2025年10月 保髋进展 JCRQ 3-4

Femoroacetabular impingement syndrome significantly impacts athletic performance across various sports. Recent literature shows high overall return-to-sport rates (87%-93%) following surgical treatment, particularly with arthroscopic approaches, though return to preinjury performance levels varies (55%-83%). Athletes typically resume sport within 4 to 8 months postsurgery, with outcomes influenced by factors like symptom duration, rehabilitation adherence, and sport-specific demands. Professional athletes generally show better outcomes than recreational athletes, though many experience temporary performance declines in their first season back. Early intervention and sport-specific rehabilitation protocols appear crucial for optimal outcomes.

Femoroacetabular impingement (FAI) is a common cause of hip pain in female athletes. There are limited data on midterm outcomes for female athletes undergoing hip arthroscopic surgery. To evaluate return-to-sport rates and clinical outcomes in female athletes with FAI after primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty. Case series; Level of evidence, 4. A retrospective analysis of a single institution's database was performed to identify female athletes who underwent primary hip arthroscopic surgery with labral repair and femoral osteochondroplasty from July 2011 to October 2019 with a minimum 5-year follow-up. Preoperative radiographs were evaluated for the lateral center-edge angle, Tonnis angle, Tonnis grade, and alpha angle. Patient-reported outcome measure (PROM) scores, including those for the modified Harris Hip Score, Hip Outcome Score, Tegner Activity Scale, and visual analog scale for pain, as well as patient satisfaction with surgery were analyzed postoperatively. Female athletes who underwent primary hip arthroscopic surgery for FAI had significant improvements in PROM scores and moderate return-to-sport rates at a minimum 5-year follow-up. Most athletes discontinued sports because of non-hip-related factors, although hip-related issues were also cited. Our analysis highlights the need for thorough perioperative counseling and establishing appropriate patient expectations for female athletes before hip arthroscopic surgery.

Femoroacetabular impingement syndrome significantly impacts athletic performance across various sports. Recent literature shows high overall return-to-sport rates (87%-93%) following surgical treatment, particularly with arthroscopic approaches, though return to preinjury performance levels varies (55%-83%). Athletes typically resume sport within 4 to 8 months postsurgery, with outcomes influenced by factors like symptom duration, rehabilitation adherence, and sport-specific demands. Professional athletes generally show better outcomes than recreational athletes, though many experience temporary performance declines in their first season back. Early intervention and sport-specific rehabilitation protocols appear crucial for optimal outcomes.

The ligamentum teres (LT) plays an important role in the general stability of the hip joint. A high prevalence of concomitant LT pathology has been noted in patients undergoing hip arthroscopy. This increased prevalence has led to the development of multiple treatment options, including reconstruction techniques using different types of grafts. The current literature on outcomes of LT reconstruction is limited. To evaluate the outcomes of LT reconstruction with tibialis anterior allograft treatment for LT tears with a minimum 2-year follow-up. Case series; Level of evidence, 4. Data were retrospectively analyzed for all patients who underwent arthroscopic LT reconstruction with a tibialis anterior allograft between 2014 and 2021. Preoperatively and a minimum of 2 years postoperatively, included patients had completed questionnaires for the following patient-reported outcome (PRO) measures: modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), 12-item International Hip Outcome Tool (iHOT-12) score, visual analog scale (VAS) for pain score, and patient satisfaction score; or they had a documented endpoint within the study's time frame. The minimal clinically important difference (MCID) was calculated for the mentioned PROs and included in the analysis. Survivorship was also evaluated and included in the analysis. A total of 22 patients were included in the study. Significant improvement was shown in mHHS, NAHS, HOS-SSS, iHOT-12 score, and VAS pain score. A high patient satisfaction score was also observed at the latest follow-up. Furthermore, a high percentage of patients reached the calculated MCID for the mHHS, NAHS, HOS-SSS, and VAS score. Patients demonstrated 95.5% survivorship. Arthroscopic LT reconstruction with a tibialis anterior allograft, concomitant with labral repairs and osteoplasties for femoroacetabular impingement, has shown favorable outcomes, high patient satisfaction rates, and a high percentage of patients reaching clinically important thresholds, with a low rate of complications and total hip arthroplasty conversion at a minimum 2-year follow-up. Furthermore, the choice of a graft rests in the hands of the surgeon based on training, familiarity, circumstances, and resources, as the optimal graft option has yet to be elucidated.

Lower extremity amputations (LEAs) significantly alter an individual's long-term functional capabilities and cardiovascular health. These outcomes vary significantly across LEA levels, affecting mobility, independence, and overall quality of life. This article reviews current literature to analyze these outcomes across different LEA levels including hemipelvectomy, hip disarticulation, above-knee amputation, knee disarticulation, below-knee amputation, Syme amputation, Chopart amputation, Lisfranc amputation, and toe disarticulation to elucidate outcomes, understand variations, and suggest directions for future research and informed clinical management. Although mechanical and hemodynamic systems undergo significant adaptations following all levels of LEA, improved functional and cardiovascular outcomes are a direct result of retained body mechanics, preservation of joint function, and the degree of energy expenditure. Surgical severing of blood vessels and increased effort to effectively supply oxygenated blood throughout the body substantially raise the risk of developing diseases such as myocardial infarction, hypertension, aortic aneurysm, and peripheral arterial disease. Patient comorbidities not only necessitate amputation but also remain factors impacting wound complications, morbidity, mortality, and reamputation rates. Morbidity and mortality rates are notably high for higher level amputations due to the complexity of the surgery and the associated risk of complications. Complications such as infection, phantom limb pain, and deep vein thrombosis vary greatly by level of amputation and often present alongside markers of hemodynamic instability and shock. Recognizing the effects of each LEA level on patient quality and function of life is crucial for optimizing rehabilitation strategies and providing comprehensive patient support.

To compare three capsular management strategies in hip arthroscopy (capsule preservation [CP], capsule repair [CR] and capsule unrepaired [CU]) for femoroacetabular impingement syndrome (FAIS). We hypothesized that CP and CR would provide superior outcomes compared with CU. A systematic search of PubMed, Embase, CENTRAL and Epistemonikos was conducted up to 31 May 2025. Outcomes of CP, CR and CU were compared using a frequentist multilevel random-effects meta-analysis with restricted maximum likelihood estimation and Hartung-Knapp adjustment. Ultimately, 47 primary studies met the inclusion criteria and were included in the meta-analysis. A total of 7366 hips (7276 patients) were included across the 47 studies. These were distributed into three capsular management groups: (I) CP: 1352 hips, (II) CR: 5043 hips and (III) CU: 971 hips. CR showed the greatest improvement in modified Harris Hip Score with a mean change of 24.00 (95% confidence interval [CI]: 20.86-27.14), while CP achieved the highest MCID rate at 12 months post-operatively with a mean of 9.30 (95% CI: 7.47-11.14). No other consistent statistically significant differences were observed between groups across post-operative scores, change scores or complication rates. CP and CR both demonstrated superior outcomes compared to CU in selected functional parameters. All three strategies showed comparable results in pain reduction, revision rate, conversion to total hip arthroplasty and overall complication incidence. CR and CP yield superior outcomes compared to leaving the CU. Surgeons should close or preserve the capsule, while future trials will clarify the optimal strategy. Level II, systematic review and meta-analysis of predominantly Level III studies, with additional contributions from Levels I and II studies.

To determine whether there is an association between increasing posterior tibial slope and meniscal tears in a group of patients with isolated, noncontact and acute anterior cruciate ligament (ACL) ruptures from a large ACL registry. Our institution's ACL Registry was consulted to identify patients between the age of 18 and 45 years who underwent primary ACL reconstruction between January 2019 and July 2022 for acute, noncontact ACL rupture. Patients with pre-existing meniscal pathology, chronic ACL reconstructions, revisions, and multiligament knee injuries were excluded. Preoperative magnetic resonance imaging scans were used to measure lateral and medial posterior tibial slope. Meniscal injuries seen during arthroscopy were recorded on the basis of operative reports. Independent cohorts were created on the basis of the presence or absence of a meniscal tear. Two-tailed Student t tests were used to compare average medial and lateral posterior tibial slopes between groups. Separate analyses were performed for the presence of isolated lateral meniscal tears, isolated medial meniscal tears, and both medial and lateral meniscal tears. Multivariable logistic regression models were generated to evaluate other potential risk factors for each tear outcome, including age, sex, and body mass index (BMI). Receiver operating characteristic curve analysis was conducted to explore the potential of identifying an optimal threshold for predicting the presence of a meniscal tear based on lateral posterior tibial slope. In total, 1,056 patients ultimately met inclusion criteria. There were 498 (47%) patients with any meniscal tear, 346 (33%) patients with lateral meniscus tears, 245 (23%) patients with medial meniscus tears, and 93 (9%) patients with both medial and lateral tears. The average lateral and medial posterior tibial slopes were 5.5° (-4.2° to 13.4°) and 5.7° (0° to 15.7°), respectively. Increased lateral tibial slope was associated with a statistically significant increase in rate of any meniscal tear (adjusted odds ratio 1.10, 95% confidence interval 1.04-1.16, P < .001) and lateral meniscal tear, specifically (adjusted odds ratio 1.11, 95% confidence interval 1.04-1.18, P < .001). In regression analysis, male sex and body mass index ≥35 were found to increase the risk of all meniscal tear types. With a receiver operating characteristic curve analysis identifying lateral posterior tibial slope threshold values that resulted area under the curve ranges from 0.55 to 0.57, we were unable to identify an optimal threshold for posterior tibial slope in predicting meniscal tears. In this single-institution, registry-based study, increasing lateral posterior tibial slope was associated with a greater rate of meniscus injury in acute ACL ruptures, whereas medial tibial slope demonstrated no correlation. No optimal threshold of posterior slope could be identified above which the odds of a meniscal tear were significantly elevated. Regression analysis identified BMI ≥35 and male sex as independent risk factors for meniscal tear in this select population. Level III, comparative retrospective case series.

The transfemoral or transhumeral Osseoanchored Prostheses for the Rehabilitation of Amputees (OPRA) osseointegration technique is indicated in patients with transfemoral or transhumeral amputations who have difficulty with use of a conventional socket and traditional prosthesis. Augmentations to the procedure, such as targeted muscle reinnervation (TMR) and/or a regenerative peripheral nerve interface (RPNI), serve to enhance function (in the case of TMR) and/or improve residual-limb neuropathic pain (in the case of combined TMR and RPNI) in the same patient population. This surgical technique is typically performed as a 2-stage procedure with approximately 6 weeks to 3 months between stages to allow for adequate bone graft healing and osseointegration of the fixture to the surrounding bone. Stage 1: Position the fluoroscopy machine on the opposite side of the patient. Because all transfemoral amputations rest in slight external rotation, obtain a true anteroposterior view of the hip, note the rotation of the C-arm, and subtract 90° to obtain a true lateral radiograph. Utilizing the prior incision, develop cutaneous flaps and distally approach the bone of the residual limb. Most patients will require a thighplasty procedure to manage excess soft tissues. Thighplasty may be performed during stage 1 and/or stage 2. The previous muscle platform is encountered, and an osteotomy is performed perpendicular to the long axis of the bone. A bone graft (5 to 10 cc) is harvested from the proximal humerus or femur with use of a curved curet. Next, the bone is progressively reamed under fluoroscopic guidance until the cortex is encountered. Reaming is done by hand in order to avoid thermal necrosis. Care is taken to avoid reaming too much of the anterior cortex proximally. A tap is selected that is 1.5 mm thicker than the final reamer, and the bone is tapped with use of the line-to-line technique to the size of the fixture. In cases of soft bone, we choose to under-tap by 0.5 mm prior to inserting the fixture. The final OPRA implant is inserted into the bone. The central screw is inserted and tightened to 80 N-cm. The healing cylinder is placed, which serves as a mold for the bone graft, and the previously harvested bone graft is packed around it. The graft screw and large washer are placed to compress the bone graft. Placement of the implant and healing components is confirmed on biplanar fluoroscopy. Stage 2: Through a limited incision, the graft screw and components are removed. The bone graft is inspected for proper integration around the distal fixture. The purpose of the bone graft is to provide a broad, vascular base onto which the full-thickness skin graft heals. Then, cutaneous flaps are elevated and fasciotomies are made. A medial or lateral-based thighplasty can be performed to address any soft-tissue redundancies that may prevent a tight soft-tissue platform at closure. The fascia from the muscle is attached to the bone approximately 1.5 cm proximal to the distal bone with use of 0 Vicryl (Ethicon) suture. A purse-string stitch is utilized to further reinforce the myoplasty. If there is muscle herniation, utilize 0 Vicryl suture to perform side-to-side closure of the fascia over the underlying muscle. The cutaneous flap is thinned, and a suitable position for the aperture is identified on the superior flap. A 9-mm (for transfemoral) or 6-mm (for transhumeral) punch-biopsy tool is utilized to create the skin penetration site or aperture. With use of the abutment as a guide, the fat layer is removed to expose the undersurface of the dermis. The flap is then rotated into position atop the distal femur and bone graft with use of a series of 2-0 Vicryl sutures. The abutment is then inserted, and the internal threads are cleaned with an angiocatheter and saline solution. The threads are dried with use of cotton-tip applicators, and the abutment screw is tightened by hand (it is further tightened to 12 Nm at the first follow-up visit). The incision is closed with 2-0 Monocryl (Ethicon), 3-0 Monocryl, and a self-adhering mesh with 2-octylcyanoacrylate liquid adhesive. Topical nitroglycerin is placed around the aperture and sealed with an antimicrobial foam dressing bolster. The bolster dressing is held in place with use of a bolster that is shaped like a skateboard wheel. The patient avoids range of motion of the limb for 5 days to allow for healing of the aperture. Peripheral nerve management: Terminal neuromas are identified. Mixed sensory and motor nerve branches to neighboring muscle targets are identified with use of a handheld nerve stimulator and then are preserved. The terminal neuroma is transected to freshly bleeding fascicles, and the newly freshened nerve end is coapted to a newly divided nearby motor nerve of a deliberately de-innervated muscle motor branch for TMR. This step is performed with a single centralizing 8-0 suture and several 6-0 epineurial to epimysial sutures. For RPNI, the transected nerve is sutured to the harvested segments of muscle from the distal lower leg with use of 8-0 epineurial-to-epimysial sutures that are then reinforced with 4-0 Vicryl sutures. Vascularized RPNI is an alternative technique performed by tunneling the nerve through and embedding its ending in a neighboring muscle belly. Fibrin glue may also be utilized to reinforce the suture fixation. Closure: At the end of the above procedures, meticulous hemostasis is obtained with electrocautery and thrombin spray. The wound is copiously irrigated. One gram of vancomycin powder is placed into the wounds to decrease infection risk and the severity of heterotopic ossification. The residual limb is irrigated, a drain is placed laterally, and the soft tissues are closed sequentially in a standard layered fashion to prevent bursa formation. Alternative treatments include local soft-tissue rearrangement, such as thighplasty that allows for improvement in socket use. Additionally, multiple percutaneous implant systems exist for clinical use internationally. Each of these implants utilizes osseointegration biology to create a stable bone-implant interface for direct skeletal attachment while attempting to avoid complications such as infection and loosening. Direct skeletal attachment of a terminal prosthesis to a bone-anchored implant allows amputees who have previously had trouble with socket wear to experience improved function, mobility, and quality of life. Appropriate soft-tissue management is the most important part of any osseointegration procedure.A 2-stage procedure ensures a well-vascularized bone surface to accept a full-thickness skin graft and ensures that there is no relative motion at the skin-implant interface.The goal is to produce a stable soft tissue platform with minimal tissue movement at the skin penetration site (also called aperture or stoma). TMR = targeted muscle reinnervationRPNI = regenerative peripheral nerve interfaceRLP = residual-limb pain.

Femoroacetabular impingement syndrome significantly impacts athletic performance across various sports. Recent literature shows high overall return-to-sport rates (87%-93%) following surgical treatment, particularly with arthroscopic approaches, though return to preinjury performance levels varies (55%-83%). Athletes typically resume sport within 4 to 8 months postsurgery, with outcomes influenced by factors like symptom duration, rehabilitation adherence, and sport-specific demands. Professional athletes generally show better outcomes than recreational athletes, though many experience temporary performance declines in their first season back. Early intervention and sport-specific rehabilitation protocols appear crucial for optimal outcomes.

Hip fractures frequently cause severe pain and functional decline in adults presenting to emergency departments (EDs). Although intravenous (IV) opioids are widely used for pain control, their use may be limited by adverse effects, especially in patients with comorbidities or cognitive impairment. Ultrasound-guided femoral nerve block (FNB) offers a regional analgesic technique that may provide effective pain relief while reducing opioid-related complications. However, comparative randomized trials in the ED setting remain limited. In this single-center, randomized, double-blind clinical trial, adult patients with radiologically confirmed hip fractures were assigned to receive either ultrasound-guided FNB (20 mL 0.5 % bupivacaine) or IV fentanyl (1 μg/kg). To preserve blinding, patients in each group received a placebo injection mimicking the alternative treatment. Pain severity was measured at baseline and 20 min post-intervention using the Numeric Pain Rating Scale or the Pain Assessment in Advanced Dementia Scale (PAINAD), based on cognitive status. The primary outcome was change in pain score at 20 min. Secondary outcomes included rescue analgesia requirement within four hours and adverse events. A total of 104 patients were enrolled and randomized. The FNB group experienced greater median pain reduction compared to the fentanyl group (4 [IQR 3-5] vs. 2 [IQR 2-3]; median difference: 2, 95 % CI: 1-2). Rescue analgesia was required in 21.1 % of FNB patients versus 61.5 % in the fentanyl group. Adverse events were observed only in the fentanyl group, including nausea (23 %), dizziness (15 %), headache (9.6 %), and hypotension (5.7 %). No FNB-related complications were reported. Subgroup analysis showed consistent efficacy among cognitively impaired patients. FNB resulted in superior analgesia, fewer side effects, and lower need for rescue opioids compared to IV fentanyl. Additionally, FNB has shown an effective and safe pain control in patients with cognitive impairment compared to patients without cognitive impairment. ClinicalTrials.gov Identifier: NCT06862154.

To compare minimum 2-year outcomes of periacetabular osteotomy (PAO) with concomitant hip arthroscopy (HA) versus isolated HA with capsular plication in patients with borderline hip dysplasia (BHD). Data were retrospectively reviewed for patients who underwent surgery for femoroacetabular impingement in the setting of BHD between September 2008 and December 2021. Included patients had preoperative and minimum 2-year patient-reported outcome (PRO) scores. Patients who underwent staged PAO and HA comprised the PAO group. Patients who underwent isolated HA with capsular plication comprised the HA group. Matching occurred at a 1:1 ratio based on age, sex, body mass index, and Tönnis grade. A total of 74 hips were included. In the HA group, the mean postoperative modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale score were 90.32 ± 12.39, 89.46 ± 11.57, 81.47 ± 20.54, and 1.74 ± 1.89, respectively. In the PAO group, these PRO values were 90.69 ± 13.46, 91.59 ± 10.80, 82.20 ± 21.23, and 1.49 ± 1.94, respectively. The HA group met the minimal clinically important difference for the modified Harris Hip Score (89.19%), Nonarthritic Hip Score (86.49%), and Hip Outcome Score-Sports Specific Subscale (72.97%) at similar rates to the PAO group (89.19%, 86.49%, and 78.38%, respectively). The rates of achieving the patient acceptable symptom state for these PROs were 86.49%, 72.97%, and 67.57%, respectively, in the HA group and 86.49%, 78.38%, and 70.27%, respectively, in the PAO group. The rates of achieving maximal outcome improvement for these PROs were 81.1%, 75.68%, and 70.27%, respectively, in the HA group and 75.68%, 75.68%, and 70.27%, respectively, in the PAO group. Complications occurred in 10.81% of patients in the PAO group and 5.41% of those in the HA group (P = .67). PAO with concomitant HA and isolated HA with capsular plication in the setting of BHD yielded favorable and comparable outcomes. A high percentage of patients in both the HA and PAO groups reached clinically relevant thresholds, with similar rates of revision and conversion to arthroplasty at minimum 2-year follow-up. Level III, retrospective comparative study.