Clinics in Orthopedic Surgery最新文献

Backgroud: The Proximal Humeral Internal Locking System (PHILOS) plate, designed for the treatment of proximal humeral fractures, demonstrates versatility when used in an inverted (upside-down) configuration. We aimed to retrospectively compare the clinical and radiographic outcomes of patients who underwent surgical treatment for extra-articular diaphyseal distal humeral fractures using either an extra-articular distal humerus plate (EADHP) or a modified PHILOS locking compression plate.

Methods: This study included 58 patients: 39 in the EADHP group (group A) and 19 in the PHILOS plate group (group B). Clinical outcomes were assessed using a visual analog scale for pain rating, the Mayo Elbow Performance Score, and range of motion measurements. Radiological evaluation was performed using anteroposterior, lateral, and oblique views of the humerus. The presence of radial nerve symptoms was evaluated before and after surgery.

Results: Patients in group B exhibited substantially shorter average operation times (105.8 minutes) and less mean blood loss (250.0 mL) than those in group A with an average operation time of 123.3 minutes and mean blood loss of 456.4 mL. Furthermore, a higher incidence of hardware removal was observed in group A (23.1%) than in group B (15.8%), with the procedure typically occurring approximately 15 months postoperatively in both groups. However, no significant discrepancies were found in clinical outcomes between the 2 groups, including time to fracture union and radial nerve injury rates, with no statistically significant distinctions detected between them.

Conclusions: Application of the modified PHILOS plate demonstrated outcomes comparable to those of the EADHP in treating extra-articular diaphyseal distal humerus fractures, with significantly reduced operation time and blood loss.

Background: This study aimed to investigate the graft isometry of anatomical single-bundle anterior cruciate ligament (ACL) reconstruction using a novel method.

Methods: Seventy-three patients (mean age, 28.4 ± 9.5 years, 71 men and 2 women) underwent unilateral ACL reconstruction using hamstring autografts and an anteromedial drilling technique. Femoral tunnels were positioned in the high portion of the anteromedial bundle insertion; tibial tunnels were positioned at the center of the ACL tibial footprint. Graft laxity was evaluated using a new method based on Endobutton flip. Two knots were tied on the pulling sutures of the Endobutton, and the distance changes between the knots during flipping were measured, which represented the extent of flipping and the graft laxity. Measurements were conducted at 0°, 30°, 60°, 90°, and 120° of knee flexion, respectively. The patterns of graft laxity and their association with femoral tunnel positions were analyzed.

Results: The grafts were taut at knee extension but exhibited laxity during knee flexion in nearly all patients. Three patterns of graft laxity were observed: pattern 1, constant laxity throughout flexion (n = 39); pattern 2, lax at mid flexion, and taut again at high flexion (n = 11); and pattern 3, gradually increasing laxity with knee flexion (n = 15). Compared to pattern 1, the femoral tunnels were significantly higher and shallower in pattern 2 and significantly lower and deeper in pattern 3.

Conclusions: Positioning a graft in the high portion of the anteromedial bundle insertion on the femoral side does not achieve absolute isometry, but exhibits laxity changes similar to the overall pattern presented by the native ACL during the range of knee motion. Minor variations in the positions of femoral tunnels are associated with distinct patterns of graft laxity. Tensioning and fixation of the ACL graft at knee extension are suggested.

Backgroud: Subacromial erosion and impingement syndrome are frequently reported complications following clavicle hook plate (CHP) fixation in Thai orthopedic practice. These complications may result from CHP designs that do not adequately accommodate the acromioclavicular joint (ACJ) anatomy of the Thai population. Currently, only 2 CHP sizes (12 mm and 15 mm in depth) with a 0° angle are commercially available, potentially increasing the risk of osteolysis due to direct point contact with the acromion. This study aimed to determine the average depth and angle of the ACJ in the Thai population to optimize CHP design.

Methods: This study analyzed 74 embalmed Thai cadavers (39 males and 35 females) donated for medical research. ACJ depth and inclination angle were measured bilaterally using 2 modified metric gauges constructed from stainless steel. The hanging hook of the depth measurement device was inserted close to the posterior ACJ before measuring the distance between the acromion process and the superior surface of the distal clavicle. The hypothetical ACJ angle was measured by reading at the scale on a standard protractor that complied with the matric tools.

Results: The mean ACJ depth in Thai cadavers was 12.02 ± 4.11 mm (95% CI, 11.06-12.97 mm), while the mean inclination angle was 16.90° ± 6.76° (95% CI, 15.33°-18.46°). Males had significantly greater ACJ depth (14.06 ± 3.69 mm) compared to females (9.74 ± 3.31 mm, p < 0.01), but no significant difference was found between left and right clavicles. The ACJ inclination angle did not differ significantly between sexes. However, it was shown that the right ACJ angle (20.91° ± 6.94°) of Thais was significantly wider than the left side (14.05° ± 4.96°).

Conclusions: The optimal ACJ depth in the Thai population remains within the commercially available range of 12 to 15 mm. However, a CHP with an inclination angle of approximately 16° may help reduce postoperative complications such as subacromial erosion and impingement syndrome. The differences in ACJ depth between sexes and angle between sides should also be clinically considered before fixation.

Background: Sarcopenia research has primarily focused on the diagnostic value of the psoas and paraspinal muscles due to their accessibility and reflection of the total skeletal muscle mass. This focus has overlooked the gluteal muscles, which are essential for mobility, balance, and prevention of falls, especially in elderly individuals. This prospective observational cohort study aimed to investigate the predictive value of the gluteal muscle index (GMI) for diagnosing sarcopenia in community-dwelling healthy adults.

Methods: The analysis included 290 community-dwelling healthy adults using health examination data. Sarcopenia was diagnosed using bioimpedance analysis. The psoas muscle index (PMI), paraspinal muscle index (PaMI), and GMI were measured via abdominal-pelvic computed tomography and adjusted for height. Additionally, body mass index, bone mineral density, and visceral and subcutaneous fat indices were analyzed.

Results: Among the 290 patients, 26 (9.0%) were diagnosed with sarcopenia. GMI (48.6 ± 8.4 cm²/m² vs. 41.0 ± 7.9 cm²/m², p < 0.001), PaMI (14.5 ± 3.2 cm²/m² vs. 12.2 ± 3.3 cm²/m², p < 0.001), and PMI (5.7 ± 1.7 vs. 4.9 ± 1.6, p = 0.033) were significantly lower in the sarcopenia group. The receiver operating characteristic curves for GMI indicated an area under the curve of 0.872 for men and 0.811 for women, with cutoff values of 50.6 cm²/m² and 34.5 cm²/m², respectively.

Conclusions: The present study highlights the potential of GMI as a clinically meaningful predictor of sarcopenia, outperforming the psoas muscle in diagnostic accuracy. Furthermore, the sex-specific cutoff values identified from the study could aid in early detection and risk stratification, offering a novel approach for sarcopenia assessment in community-dwelling adults.

Background: Conical stems are effective in total hip arthroplasty for high-degree dysplasia, but no comparative studies about modular and non-modular versions are available. By comparing 3 conical stems in 3-dimensional (3D) computed tomography (CT)-based simulations in Crowe III and IV dysplasia, the study sought to assess the rate of implants allowing correct biomechanical reconstruction and the correlations between the 3 stem reconstructions and native hip morphology.

Methods: Using a 3D CT-based simulation, 3 different conical stems (single-taper, modular neck, and proximal junction modularity) were implanted in the same high-degree dysplastic hips. Proximal biomechanical restorations (femoral fitting, combined anteversion, offset reconstruction, leg lengthening, and tilt) were compared, and correlations with native anatomy were assessed. After a power analysis, 61 hips in 55 patients were included, with a mean age at CT of 56.26 ± 10.71 years: 41 hips (67.21%) were classified as Crowe III and 20 (32.79%) as Crowe IV.

Results: The rate of global acceptability (matching all 6 reconstructive parameters) was similar between the 3 stems: W, 52.5%; A, 47.5%; and M, 55.7% (p = 0.66). No single stem demonstrated superior performance in any reconstructive parameter (p > 0.05). No specific native anatomical features favored one stem design over another; the primary predictors for each femoral reconstruction were native center of rotation height and cup medialization. Native femoral anteversion had no impact on the reconstruction.

Conclusions: Similar proximal biomechanical reconstructions were provided by modular and non-modular stems: modular stems should be used with caution even in high-grade dysplastic hips, but may be useful in high offset anatomies.

Background: This study aimed to explore the incidence of cardiac complications including myocardial infarction, acute heart failure, and cardiogenic shock and identify associated risk factors during index hospitalization following total knee arthroplasty (TKA) using the National Inpatient Sample (NIS) database, with the goal of providing actionable insights to refine risk stratification protocols and optimize perioperative clinical decision-making.

Methods: This national retrospective cohort study analyzed adults undergoing primary TKA between 2010 and 2019, excluding patients with preexisting cardiac conditions or prior knee surgeries to mitigate confounding. Utilizing the NIS, we identified risk factors for postoperative cardiac complications including myocardial infarction, acute heart failure, and cardiogenic shock occurring during index hospitalization following primary TKA through multivariate logistic regression analysis of demographics, hospital characteristics, preoperative comorbidities, and postoperative complications.

Results: A total of 1,283,093 patients undergoing TKA were included in the analysis. The overall incidence of cardiac complications after TKA was 2.78% (n = 35,723). Advanced age, male sex, Black race, larger hospital size, teaching hospital status, and non-elective admissions were significant risk factors. Comorbidities, such as chronic pulmonary disease, hypertension, and chronic renal failure, were strongly associated with cardiac complications. Additionally, the occurrence of cardiac complications was associated with postoperative complications such as pneumonia, deep vein thrombosis, and arrhythmias.

Conclusions: Cardiac complications after TKA were influenced by both patient-specific factors, such as age, sex, race, and comorbidities, and hospital-related factors, including hospital size and teaching status. Our analysis highlights the need for preoperative risk assessments and perioperative care, especially for high-risk patients with multiple comorbidities.

Backgroud: Subchondral bone is a potential target for osteoarthritis (OA) prevention. Antiresorptive therapy has been demonstrated to be chondroprotective in surgically induced OA animal models, but results were mixed in clinical studies. We aimed to determine whether patients with traumatic joint injury could benefit from antiresorptive therapy and whether the osteoporosis status might affect the chondroprotective effect, if any, of the therapy.

Methods: We retrospectively reviewed 299 women (mean age, 64.7 ± 8.6 years) who underwent surgery for an intra-articular distal radius fracture (DRF). We evaluated radiographic and symptomatic OA development at 1 year postoperatively. The odds ratio (OR) for the OA development was analyzed using logistic regression for factors including age, lowest T score, bone mineral density, presence of osteoporosis, residual intra-articular step-off, and antiresorptive therapy. To delineate the effect of the osteoporosis status, subgroup analyses were performed.

Results: Development of radiographic OA was identified in 80 patients (27%), and the mean pain score on a visual analog scale was 2.2 ± 1.1. In the regression analysis, radiographic OA was associated with the presence of osteoporosis (OR, 3.97; 95% CI, 1.89-8.32), residual intra-articular step-off (OR, 3.68; 95% CI, 1.45-9.39), and not starting antiresorptive therapy (OR, 0.29; 95% CI, 0.14-0.61). In subgroup analysis, radiographic OA was associated with not starting antiresorptive therapy (OR, 0.24; 95% CI, 0.07-0.93) for patients without osteoporosis. However, for patients with osteoporosis, no association was found between radiographic OA and the evaluated factors.

Conclusions: Initiation of antiresorptive therapy was associated with a lower incidence of radiographic OA after an intra-articular DRF, especially in those without osteoporosis. This study suggests that attempts to decrease bone remodeling might be effective for OA prevention in a joint at risk.

Backgroud: Osteoporotic vertebral compression fractures (OVCFs) with neurological symptoms often require extensive fusion surgery, which carries significant risks for older adults. This study evaluated the clinical outcomes of biportal endoscopic lumbar decompression (BELD) combined with percutaneous vertebroplasty (PVP) as a minimally invasive alternative.

Methods: We retrospectively analyzed 21 older adults (mean age, 80.24 years) who underwent BELD with PVP for OVCFs between July 2017 and June 2022. Indications included neurological deficits or severe, intractable pain refractory to conservative treatment. Clinical outcomes were assessed using the visual analog scale (VAS), Oswestry Disability Index (ODI), European Quality of Life-5 Dimensions (EQ-5D), and modified MacNab criteria. Radiographic parameters included vertebral compression rate and wedge angle.

Results: The mean operation time was 86.81 minutes, with an average blood loss of 136.19 mL. According to modified MacNab criteria, 76.2% of patients achieved excellent or good outcomes. Clinical parameters, including VAS, ODI, and EQ-5D, showed significant improvement over 24 months (p < 0.001). Neurological function improved in most patients, with the number of Frankel grade 5 cases increasing from 14 to 17. Radiographic parameters demonstrated significant initial improvement at 3 months (p < 0.001); however, changes were not statistically significant over time. Complications included cement leakage (4 cases), adjacent fracture (2 cases), and 1 revision surgery; no major perioperative complications or mortality occurred.

Conclusions: BELD combined with PVP is a safe and effective, minimally invasive option for older adults with OVCFs and neurological symptoms. This technique provides adequate neural decompression and vertebral stabilization while minimizing the risks associated with extensive fusion surgery in this vulnerable population.

Humeral head fractures, though relatively rare, pose significant challenges due to the risk of complications such as osteoarthritis and avascular necrosis. Particularly in younger patients, joint-preserving procedures are prioritized over arthroplasty, and their higher activity demands necessitate more precise and reliable reduction and fixation. We have developed a less invasive, more accurate, and more stable surgical technique utilizing arthroscopy and a polyaxial locking plate. Since this approach resulted in a favorable clinical outcome, we describe this technique comprehensively.

Background: The benefits of long-term follow-up of patients following hip and knee joint replacement surgery are currently debated. This study evaluated a questionnaire-based model for remotely monitoring patients. Primary outcomes included response rates, acceptability to patients, and whether remote review identified patients requiring reoperation.

Methods: Data were collected over a 7-year period from a large regional teaching hospital in Australia. Hard-copy questionnaires were sent to patients at 1, 5, and 8 years after joint replacement and biennially thereafter. The questionnaire assessed whether patients had pain or concerns regarding their joint replacement and whether orthopedic review was requested. Response rate was determined as the proportion of patients who returned the questionnaire and was considered acceptable if it was not significantly lower than the proportion of patients who attended a 1-year in-person appointment in the 3 years prior to introducing remote-review. Patient preferences for remote versus in-person review were collected from a subgroup of patients (n = 488) using an investigator-designed questionnaire. All reoperations during the study period were examined to determine if they were first identified via the remote-review questionnaire.

Results: The response rate at 1 year was 69.3% (2,266 responses from 3,268 questionnaires sent), which was significantly lower than historical in-person outpatient attendance rates (82.7%, p < 0.001). A majority of patients (62.1%) preferred remote follow-up to in-person review. Of the 116 reoperations that occurred during the study period, remote review identified 5 patients, representing 0.1% of questionnaire responses. Most complications requiring reoperation were first identified via emergency departments (56.9%) or general practice (31.9%).

Conclusions: While remote review following joint replacement surgery was consistent with most patients' preferences for follow-up care, response rates were lower than historical attendance rates for in-person outpatient appointments. Routine remote review was an inefficient mechanism for identifying complications requiring reoperation, most of which were first identified via emergency departments and general practice.