Journal of the American Academy of Orthopaedic Surgeons最新文献

Objective: The purpose of this study was to evaluate the clinical outcomes in patients who underwent bilateral total shoulder arthroplasty (TSA) at a single institution. Secondarily, we evaluated the influence of the time interval between successive TSAs on clinical outcomes of the second TSA.

Methods: A single-institution shoulder arthroplasty database was reviewed for patients undergoing bilateral primary anatomic TSA (aTSA) or reverse TSA (rTSA) between 2000 and 2022. Clinical outcomes, including outcome scores, range of motion, and shoulder strength, were assessed in patients with minimum 2-year follow-up. Postoperative complications and achievement of the minimal clinical important difference, substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) were evaluated. Statistical comparisons were made between first and second TSAs, between TSA variations, and based on time between TSAs (<1, 1 to 5, >5 years).

Results: We identified 180 bilateral TSA patients (68 aTSA/aTSA, 29 aTSA/rTSA, three rTSA/aTSA, 80 rTSA/rTSA). When evaluating side-to-side differences, the second rTSA in the aTSA/rTSA group had more favorable postoperative Shoulder Pain and Disability Index ( P = 0.032) and forward elevation strength ( P = 0.028) compared with the first aTSA. No other side-to-side comparisons were statistically significant or exceeded the minimal clinical important difference, SCB, or PASS. Patients undergoing second aTSA after first aTSA or undergoing first rTSA had superior SCB and PASS for active external rotation ( P = 0.009 and P = 0.005, respectively). Complications were similar between strata, but revision rates were lowest after first rTSA in rTSA/rTSA patients. The time interval between successive TSAs did not influence the clinical outcome.

Conclusion: All bilateral TSA combinations demonstrated excellent outcomes with most patients achieving clinically relevant benchmarks, with no influence of timing between arthroplasties.

Level of evidence: III, retrospective comparative cohort study.

Introduction: Fragility fractures can be substantially life-altering with notable effects on patient well-being and mental health. The purpose of this study was to evaluate the risk of developing a new mental disorder diagnosis within 2 years following osteoporotic fragility fracture.

Methods: A retrospective cohort study was conducted using a large national insurance claims database. Patients with proximal humerus, wrist, pelvis, hip, and spine fractures were matched in a 1:4 ratio with nonfracture control patients. Rates of mental disorders after primary fragility fractures were compared using multivariable logistic regression. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, posttraumatic stress disorder, and suicide attempt.

Results: Elderly patients who sustained fragility fractures had a statistically significant increased risk of being diagnosed with many of the queried mental disorders within 2 years following fracture compared with control patients with no fracture. Comparing each individual fragility fracture demonstrated that hip fractures had the greatest risk of developing any of the queried mental disorders (OR:1.88, CI: 1.74-2.03).

Conclusion: There is an increased risk of being diagnosed with a new mental disorder following fragility fracture in patients older than 65 years. Mental health screening and potential psychiatric evaluation should be considered for patients following fragility fracture.

Study design: Original Research (Level III).

Painful neuromas are a complex clinical condition that results in notable disability and functional impairment after injury to a peripheral nerve. When regenerating axons lack a distal target, they form a stump neuroma. Up to 60% of neuromas are painful because of mechanical sensitivity and crosstalk between nerve fibers. Clinical evaluation includes a thorough history and physical examination followed by directed diagnostic imaging and procedures to assess pain generators and their effect on quality of life. Nonsurgical management options may include pharmacological interventions, desensitization strategies, injections, and therapies to reduce pain perception and improve function. Surgical interventions, such as nerve reconstruction by direct repair or grafting, redirection to alternative targets, and containment of regenerating axons by relocation into innervated tissues or in grafts, are considered when conservative measures fail. A comprehensive and individualized treatment plan is crucial for optimizing patient outcomes with painful neuromas. The plan should consider the underlying pathology, pain generators, and psychosocial factors contributing to the patient's pain.

Hereditary sensory and autonomic neuropathies (HSANs) encompass a diverse group of inherited neuropathies characterized by notable sensory and autonomic involvement that affects musculoskeletal structures and systemic function. There are 8 recognized types of HSAN. The orthopaedic manifestations of HSAN are complex and diverse, including spinal deformity, Charcot arthropathy, osteomyelitis, fractures, osteonecrosis, osteoporosis, and skeletal deformities. The sensory neuropathy with involvement of small nerve fibers can lead to unnoticed burns, fractures, and joint trauma. Spinal involvement includes progressive scoliosis/kyphosis and acute neurologic compromise. Diagnosis is dependent on clinical suspicion and confirmed with genetic analysis. Treatment is focused on the eradication of infection, stabilization of fractures, and prevention of joint instability in the spine and extremities. This review focuses on the orthopaedic manifestations to aid healthcare professionals in the recognition and treatment of these conditions.

Purpose: Although the hematologic benefits of tranexamic acid (TXA) have been thoroughly evaluated, an additional value demonstrated in knee arthroplasty and rotator cuff repair is improved early postoperative range of motion (ROM). This study aims to evaluate whether TXA given during total shoulder arthroplasty (TSA) confers improved early postoperative ROM or pain.

Methods: We did retrospective review of 653 TSAs (223 anatomic TSA [aTSA] and 430 reverse TSA [rTSA]) performed in 596 patients at a single institution from 2007 to 2022. Intraoperative TXA use was implemented on a case-by-case basis starting in 2014 then became standard practice in 2016. Pre- to postoperative improvement in ROM was evaluated at 6 weeks, 3 months, 6 months, 1 year, and 2-years of follow-up. Mixed-effects models were used to evaluate whether administration of TXA intraoperatively improved ROM or pain at each follow-up time point.

Results: TXA was administered to 26% (n = 58) of aTSAs and 43% (n = 179) of rTSAs. Patients with a history of hypertension received TXA at a higher rate for both aTSA ( P = 0.009) and rTSA ( P = 0.005). Intraoperative TXA was not associated with improved ROM or pain for aTSA or rTSA at any time point investigated. Average estimated intraoperative blood loss was markedly less in the TXA group for both aTSA [250 to 300 mL] ( P < 0.001) and rTSA [200 to 300 mL] ( P < 0.001) when compared with the non-TXA groups [300 to 400 mL for both].

Conclusion: Intraoperative TXA does not improve ROM or pain after TSA. However, intraoperative blood loss was reduced, further supporting the routine use of TXA to reduce hematologic complications and improve intraoperative visibility.

This overview approaches the acromioclavicular joint (ACJ) and ACJ injuries from a mechanical perspective that places the ACJ complex-the scapula, clavicle, ACJ, AC and coracoclavicular ligaments, and periscapular muscles-into the context of its ability to facilitate scapulohumeral rhythm (SHR) functions of scapula placement and humeral mobility. Mechanical concepts underlying this perspective include linkage of the scapula and clavicle into a single segment, the "claviscapula," the role of the AC and coracoclavicular ligaments in torque transduction and horizontal and vertical stability, and the deleterious effects of decoupling the claviscapular segment. The clinical examination and surgical treatment should address anatomic restoration of individual structures and the effect on the functional integrity of the entire ACJ complex within SHR. This context, which unifies anatomic injury with functional consequences, can be used to create a more comprehensive understanding of the clinical presentation and effect on ACJ function and SHR.

Introduction: Clinicians use imaging studies to help gauge the degree to which structural factors within the knee account for patients' pain and symptoms. We aimed to determine the degree to which commonly used structural features predict a patient's knee pain and symptoms.

Methods: Using Osteoarthritis Initiative data, a 10-year study of 4,796 patients with knee osteoarthritis (KOA), participants' KOA was characterized by radiographs and MRI scans of the knee. Salient features were quantified with two established grading systems: (1) individual radiographic features (IRFs) and (2) MRI Osteoarthritis Knee Scores (MOAKS) from MRI scans. We paired participants' IRFs (24,256 readings) and MOAKS (2,851 readings) with side-specific Knee Injury and Osteoarthritis Outcome Scores (KOOS). We trained generalized linear models to predict KOOS from features measured in IRF and MOAKS. We repeated the analysis on four subsets of the cohort. The models' predictive performance was evaluated using root mean square errors and coefficient of determination (R2).

Results: Neither radiographic features used to determine IRF grades nor MOAKS were predictive of patient pain or symptoms. MOAKS's performance was slightly more predictive of KOOS than IRF's. IRF's prediction of KOOS achieved a maximum R2 of 0.15 and 0.28 for MOAKS, indicating a low level of accuracy in predicting the target variable.

Discussion: Commonly used structural features from radiographs and MRI scans cannot predict KOA pain and symptoms-even when imaging features are codified by established grading systems like IRF or MOAKS. The predictive performance of these models is even worse as symptom severity worsens.

Level of evidence: IV.

As anatomic shoulder arthroplasty continues to increase in popularity, there will be a similar need for revising these implants to reverse total shoulder arthroplasty. To address this problem, convertible glenoid and humeral components have been developed to facilitate a less complicated, less traumatic, and bone-preserving procedure. However, convertible glenoids have a historically higher failure rate due to loosening and joint overstuffing when used for anatomic shoulder arthroplasty, and convertible humeral stems can be problematic at the time of revision and often need to be removed because of stem malposition. Despite these issues, there have been recent advances with the humeral and glenoid components which continue to make these implant options appealing and relevant. At the same time, there is a trend toward stemless arthroplasty which makes a convertible humeral stem less important due to the ease of revision from a stemless component to a stemmed reverse shoulder arthroplasty.

Background: Birth brachial plexus palsy (BBPP) can severely impair shoulder function by restricting external rotation and abduction, often leading to posterior subluxation or dislocation. Progressive shoulder dysplasia, a secondary condition of BBPP, further exacerbates functional disability by limiting shoulder function. Several techniques have been developed to address these challenges, including microsurgery, muscle transfer, and bony procedures. Recent reports on lower trapezius muscle transfer to the infraspinatus footprint demonstrate promising results in restoring shoulder biomechanics in adults. In this study, we aimed to treat patients younger than 7 years with BBPP through lower trapezius muscle transfer without allograft support.

Patients and methods: Between 2014 and 2018, 15 patients with BBPP and impaired shoulder external rotation and/or abduction (mean age, 22 months; range: 10 to 41 months) underwent lower trapezius muscle transfer surgery at our institution. A glenoid osteotomy was performed in patients without concentric joints, followed by the transfer of the lower trapezius muscle to the footprint of the infraspinatus. Patients were followed for an average of 25 months (range: 14 to 46 months). Outcomes assessed included shoulder external rotation, shoulder abduction, hand-to-mouth, hand-to-back, hand-to-neck, and Mallet scores.

Results: Significant improvements were observed in hand-to-mouth, hand-to-neck, global shoulder abduction, global shoulder external rotation, and total Mallet scores (P < 0.01). A nonsignificant decrease in hand-to-back was noted (P > 0.05). Both shoulder external rotation and abduction increased significantly (P < 0.01). No complications were reported after the muscle transfer procedure.

Discussion: Lower trapezius muscle transfer to the infraspinatus footprint markedly improves shoulder external rotation and abduction in children younger than 7 years without adverse effects on daily activities. This procedure is an effective treatment option for patients who present outside the optimal window for nerve transfer.

Level of evidence: Level IV; Case Series; Treatment Study.

Associated coalitions of tarsal bones, either unilateral or bilateral, may be classified to developmental or syndromic types. There are no specific patterns for osseous or nonosseous configurations of associated tarsal coalitions. Associated developmental tarsal coalitions can be categorized into dual, threefold, massive, and total tarsal coalitions according to the number and sites of the involved joints. Dual coalitions are more common than other types. Among dual tarsal coalitions, the most frequent combination is talocalcaneal (TC) and calcaneonavicular coalitions, also referred to as double coalition, followed by combination of TC and talonavicular coalitions. The most frequent threefold coalition is the triple coalition, defined as concomitant TC, calcaneonavicular, and talonavicular coalitions. Massive tarsal coalition is defined as a nonsyndromic abnormality with involvement of more than three intertarsal joints or occurrence of a concomitant coalition outside the intertarsal joints, that is, tarsometatarsal joints and/or between metatarsal bases. Total tarsal coalition is the synostosis between all tarsal bones. Syndromic multiple tarsal coalition is a part of a hereditary complex skeletal malformation such as different phocomelia, craniosynostosis, and tarsal-carpal coalition syndromes. This literature review discusses associated coalitions, focusing on anatomical classification, workup, and treatment.