Archives of Orthopaedic and Trauma Surgery最新文献

Purpose: To compare re-rupture rates and clinical outcomes between bone-patellar tendon-bone (BTB) and hamstring tendon (HT) grafts in anterior cruciate ligament (ACL) reconstruction according to patient risk levels.

Methods: This retrospective cohort study included patients who underwent primary ACL reconstruction at a single institution between 2018 and 2022, with outcomes assessed at a fixed 2-year postoperative follow-up. The primary endpoint was graft re-rupture, defined as a traumatic graft failure confirmed clinically and by magnetic resonance imaging, and the secondary endpoint was the Knee injury and Osteoarthritis Outcome Score (KOOS). High-risk status was defined as the presence of all three risk factors: age ≤ 20 years, posterior tibial slope. (PTS) ≥ 12°, and participation in pivoting sports. For patients with two or fewer risk factors, propensity score matching was performed using age, sex, body weight, generalized joint laxity, knee hyperextension, participation in pivoting sports, and PTS as covariates to compare outcomes between BTB and HT grafts.

Results: In the high-risk group, the BTB graft showed a significantly lower re-rupture rate compared to the HT graft (12.9% vs. 35.7%, p = 0.03), with no significant difference in KOOS overall score (96.3 ± 3.7 vs. 96.6 ± 6.3, p = 0.85). In the lower-risk group after matching, the BTB graft showed a similar re-rupture rate compared to the HT graft (6.9% vs. 5.2%, p = 0.99), with no significant difference in KOOS overall score (92.6 ± 6.9 vs. 94.8 ± 5.7, p = 0.10).

Conclusion: BTB grafts reduced re-rupture rates compared to HT grafts in high-risk ACL reconstruction patients, while clinical outcomes were similar. In lower-risk patients, no significant differences were observed between graft types in either re-rupture rates or KOOS overall score.

Level of evidence: Level III.

Background: Varying degrees of flexion contracture appear commonly in total knee arthroplasty (TKA) patients and can be corrected using increasing distal femoral bone resection. Robotic-assisted (RA) technology aims to avoid ligament release through optimized bony resections. This study evaluated the influence of preoperative flexion contracture on the magnitude of resections surgeons perform to balance knees in RA-TKA.

Materials and methods: We reviewed 789 primary RA-TKAs from 2023 to 2024 using cruciate-retaining (CR) implants. The cohort was divided by native flexion deformity into three groups: <0° flexion ("hyperextension", n = 157), 0-9.9° flexion ("minimal contracture", n = 457), and ≥ 10° flexion ("clinically important contracture", n = 175). Mean preoperative flexion contracture was - 3.8, 4.1, and 13.5° for the hyperextension, minimal contracture, and clinically important contracture cohorts, respectively. Demographics, implants, and intraoperative data were collected and analyzed. The arithmetic hip-knee-ankle (aHKA) angle was used to determine native deformity groups for additional subanalyses.

Results: Significant differences were found between cohorts for mean distal femur and proximal tibia resections, with the clinically important contracture group having the largest resections. After accounting for implanted polyethylene thickness, differences in mean tibia resections were quite small, varying by 0.9 millimeters (mm) laterally and 0.7 mm medially. Similarly, the mean distal femoral resection varied by only 1.4 mm laterally and 0.7 mm medially between the hyperextension and clinically important contracture cohorts. Indeed, 85% of cases with clinically important contractures were managed with less than 2 mm of additional distal femoral resection compared to the minimal contracture cohort.

Conclusion: With robotic-assisted TKA, bone resections can be guided by collateral ligament tension in flexion and extension. Our data suggest that surgeons can follow this strategy and successfully address flexion contractures with very small increases in resection magnitudes, which may help to maintain the joint line.

Introduction: Symptomatic neuromas result from disorganized nerve growth at the site of amputation, causing pain that affects recovery and quality of life. In patients with diabetes mellitus (DM), nerve regeneration is impaired, compounded by comorbidities such as obesity, hypertension, and hyperlipidemia. Surgical approaches including targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI) have shown promise for managing symptomatic neuroma, but their effectiveness in diabetic patients is uncertain due to unique challenges in nerve regeneration. This narrative review explores the protective effects of DM on symptomatic neuroma formation and to evaluate the implications for surgical intervention.

Materials and methods: A systematic search of PubMed was conducted, and relevant studies discussing symptomatic neuroma formation in amputees were included.

Results: Symptomatic neuromas were reported in 9.5-50% of amputees involving 9.5% of upper extremity, and 3.8% of lower extremity amputees. Younger age and proximal amputations were identified as significant risk factors. While it is suggested that Interleukin (IL)-10 and brain-derived neurotropic factor (BDNF) levels are involved in protecting against symptomatic neuroma formation, IL-1β and IL-6 promote neuroma formation. Although evidence is mixed, some evidence suggests that DM and diabetic peripheral neuropathy decrease symptomatic neuroma formation by impairing axonal regeneration, altering the extracellular matrix and modulating inflammatory responses.

Conclusions: Although surgical approaches such as TMR and RPNI have shown potential in reducing neuroma-related pain, further studies are needed to ensure that this benefit extends to diabetic patients whose disease puts them at increased risk of postoperative complications. Additional studies are required to confirm these findings and optimize surgical strategies for high-risk patient populations.