Journal of the American Academy of Orthopaedic Surgeons最新文献

The treatment of degenerative cervical myelopathy (DCM), which encompasses cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament, has progressed markedly over the past few decades. The natural history of DCM includes multiple phenotypes: a slow deterioration, a stepwise pattern of decline, and rapidly progressive functional decline. Symptoms include gait disturbance, decreased fine motor abilities, weakness, sensory changes, and neck pain. Classically, those with minimal or early symptoms were treated conservatively with observation; however, newer investigations suggest evidence for early surgical treatment. Those with objective myelopathic symptoms confirmed by imaging demonstrating spinal cord compression are indicated for surgery. Surgical treatment can be accomplished with multiple different technical approaches including anteriorly based surgery, posteriorly based surgery, and combined techniques. Traditionally, anterior surgery included anterior cervical diskectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF), but increasing investigations incorporate cervical disk arthroplasty in this cohort of patients. Historically, laminectomy for posterior decompression was a hallmark of treatment in DCM; however, this led to complications such as postlaminectomy kyphosis and instability which has led to substitution of this treatment by laminoplasty and laminectomy + fusion. Surgical adjuncts such as Riluzole have demonstrated promise in the treatment of DCM patients. Success in surgical treatment is defined by decompression of the spinal cord to halt progression of symptoms and in some patients improve function. Although surgical treatment has yielded success in the treatment of DCM, perioperative complications can be devastating which make surgical technique and patient selection paramount.

Sagittal spinopelvic alignment plays a crucial role in the clinical course and surgical treatment of adult spinal deformity. Knowledge pertaining to adult thoracolumbar spinal deformity and corrective surgery continues to advance. Much of this is due to recent advances in understanding in sagittal alignment. In this review article, we review standard principles related to sagittal alignment in adult thoracolumbar spinal deformity surgery. In addition, we will review recent philosophies and schools of thought.

Coronal fractures of the distal femur, although uncommon in isolation, represent a distinct fracture pattern different from other distal femur fracture subtypes. Popularly known as the Hoffa fractures, these injuries are characterized by obliquely oriented fracture lines in the coronal plane with or without articular comminution. These partial articular fractures are commonly seen on the lateral condyle as a result of translational shearing forces on the posterior femoral condyle with the knee in flexion. These fractures were often missed before the advent of routine use of CT scans because they appear subtle on plain radiographs. The frequent presence of major and more proximal associated skeletal injuries is another reason that these fractures may be missed in the initial evaluation. Hoffa fractures, being articular injuries, need anatomical reduction and a stable fixation to facilitate early knee motion and prevent arthrofibrosis. Surgical treatment of these fractures needs a careful understanding of various fracture patterns, presence of comminution, articular impaction, fragment size, and location to choose the optimal surgical approach, reduction, and fixation techniques. This review will outline strategies for surgical management of Hoffa fractures and discuss outcomes and complications based on published evidence.

Purpose: The purpose of this study is to compare intramedullary headless screw (IMN) versus plate and screw fixation (open reduction internal fixation [ORIF]) in metacarpal (MC) fractures, specifically looking at implant cost, operating room time, outcomes, and complications. We hypothesize that IMN will provide at least equivalent outcomes and complication rates compared with ORIF while simultaneously decreasing operating room time and lowering overall costs.

Methods: Patients with MC fractures treated surgically at a single, level-one, trauma center between January 2018 and December 2022 were identified. Eighty-five patients and 108 fractures were included. Records were retrospectively reviewed for demographic information, injury data, surgical details, and follow-up information.

Results: The average age of included patients was 32.4 years. The leading causes of injury included altercations, falls, and motor vehicle collisions. Tourniquet time was an average of 79.9 minutes in the ORIF group and 37.6 minutes in the IMN group. Average cost of the implant and time to union were similar in both the groups. IMN fixation had faster time to motion and time to full range of motion. Complications, including revision surgery rates, wound infections, implant complications, and non/mal unions, were collected. Nine patients underwent revision surgery, eight in the ORIF group and one in the IMN group. Two superficial wound infections were noted in the ORIF group. One implant complication was observed in the ORIF group, as defined by implant breakage after the patient punched a wall. Three implant removals were noted, all in the ORIF group.

Conclusion: In our experience, the use of an intramedullary screw for fixation of MC fractures is a reliable and safe method of fixation. The use of this procedure provides patients with quicker return to motion, faster time to full range of motion, and similar time to union with fewer complications. Furthermore, it resulted in decreased tourniquet time resulting in decreased overall cost.

Level of evidence: Retrospective review, Level III Therapeutic.

Objectives: Deep fracture-related infections (FRIs) are a common complication of type III open lower extremity fractures, resulting in notable patient morbidity. The purpose of this study was to determine whether topical application of antibiotic (ABX) powder to type III open lower extremity fracture wounds upon presentation to the emergency department (ED) reduces the rate of FRI.

Methods: This is a retrospective review of ABX powder application compared with a historical cohort at 4 level 1 trauma centers. Patients with type III open lower extremity fractures from July 1, 2019, to October 1, 2022, who received topical ABX powder (1 g vancomycin and 1.2 g tobramycin) in the ED were compared with patients from a 4-year historical cohort who were treated through the same protocol without topical ABX powder. Outcomes include the development of FRI within 6 months of follow-up. Patient demographics, injury characteristics, and postoperative data were analyzed in addition to FRI.

Results: One hundred fifteen patients received topical ABX powder in the ED and were compared with 135 patients who were treated without topical ABX powder. The rate of FRI in the intervention group was 8 of 115 (6.96%) vs. 22 of 135 (16.30%) in the control cohort ( P = 0.024). Multivariate regression analysis demonstrated higher body mass index as a risk factor for the development of FRI ( P = 0.003). When excluding those with intraoperative ABX powder use, there was still a markedly lower rate of FRI when ED ABX powder was used on regression analysis ( P = 0.048).

Conclusion: Antibiotic powder application to type III open fracture wounds in the ED markedly reduces the incidence of FRI in this multicenter study. Further large-scale studies are warranted.

Level of evidence: Therapeutic Level III.

Proximal junctional kyphosis (PJK) occurs commonly after surgery for adult spinal deformity. PJK exists on a spectrum, from a pure radiographic diagnosis to those patients with more severe deformity leading to notable pain, morbidity, and neurologic compromise requiring revision surgery-often described as proximal junctional failure (PJF). In this review, we describe the evaluation of patients with PJK and PJF, including different classification systems as well as modifiable and nonmodifiable risk factors. We then discuss the wide variety of strategies that have been proposed to reduce the risk of PJK and PJF. These include optimizing bone health with anabolic agents, use of bone cement at levels above the upper instrumented vertebra, optimizing alignment targets for correction, upper instrumented vertebra selection, posterior ligamentous complex preservation and augmentation, inducing a more gradual transition in stiffness above the construct, and instrumentation modifications. We end with a discussion of nonsurgical and surgical management of PJK, as well as our approach to revision surgery after PJF. Although a substantial increase in research on this topic has enhanced our understanding of proximal junction pathologies, notable work remains to demonstrate the reliability and reproducibility of prevention strategies.

Introduction: Dislocation is a known risk after total hip arthroplasty (THA), occurring in approximately 2% of cases. Although the posterolateral approach is the most commonly used approach to the hip, the disruption of posterior soft tissue is a concern for implant stability. The introduction of robotic assistance in arthroplasty has demonstrated improved implant positioning, although the effect on outcomes is still being assessed. The purpose of our study was to assess the 90-day dislocation rate between robotic-assisted and manual primary THA through the PL approach.

Methods: Data were collected from two board-certified adult reconstruction surgeons who performed THA through a PL approach from 2014 to 2023. These two surgeons had high-volume arthroplasty practices and transitioned from manual to robotic-assisted surgery within this period. Variables including patient demographic information, use of robotic assistance, total 90-day complications, and Hip Disability and Osteoarthritis Outcome Score were collected and analyzed. Statistical analysis for numerical values was conducted using Student t -test and categorical variables with chi-square analysis, with alpha set at 0.05.

Results: Two thousand five hundred forty-eight patients underwent a THA through the PL approach at our institution from 2014 to 2023. One thousand seven hundred twenty-seven patients had a manual THA, and 821 patients had a robotic-assisted THA. No significant difference was noted in total complication rates (n = 59, 3.4% vs. n = 18, 2.2%, P = 0.092) or dislocation rates (n = 7, 0.4% vs. n = 3, 0.4%, P = 0.88) between the manual and robotic-assisted groups, respectively. No statistical difference was found in the Hip Disability and Osteoarthritis Outcome Score at any of the postoperative time points. Total surgical time was markedly longer for the robotic-assisted group (88 minutes) compared with the manual group (74 minutes).

Conclusion: This study demonstrated no notable difference in 90-day dislocation rates for high-volume arthroplasty-trained surgeons when comparing manual versus robotic-assisted THA when using the PL approach.

Introduction: Although lag screws (LSs) provide increased compression, they are not always clinically feasible (eg, bone quality, fracture configuration) and have not been shown to be clinically superior to clamp compression and positional screw (PS) fixation. The purpose of this study is to compare clinical outcomes of fibular fractures between the two screw techniques.

Methods: Consecutive patients of >18 years of age, between 2015 and 2020, were identified based on current procedural terminology codes for surgical fibula fixation. Patients with fibular fractures fixed with an interfragmentary screw and with a minimum of 6 months of follow-up were included in the study. This patient cohort was divided into two groups: LS and PS.

Results: A total of 189 patients were included. Average age was 45 years with 51% female. Forty had distal fibula fractures only, 69 had bimalleolar, and 80 had trimalleolar fractures; 66 (37.5%) had syndesmotic injuries. Eighty-four fibula fractures were fixed with clamp compression and PS, and 105 with a LS. Groups were similar with regard to age, sex, diabetes, and smoking. Union rate in both groups was 100%. Revision surgery rate was higher in the LS group (10.5% vs. 3.6%, P = 0.072).

Conclusion: Our study indicates noninferiority of interfragmentary PS technique (clamp compression and PS use) for lateral malleolus fractures with high rates of union and low rates of revision surgery.

Level of evidence: Therapeutic Level III.

Metacarpal fractures are among the most common fractures of the hand and upper extremity and can lead to substantial disability. Clinical and radiographic features of these fractures are important in approaching their management. While most metacarpal fractures can be treated nonsurgically with reduction and/or immobilization, some fractures and patients can have improved patient-centered outcomes with surgical fixation. Outcomes of surgical fixation (eg, percutaneous Kirschner wire fixation, plate/screws, interfragmentary screws alone, and intramedullary fixation) and postoperative care are best when tailored to the fracture pattern and patient.

Background: To assess the effect of low-molecular-weight heparin (LMWH) combined with evoked potentials somatosensory evoked potential (SEP) on the prevention of deep vein thrombosis (DVT) in patients undergoing spinal surgery.

Methods: One hundred twenty-eight patients who underwent spinal surgery from August 2022 to August 2023 were chosen, and the patients were randomly classified into the control group and the observation group, with 64 cases in each group. The control group received LMWH injections.The observation group received SEP monitoring on the basis of the control group. The blood flow velocity of popliteal veins of both lower limbs was measured by Color Doppler ultrasonography. The D-dimer concentration was measured using intravenous blood samples taken 1 day before surgery, after surgery, and 24 hours after surgery. The incidence of lower extremity DVT was diagnosed by ultrasonography during surgery and 24 hours after surgery.

Results: Compared with the control group, the blood flow velocity of the popliteal veins in both lower limbs in the observation group increased at T 2-4 ( P < 0.001), and the D-dimer and FIB concentrations in the observation group were decreased ( P < 0.001); the occurrence of DVT in the observation group was lower than that in the control group ( P < 0.05).

Conclusion: LMWH combined with SEP monitoring can effectively prevent the occurrence of lower limb DVT in patients with spinal surgery.