Clinics in Orthopedic Surgery最新文献

Backgroud: This study aimed to evaluate the differences in long head of biceps (LHB) motion between the normal and subscapularis intrasubstance partial tear conditions and identify the arm positions that exhibit the most significant LHB motion differences using a cadaveric biomechanical study.

Methods: The LHB tendons of 6 fresh-frozen cadaveric shoulders (2 men and 4 women; mean age, 68.4 ± 2.3 years; range, 65-71 years) were marked with metal beads and mounted in a custom-made shoulder testing system. Data for arm positions at 20° or 60° of forward flexion or abduction, with neutral rotation and maximum internal and external rotation with a torque of 1.5 N·m, were collected. Considering the scapulohumeral rhythm, 20° or 60° forward flexion or abduction in a cadaveric shoulder corresponds to 30° or 90° shoulder elevation in vivo . Mediolateral (subluxation) and inferosuperior (excursion) LHB motions were measured using a 3-dimensional digitizer, and the differences between normal and subscapularis partial tear conditions were analyzed.

Results: While the LHB mediolateral motion difference was the highest during 60° forward flexion with neutral rotation (1.2 ± 0.4, p = 0.042), 20° forward flexion with neutral rotation (0.9 ± 0.3, p = 0.024) and 60° abduction with maximum external rotation (0.9 ± 0.3, p = 0.036) also demonstrated high mediolateral LHB motion difference between the normal and subscapularis partial tear conditions. In contrast, the LHB inferosuperior motion difference was the highest during 20° forward flexion with neutral rotation (0.7 ± 0.3, p = 0.045) between the normal and subscapularis partial tear conditions.

Conclusions: Upon comparing normal and subscapularis partial tear conditions in this cadaveric study, high pathological movements of the LHB were observed during arm forward flexion with neutral rotation and abduction with external rotation. Repetitive activity in these arm positions could aggravate the condition in a partial subscapularis tear.

Background: Due to limited access to hospital-based rehabilitation, many active-duty soldiers return to duty after lateral ankle sprain (LAS) without the opportunity for stepwise rehabilitation, despite the risk of delayed functional recovery and re-injury. This prospective cohort study aimed to introduce and evaluate the effectiveness of a low-cost, self-applicable, stepwise, target-oriented protocol for LAS (STOP-Sprain) in facilitating functional recovery.

Methods: A total of 60 participants were finally included and divided into 2 groups: those who followed the protocol (under protocol, group U = 45) and those who did not (out of protocol, group O = 15). Group U was further divided into the regular check-up group with frequent hospital visits (group UR = 28) and the self-application group (group US = 17). We analyzed comparative outcomes at 3 months, including recovery rates, re-sprain rates, pain numerical rating scale, and Foot and Ankle Ability Measure (FAAM) scores.

Results: Recovery rates (p = 0.013), pain improvement (p = 0.029), FAAM score improvement (p = 0.006) at 3 months were higher in the group U compared to the group O. However, there was no statistically significant difference between the 2 subgroups in group U (group UR vs. group US: recovery rate, p = 0.502; pain improvement, p = 0.293; FAAM score improvement, p = 0.975). Recovery rates were higher in groups UR (78.6%) and US (64.7%) than in group O (33.3%) (p = 0.013). Re-sprain rates were highest in group O (53.3%), followed by groups UR (28.6%) and US (17.6%) (p = 0.085); however, the differences were not statistically significant.

Conclusions: STOP-Sprain, a novel self-applicable protocol for LAS, showed short-term improvements in recovery rate, pain, and clinical scores, achieving high patient satisfaction without the need for additional equipment or facilities. It is particularly beneficial in settings where hospital-based rehabilitation is challenging.

Background: Research on the ideal fixation position for plates in medial opening-wedge high tibial osteotomy (MOWHTO) directly applicable in clinical settings is scarce. Therefore, this study aimed to evaluate the biomechanical effects of different plate positions in MOWHTO through finite element analysis (FEA) to explore a potentially optimal plate position.

Methods: Utilizing the computed tomography images of a 67-year-old man, a 3-dimensional model of the knee, along with an implant (TomoFix standard plate and screws), was created to simulate a virtual MOWHTO with a 10° medial opening gap. Biomechanical stability analysis of the bone-implant construct was conducted through FEA under physiologic loading simulating a 1-legged stance, with varying plate positions. Configurations for plate fixation, determined by anterior-posterior depth and height, resulted in a total of 9 fixation positions (anterior, center, and posterior in terms of depth; proximal, middle, and distal in terms of height). Criteria for assessment included inter-fragmentary micromotion at the medial opening gap, mean stress on the lateral hinge, the entire tibial bone, and the implant, stress shielding effect, and peak von Mises stress (PVMS).

Results: The inter-fragmentary micromotion at the medial opening gap exhibited a tendency to decrease as the fixation position of the plate moved posteriorly and proximally, observed in both axial and shear micromotion. The mean stress on the lateral hinge of the tibia progressively decreased with more posterior or proximal plate placement, reaching its minimum in the most posterior and proximal position. In terms of the mean stress imposed on both the entire bone and implant, it decreased when the plate was positioned posteriorly and proximally, and this position was deemed favorable from the perspective of the stress shielding effect. PVMS predominantly occurred at hole 1 of the plate and its corresponding screw, and it was lower than the yield strength of the titanium alloy regardless of the plate's position.

Conclusions: Placing the plate more posteriorly and proximally in MOWHTO could minimize inter-fragmentary micromotion, reduce stress on the lateral hinge and bone-implant construct, and enhance stress shielding, all without increasing the risk of implant breakage, suggesting it as a potentially optimal plate position.

Backgroud: The critical shoulder angle (CSA) is an important radiologic measurement that is significantly associated with deltoid and rotator cuff biomechanics. It was hypothesized that the CSA affects the biomechanics of the shoulder joint before and after reverse total shoulder arthroplasty (RTSA).

Methods: One hundred and fifty-six patients (156 shoulders) who underwent RTSA with medial glenoid/lateral humerus design were divided into 3 groups according to preoperative CSA: low CSA group (< 30°), intermediate CSA group (30°-35°), and high CSA group (> 35°). The preoperative and postoperative lateral humeral offset (LHO) and acromiohumeral distance (AHD) and postoperative deltoid wrapping angle (DWA) and deltoid moment arm (DMA) were measured on x-ray and computed tomography and compared between the 3 groups. The improvement of the pain score, assessed using the visual analog scale at rest and motion, American Shoulder and Elbow Surgeons score, University of California, Los Angeles shoulder score, and Constant shoulder score were compared between the 3 groups.

Results: The postoperative LHO was the highest in the low CSA group (16.62 ± 4.76 mm) and the smallest in the high CSA group (13.68 ± 5.59 mm, p = 0.03). The postoperative AHD was the highest in the low CSA group (28.72 ± 5.42 mm) and the lowest in the high CSA group (25.21 ± 5.12 mm) (p = 0.004). The postoperative DWA, DMA, and improvement of clinical scores were not significantly different between the groups (p > 0.05). Five patients (3.2%) experienced acromion fractures in the postoperative period, including 1 in the intermediate CSA group and 4 in the high CSA group.

Conclusions: RTSA with lateralized humeral design in patients with a low CSA resulted in more lateralization and distalization than in patients with an intermediate or high CSA, although the difference was less than 5 mm. The imaging and postoperative improvement in clinical outcomes associated with deltoid action such as range of motion, DWA, and DMA were not significantly different between patients with different CSAs. Therefore, the CSA is not useful in the selection of humeral components during RTSA, since there is no significant difference in clinical or functional outcomes based on CSA.

Background: Overgrowth of the limb often occurs after pediatric tibial shaft fractures; however, risk factors for this phenomenon differ across studies. In addition, overgrowth of the ipsilateral femur is not well known. This study aimed to analyze ipsilateral femoral overgrowth after pediatric tibial shaft fracture and to compare the risk factors for tibial and ipsilateral femoral overgrowth.

Methods: Among the 85 patients who were diagnosed with tibial shaft fractures between January 2012 and December 2022 under the age of 14 years and followed up for more than a year, 6 patients who had missing initial plain radiographs, associated fractures or bone lesions in the lower extremities, or reoperation due to complications were excluded. After exclusion, 79 patients were included in this retrospective study. Medical records and radiographic data were collected, including information on tibial overgrowth, femoral overgrowth, and leg-length discrepancy (LLD) at the latest follow-up. Age, sex, laterality, fracture stability, fracture location, fracture comminution, fibular involvement, open or closed fractures, fracture site shortening, and treatment type were selected as variables for univariate and age-sex adjusted multiple logistic analyses to identify risk factors for tibial and femoral overgrowth.

Results: Femoral overgrowth occurred in 35 patients (44%). Among the 17 patients with LLD ≥ 1 cm, 13 patients (76%) showed femoral overgrowth, and the proportion of femoral overgrowth in LLD was 25% (interquartile range, 18%-31%). The distal location was identified as a risk factor for femoral overgrowth; however, for tibial overgrowth, length-stable fracture pattern, fibular involvement, operative treatment, and fracture site shortening were identified as risk factors.

Conclusions: Femoral overgrowth can occur after pediatric tibial shaft fractures; however, its contribution to the LLD was not significant. The risk factors for tibial and femoral overgrowth differed, which may be the result of different mechanisms that affect the overgrowth of the fractured tibia and the ipsilateral femur.

Background: In patients with reverse shoulder arthroplasty (RSA), the relationship between the patient's body size and implant size is important for postoperative shoulder function. Asian patients, who have a short stature, could find the conventional RSA implant too big and tight. This study aimed to evaluate the clinical and radiological outcomes after RSA in Asian patients using a new implant designed to fit the body size of Asian patients. We also aimed to compare these outcomes with those who received a conventional implant.

Methods: This prospective study enrolled 120 patients who underwent RSA for a symptomatic irreparable massive rotator cuff tear, cuff tear arthropathy, or primary osteoarthritis with a full-thickness rotator cuff tear. Patients were randomly allocated 2:1 to receive an Asian-type RSA implant (group I) or conventional RSA implant (group II). All patients underwent plain radiography to evaluate acromiohumeral distance, acromion-deltoid tuberosity distance, lateral humeral offset, and center of rotation distance. Postoperative 1-year computed tomography (CT) scans were obtained for all patients to evaluate the position of peg screws and baseplates and the presence of scapular notching. Clinical outcomes were evaluated using American Shoulder Elbow Surgeons (ASES) score, Constant score, and active range of motion.

Results: Finally, 112 patients (80 in group I and 32 in group II) were included in this study. The mean patient age was 74.0 ± 5.5 years, and the mean patient height was 154.6 ± 8.1 cm. At the last visit, clinical scores and active range of motion significantly improved in both groups; however, the improvements did not differ significantly between the 2 groups. On the postoperative 1-year CT scan, the glenoid baseplate was more anteriorly placed in group II than in group I. The supero-inferior position of the glenoid baseplate did not significantly differ between the 2 groups. Other radiological parameters obtained through plain radiography showed no significant differences between the 2 groups. No differences were found in scapular notching (p = 0.999) and acromial stress fracture (p = 0.872) between the 2 groups.

Conclusions: Asian-type RSA implants showed comparable clinical and radiological outcomes with conventional RSA implants. Asian-type RSA implants allowed more accurate positioning of the glenoid baseplate, although that did not translate into superior clinical and radiological outcomes.

Background: The clinical benefits of combining cartilage procedures with high tibial osteotomy (HTO) remain undetermined. This study aimed to evaluate the additional clinical benefits by comparing a combined procedure group with an isolated HTO group, with stratification based on the success of cartilage regeneration.

Methods: Patients who underwent medial open-wedge HTO from 2010 to 2022 with a minimum 2-year follow-up were retrospectively reviewed. Patients were divided into 2 groups: HTO + combined cartilage procedures (C group) and isolated HTO (I group). C group was further divided into 2 subgroups based on the medial femoral condyle (MFC) cartilage status assessed on second-look arthroscopy: well-regenerated cartilage (C1 group) and poorly regenerated cartilage (C2 group). Propensity score-matched I groups were formed for each C1 and C2 group (C1-matched and C2-matched group I), based on baseline factors affecting clinical outcomes. Comparative analysis was performed for each matched pair based on patient-reported outcomes (PROs).

Results: A total of 313 patients were retrospectively reviewed in this study, with 199 patients included in the analysis: 83 patients in the C group (49 in the C1 group and 34 in the C2 group) and 116 patients in the I group. Baseline characteristics showed no significant difference between the matched groups after propensity score matching. The mean follow-up period for all groups was approximately 3 years with no significant differences. The C1 group showed significantly better PROs and improved PROs at the final follow-up compared to the C1-matched I group (visual analog scale score, p < 0.001; Lysholm, p = 0.004; Knee injury and Osteoarthritis Outcome Score subscales, p ≤ 0.018). However, the C2 group did not show any differences in PROs compared to the C2-matched I group at the final follow-up.

Conclusions: Only patients with well-regenerated cartilage after combined cartilage repair procedures showed additional clinical outcome improvements with HTO. When considering combined cartilage repair procedures with HTO, selecting appropriate candidates for achieving successful cartilage regeneration is necessary to yield additional clinical benefits.

Background: The Hip Fracture Nail (HFN), developed by modifying the design and diameter of the INTERTAN nail, has been introduced to the market. The purpose of our study was to evaluate the clinical and radiological outcomes, as well as the perioperative complications, associated with the use of the HFN in Asian patients with intertrochanteric fractures.

Methods: Patients over the age of 60 years with intertrochanteric fractures were prospectively enrolled at 6 university hospitals in South Korea and underwent surgical treatment using the HFN between October 2018 and January 2022. Patients who died or were lost to follow-up within 1 year were excluded from the analysis. Intraoperative surgical records related to the HFN, along with postoperative clinical and radiological data, were prospectively collected. Intraoperative and postoperative complications were recorded during the 1-year follow-up after surgery.

Results: Of the 320 patients, 159 patients were followed up for at least 1 year. The mean follow-up period was 17 ± 3 months. A total of 111 patients (70%) recovered their pre-fracture status. The mean time to bony union was 10.2 weeks. Reduction quality was acceptable or good in 99% of patients. Superior positioning of the lag screws in the femoral head occurred in only 2 cases. Difficulty in targeting the distal interlocking screw hole during the operation occurred in 4 cases (2.6%), with 2 of these patients developing periprosthetic fractures at distal interlocking screw holes. Postoperative complications requiring reoperation occurred in 5 patients (3.1%). Two cases of cut-out accompanied by nonunion underwent replacement arthroplasty (nonunion rate, 1.3%). Three cases of periprosthetic fractures at the distal static screw hole underwent refixation with a longer intramedullary nail. The remaining postoperative complications, including collapse at the fracture site in 5 cases (3.1%), the lateral wall fractures in 1 case (0.6%), and malunion in 1 case (0.6%), did not require surgical intervention.

Conclusions: This study demonstrated that the HFN provided good clinical and radiological outcomes in Asian patients with intertrochanteric fractures. However, difficulty in targeting the distal interlocking screw hole may occur with low probability, requiring caution during surgery.

Background: Dual mobility cups (DMCs) have emerged as a promising option for enhancing hip stability in primary and revision total hip arthroplasty (THA). In this study, we aimed to determine the trends in DMC utilization, compare the outcomes of DMCs with those of conventional cups in primary THA, and assess DMC outcomes in revision THA.

Methods: We collected data on all primary and revision THAs performed from 2015 to 2022 based on procedure codes from the Korean Health Insurance Review and Assessment database. Revision THAs included both stem-and-cup revisions and cup-only revisions. Univariate and multivariable analyses were conducted to identify the baseline characteristics influencing DMC usage. Propensity score matching was applied to compare periprosthetic complications (dislocation, periprosthetic fracture, periprosthetic joint infection, and revision) between patients receiving DMCs and those receiving conventional cups.

Results: Among 70,760 primary THAs, 7,670 utilized DMCs, whereas 751 of 3,595 revision THAs adopted DMCs, reflecting an increasing trend up to 25.8% and 28.7% in 2022, respectively. In primary THA, DMC use increased significantly in patients aged 60 years and older, with univariate analysis indicating an increased use in patients with previous lumbar spine fusion, heart failure, diabetes, stroke, and hemiplegia. However, after adjusting for age, only age remained significant, with a 3% increase in the likelihood of DMC use in primary THA per year. Additionally, both DMC and conventional cups showed an age-related increase in dislocation rates, although the overall dislocation rate remained significantly lower in the DMC group compared to the conventional cups. Remarkably, 37.3% of cup revisions were performed using DMC. The Kaplan-Meier curve revealed a 3-year survival rate of 94.6% for re-revision in revision THAs using DMCs.

Conclusions: DMC use increased with age and was used in up to 26% of primary THAs and 29% of revision THAs by 2022. In primary THA, DMC significantly reduced dislocation rates compared to conventional cups without increasing other periprosthetic or medical complications. DMCs also showed favorable outcomes in revision THAs, supporting their broader utilization in both primary and revision THAs.

Backgroud: Vitamin D binding protein (VDBP) is a major transport protein for vitamin D (VD) and its level is known to change with systemic inflammatory responses. We aimed to investigate whether acute musculoskeletal injury affects VDBP levels and thus also impacts VD levels.

Methods: We measured serum VDBP levels, free 25(OH)D, and total 25(OH)D in 2 age-matched (mean age, 56 years) female groups: one diagnosed with a wrist fracture (n = 35) and the other consisting of healthy volunteers (n = 35). We tested differences between the groups and correlations between the measurements.

Results: VDBP levels were significantly lower in the wrist fracture group (350.4 ± 151.2 µg/mL) than in the healthy volunteer group (478.6 ± 47.0 µg/mL, p < 0.001). However, the free and total 25(OH)D levels were not significantly different between the groups. The correlation between free and total 25(OH)D levels was strong in the healthy volunteer group (R = 0.885) but moderate in the wrist fracture group (R = 0.605).

Conclusions: The lower VDBP levels in wrist fracture patients compared to the healthy volunteers indicate that acute musculoskeletal injuries affect VDBP levels. However, the decrease in the VDBP levels did not affect free and total VD levels. Further research might determine whether the current measurement of total 25(OH)D in fracture patients can reflect the VD status.