Clinics in Orthopedic Surgery最新文献

Background: We hypothesized that surgical treatment for acute distal radius fractures (DRFs) plays a major role in minimizing malunion; thus, we sought to estimate the overall incidence of refracture in the distal radius in elderly populations using a real-world, nationwide cohort from the National Health Information Database of Korea.

Methods: A total of 201,146 participants from 49.4 million Korean people met the inclusion criteria. The inclusion criteria were as follows: female sex, age older than 65 years at the time of index injury (first episode of DRF), diagnosis between 2010 and 2015, and at least 2 years of follow-up since the index fracture.

Results: Among the 201,146 enrolled patients, 22,597 (11.3%) experienced a refracture during the follow-up period. Of the 178,549 patients who did not experience a refracture, 119,871 (59.6%) were treated conservatively (scenario 1), while 58,678 (29.2%; scenario 2) underwent surgical management without refracture. The surgical methods used in these patients included Kirschner wires (19,823, 9.8%), plates without removal (12,601, 6.2%), and external fixators (1,253, 0.6%). Among the 58,678 surgically treated patients, 25,001 later underwent implant removal (plate). Refractures were identified in 22,597 patients (11.3%), with 4.1% treated conservatively again at refracture (scenario 3) and 2.9% treated surgically for refractures after initial recovery from the first fracture via a conservative approach (scenario 4). Additionally, corrective surgeries for second fractures were identified in 1,046 patients (0.5%) (scenario 5), where the initial fracture was managed conservatively. Within the current cohort, refracture after surgical treatment for the first event occurred in 7,386 patients (3.7%; scenarios 6, 7, and 8).

Conclusions: The refracture rate within this retrospective DRF cohort was revealed to be as common as the overall DRF rate in older patients. Considering the lack of knowledge regarding refractures to date, surgical treatment at initial fracture appears to minimize the risk of typical malunion, thus providing an easier approach to treating refractures. However, further studies should be conducted to rationalize surgical treatment for DRF with respect to refractures at the radius malunion.

Backgroud: Despite the increasing use of non-screw free bone graft fixation methods for glenoid defects associated with anterior shoulder instability, biomechanical knowledge of their effectiveness remains limited. This study aims to evaluate the biomechanical stability of different non-screw iliac crest graft fixation methods for anterior shoulder instability.

Methods: Forty-eight scapula bone models were used to compare the mechanical properties of non-screw fixation methods. The amples were divided into 4 groups: group 1 with 2 anchors, group 2 with 2 EndoButtons, group 3 with a combination of 2 anchors and 1 EndoButton, and group 4 with the Locking Anchor EndoButton System (LAES). Following fixation, dynamic testing began with a 10-N preload. After the preload, cyclic loading was applied between 10 N and 150 N for 100 cycles. Static loading was then conducted at a rate of 0.08 mm/sec. The test continued until either system failure occurred or the graft displacement reached 7 mm. Stiffness and maximum load values were determined. Rotational tests were performed at an angular velocity of 10°/sec. Torsional stiffness and maximum torque capacity were determined.

Results: Under dynamic loading conditions, the LAES group exhibited significantly less displacement compared to all other groups, while no significant differences were observed among the remaining groups. In static testing, the LAES group demonstrated the highest stiffness (183.354 ± 33.295 N/mm), significantly exceeding that of the Anchor group (93.847 ± 20.401 N/mm) and Anchor-EndoButton group (135.036 ± 37.815 N/mm). The EndoButton and LAES groups withstood significantly higher maximum loads than the Anchor and Anchor-EndoButton groups, with the LAES group achieving the highest load capacity (543.333 ± 100.851 N). In rotational testing, the LAES group displayed significantly greater torsional stiffness (0.182 ± 0.063 N·m/°) compared to all other groups. Additionally, the LAES group withstood the highest maximum torque (3.068 ± 1.194 N·m), significantly surpassing the Anchor, EndoButton, and Anchor-EndoButton groups.

Conclusions: All tested fixation methods provided sufficient stability under early postoperative loading conditions. However, the LAES demonstrated superior biomechanical performance, particularly in terms of rotational stability, compared to other non-screw fixation techniques.

Backgroud: The use of deep learning algorithms in medical imaging has increased rapidly. This study aimed to develop an automated, hybrid approach combining a deep learning architecture and a conventional computer-aided diagnostic method to detect anatomical landmarks and measure radiological parameters in wrist radiography.

Methods: Overall, 487 wrist radiographs were randomly sampled for training and validation, and 100 radiographs collected from 2 institutions were used as the test set. Anatomical landmarks for 4 commonly used parameters, namely, radial inclination (RI), radial length (RL), volar tilt (VT), and ulnar variance (UV), were identified and labeled. A 2-step hybrid method combining a deep learning model with conventional computer-aided diagnosis was developed to measure radiological parameters using these anatomical landmarks. Measurements were obtained from the test set. The mean value of each parameter determined by 2 hand surgeons served as the reference standard. The performance of the deep learning algorithm was evaluated using the successful detection rate (SDR), mean absolute error (MAE), intraclass correlation coefficient (ICC), and Pearson correlation coefficient (r).

Results: The SDR of the model ranged from 97% to 98% at the 1 mm threshold and 99% at the 2 mm threshold. The RI, RL, VT, and UV generated by the model were 26.41° ± 4.01°, 12.63 ± 2.72 mm, 14.01° ± 8.02°, and 2.09 ± 2.76 mm, respectively. The overall MAEs for RI, RL, VT, and UV between the manually and automatically measured parameter values were 1.62° ± 1.26°, 1.56 ± 1.23 mm, 1.88° ± 1.68°, and 0.43 ± 0.41 mm, respectively. In the correlation analysis, good or high reliability was observed for RI, VT, and UV (ICC: 0.86, 0.95, and 0.98; r = 0.86, r = 0.95, and r = 0.98, respectively), and moderate reliability was observed for RL (ICC: 0.75, r = 0.78).

Conclusions: This novel automated hybrid method can accurately identify landmarks on wrist radiographs and automatically generate the radiological parameters of the distal radius. This method saves time and reduces human labor in creating datasets for training segmentation models and developing image processing algorithms.

The purpose of this study was to assess the accuracy and validity of the "ball tip widening technique." We designed a retrospective analysis of 212 pedicle screws inserted in correction surgery for pediatric scoliosis, using posterior spinal instrumentation and fusion with pedicle screws at Seoul National University Bundang Hospital between July and August of 2021. The accuracy of pedicle screw placement was then classified using intraoperative computed tomography (CT; O-arm). Intraoperative CT revealed that 86.8% of pedicle screws (184 / 212) were placed in pedicle. The ball tip widening technique introduced in this study can enhance the accuracy of screw insertion into small pedicles. Furthermore, this technique may also be applied to lumbar surgery for degenerative conditions in the future.

Background: Patients with hallux valgus (HV) deformity often experience shoe-wearing discomfort, and increased foot width is considered a contributing factor. We assessed foot width using standing radiographs and 3-dimensional (3D) scans. This study aims to evaluate how these measurements are related to clinical outcomes in HV patients.

Methods: This cross-sectional study enrolled 19 consecutive adults presenting for hallux valgus evaluation. All participants underwent weight-bearing radiographs and 3D structured-light scanning, followed by completion of patient-reported outcome measures including pain visual analog scale, EuroQol 5-Dimension 5-Level (EQ-5D-5L), and Manchester-Oxford Foot Questionnaire (MOXFQ). Radiographic measurements included intermetatarsal angle, hallux valgus angle, bone width, and soft tissue width. 3D parameters included maximal and horizontal forefoot width, ball circumference, instep circumference, and ball-to-instep ratio. Pearson correlations and multivariable regression analyses examined relationships between morphological parameters and patient-reported outcomes.

Results: The cohort consisted of 14 women and 5 men with a median age of 57.0 years. Strong correlations were observed between radiographic and 3D measurements of bone and soft-tissue width (r = 0.93-0.97). The intermetatarsal angle showed moderate correlations with all 3D foot-width parameters (r = 0.54-0.65), while hallux valgus and interphalangeal angles did not demonstrate meaningful associations. In multivariable analyses, bone width was the predictor of MOXFQ-index scores and served as the predictor of social interaction difficulties. No dimensional parameters correlated with EQ-5D-5L scores. Domain-specific analysis revealed that bone width predicted social interaction problems, while maximal and horizontal width predicted walking/standing difficulties.

Conclusions: In hallux valgus patients, both radiographic bone width and 3D-scan-derived ball-to-instep ratio show notable associations with social interaction difficulties on the MOXFQ, highlighting the role of forefoot width in shoe wearing discomfort and patient-reported outcomes. Integrating these measurements into clinical evaluation may inform personalized footwear selection and design, such as wider toe boxes or customized last shapes, to alleviate symptoms and improve functional and social outcomes for patients with hallux valgus.

Background: Electrolyte disorders are uncommon but associated with adverse outcomes following lumbar spinal fusion. No previous study has examined rates of electrolyte disturbances after interbody fusions and compared them between anterior/lateral and posterior-based interbody fusions. The purpose of this study is to identify the incidence of electrolyte disturbances following lumbar interbody fusion and compare the difference in incidence between anterior/lateral lumbar interbody fusions (ALIF/LLIF) and posterior/transforaminal lumbar interbody fusions (PLIF/TLIF).

Methods: A large multi-payer database was queried to identify patients who underwent ALIF/LLIF or PLIF/TLIF from 2010 to 2022. The incidence of electrolyte abnormalities following each procedure was examined for up to 7 days postoperatively. The cohorts were matched 1 : 1 by demographics and comorbidities.

Results: Among 132,837 ALIF/LLIF and 492,129 PLIF/TLIF patients, the mean age was 60.18 years, 57.5% were female, and the mean Charlson Comorbidity Index was 1.76. There was a downward trend in the incidences of electrolyte abnormalities over the postoperative course except for hypercalcemia (anterior/lateral: p = 0.368; posterior: p = 0.764) and alkalosis (anterior/lateral: p = 0.764; posterior: p = 0.764) in both cohorts, as well as hypernatremia (p = 0.368) in the anterior/lateral cohort, in the first 7 days postoperatively. Patients with electrolyte abnormalities had higher rates of early postoperative ileus (5.84% vs. 1.26%), longer length of stay (9.22 vs. 6.08), higher rates of 90-day readmissions (17.30% vs. 4.48%), and higher costs ($19,946.70 vs. $15,190.87) (all p < 0.001). After matching, the anterior/lateral cohort had higher rates of hypokalemia (anterior = 1.19% vs. posterior = 1.00%, p < 0.001) and acidosis (0.25% vs. 0.18%, p < 0.001) than the posterior cohort.

Conclusions: Electrolyte disturbance following lumbar interbody fusion is associated with ileus, prolonged length of stay, and increased readmission rates and cost. Given the influence of electrolyte disturbances on postoperative outcomes, ongoing efforts to identify the prevalence and risk factors for electrolyte derangement in the perioperative period are warranted.

Background: Noncompliance with bracing and its protocol is the most common cause of clubfoot deformity relapse after correction. The literature does not clarify when patient noncompliance with the brace occurs-during which period of the bracing phase, or in which age group. This study aimed to determine when noncompliance is most likely to occur.

Methods: This descriptive observational study included children with idiopathic talipes equinovarus deformity for whom the foot abduction brace was applied to their feet after complete correction via the Ponseti method. Each patient was observed until the end of the brace-wearing program (at the end of the fourth year) and had 18 follow-up appointments. The patient's age and compliance (yes or no) were recorded at each appointment.

Results: Thirty-four cases (21 males and 13 females) with 58 feet were included in the current study. The mean age at the time of deformity correction and commencement of the brace was 2.3 months (standard deviation [SD], 0.6 months), and that at the final follow-up appointment was 50.6 months (SD, 0.9 months). Noncompliance occurred in 11 of 34 cases (32.4%). It started after the end of the first year of life, when the mean age of the patients was 14.6 months (SD, 0.8 months). A prominent rise in noncompliance was observed after the end of the second year of life, when the mean age was 26.6 months (SD, 0.9; 95% CI, 26.3-26.9). There was a significant positive correlation between instances of noncompliance and both the number of brace phase appointments and the age of the patient (p < 0.001).

Conclusions: Noncompliance with foot abduction brace started at the end of the first year and peaked after the end of the second year.

Backgroud: Rotator cuff (RC) tears are a common shoulder disorder associated with pain, dysfunction, and progressive muscle degeneration. Postoperative muscle atrophy and fatty infiltration are key factors contributing to poor healing outcomes, increased rerupture rates, and long-term functional impairment. While acetaminophen (APAP) is widely used for pain management, its potential effects on muscle fatty infiltration and tendon-bone interface (TBI) healing remain unclear. This study aimed to investigate whether APAP influences fatty infiltration and TBI healing after RC surgery. We hypothesized that APAP would reduce fatty infiltration by downregulating peroxisome proliferator-activated receptor gamma (PPAR-γ) while preserving histological and biomechanical TBI integrity.

Methods: A RC repair rat model was created using 12-week-old male Sprague-Dawley rats. Ten rats in the APAP group received an oral dose of 30 mg/kg APAP daily for 4 weeks after RC tendon transection, and 10 rats in the control group were administered only 0.9% saline. All rats were sacrificed 4 weeks after surgery. Fatty infiltration was analyzed qualitatively and quantitatively in the proximal part of the supraspinatus muscle. TBI was evaluated for RC healing effect through general tissue staining and biomechanical strength measurements.

Results: Four weeks after tendon repair, the APAP group showed significant prevention of supraspinatus fatty infiltration compared to the control group (p < 0.001). These results were confirmed through immunohistochemical results showing that PPAR-γ, a marker gene for fatty infiltration, was significantly decreased in the APAP group (p < 0.001). Histological healing assessments between the 2 groups were not significantly different (p = 0.634). Additionally, mechanical strength was not negatively affected.

Conclusions: APAP treatment was associated with prevention of supraspinatus fatty infiltration without adversely affecting TBI healing in an RC repair model.

Backgroud: The etiology and pathogenesis of Kienbock's disease (KD) have not been clearly established. In osteonecrosis of other bones, such as the proximal femur, the interface between necrotic and normal bone is evident in early stages. The purpose of this study was to retrospectively review and analyze magnetic resonance (MR) images of early-stage KD to confirm whether the double-line sign or an abnormal signal intensity band corresponding to the reactive interface is present.

Methods: We retrospectively reviewed 31 cases of 30 patients (average age, 41.2 years) diagnosed with early-stage KD. Lichtman staging revealed 9 cases of stage I and 22 cases of stage II. We evaluated their MR images of various sequences with special interest in signal intensity changes and the presence of the double-line sign.

Results: In all lunates, no abnormal signal intensity band representing a reactive interface was observed. Instead, diffuse signal intensity changes with a bone marrow edema pattern (BMEP) of various extents were detected in all 31 lunates. Furthermore, a fracture line was found in 10 lunates and BMEP in the surrounding carpal bones was present in 8 cases.

Conclusions: In lunates with stage I and II KD, the main MR finding was diffuse BMEP without an abnormal signal intensity line of a reactive interface, and some cases showed abnormal signal intensity bands suggestive of a fracture line.

Background: Cementless fixation in total knee arthroplasty (TKA) has theoretical advantages of being biological and bone preserving, but some surgeons are less confident in using it given previous reports of high failure rates in some implant designs. This study aimed to investigate the effect of fixation method on tibial bone density, clinical outcome, and survivorship. The main research question was whether fixation method would affect the postoperative change in tibial bone density in TKA.

Methods: This study analyzed 53 cementless TKAs and 53 cemented TKAs of the same brand (Triathlon, Stryker). Digital radiological densitometry (DRD) was used to quantify the changes in regional tibial bone density (RTBD) within the first 2 years. Clinical outcome scores and survivorship were recorded.

Results: Significant decreases in RTBD were observed in both groups in all tibial regions (p < 0.001 at all time points). RTBD was significantly higher in 7 of 8 tibial regions in cementless TKA at 6 months. The significance persisted in 2 regions of the lateral tibial condyle until the second year (p = 0.014 and p = 0.029). Clinical outcome scores (Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index, and Forgotten Joint Score) were similar. No case of aseptic loosening was reported.

Conclusions: Proximal tibial bone resorption was common in both cementless and cemented TKAs. Cementless fixation preserved more tibial metaphyseal bone globally at 6 months and at the lateral tibial condyle at 24 months. Its early clinical outcomes and survivorship were comparable to those of cemented fixation.