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

Background: Greater trochanteric pain syndrome (GTPS) is a painful condition that can impair a patient's quality of life. If nonoperative measures fail, progressively more invasive treatment options may be required. This clinical trial aimed to evaluate the effectiveness of ultrasound-guided leukocyte-rich platelet-rich plasma (LR-PRP) injections in the treatment of refractory GTPS caused by bursitis and/or gluteal tendinopathy.

Methods: An ethically approved, adequately powered, double-blinded randomized controlled trial (RCT) was conducted to evaluate the clinical outcomes in randomized LR-PRP and placebo groups using the International Hip Outcome Tool-12 (iHOT-12), a visual analogue scale (VAS) for pain, the modified Harris hip score (mHHS), the EuroQol 5-Dimensions (EQ-5D) questionnaire, and the presence or absence of complications. All injections were performed under ultrasound guidance into the trochanteric bursa and gluteus medius tendon.

Results: The final analysis included 79 patients (39 in the LR-PRP and 40 in the placebo group; 73 female and 6 male; all Caucasian). Both the LR-PRP and the placebo group generally had improvement from baseline that was maintained to 12 months. The only deterioration in scores compared to baseline was seen in the LR-PRP group for the iHOT-12 at 12 months, the EQ-5D index at 3 and 6 months, and the EQ-5D VAS at all follow-up time points. However, there was no significant difference between the 2 groups at any follow-up point (p > 0.05). A multivariable linear regression model, with adjustment for age, sex, body mass index, and preoperative baseline score, did not reveal any significant associations between iHOT-12 and EQ-5D score gains at 12 months and treatment.

Conclusions: This randomized trial found no significant difference in outcomes between LR-PRP and placebo for the treatment of greater trochanteric pain up to 6 months following the intervention. As a result, we do not support the routine use of PRP for the treatment of this condition.

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

Background: The financial and resource burden of management of olecranon fractures in the elderly is likely to increase with an aging population. There is limited evidence guiding treatment choice in this cohort. This study aimed to determine whether operative treatment of displaced olecranon fractures in elderly patients provides superior 12-month functional outcomes compared to nonoperative treatment.

Methods: A multicenter pragmatic randomized controlled trial was conducted across 24 hospitals in Australia and New Zealand. Patients aged ≥75 years presenting with an acute (within 14 days), displaced, closed, isolated olecranon fracture were included. Operative treatment involved reduction and stabilization using tension band wiring or plate fixation. Nonoperative treatment consisted of a sling for comfort and early movement as tolerated. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes were the DASH score at 3 months and pain, quality of life, Mayo Elbow Performance Score (MEPS), active elbow range of motion, and complication rate at 3 and 12 months. Data were analyzed based on an intention-to-treat principle, with sensitivity analyses using as-treated groups.

Results: Sixty participants were randomized, 27 to the operative group (mean age and standard deviation [SD], 83 ± 5.8 years; 22 [81%] females) and 33 to the nonoperative group (mean age, 82 ± 4.5 years; 23 [70%] females), with no significant difference in baseline characteristics. There was no significant difference (mean difference, -6.6; 95% confidence interval [CI] = -14.9 to 1.8; p = 0.12) in the mean DASH scores at 12 months (the primary outcome) between the operative (12.3 ± 14) and nonoperative (18.9 ± 18) groups. Although active elbow extension was significantly superior in the operative group at 12 months, no other secondary outcome differed significantly between groups at 12 months.

Conclusions: The study found no significant difference in DASH scores at 12 months between the operative and nonoperative groups. This supports nonoperative treatment as a reasonable option for displaced stable olecranon fractures in elderly patients.

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

Background: The purpose of this study was to report on 2-year results of vertebral body tethering (VBT), performed under a Food and Drug Administration protocol, to obtain insight into outcomes and complications.

Methods: Forty prospectively enrolled patients with adolescent idiopathic scoliosis (AIS) who had a Sanders score of ≤4 or a Risser score of ≤2 underwent VBT for curves between 40° and 70°. Surgical, radiographic, and patient-reported outcomes were reviewed at a minimum 2-year follow-up.

Results: Mean age at surgery was 13 (range, 10 to 16) years. The 40 patients were 90% female; 95% White, 2.5% other, and 2.5% unreported; and 92.5% non-Hispanic, 5% Hispanic, and 2.5% unreported. A mean of 8 (range, 5 to 12) levels were instrumented. Most patients were at Sanders 4 (65%) and Risser 0 (63%). Mean length of stay was 3 ± 1 days, estimated blood loss was 236 ± 158 (range, 25 to 740) mL, and operative time was 4.4 ± 1.4 hours. Mean correction of the major curve was 44% (range, 22% to 95%) on the 3-month standing radiograph, 49% at 1 year, and 46% (range, -10% to 93%) at 2 years. The mean major Cobb angle improved from 51° ± 8° (range, 40° to 70°) preoperatively to 27° ± 11° (range, 3° to 56°) at 2 years. Success at 2 years, defined by a Cobb angle of <35° and no reoperation, was seen in 30 patients (75%) and was associated with a mean Cobb angle of <35° on the first postoperative standing radiograph (p < 0.001). Twelve patients (30%) demonstrated improvement in the curve with growth. By 2 years, 2 (5%) of the patients underwent repeat surgery (1 release for overcorrection, 1 lumbar VBT for lumbar curve progression after thoracic VBT). The Scoliosis Research Society (SRS) satisfaction score improved 2 years following surgery (p < 0.001), but other SRS domains only remained stable over time. Beyond 2 years, 1 additional lumbar tether was required after thoracic VBT, 1 implant was removed, and 3 fusions were performed, for a 10% fusion rate and overall 20% reoperation rate at a mean of 3.8 ± 1.1 years of follow-up. The rate of cord breakage in the study population was 20%.

Conclusions: In skeletally immature patients treated in the U.S. under a prospective Investigational Device Exemption, there was a 75% rate of successful outcomes at 2 years. Most correction was obtained at the time of surgery, and inadequate intraoperative curve correction was associated with a higher Cobb angle on the first postoperative standing radiograph and failure by 2 years.

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

Background: Subtrochanteric proximal femoral fractures are generally treated with cephalomedullary nail fixation. We aimed to compare outcomes of subtrochanteric fracture fixation using a single lag screw (Gamma3 nail, GN) or dual lag screw (INTERTAN nail, IN) device.

Methods: The primary outcome measure was mechanical failure, defined as lag screw cut-out or back-out, nail breakage, or peri-implant fracture. Secondary outcomes included reoperation for mechanical failure, deep infection, or nonunion, and technical predictors of mechanical failure. Adult patients (≥18 years of age) with a subtrochanteric proximal femoral fracture treated at a single center were retrospectively identified using electronic records. All patients who underwent fixation using either a long GN (November 2010 to January 2017) or IN (March 2017 to April 2022) were included. Medical records and radiographs were reviewed to identify operative complications.

Results: A total of 587 patients were included: 336 in the GN group (median age, 82 years; 73% female) and 251 in the IN group (median age, 82 years; 71% female). The risk of mechanical failure was 3-fold higher in the GN group (adjusted hazard ratio [aHR], 2.87; p = 0.010), with screw cut-out (p = 0.04) and back-out (p = 0.04) only observed in the GN group. We observed a greater risk of reoperation for mechanical failure in the GN group, but this did not achieve significance (aHR, 2.02; p = 0.16). Independent predictors of mechanical failure included varus malalignment of >5° for cut-out (aHR, 17.43; p = 0.012), a tip-to-apex distance of >25 mm for back-out (aHR, 9.47; p = 0.019), and shortening of >1 cm for peri-implant fracture (aHR, 5.44; p = 0.001).

Conclusions: For older patients with subtrochanteric and reverse-oblique femoral fractures, the dual lag screw design of the IN nail was associated with a lower risk of mechanical failure compared with the single lag screw design of the GN nail.

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

Background: Weight optimization methods in morbidly obese patients with a body mass index (BMI) of ≥40 kg/m2 undergoing total knee arthroplasty (TKA) have shown mixed results. The purpose of this study was to evaluate the effect of perioperative use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in patients with a BMI of ≥40 kg/m2 undergoing primary TKA.

Methods: Using an administrative claims database, patients with morbid obesity undergoing primary TKA were stratified into GLP-1 RA use for 3 months before and after the surgical procedure (treatment group) and GLP-1 RA non-use (control group), and were matched on the basis of patient age, gender, diagnosis of type-2 diabetes mellitus, and Charlson Comorbidity Index (CCI). In addition, these groups were compared with a contemporaneous cohort of patients undergoing TKA with a BMI of 35.0 to 39.9 kg/m2. Outcomes including infection, complications, revision, and readmission were compared between the matched cohorts.

Results: There were significant decreases in the rates of 90-day periprosthetic joint infection (PJI) (1.0% compared with 1.8%; p = 0.037), any medical complications (10.6% compared with 12.7%; p = 0.033), pulmonary embolism (<0.4% compared with 0.6%; p = 0.050), and readmissions (5.3% compared with 8.9%; p < 0.001) in patients with a BMI of ≥40 kg/m2 who were taking GLP-1 RA versus the control group who were not. There were no differences in the 2-year rates of surgical complications (p > 0.05) between these groups. Compared with obese patients (BMI of 35.0 to 39.9 kg/m2), patients who had a BMI of ≥40 kg/m2 and were taking a GLP-1 RA did not have increased rates of infection or 90-day or 2-year complications (p > 0.05).

Conclusions: GLP-1 RA administration for at least 90 days prior to and after primary TKA in patients with a BMI of ≥40 kg/m2 was associated with reductions in the risks of 90-day PJI, any medical complications, and readmission. Additionally, the reduced complication rate that was achieved was similar to that of obese patients with a BMI of 35.0 to 39.9 kg/m2 undergoing TKA. Randomized clinical trials are needed to define the true effect of these agents on clinical outcomes following TKA.

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

Background: Studies investigating constitutional alignment across various grades of osteoarthritis (OA) are limited. This study explored the distribution of Coronal Plane Alignment of the Knee (CPAK) types and associated radiographic parameters with increasing OA severity.

Methods: In this retrospective cross-sectional study, 17,365 knees were analyzed using deep learning software for radiographic measurements. Knees were categorized on the basis of the Kellgren and Lawrence (KL) grade and CPAK type. Radiographic measurements were the hip-knee-ankle angle (HKAA), lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), arithmetic HKAA (aHKA), joint line obliquity (JLO), and joint line convergence angle (JLCA). Age-stratified analysis was performed to differentiate the impact of age on OA severity.

Results: A shift in the most common CPAK type from II to I was found with increasing KL grade (p < 0.05). Furthermore, there was a corresponding increase in LDFA and JLCA with increasing KL grade, while HKAA, MPTA, and aHKA decreased after KL grade 2. Age exhibited limited association with LDFA and MPTA, suggesting that OA severity is the dominant factor related to the CPAK distribution.

Conclusions: The study found a shift in CPAK type with worsening OA. It is possible that constitutional varus types are more susceptible to OA, or that their increased OA prevalence is related to anatomical changes. This analysis offers new insights into alterations in CPAK type that occur with OA and underscores the importance of understanding pre-arthritic anatomy when performing joint reconstruction.

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

Background: Previous research has estimated that over one-half of patients with orthopaedic trauma experience financial distress after the injury. However, it is unknown what proportion of patients lived under financial distress before the injury and, therefore, the causal effect of the injury on financial distress. This study examined changes in financial distress after the injury and factors associated with new post-injury financial distress.

Methods: A prospective cohort study was performed at a single academic trauma center, leveraging patients' 2-week recall of their pre-injury financial circumstances to permit a quasi-experiment design. Adult patients with a surgically treated lower-extremity fracture were included. The primary outcome was self-reported financial distress. Pre-injury financial distress was compared with financial distress in the 6 months after the injury. Multinomial logistic regression was used to identify factors associated with new financial distress after the injury.

Results: A total of 200 study participants were enrolled (median age, 42 years [interquartile range, 32 to 59 years]); 56% of patients were male. Financial distress was present in 40% of the study participants before the injury. The fracture was associated with an absolute increase of 19% (95% confidence interval [CI], 5% to 34%; p < 0.001) in the prevalence of financial distress. New post-injury financial distress was associated with working before the injury (odds ratio [OR], 6.9 [95% CI, 2.2 to 22]; p < 0.001) and earning <$70,000 per year (OR, 3.6 [95% CI, 1.2 to 10]; p = 0.02).

Conclusions: The findings suggest that 2 of 5 patients with a lower-extremity fracture had experienced financial distress before the injury. The prevalence of financial distress increased to 3 of 5 after the injury. Working and earning <$70,000 per year before the injury substantially elevated the patients' risk of new financial distress post-injury. Future efforts should target interventions to reduce financial distress in this at-risk population.

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

Background: Schatzker type-4 to 6 tibial plateau fractures most commonly occur when the distal femur is driven through the proximal tibial articular surface. This mechanism of injury can be equivalent to a knee dislocation and carries an increased risk of vascular injury. Our institution screens all Schatzker type-4 to 6 tibial plateau fractures with symmetric pulses for a vascular injury by measuring the ankle-brachial index (ABI). The purpose of this study was to describe our screening protocol and to determine its effectiveness at identifying vascular injuries.

Methods: Our screening protocol consisted of measuring the ABI of the injured limb for all Schatzker type-4 to 6 tibial plateau fractures that presented with symmetric pulses. An ABI of ≤0.9 prompted a computed tomographic angiogram (CTA) of the injured extremity. We retrospectively reviewed all Schatzker type-4 to 6 tibial plateau fractures from 2006 to 2023 that presented to a single level-I academic trauma center. We collected demographic, fracture, ABI, and vascular injury data and examined the effectiveness of our screening protocol.

Results: We identified 437 Schatzker type-4 to 6 tibial plateau fractures (mean age, 47 years; 59% male). There were 102 (23%) Schatzker type-4 fractures, 4 (1%) type-5 fractures, and 331 (76%) type-6 fractures. Eight fractures (2%) had a concomitant vascular injury; none of the vascular injuries were missed. An ABI of ≤0.9 had a positive predictive value of 0.250, and an ABI of >0.9 had a negative predictive value of 1.000. The sensitivity of the ABI was 1.000, whereas the specificity was 0.056. Thirty-seven fractures were in patients with an ABI of >0.9 at presentation who underwent a CTA of the injured limb for nonorthopaedic indications, with no vascular injuries identified.

Conclusions: The ABI has frequently been cited as a valuable screening tool for vascular injury after a knee dislocation, but its application to Schatzker type-4 to 6 tibial plateau fractures had not yet been described. Our results indicate that this screening protocol is both safe and effective, with no missed vascular injuries over a 17-year period.

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