Clinics in Orthopedic Surgery最新文献

Background: Treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments is a challenge. To treat this difficult fracture, we perform articular fragment detachment and separate fixation for coronal split articular and inferior pole fragments. We aimed to evaluate the radiological and clinical outcomes of our technique in comminuted patellar fractures at least 1 year after surgery.

Methods: Between January 2019 and June 2022, 15 patients diagnosed with comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments based on preoperative computed tomography underwent surgery using the articular detachment technique. The key point of this technique was anatomical reduction and subchondral fixation of the coronal split articular fragment to the superior main fragment after complete detachment of the coronal split fragment from the inferior pole. The remaining inferior pole was fixed using a separate construct. Postoperative articular gap, articular step-off, and complications, including resorption, reduction loss, and avascular necrosis of fixed articular fragments, were evaluated as radiological outcomes. Range of motion and the Lysholm scores were used to evaluate clinical outcomes.

Results: Among the 15 patients, the coronal split articular fragments were fixed using Kirschner wires in 13 patients and headless screws in 2 patients. The inferior poles were fixed using separate vertical wiring in 13 patients and tension-band wiring in 2 patients. A postoperative articular gap was noted in 7 patients, with an average articular gap of 1.0 mm (range, 0.7-1.6 mm). No articular step-off was observed. Bone union and normal range of motion were achieved in all patients. On the 1-year postoperative lateral radiograph, resorption of the articular fracture site was seen in 5 patients. There was no loss of reduction or avascular necrosis of the coronal split articular fragments. The average postoperative Lysholm score at 1 year was 89.3 ± 4.1 (range, 82-95).

Conclusions: The technique would be a reliable and safe option for the surgical treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments in terms of anatomical reduction and stable fixation of articular fragments without risk of avascular necrosis.

Background: The Coronal Plane Alignment of the Knee (CPAK) classification system has been developed as a comprehensive system that describes 9 coronal plane phenotypes based on constitutional limb alignment and joint line obliquity (JLO). Due to the characteristics of Asian populations, which show more varus and wider distribution in lower limb alignment than other populations, modification of the boundaries of the arithmetic hip-knee-ankle angle (aHKA) and JLO should be considered. The purpose of this study was to determine the knee phenotype in a Korean population based on the original CPAK and modified CPAK classification systems.

Methods: We reviewed prospectively collected data of 500 healthy and 500 osteoarthritic knees between 2021 and 2023 using radiographic analysis and divided them based on the modified CPAK classification system by widening the neutral boundaries of the aHKA to 0° ± 3° and using the actual JLO as a new variable. Using long-leg standing weight-bearing radiographs, 6 radiographic parameters were measured to evaluate the CPAK type: the mechanical HKA angle, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), aHKA, JLO, and actual JLO.

Results: From 2 cohorts of 1,000 knees, the frequency distribution representing all CPAK types was different between the healthy and arthritic groups. The most common categories were type II (38.2%) in the healthy group and type I (53.8%) in the arthritic group based on the original CPAK classification. The left and upward shift in the distribution of knee phenotypes in the original classification was corrected evenly after re-establishing the boundaries of a neutral aHKA and the actual JLO. According to the modified CPAK classification system, the most common categories were type II (35.2%) in the healthy group and type I (38.0%) in the arthritic group.

Conclusions: Although the modified CPAK classification corrected the uneven distribution seen when applying the original classification system in a Korean population, the most common category was type I in Korean patients with osteoarthritic knees in both classification systems. Furthermore, there were different frequencies of knee phenotypes among healthy and arthritic knees.

Background: Total ankle arthroplasty (TAA) enhances patients' subjective outcomes with respect to pain and function. The aim of this study was to analyze the biomechanical changes of the affected limb following TAA using gait analysis with a 3-dimensional multi-segment foot model (3D MFM).

Methods: We reviewed medical records, simple radiographs, and gait analyses using a 3D MFM of patients who underwent TAA for severe varus ankle arthritis. Preoperative and postoperative gait data of 24 patients were compared. Postoperative gait analyses were done at least 1 year after surgery.

Results: TAA significantly increased stride length (p = 0.024). The total range of motion of all planes in the hindfoot and forefoot showed no significant changes between preoperative and postoperative states. Hindfoot was significantly plantarflexed and pronated after TAA, while forefoot was significantly supinated in all phases. After appropriate calculations, the genuine coronal motion of the hindfoot showed no changes after TAA in all phases.

Conclusions: TAA did not result in biomechanical improvements of segmental motions in the forefoot and hindfoot, except for changes to the bony structures. Therefore, it is important to point out to patients that TAA will not result in significant improvement of ankle function and range of motion. Clinicians can consider this information during preoperative counseling.

Background: Operative management with intramedullary nail fixation remains the definitive treatment of choice for osteoporotic subtrochanteric (ST) fractures; however, there remains no consensus regarding the proper nail length. We aimed to use 3-dimensional finite element (FE) analysis to determine the optimal nail length for the safe fixation of osteoporotic ST fractures.

Methods: Nine modes of FE models were constructed using 9 different lengths of cephalomedullary nails (short nails: 170, 180, and 200 mm; long nails: 280, 300, 320, 340, 360, and 380 mm) from the same company. The interfragmentary motion was analyzed. Additionally, the peak von Mises stress (PVMS) in the cortical bone, cancellous bone of the femoral head, and the nail were measured, and the yielding risk for each subject was investigated.

Results: Long nails were associated with less interfragmentary motion. In the cortical bone, the PVMS of short nails was observed at the distal locking screw holes of the femoral medial cortex; however, in long nails, the PVMS was observed at the lag screw holes on the lateral cortex. The mean yielding risk of long nails was 40.1% lower than that of short nails. For the cancellous bone of the femoral head, the PVMS in all 9 FE models was in the same area: at the apex of the femoral head. There was no difference in the yielding risk between short and long nails. For implants, the PVMS was at the distal locking screw hole of the nail body in the short nails and the nail body at the fracture level in the long nails. The mean yielding risk was 74.9% lower for long nails than that for short nails.

Conclusions: Compared to short nails, long nails with a length of 320 mm or more showed less interfragmentary motion and lower yielding risk in low-level osteoporotic ST fractures. The FE analysis supports long nails as a safer option than short nails, especially for treating transverse-type low-level osteoporotic ST fractures.

Background: Hemiarthroplasty is frequently used to treat displaced femoral neck fractures in elderly patients, but it has a higher risk of postoperative dislocation. We introduced the posterior approach and inferior capsulotomy (PAICO) to enhance joint stability after bipolar hemiarthroplasty for femoral neck fracture. We evaluated whether the PAICO would have a lower dislocation rate than the conventional posterior approach with superior capsulotomy.

Methods: From January 2021 to December 2021, we prospectively recruited 25 patients (25 hips) aged 50 years or older who underwent bipolar hemiarthroplasty for femoral neck fractures due to low-energy trauma as the PAICO group. We compared the PAICO group with a historical control group who had undergone hemiarthroplasty in 7 institutes between 2010 and 2020. The primary endpoint was dislocation within 1 year after the surgery. We compared data from the PAICO group with the data from the historical control group from the Korean Hip Fracture Registry which was carried out in South Korea.

Results: A total of 25 patients (25 hips) were enrolled in the present study; 3,477 patients (3,571 hips) who underwent bipolar hemiarthroplasty were reviewed as the historical control group. In the PAICO group, we observed no dislocation, whereas the dislocation rate in the control group was 1.3%.

Conclusions: In patients with displaced femoral neck fractures, the PAICO approach demonstrated comparable results in operation time and complication rates when compared to bipolar hemiarthroplasty using superior capsulotomy. Notably, there were no observed cases of dislocation among patients who underwent the PAICO approach. We recommend this PAICO approach to surgeons using the posterior approach, hoping to prevent dislocation in bipolar hemiarthroplasty.

Background: While it is known that patients with end-stage renal disease (ESRD) are at an increased risk of complications following total hip arthroplasty (THA), there is a gap in the literature in comparing patients with ESRD to patients who undergo renal transplant (RT) before or after THA. This study is to address this gap by analyzing outcomes of THA in ESRD patients, RT patients, and RT candidates.

Methods: Using the PearlDiver Mariner database, ESRD patients, RT patients, and RT candidates undergoing primary THA were identified and compared. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. Ninety-day emergency department (ED) visits and inpatient readmission were also documented.

Results: A total of 7,868 patients were included: 5,092 had ESRD, 2,520 had RT before THA, and 256 were candidates for RT. Compared to patients with ESRD, RT patients demonstrated lower rates of medical complications such as pneumonia (3.61% vs. 5.99%, p = 0.039) and transfusion (4.60% vs. 7.66%, p < 0.001). Additionally, RT patients displayed decreased rates of surgical complications, including wound complications (2.70% vs. 4.22%, p = 0.001), periprosthetic joint infection (PJI) at 1 year (2.30% vs. 4.81%, p < 0.001) and 2 years (2.58% vs. 5.42%, p < 0.001), and aseptic loosening at 2 years (0.79% vs. 1.43%, p = 0.006). Similarly, when compared to RT candidates, RT patients demonstrated a lower incidence of postoperative complications, including 1-year PJI (2.30% vs. 5.08%, p = 0.013), 2-year PJI (2.58% vs. 5.08%, p = 0.028), 1-year aseptic loosening (0.56% vs. 2.73%, p < 0.001), and 2-year aseptic loosening (0.79% vs. 2.73%, p = 0.005). RT patients also had lower rates of ED visits and hospital readmissions.

Conclusions: Compared to ESRD patients and RT candidates, patients with RT have a significantly lower likelihood of medical complications, PJI, aseptic hardware loosening, ED visits, and hospital readmission. Patients with ESRD on the RT waiting list should delay THA until after RT surgery. For those not eligible for RT, it is vital to take extra precautions to reduce the risk of complications.

Background: Computer-assisted navigation surgery (CAS) during primary total knee arthroplasty (TKA) may help improve outcomes for patients with extra-articular deformity (EAD); however, this has not been extensively studied. Therefore, we aimed to investigate the clinical and radiological outcomes following primary TKA using CAS in patients with EAD.

Methods: We searched Medline, Embase, and the Cochrane Library up to March 3, 2023 for studies investigating surgical outcomes of using the navigation system for TKA to treat patients with EAD. From 14 studies, 539 knees with EAD that underwent navigation TKA were enrolled. We investigated the knee range of motion (ROM), outcome scores at final follow-up (Knee Society Score [KSS] and Knee Functional Score [KFS]), and pre- and postoperative mechanical hip-knee-ankle (mHKA) angle using lower extremity scanogram. The meta-analysis was based on the single-arm method, and all data were pooled using a random-effects model.

Results: Following our meta-analyses, the mean knee ROM changed from 87.0° (95% confidence interval [CI], 75.9°-98.1°) preoperatively to 109.4° (95% CI, 97.9°-120.8°) postoperatively. The adjusted KSS was 93.45 points (95% CI, 88.36-98.54 points), and the adjusted KFS was 91.57 points (95% CI, 86.80-96.33 points) in knees with EAD that underwent CAS-TKA. As a radiological outcome, the mHKA angle changed from 169.53° (95% CI, 166.90°-172.16°) preoperatively to 178.81° (95% CI, 178.31°-179.30°) postoperatively.

Conclusions: CAS-TKA yielded positive clinical results and demonstrated a satisfactory alignment of the lower limb's mechanical axis. CAS-TKA showed promise for primary TKA procedures, demonstrating favorable clinical and radiological outcomes even in complex cases involving EAD.

Background: This study aims to report the midterm outcomes after surgical treatment of Hawkins Classification III Talar neck fractures.

Methods: From March 2010 to April 2022, among a total of 155 patients who visited our hospital with talus fractures, 31 patients underwent surgical treatment for Hawkins classification III talar neck fractures. The inclusion criteria comprised patients with a symptom duration of over 1 year who were available for outpatient follow-up and underwent magnetic resonance imaging (MRI) follow-up 2 months after surgery. Exclusion criteria included patients without preoperative ankle periarticular arthritis, and a total of 27 patients were enrolled. Traffic accidents and falls accounted for 86% of 23 cases, open fractures were 8 cases, and the mean follow-up period was 34.10 months (range, 12-80 months). Clinical outcomes were measured by American Orthopaedic Foot and Ankle Society (AOFAS) score and Foot function index (FFI), and radiological results were obtained using simple radiographs before and after surgery and MRI at 2 months postoperatively to confirm bone union and complications.

Results: Complete bone union was achieved in all cases, and the mean duration of union was 4.9 months (range, 4-6 months) and there were no nonunion and varus malunion. At the final follow-up, the mean AOFAS score was 80.18 points (range, 36-90 points) and the mean FFI score was 31.43 points (range, 10-68 points), showing relatively good clinical outcomes. There were 15 cases of avascular necrosis, 6 cases of traumatic arthritis of the ankle joint, 6 cases of irritation of the posterior tibial nerve, and 4 cases of wound problems.

Conclusions: Hawkins classification III talar neck fractures are mostly caused by high-energy injuries and have a relatively poor prognosis due to the high incidence of complications such as avascular necrosis or posttraumatic arthritis. However, if correct anatomical reduction and rigid internal fixation are performed within a short time after the injury, good results can be expected.

Background: The gait analysis method that has been used in clinical practice to date is an optical tracking system (OTS) using a marker, but a markerless gait analysis (MGA) system is being developed because of the expensive cost and complicated examination of the OTS. To apply this MGA clinically, a comparative study of the MGA and OTS methods is necessary. The purpose of this study was to evaluate the compatibility between the OTS and the MGA methods and to evaluate the usefulness of the MGA system in actual clinical settings.

Methods: From March 2021 to August 2021, 14 patients underwent gait analysis using the OTS and MGA system, and the spatiotemporal parameters and kinematic results obtained by the 2 methods were compared. To evaluate the practicality of the MGA system in an actual clinical setting, MGA was performed on 14 symptomatic children with idiopathic toe walking, who had been treated with a corrective cast, and the pre-cast and post-cast results were compared. For the OTS, the Motion Analysis Eagle system was used, and for MGA, DH Walk was used.

Results: The spatiotemporal parameters showed no significant difference between the OTS and MGA system. The joint angle graphs of the kinematics along the sagittal plane showed similar shapes as a whole, with particularly high correlations in the hip and knee (pelvis: 29.4%, hip joint: 96.7%, knee joint: 94.9%, and ankle joint: 68.5%). A quantified comparison using the CORrelation and Analysis (CORA) score also showed high similarity between the 2 methods. The MGA results of pre-cast application and post-cast removal for children with idiopathic toe walking showed a statistically significant improvement in ankle dorsiflexion after treatment (p < 0.001).

Conclusions: MGA showed a good correlation with the conventional OTS in terms of spatiotemporal parameters and kinematics. We demonstrated that ankle sagittal kinematics improved after treatment by corrective cast in children with idiopathic toe walking using the MGA method. Thus, after the improvement of a few limitations, the MGA system may soon be able to be clinically applied.

Background: To use the top 100 articles pertaining to total shoulder arthroplasty (TSA) to understand the impact that social media platforms have on the dissemination of shoulder research while highlighting bibliometric factors associated with Altmetric Attention Score (AAS) to offer insight into the impact that social media platforms have on the dissemination, attention, and citation of shoulder research publications.

Methods: In June 2023, the Altmetric database was searched using the following PubMed MeSH terms: "total shoulder arthroplasty" or "TSA." Articles with the highest AAS were screened to exclude other topics unrelated to TSA. The top 100 articles that met inclusion criteria were used in the final analysis. Bibliometric factors pertaining to each study were collected for further analysis of article characteristics in accordance with prior studies.

Results: The Altmetric Database query yielded 1,283 studies. After applying our inclusion criteria, the top 118 articles with the highest AAS were identified. The mean AAS was 29.14 ± 42.35, with a range of 13 to 402. The included articles represented 27 journals, with 70 articles attributed to 2 journals: Journal of Shoulder and Elbow Surgery (JSES; 43%) and the Journal of Bone and Joint Surgery (JBJS; 16%). There was a significant increase in AAS for the presence of a conflict of interest (p = 0.042) and open access status (p < 0.01), but no association between the score and citation rate (p > 0.05).

Conclusions: Top articles on TSA, as defined by high AAS, mostly comprise original clinical research performed in the United States or Europe. The presence of a conflict of interest and open access status is associated with an increase in AAS, but there was no association between AAS score and citation rate.