Bulletin of the Hospital for Joint Disease (2013)最新文献

Anterior shoulder instability has been a common shoulder problem since the earliest of human civilizations. Over the course of thousands of years, our understanding regarding shoulder instability and treatment options have evolved tremendously. Specifically, over the past several decades we have seen a gradual but substantial development in our understanding of the natural history of anterior shoulder instability with and without surgical treatment. There is increasing recognition and improved understanding of the role of bone loss in the pathophysiology of shoulder instability, with ongoing emphasis on restoring native anatomy with minimally invasive techniques. The rich history of successes and failures of past surgical procedures forms the basis of the many innovative surgical techniques currently used, including both bony and soft tissue procedures. The purpose of this review is to highlight some of the most influential and important breakthroughs in the evolution of our understanding and management of anterior shoulder instability.

The management of acetabular bone loss during revision arthroplasty is a challenging problem. Not only are there a wide variety of potential defects, but the location of these defects can also drastically change the hip center of rotation, stability, and biomechanics. First, the assessment of the severity and location of bone loss preoperatively is highlighted as it is imperative to evaluate the acetabular bone stock remaining. It is especially important to determine how to identify a pelvic discontinuity. Various classification systems are discussed to help surgeons adequately assess and evaluate these defects. There are also numerous implants and treatment strategies available to manage the problem, all of which are determined by that preoperative assessment and classification. We review the history of managing these defects and how management has evolved into modern designs, including but not limited to structural allograft, distraction arthroplasty, jumbo cups, metal augments, cup-cages, and custom triflanges. This review then describes the up-to-date clinical results of these various techniques, highlighting the surgical execution needed to obtain a successful result. By describing the preoperative assessment, the acetabular defect classifications, and proposed evidence-based treatment algorithms, we hope that this review will enhance the understanding of these challenging reconstructions in the setting of acetabular bone defects.

Ulnar sided wrist pain often presents a diagnostic challenge. Creating a meaningful differential diagnosis is possible with a detailed history and systematic physical exam using provocative maneuvers. Targeted imaging studies can allow for further narrowing of the differential and ultimate diagnosis.

Cannabis has a rich history as a therapeutic tool with wide ranging applications. The efficacy of cannabidiol (CBD), the non-psychoactive component of cannabis, has been well demonstrated for pain management. Further, recent orthopedic studies have demonstrated positive effects of CBD on wound healing, inflammation, bone marrow density, and fracture healing. Despite the growing interest in CBD, there is a paucity of research on its impact on fracture risk and bone density in human clinical trials and the existing literature has significant limitations. As the rate of cannabis consumption increases, further research is essential to delineate the therapeutic qualities of CBD and its long-term effects on fracture healing and bone metabolism in order to optimize patient outcomes.

Technological advances have paved the way for surgical innovation in spine surgery. These advances have allowed for the creation of more accurate and less invasive surgical techniques. Spine surgeons play a critical role in the integration of new technology into the surgical workflow with the goal of improving safety, efficiency, and clinical outcomes. Navigation and robotic techniques are emerging technologies that have begun to revolutionize spine surgery. One particular advancement these technologies have recently enabled is single position prone lateral surgery. This review provides a history and brief overview of the different applications of new technologies in spine surgery. It will also discuss their enablement of single position prone lateral surgery in order to more critically evaluate their utilization.

Background: Bone morphogenetic protein 2 (BMP-2) is one of the most widely used biologics in spine surgery. Its osteoinductive properties have been shown since its inception to improve fusion rates. Despite the positive effects on promoting fusion, there remains concerns regarding the significant costs associated with its use. The goal of this review was to investigate the value of BMP-2 in spine surgery.

Methods: A literature search was performed on various studies that report on the cost effectiveness and the value of BMP-2 in spine surgery. The value of BMP-2 was analyzed in two distinct settings: comparison to the gold standard iliac crest autograft and demineralized bone matrix. The value of BMP-2 was further analyzed in the setting of spinal deformity surgery.

Results: The findings of our review determined that BMP-2 offers significant improvement in outcomes related to improvement of fusion rates and minimization of pseudoarthrosis and reoperations related to pseudoarthrosis and donor site morbidity from harvesting iliac crest bone graft. However, BMP-2 has been found to be significantly more expensive in comparison to iliac crest bone graft and other bone graft substitutes, which detracts from its positive value. In deformity surgery, BMP-2 is associated with improvement in fusion rates as well as reducing the rate of reoperations and pseudoarthrosis. These positive outcomes, however, are associated with an expensive upfront cost for BMP-2.

Conclusions: In terms of value, BMP-2 is associated with improvement in quality outcomes related to a reduction in pseudoarthrosis and reoperations. It also leads to improved outcomes with a reduction in donor site morbidity associated with iliac crest bone graft harvest. However, the value of BMP-2 is negatively affected because of its significant costs. As a result, higher expense thresholds are needed to increase quality adjusted life years in patients who receive BMP-2. Further research investigating ways to minimize the costs associated with BMP-2 use can further improve its value in spine surgery.

Total joint arthroplasty relies on the use of biomaterials that are biologically inert and capable of forming wear-resistant articulating surfaces. Polyethylene use in arthroplasty has become ubiquitous since its introduction in the 1960s. Early arthroplasty procedures of the hip utilized poly-tetra-flouroethylene, or "Teflon," due to its low coefficient of friction that was presumed to closely mimic the hyaline cartilage of native joints. Early catastrophic wear of Teflon caused a significant local tissue reaction contributing to osteolysis, aseptic loosening, and clinical failure ultimately limiting the material's surgical utility. Advancements in biomaterial synthesis and processing led to the fortuitous discovery of ultra-high-molecular-weight-polyethylene (UHMWPE) and the eventual evolution to highly cross-linked polyethylene (HXLPE) as a bearing surface in hip arthroplasties with robust, long-term clinical success. Ultra-high-molecularweight-polyethylene was readily adopted for use in total knee arthroplasty following the material's successful use in hip replacement, however, the unique biomechanics of the knee have posed unique challenges. The use of HXLPE in knee arthroplasty has increased, however, clear data regarding its benefit over UHMWPE are conflicting. Recently, clinical as well as research and development studies of UHMWPE and HXLPE have focused on alternative postprocessing methods to optimize material stability and wear resistance. Second generation HXLPE utilizing sequential annealing processes or vitamin E to stabilize free radicals are promising means to improve mechanical stability and wear resistance for use in joint arthroplasty, however, more data is required to evaluate long-term outcomes and cost-effectiveness. In this review, we discuss the history and innovation of polyethylene use in orthopedic surgery and evaluate the current literature on outcomes of polyethylene use in hip and knee replacement.

The anterior cruciate ligament (ACL) is the primary restraint to tibial internal rotation and is supported by secondary stabilizers, including the iliotibial band (ITB), anterolateral ligament (ALL), anterolateral capsule, and lateral meniscus, which provide additional rotational control. Combined injury to primary and secondary rotational stabilizers can lead to anterolateral rotatory instability. This can best be demonstrated in patients with large pivot-shifts. Biomechanical studies have demonstrated that ACL reconstruction (ACLR) alone does not restore native kinematics in the setting of a combined injury. Concomitant anterolateral ligament reconstruction (ALLR) and lateral extra-articular tenodesis (LET) techniques have been evaluated as a possible solution. Both the LET and ALLR may help restore rotational control, with the LET being slightly more powerful due to its more horizontal force vector based on biomechanical studies. However, there may be a slight risk of overconstraint with both techniques, more pronounced with the LET. Clinical studies evaluating the techniques for both primary and revision ACLR have generally found both to be safe and effective, leading to decreased rates of re-rupture and improved outcome scores. Either technique is a reasonable addition to ACLR when additional rotational control is indicated, though the LET may be more reproducible.

Carpometacarpal (CMC) arthritis of the thumb is one of the most common pathologies encountered in clinical hand and orthopedic surgery practices. Anatomy of the CMC joint and its biomechanics are theorized to predispose the articulation to laxity and subsequent degenerative changes. Diagnosis of CMC arthritis is primarily based on history, physical examination, and imaging findings, all of which coalesce to guide treatment. There are a multitude of treatment options for CMC arthritis, each with its own set of pearls and pitfalls with treatment decision making shared by surgeon and patient. Continued research and longitudinal data on outcome measures will assist in determining the ultimate "rule of thumb" for the treatment of CMC arthritis.

The consequences of malnutrition in spine surgery have been studied to a lesser degree compared to other orthopedic subspecialties. However, there is growing interest in understanding the effects of preoperative malnutrition on spine surgery outcomes. Literature on the relationship between malnutrition and spine surgery outcomes appeared sporadically in the late 1990s and early 2000s. Over the last decade, however, there has been a push to understand the sequelae of malnutrition on patients undergoing spine surgery. The aims of this review are to highlight: 1. the different parameters by which malnutrition has been defined and measured in spine surgery; 2. the prevalence of malnutrition in spine surgery; 3. the outcomes of spine surgery in malnourished patients; and 4. the effects of nutritional supplementation or interventions on spine surgery outcomes. Malnutrition has often been defined utilizing specific serological laboratory values or nutritional indices. Serologic values of malnutrition include an albumin < 3.5 g/dL, transferrin < 150 mg/ dL, or a total lymphocyte count of < 1,500 cells/mm3 . The available literature reports that the prevalence of malnutrition in patients undergoing lumbar spine surgery ranges from 5% to 50%, with most literature supporting a value toward the higher end of this spectrum. Malnourished patients undergoing spine surgery have higher rates of surgical site infections, medical complications, lengths of stay, ICU admissions, 30-day and 1-year mortalities, reoperations, 30-day readmissions, and costs of care. Given the plethora of spine surgeries performed in the country annually and the prevalence of malnutrition in up to 50% of our patients, we recommend performing preoperative nutritional assessments on all patients to ensure their optimization prior to surgery.