JBJS Reviews最新文献

Background: This review aims to synthesize current knowledge on capitate fractures, with an emphasis on diagnostic challenges, therapeutic approaches, and long-term complications, including nonunion and avascular necrosis.

Methods: A narrative literature review was conducted using databases including PubMed, Scopus, and Google Scholar for studies published up to April 2025. Keywords included "capitate fracture," "carpal injuries," "avascular necrosis of the capitate," and "capitate nonunion." Because of the rarity of these fractures, both clinical studies and case reports were included. Articles were selected if they described clinical features, imaging modalities, fracture classification, surgical or conservative treatments, complications, or rehabilitation protocols. Non-English publications and those lacking clinical detail were excluded.

Results: Capitate fractures are rare and frequently missed because of their central anatomic location and variable presentation. Plain radiographs often fail to detect these fractures; however, computed tomography and magnetic resonance imaging significantly improve diagnostic accuracy. Nondisplaced fractures may be treated nonoperatively, whereas displaced or rotated fractures typically are treated with surgical intervention such as open reduction and internal fixation. Avascular necrosis and nonunion, though uncommon, are serious complications requiring individualized surgical management, including bone grafting or salvage procedures. Structured rehabilitation is essential for restoring wrist function and preventing chronic impairment.

Conclusion: Timely recognition and thoughtful management of capitate fractures, including the use of advanced imaging and individualized surgical strategies, may help reduce the risk of long-term complications and support favorable outcomes in select cases. Enhancing clinical awareness and working toward more standardized treatment frameworks could provide better care for these uncommon but potentially significant wrist injuries.

Level of evidence: Level V. See Instructions for Authors for a complete description of levels of evidence.

Background: Understanding the characteristics of intraoperative graft contamination (IOGC) in anterior cruciate ligament reconstruction (ACLR) may guide infection control measures. Our aim was to determine the rate and characteristics of IOGC during ACLR and its clinical impact in relation to the development of postoperative infection.

Methods: A systematic review and meta-analysis using Cochrane methodology were performed. PubMed, Embase, CINAHL, and Cochrane CENTRAL were searched. Studies reporting on the rate of autograft contamination during ACLR were included. Meta-analysis was conducted using a fixed- or random-effects model as indicated. The study was prospectively registered with PROSPERO (CRD42024570199).

Results: Literature search identified 175 studies, of which 12 qualified for evaluation. Meta-analysis showed that the estimated rate of graft contamination during ACLR was 12.3% (confidence interval [CI] 7.8%-19%) when examining HT and BPTB grafts together. Similar rates were observed when examining HT and BPTB grafts in isolation (11.9%, CI 7.2-18.9, vs. 14%, CI 7.1%-25.6%). Meta-analysis of 2 studies that directly compared contamination between the graft preparation stage vs. harvesting stage showed a higher risk for the former, OR 3.23 (1.01-10.39, p = 0.049). Cultures were mostly monomicrobial, with Staphylococcus epidermidis being the most commonly isolated organism. There was no clear association between IOGC and postoperative clinically apparent infection, but the evidence assessing this parameter was sparse, and any link to chronic low-grade infection could not established.

Conclusion: There is a high rate of autograft contamination during ACLR, and elaborate infection prevention measures are required to reduce this.

Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Although various total knee arthroplasty (TKA) philosophies exist, with different component and limb alignment targets, there is no consensus on which is superior. This study compared outcomes among randomized controlled trials (RCTs) of TKAs performed to achieve mechanical (MA), anatomical (AA), kinematic (KA), restricted KA (rKA), and functional alignment (FA).

Methods: Scopus, Ovid/MEDLINE, PubMed, Cochrane Database of Systematic Reviews, and Cochrane Central Registry of Controlled Trials were queried in April 2025 (PROSPERO: CRD420251017962). A frequentist model network meta-analysis of eligible prospective RCTs assessed complications, revisions, and patient-reported outcomes (PROs) using P-scores.

Results: Among 3,605 studies, 22 RCTs totaling 1,411 patients (1,428 primary TKAs) with median (interquartile range) age of 68.2 years (6.8) and follow-up of 29.1 months (48) were included for meta-analysis. The distribution of alignment philosophies was MA (n = 708, 49.6%), AA (n = 101, 7.1%), KA (n = 394, 27.6%), rKA (n = 160, 11.2%), or FA (n = 65, 4.6%). Compared to MA, the mean Knee Society Score (KSS) knee score improvements from baseline were statistically lower (worse) with AA (mean difference [MD] -0.503; 95% confidence interval [CI] -0.96 to -0.04; p = 0.0320) and KA (MD -0.623; 95% CI -1.07 to -0.18; p = 0.006), and mean KSS combined changes were also statistically lower (worse) with KA (MD -0.314; 95% CI -0.55 to -0.08; p = 0.009) versus MA. However, each statistically significant change had high heterogeneity and failed to reach the minimum clinically important difference. There were no significant changes in the mean Western Ontario and McMaster Universities Osteoarthritis Indices, KSS function, Oxford Knee, or Forgotten Joint scores among each alignment philosophy. In addition, postoperative knee flexion, complications, and reoperation rates with or without implant removal were similar among all techniques.

Conclusion: This study found no clinically meaningful difference in PROs nor complication rates among TKA alignment philosophies, supporting comparable short-term to mid-term outcomes. However, longer follow-up is required to accurately assess implant failure and revision rates.

Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

» Affordable Care Act Medicaid expansion increased orthopaedic surgery access and utilization among Medicaid patients, including for racial and ethnic minorities.» Despite improved coverage, Medicaid patients continue to face significant real-world barriers to orthopaedic care, including lower appointment success and longer wait times compared with privately insured patients.» Evidence on cost and quality impacts remains limited, with early signals of increased reimbursements, higher charges, and some quality improvements postexpansion.

» Delaminated rotator cuff tears (DRCTs) represent a unique type of tear characterized by horizontal splits within the supraspinatus tendon, occurring in both partial-thickness and full-thickness tears, with or without retraction of the bursal or articular surfaces.» The pathogenesis of DRCTs lies in the anatomical layered architecture of the supraspinatus and infraspinatus tendons and the interlayer shear stress disparities. Furthermore, during shoulder abduction, hypovascular-driven degeneration and biomechanical strain gradients also contribute to this layered pathogenesis.» Accurate diagnosis of DRCTs mainly relies on imaging methods such as magnetic resonance imaging, magnetic resonance arthrography, and ultrasonography. Recent advances in shear wave elastography have enhanced diagnostic accuracy by delineating tear morphology and quantifying tendon stiffness.» Management of DRCTs requires individualized strategies based on tear size, muscle quality, and chronicity. Nonoperative approaches, including activity modification, nonsteroidal anti-inflammatory drugs, and targeted physiotherapy, may be considered for acute partial-thickness DRCTs. Surgical repair becomes necessary for chronic, severely retracted, or full-thickness DRCTs, as well as for cases where nonoperative treatments have failed to achieve satisfactory outcomes, using either en masse or dual-layer techniques.» Although en masse and dual-layer repairs show comparable clinical outcomes and retear rates, dual-layer repair demonstrates superior pain control and functional recovery, making it a preferred surgical approach.

Background: Spine surgery is a high-risk specialty for litigation, with most practicing surgeons encountering at least 1 malpractice claim during their careers. This systematic review aimed to evaluate the trends and characteristics of medical malpractice claims after spine surgery.

Methods: A systematic search was conducted on PubMed, Scopus, Embase, and Web of Science to find studies reporting on patients who underwent spine surgery and sued their surgeons. Studies that included original extractable data on litigation after spine surgery were included without date or geographical restrictions. Outcome measures included demographic details, anatomic regions, diagnosis, procedure, verdict, defendant's specialty, reason for litigation, patient injuries or damages, and payouts. Two reviewers independently screened and selected the articles. The protocol was prospectively registered on PROSPERO.

Results: This review reports on 5,514 malpractice cases in 54 studies covering 1968 to 2023. Most of the literature has been published in the United States (28/54 studies). The numbers of males (n = 1,192, 50.6%) and females (n = 1,166, 49.4%) were almost equal. Most patients had undergone lumbar spine surgery (53.9%), followed by cervical (26.6%) spine surgery. Most surgeries were performed electively (70.9%), with a minority (29.1%) being emergent surgeries. The top 3 common alleged reasons for litigation were (1) delay or failure to diagnose or treat (1,380 cases), (2) intraoperative/procedural error (901 cases), and (3) inadequate informed consent (694 cases). The top 3 common injuries reported were (1) new neurological deficit, that is, nerve or spinal cord injury (1,423 cases); (2) persistent pain or suffering (585 cases); and (3) additional surgery required (381 cases). Most cases concluded with either a defense verdict (56.8%) or settlement (11.1%), with only 29.3% resulting in a plaintiff verdict. Orthopaedic surgeons represented 47.1% of the providers sued, whereas 35.9% were neurosurgeons. Payouts resulting from plaintiff verdicts were significantly higher than payouts in settlement (mean difference = $1,304,100, 95% confidence interval $93,430-$2,514,780, p = 0.01).

Conclusion: The most common reason for litigation after spine surgery is a new neurological deficit, mainly resulting from a delay in diagnosis or treatment, intraoperative error, or inadequate informed consent. Emphasizing communication and informed consent is an effective method of improving patient care and decreasing litigation.

Level of evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

» Lateral meniscus oblique radial tears (LMORTs) predominantly affect younger individuals younger than 30 years, especially men with a higher body mass index, presenting unique challenges in surgical management.» The diagnosis of LMORTs is challenging because of the variable sensitivity of magnetic resonance imaging (MRI), particularly in cases with concurrent anterior cruciate ligament (ACL) injuries, necessitating the integration of MRI findings with clinical and intraoperative evaluations for accurate diagnosis.» LMORTs significantly affect knee stability and joint mechanics, negatively influencing function and predisposing patients to subsequent joint degeneration.» Treatment strategies for LMORTs have evolved to favor meniscus preservation, with arthroscopic repair techniques such as transosseous pullout suture and side-by-side repair being recommended for more severe tear types.» Future research directions include advancing imaging techniques, conducting long-term outcome studies, exploring LMORTs in non-ACL injuries, performing biomechanical studies focused on healing outcomes, and emphasizing patient-reported outcomes to improve diagnostic accuracy and treatment effectiveness.

Background: Operative management of acetabular fractures can be complicated by the development of symptomatic post-traumatic arthritis, which may necessitate conversion total hip arthroplasty (THA). There is increased interest in treatment with THA for acute management, but optimal patient selection depends on identifying those at risk of later symptomatic post-traumatic arthritis requiring conversion THA.

Methods: We systematically reviewed prognostic factors associated with conversion THA in adult patients with operatively managed acetabulum fractures. We searched MEDLINE and EMBASE from inception to September 27, 2024. Screening, data extraction, risk of bias assessment, and evidence grading were completed in duplicate. Data were pooled using a random-effects model to produce summary odds ratios (ORs), hazard ratios (HRs), and mean differences, with 95% confidence intervals (CIs). Risk of bias was assessed using the Quality in Prognosis Studies tool. Certainty of evidence was evaluated using the Grade of Recommendation, Assessment, Development, and Evaluation framework.

Results: A total of 3,054 citations were screened, and 38 studies (6,931 fractures) met inclusion criteria. Eight factors were associated with conversion THA in unadjusted analyses: acetabular impaction (OR 2.08, 95% CI 1.60-2.70, moderate certainty), femoral head impaction (OR 2.70, 95% CI 1.80-4.06, moderate certainty), dislocation (OR 2.20, 95% CI 1.51-3.19, moderate certainty), nonanatomic reduction on radiography (OR 2.36, 95% CI 1.58-3.51, moderate certainty), nonanatomic reduction on computed tomography (OR 3.46, 95% CI 1.25-9.57, moderate certainty), associated fracture type (OR 1.76, 95% CI 1.29-2.41, moderate certainty), female sex (OR 1.48, 95% CI 1.15-1.88, moderate certainty), and posterior wall involvement (OR 1.82, 95% CI 1.18-2.80, moderate certainty). In multivariable analyses, age (adjusted OR 1.04, 95% CI 1.02-1.06, high certainty; adjusted HR 1.04, 95% CI 1.03-1.05, high certainty) and femoral head impaction (adjusted HR 3.19, 95% CI 1.16-8.75, moderate certainty) were associated with conversion THA. The weighted proportion of patients requiring THA conversion was 17.6% (95% CI 15.2%-20.4%, low certainty).

Conclusion: Older age and femoral head impaction were the only factors associated with conversion to THA in univariable and multivariable analyses.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: As interest in hip resurfacing arthroplasty (HRA) expands to complex pathologies, developmental dysplasia of the hip (DDH) has emerged as a challenging but increasingly considered indication. Although severe DDH often precludes resurfacing because of distorted anatomy, mild cases (Crowe I and II) may provide favorable conditions. This review evaluates outcomes of HRA in mild DDH, compares them with outcomes of total hip arthroplasty (THA) in DDH and HRA in primary osteoarthritis (OA) and assesses the potential of HRA to improve long-term function in this population.

Methods: A systematic search of PubMed, Embase, and Scopus identified studies reporting outcomes of HRA in DDH. Titles and abstracts were screened, followed by full-text review. Data on demographics, outcomes, and radiographic findings were extracted. Pooled complication and survivorship rates were calculated. A random-effects meta-analysis compared revision risk in HRA-treated patients with DDH vs. OA, and in patients with DDH treated with HRA vs. THA. Statistical significance was defined as a 95% confidence interval (CI) excluding 1. A separate meta-analysis compared mean postoperative flexion in patients with DDH treated with HRA vs. THA, with significance defined as a 95% CI excluding 0.

Results: From 65 screened articles, 11 met inclusion criteria, totaling 895 patients and 1,006 hips with DDH. The mean age was 45.26 years, with an average follow-up of 7.06 years. The pooled survivorship was 93%, and the complication rate was 13%. No significant difference in revision risk was found between DDH and OA HRA cohorts, or between HRA and THA in DDH, although both trends favored OA and THA. Patients with HRA-treated DDH had significantly greater postoperative flexion (standardized mean difference -1.21, 95% CI -1.54 to -0.87).

Conclusion: Despite anatomical challenges and a potential for higher revision or complication rates in patients with DDH, mid-term outcomes, including patient-reported outcome, were comparable with those in primary osteoarthritis and THA cohorts. This review supports the selective use of HRA in patients with Crowe I and II DDH, particularly when modern surgical techniques and DDH-specific implants are used.

Level of evidence: Level III, systematic review of Level I, III, and IV studies. See Instructions for Authors for a complete description of levels of evidence.

Background: Brucella species are zoonotic pathogens responsible for brucellosis, a systemic bacterial infection primarily transmitted through direct contact with infected animals or consumption of unpasteurized dairy products. While Brucella infections following total knee arthroplasty (TKA) are rare, they pose significant diagnostic and therapeutic challenges with limited reported cases.

Methods: A systematic review, following the Preferred Reporting in Systematic Reviews and Meta-Analyses guidelines, was performed on February 22, 2025, using the databases PubMed and Google Scholar for Brucella TKA periprosthetic joint infections (PJIs) in patients older than 18 years. The search was further narrowed by excluding articles before 2015 to reflect the most current trends and practices. Our eligibility criteria were guided by the Population, Intervention, Comparison, and Outcome framework. We considered outcomes including, but not limited to, successful eradication of infection, complications, and functional outcomes following intervention.

Results: Fifteen studies met inclusion criteria. Brucella PJIs in a TKA typically present late with nonspecific symptoms, often mimicking aseptic loosening or culture-negative PJIs. Most patients had identifiable risk factors, including travel to endemic regions, animal exposure, or consumption of unpasteurized dairy. Two-stage revision was used in 11 of 15 cases. Conservative management with implant retention was successful when no loosening was present in 3 out of the 15 cases. The most common antibiotic treatment was doxycycline plus rifampicin with duration ranging from 3 to 12 months, most commonly for a total of 6 months. Successful outcomes are possible with prolonged combination antibiotics and often require 2-stage revision arthroplasty, though diagnostic and treatment approaches vary widely.

Conclusion: This is an updated systematic review of Brucella infections following TKA within the last 10 years. Given the insidious onset and potential for chronic infection, orthopaedic surgeons and infectious disease specialists must be aware of the possibility of Brucella PJIs in patients with the appropriate history and clinical examination.

Level of evidence: Level III. See Instructions for Authors for a complete description of levels of evidence.