromedial hamstring harvest showed greater saphenous nerve injury and longer operative times compared to the posteromedial approach, along with a longer graft. However, no significant differences were observed in the range of motion, flexion contracture, graft harvest, infection, or patient outcomes.

Severe bone defects pose a clinical challenge in total ankle arthroplasty (TAA) and are frequently considered contraindicated. We introduce an innovative approach that utilizes a structural tibial cut autograft to address anterior distal tibia bone defects during TAA. This technique is a viable alternative to employing revision TAA systems or resorting to excessively high tibial cuts. Furthermore, it facilitates achieving favorable sagittal alignment and ensures adequate fixation strength of the tibial component.

Background: The morphology of the suprascapular notch (SSN) and the ossification of the superior transverse suprascapular ligament (STSL) are risk factors for injury of the suprascapular nerve (SN) during arthroscopic shoulder procedures. The purpose of the current study was to compare preoperative clinical and radiologic characteristics between patients with and without STSL ossification and to evaluate SSN morphology in patients who underwent arthroscopic rotator cuff repair using a 3-dimensional (3D) reconstructed model.

Methods: Patients who underwent arthroscopic rotator cuff repair and were given a computed tomography (CT) scan from March 2018 to August 2019 were included in this study. Patients were divided into 2 groups: those without STSL ossification (group I) and those with STSL ossification (group II). Tear size of the rotator cuff and fatty infiltration of rotator cuff muscles were assessed in preoperative magnetic resonance imaging. The morphology of the SSN was classified following Rengachary's classification. The transverse and vertical diameters of the SSN and the distances from anatomical landmarks to the STSL were measured. All measurements were completed using a 3D CT reconstructed scapula model.

Results: A total of 200 patients were included in this study. One hundred seventy-eight patients (89.0%) without STSL ossification were included in group I, and 22 patients (11.0%) with STSL ossification were included in group II. Group II showed a significantly advanced age (61.0 ± 7.4 vs. 71.0 ± 7.3 years, p < 0.001) and a shorter transverse diameter of SSN (10.7 ± 3.1 mm vs. 6.1 ± 3.7 mm, p < 0.001) than group I. In the logistic regression analysis, age was an independent prognostic factor for STSL ossification (odds ratio, 1.201; 95% confidence interval, 1.112-1.296; p < 0.001). Patients in type VI showed significantly shorter transverse diameters than other types (p < 0.001). The patient with type I showed a significantly shorter distance from the articular surface of the glenoid to the SSN than those with other types (p < 0.001).

Conclusions: In the 3D morphological analysis, age was the independent factor associated with STSL ossification in patients who underwent arthroscopic rotator cuff repair. Type VI showed significantly shorter transverse diameters than other types. Type I showed a significantly shorter distance from the articular surface of the glenoid to the SSN than other types.

Background: Osteochondral autologous transplantation (OAT) has been widely used in the treatment of osteochondral lesion of the talus (OLT). Previous studies have reported successful outcomes following the use of osteochondral autogenous grafts from the intercondylar notch of the knee or a non-weight-bearing region of the femoral condyle. However, donor-site morbidity of the knee joint has been observed in several cases. This study aimed to investigate the outcomes and safety of OAT with autografts from the ipsilateral lateral talar articular facet as an alternative donor site for medial OLT.

Methods: Among 40 patients who underwent OAT, 29 patients were excluded. Eleven patients who underwent OAT with an osteochondral graft harvested from the ipsilateral lateral talar articular facet from 2011 to 2022 were retrospectively analyzed. The size of OLT was measured on ankle magnetic resonance imaging, including coronal length, sagittal length, depth, and area. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and a visual analog scale (VAS). Weight-bearing ankle radiographs were obtained postoperatively and at 1 year after surgery.

Results: The average follow-up time after surgery was 64.7 months (range, 14-137 months). The average diameter of lesions was 8.8 mm (range, 8-9.9 mm). The average size of lesions was 51.2 mm² (range, 33.6-71.3 mm²) , and all lesions included subchondral cysts. The average depth of lesions was 7.3 mm (range, 6.2-9.1 mm). Graft sizes ranged from 8 to 10 mm in diameter (8 mm, n = 1; 10 mm, n = 10) All measured clinical outcomes improved postoperatively, including the AOFAS scores (preoperative, 55.4 ± 9.0; 1-year follow-up, 92.1 ± 7.6; p = 0.001) and VAS scores (preoperative, 5.5 ± 0.7; 1-year follow-up, 1.9 ± 0.8; p = 0.001). All weight-bearing ankle radiographs of the graft and donor sites did not reveal arthritic change in the ankle joint, lateral talar dome collapse, and graft-site delayed union or nonunion at 1 year after surgery.

Conclusions: For a single medial OLT, harvesting autografts from the ipsilateral lateral talar articular facet without knee donor-site morbidities can be a good alternative in OAT for OLT.

Background: Pediatric trigger digit (TD) does not appear at birth but is diagnosed after birth by finding a flexion contracture of the thumb or other fingers. The reported incidence of pediatric TDs varies from 0.5 to 5 cases per 1,000 live births without sex-specific predominance. We performed a nationwide large-scale study to determine the prevalence and incidence of pediatric TDs and analyzed operative treatment for pediatric TDs using the National Health Insurance data of South Korea.

Methods: Patients with pediatric TDs, aged 0-10 years between 2011 and 2020, were included in this study. Children born between 2011 and 2015 were set as the reference population and followed up until 2020. We calculated the prevalence and incidence rates of pediatric TDs according to age and sex and analyzed the operation rate, age at surgery, time interval from initial diagnosis to surgery, and follow-up period. Patient selection and treatment were based on International Classification of Diseases, 10th Revision (ICD-10).

Results: The prevalence rates of pediatric TDs ranged from 0.063% to 0.084%. Girls had a higher prevalence rate (0.066%-0.094%) than boys (0.060%-0.075%). The total incidence rate was 77.6/100,000 person-years, and the incidence rate was higher in girls (84.8) than in boys (70.7). Among 2,181,814 children born between 2011 and 2015, 12,729 were diagnosed with pediatric TDs, of which 1,128 (8.9%) underwent operative management. The means of age at initial diagnosis, age at surgery, and the time interval between diagnosis and operation were 2.76 ± 1.91 years, 3.79 ± 2.19 years, and 1.15 ± 1.71 years, respectively.

Conclusions: High prevalence and incidence rates of pediatric TDs were found in 2- to 3-year-old patients. Among pediatric patients, 8.9% underwent operative management that was most frequently conducted between 2 and 3 years of age (within 1 year of initial diagnosis).

Background: Increased load bearing across the patellofemoral and tibiofemoral articulations has been associated with total knee arthroplasty (TKA) complications. Therefore, the purpose of this study was to quantify the biomechanical characteristics of the patellofemoral and tibiofemoral joints and simulate varying weight-bearing demands after posterior cruciate ligament-retaining (CR) and posterior-stabilized (PS) TKAs.

Methods: Eight fresh-frozen cadaveric knees (average age, 68.4 years; range, 40-86 years) were tested using a custom knee system with muscle-loading capabilities. The TKA knees were tested with a CR and then a PS TKA implant and were loaded at 6 different flexion angles from 15° to 90° with progressively increasing loads. The independent variables were the implant types (CR and PS TKA), progressively increased loading, and knee flexion angle (KFA). The dependent variables were the patellofemoral and tibiofemoral kinematics and contact characteristics.

Results: The results showed that at higher KFAs, the position of the femur translated significantly more posterior in CR implants than in PS implants (36.6 ± 5.2 mm and 32.5 ± 5.7 mm, respectively). The patellofemoral contact force and contact area were significantly greater in PS than in CR implants at higher KFAs and loads (102.4 ± 12.5 N and 88.1 ± 10.9 N, respectively). Lastly, the tibiofemoral contact force was significantly greater in the CR than the PS implant at flexion angles of 45°, 60°, 75°, and 90° KFA, the average at these flexion angles for all loads tested being 246.1 ± 42.1 N and 192.8 ± 54.8 N for CR and PS implants, respectively.

Conclusions: In this biomechanical study, CR TKAs showed less patellofemoral contact force, but more tibiofemoral contact force than PS TKAs. For higher loads across the joint and at increased flexion angles, there was significantly more posterior femur translation in the CR design with a preserved posterior cruciate ligament and therefore significantly less patellofemoral contact area and force than in the PS design. The different effects of loading on implants are an important consideration for physicians as patients with higher load demands should consider the significantly greater patellofemoral contact force and area of the PS over the CR design.

Background: Although the all-inside arthroscopic modified Broström operation (AMBO) and open modified Broström operation (OMBO) for chronic lateral ankle instability (CLAI) showed favorable outcomes up to 1-year short-term follow-up, concerns about the long-term stability of AMBO are still present. Therefore, we aimed to compare midterm outcomes between the 2 methods by extending the observation period.

Methods: Fifty-four patients undergoing ankle surgery between August 2013 and July 2017 were included in the AMBO (n = 37) and OMBO (n = 17) groups. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale and a visual analog scale (VAS) were used to evaluate the clinical outcomes. Anterior drawer test and talar tilt angle were used to evaluate the radiological outcomes. The mean follow-up duration was 59.69 months.

Results: The 2 groups both showed improved clinical and radiological results statistically. In addition, they did not differ in age, sex, or preoperative AOFAS ankle-hindfoot scale score, VAS score, anterior drawer test, or talar tilt angle. No significant difference in the final follow-up postoperative clinical scores or radiological outcomes was observed.

Conclusions: AMBO and OMBO as treatments for CLAI did not yield differing clinical or radiological outcomes at a mean follow-up time point of 59.69 months.

Treatment strategies for femoroacetabular impingement (FAI) syndrome have evolved in tandem with increased comprehension of FAI's impact on hip joint health. Early intervention, including arthroscopic surgery, has gained popularity due to its potential to delay the progression of osteoarthritis. Arthroscopic surgery has demonstrated significant efficacy in treating FAI syndrome, with robust evidence from randomized controlled trials and systematic reviews supporting its use. Despite arthroscopic surgery's success, complications and reoperations are not uncommon. The incidence ranges from 1% to 31% and 4% to 13%, respectively. Adjunctive biologic treatments, such as bone marrow aspirate concentrates and platelet-rich plasma, have shown promise in chondral lesion management. However, robust evidence supporting their routine use in FAI syndrome is currently lacking. Among conservative treatment methods, intra-articular injections offer diagnostic and therapeutic benefits for FAI patients. While they may provide pain relief and aid in prognosis, their long-term efficacy remains a subject of debate. Comparative studies between conservative and arthroscopic treatments highlight the importance of personalized approaches in managing FAI syndrome. In conclusion, recent advancements in FAI syndrome management have illuminated various treatment modalities. Arthroscopic surgery stands as a pivotal intervention, offering substantial benefits in pain relief, function, and quality of life. However, careful patient selection and postoperative monitoring are crucial for optimizing outcomes. Adjunctive biologics and intra-articular injections show promise but require further investigation. Tailoring treatment to individual patient characteristics remains paramount in optimizing FAI syndrome management.