Journal of Bone and Joint Surgery, American Volume最新文献

Background: To date, no studies have evaluated the longevity of calcaneal lengthening osteotomy (CLO) in patients with cerebral palsy (CP) and pes planovalgus. This study aimed to explore the changes in foot alignment following CLO in patients with CP, utilizing both radiographic evaluations and dynamic foot-pressure assessments.

Methods: A retrospective study of 282 feet in 180 ambulatory patients was performed. The mean patient age at the surgical procedure was 8.9 ± 2.6 years. The mean follow-up period was 8.0 ± 4.3 years, and the mean age at the final follow-up 16.9 ± 4.4 years. Weight-bearing radiographs at 3 separate time points (before the surgical procedure, 6 months postoperatively, and at the final follow-up) were used. The feet were classified as corrected, undercorrected, or overcorrected on the basis of the radiographic parameters.

Results: At the final follow-up, we classified 98 feet (34.8%) as corrected, 58 (20.6%) as undercorrected, and 126 (44.7%) as overcorrected. Foot-pressure analysis demonstrated that the undercorrected feet had higher relative vertical impulses in the medial forefoot and medial midfoot than in the other groups, whereas the overcorrected feet had higher impulse in the lateral midfoot. There were no significant differences in preoperative radiographic parameters between the 3 groups, except for the calcaneal pitch angle. At 6 months after the surgical procedure, we classified 181 feet (64.2%) as corrected, 58 (20.6%) as undercorrected, and 43 (15.2%) as overcorrected. However, 53.6% of initially corrected feet changed to being undercorrected or overcorrected during further follow-up, 43.1% of the undercorrected feet became corrected or overcorrected, and 16.3% of the overcorrected feet became corrected. A younger age at the surgical procedure and lower naviculocuboid overlap at 6 months after the surgical procedure were the risk factors for overcorrection.

Conclusions: Although CLO is an effective method for correcting planovalgus foot deformities and enhancing foot-pressure distribution, the extent of correction observed early after the surgical procedure was not necessarily sustained over the follow-up period in individuals with CP. Furthermore, our findings highlight a noticeable tendency toward the overcorrection of the deformity, as evidenced by increased pressure exerted on the lateral midfoot.

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

Background: Although delays in musculoskeletal care in low- and middle-income countries (LMICs) are well documented in the open fracture literature, the impact of surgical delays on closed fractures is not well understood. This study aimed to assess the impact of surgical delay on the risk of infection in closed long-bone fractures treated with intramedullary nailing in LMICs.

Methods: Using the SIGN (Surgical Implant Generation Network) Surgical Database, patients ≥16 years of age who were treated with intramedullary nailing for closed diaphyseal femoral and tibial fractures from January 2018 to December 2021 were identified. Infection was diagnosed based on the assessment by the treating surgeon. A logistic regression model, adjusting for potential confounders, was used to analyze the association between delays to surgery (in weeks) and infection.

Results: Of the 9,477 closed fractures that were included in this study, 58% were femoral fractures and 42% were tibial fractures. The mean age was 35 years, and 76.2% of the patients were men. The mean delay to surgery was 10.5 days, and the median delay to surgery was 6 days. The overall infection rate was 3.1%. The odds of developing an infection increased by 9.2% with each week of delayed surgical treatment (odds ratio,1.092; 95% confidence interval, 1.042 to 1.145). Increasing delays were also associated with longer surgery duration and higher rates of open reduction.

Conclusions: Surgical delays in LMICs were associated with an increased risk of infection in closed long-bone fractures. This study quantified the increased risk of infection due to delays in receiving care, highlighting the importance of timely surgery for closed fractures in LMICs.

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

Background: Periprosthetic joint infections (PJIs) are a major complication of total joint replacement surgeries. This study investigated the enhancement of mechanical properties and antibiotic release in ultra-high molecular weight polyethylene (UHMWPE) through the encapsulation of submicron gentamicin sulfate (GS) particles, addressing the critical need for improved implant materials in orthopaedic surgery, particularly in managing PJIs.

Methods: The present study involved embedding submicron GS particles into UHMWPE flakes at concentrations of 2% to 10% by weight. These particles were prepared and blended with UHMWPE flakes using a dual asymmetric centrifugal mixer, and the blends were consolidated. The present study compared the mechanical properties and antibiotic release rate of UHMWPE containing submicron, medium (as-received), and large (resolidified) GS particles.

Results: UHMWPE samples with submicron GS particles exhibited superior mechanical properties, including higher ultimate tensile and Izod impact strengths, compared with samples with larger particles. Additionally, the submicron GS UHMWPE blends demonstrated a markedly higher and more sustained antibiotic release rate.

Conclusions: This study highlights the potential of incorporating submicron GS particles into UHMWPE to drastically improve the feasibility of using these therapeutic and functional spacer implants in expanded indications.

Clinical relevance: By offering improved mechanical strength and effective, prolonged antibiotic release, this innovative material could be used as a spacer implant to reduce the considerably high morbidity and mortality associated with PJIs. This material has the potential to prevent PJIs not only in high-risk revision cases but also in primary total joint arthroplasty procedures.

Background: Limb-salvage surgery for malignant bone tumors can be associated with considerable perioperative blood loss. The aim of this randomized controlled trial was to assess the safety and efficacy of the intraoperative infusion of tranexamic acid (TXA) in children and adolescents undergoing limb-salvage surgery.

Methods: All participants were <18 years of age at the time of surgery and diagnosed with a malignant bone tumor of the femur that was treated with resection and reconstruction with a megaprosthesis. Exclusion criteria included anatomic locations other than the femur, reconstruction with a vascularized fibular graft, and a previous history of deep venous thrombosis, coagulopathy, or renal dysfunction. Participants were randomly allocated to either the TXA group (a preoperative loading dose infusion of 10 mg/kg of TXA followed by a continuous infusion of 5 mg/kg/hr until the end of surgery) or the placebo group (the same dosage but with TXA substituted with an infusion of normal saline solution). Intraoperative and perioperative blood loss were calculated with use of the hemoglobin balance method. Perioperative blood loss at postoperative day 1 and at discharge from the hospital were calculated. The total volumes of blood transfused intraoperatively and postoperatively were recorded. A statistical comparison between the groups was performed for blood loss and blood transfusion as well as for possible independent variables other than TXA, including age, body mass index, histopathologic diagnosis, tumor volume, preoperative hemoglobin level, type of resection, and the duration of surgery.

Results: A total of 48 participants, with a mean age of 12.5 ± 3.44 years (range, 5 to 18 years) and a male-to-female ratio of 1.18, were included. All participants were Egyptians by race and ethnicity. There were no minor or major drug-related adverse events. There was no significant difference between the groups with respect to intraoperative blood loss (p = 0.0616) or transfusion requirements (p = 0.812), but there was a significant difference in perioperative blood loss at postoperative day 1 (p = 0.0144) and at discharge from the hospital (p = 0.0106) and in perioperative blood transfusion (p = 0.023).

Conclusions: TXA can be safely infused intraoperatively in children and adolescents undergoing limb-salvage surgery, and it contributes significantly to the reduction of perioperative blood loss and transfusion requirements.

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

Background: The aim of this study was to develop an accurate and clinically relevant prediction model for 30-day mortality following hip fracture surgery.

Methods: A previous study protocol was utilized as a guideline for data collection and as the standard for the hip fracture treatment. Two prospective, detailed hip fracture databases of 2 different hospitals (hospital A, training cohort; hospital B, testing cohort) were utilized to obtain data. On the basis of the literature, the results of a univariable analysis, and expert opinion, 26 candidate predictors of 30-day mortality were selected. Subsequently, the training of the model, including variable selection, was performed on the training cohort (hospital A) with use of adaptive least absolute shrinkage and selection operator (LASSO) logistic regression. External validation was performed on the testing cohort (hospital B).

Results: A total of 3,523 patients were analyzed, of whom 302 (8.6%) died within 30 days after surgery. After the LASSO analysis, 7 of the 26 variables were included in the prediction model: age, gender, an American Society of Anesthesiologists score of 4, dementia, albumin level, Katz Index of Independence in Activities of Daily Living total score, and residence in a nursing home. The area under the receiver operating characteristic curve of the prediction model was 0.789 in the training cohort and 0.775 in the testing cohort. The calibration curve showed good consistency between observed and predicted 30-day mortality.

Conclusions: The Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30) was developed and externally validated, and showed adequate performance in predicting 30-day mortality following hip fracture surgery. The RHMP-30 will be helpful for shared decision-making with patients regarding hip fracture treatment.

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

Abstract: The Centers for Medicare & Medicaid Services (CMS) recently introduced mandatory reporting of patient-reported outcomes (PROs) following primary, elective total joint arthroplasty (TJA) procedures. This article explores the implications and implementation challenges of this policy shift in the field of orthopaedic surgery. With a review of the existing literature, we analyze the potential benefits and limitations of PROs, discuss the role of CMS in health-care quality improvement initiatives, explain the predicted difficulties in the successful implementation of this new mandate, and provide recommendations for the successful integration of the reporting of PROs in clinical practice.

Background: Joint arthroplasty effectively treats osteoarthritis, providing pain relief and improving function, but postoperative venous thromboembolism (VTE) remains a common complication. This study therefore assessed the effectiveness and safety of aspirin compared with oral anticoagulants (OACs) for VTE prophylaxis after joint arthroplasty.

Methods: A systematic review and meta-analysis was performed by searching PubMed, Embase, the Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) up to May 14, 2024, that compared the effect of aspirin versus OACs on VTE prophylaxis in adults undergoing joint arthroplasty. Data extraction followed the PRISMA guidelines. Two independent researchers conducted the literature searches and data extraction. A random-effects model was used to estimate effects. The primary outcome was the incidence of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE); secondary outcomes included bleeding, wound complications, and mortality.

Results: The meta-analysis included 11 RCTs with a total of 4,717 participants (55.1% female) from several continents. The relative risk (RR) of VTE following joint arthroplasty was 1.11 (95% confidence interval [CI], 0.93 to 1.32) for aspirin compared with OACs. Similar results were observed for DVT (RR, 1.12; 95% CI, 0.90 to 1.40) and PE (RR, 1.18; 95% CI, 0.51 to 2.71). There were no significant differences in the risks of bleeding, wound complications, or mortality between patients receiving aspirin and those receiving OACs. Subgroup analyses considering factors such as study region, type of joint surgery, type of VTE detection, year of publication, use of mechanical VTE prophylaxis, aspirin dose, type of OAC comparator, study quality, and funding also found no significant differences in VTE incidence between aspirin and OACs. The overall quality of evidence for VTE and DVT outcomes was high.

Conclusions: Based on high-quality evidence from RCTs, aspirin is as effective and safe as OACs in preventing VTE, including DVT and PE, after joint arthroplasty, without increasing complications.

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

Background: The clinical interpretation of patient-reported outcome measures (PROMs) after anterior cruciate ligament (ACL) reconstruction (ACLR) can be challenging. This study aimed to establish the clinical relevance of PROMs by determining maximal outcome improvement (MOI) thresholds at mid-term follow-up after primary ACLR.

Methods: A total of 343 patients who underwent primary single-bundle ACLR using hamstring tendon autograft at our institute were included. Patients were queried with a 2-option anchor question regarding satisfaction with their current knee symptom state. The MOI of a PROM was calculated for each patient as the percentage of improvement normalized by the maximal possible improvement. The MOI threshold for each PROM was determined as the optimal cutoff value for predicting patient satisfaction based on receiver operating characteristic curve analysis. Multivariable logistic regression analyses were performed to identify predictors of achieving these thresholds. Subgroup analyses that stratified the time from injury to surgery within the cohort were performed, and MOI thresholds were recalculated within each of these subgroups. The PROMs evaluated in this study were the modified Lysholm Knee Score and the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC) score.

Results: The calculated MOI threshold was 35.1% for the Lysholm score and 46.7% for the IKDC score. A longer time from injury to surgery reduced the odds of achieving the MOI threshold for the Lysholm score (odds ratio [OR] per time bracket = 0.7114, p < 0.0001) and IKDC score (OR = 0.8038, p = 0.0003). Male sex was associated with higher odds of achieving the MOI threshold for the IKDC score (OR = 1.9645, p = 0.0143). For patients with chronicity of ≤6 months, the MOI threshold was 35.1% for the Lysholm score and 57.9% for the IKDC score, and for patients with chronicity of >6 months, the thresholds were 24.5% and 27.1%, respectively.

Conclusions: The calculated MOI thresholds for the Lysholm and IKDC scores at mid-term follow-up after primary ACLR were 35.1% and 46.7%, respectively. Greater chronicity of the ACL injury was associated with lower odds of achieving the MOI thresholds for the PROMs at mid-term follow-up.

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