Orthopaedic Surgery最新文献

Objective: The global aging population has led to a significant increase in hip fractures among elderly patients, posing substantial clinical challenges. While early surgical intervention is widely advocated, its impact on postoperative complications and mortality in super-aged (≥ 80 years) hip fracture patients remains controversial. This study aimed to evaluate the association between early surgery and clinical outcomes in this population.

Methods: We conducted a retrospective cohort study of patients aged ≥ 80 years who underwent hip fracture surgery at a single-center orthopedic trauma center between January 2018 and November 2021. Participants were stratified into early surgery (≤ 48 h post-admission) and non-early surgery groups. Propensity score matching (PSM) was employed to control for confounding variables. Primary outcomes included 30-day, 90-day, 1-year, and 2-year mortality rates. Secondary outcomes encompassed perioperative transfusion rates, postoperative complications, hospital length of stay (LOS), and hospitalization costs.

Results: After PSM, a total of 300 patients were included. Compared with the non-early surgery group, the early surgery group had lower 1-year (11.6% vs. 28.0%, p < 0.001) and 2-year (36.0% vs. 50.7%, p = 0.010) postoperative mortality rates, a lower perioperative blood transfusion rate (32.7% vs. 53.3%, p < 0.001), lower incidences of postoperative pneumonia (15.3% vs. 29.3%, p = 0.004) and delirium (14.0% vs. 36.0%, p < 0.001), a shorter length of stay [8.6 days (7.5, 11.2) vs. 11.6 days (9.7, 14.9), p < 0.001], and lower hospitalization expenses [54,336 ¥ (48,965, 64,532) vs. 61,616 ¥ (50,758, 74,484), p = 0.001]. The serum albumin level at discharge in the early surgery group was higher (33.4 (31.6, 35.4) vs. 32.6 (30.7, 34.9), p = 0.039). Kaplan-Meier survival curve analysis showed that the all-cause mortality rate in the non-early surgery group increased (Log Rank p = 0.0066). Multivariate Cox analysis showed that age, BMI, admission hemoglobin, and non-early surgery were risk factors for 2-year mortality.

Conclusion: Early surgical intervention for hip fractures in super-aged patients is associated with improved survival, reduced complications, and better resource utilization. These findings support the implementation of protocols to minimize preoperative delays in this vulnerable population.

Background: Identifying predictors of perioperative blood transfusion is essential for optimizing patient safety and perioperative blood management in total hip arthroplasty (THA). This Study aimed to identify perioperative factors independently associated with transfusion.

Methods: This retrospective study included all elective primary THA procedures performed between 2016 and 2023 at a certified Endoprosthetic Center. Demographic, clinical, laboratory, and operative variables were extracted. Total and hidden blood loss were calculated using the Nadler and Gross/Sehat formulas. A multivariable logistic regression model was fitted to identify independent factors associated with transfusion. Receiver operating characteristic (ROC) analyzes were performed for cup inclination and the 48-h hematocrit. Cutoff thresholds were derived using Youden's index, and combined decision rules (AND/OR) were evaluated.

Results: Among 39 predictors, three variables were independently associated with transfusion: cup inclination (OR = 0.89; p = 0.0003), 48-h hematocrit (OR ≈5.17 × 10^-48; p = 0.023), reflecting quasi-separation due to a near-deterministic threshold effect rather than a literal effect size, and reoperation (OR = 13.19; p = 0.049). The model demonstrated excellent discrimination (AUC = 0.931). Inclination alone showed negligible predictive value (AUC = 0.393). The 48-h hematocrit was a strong single predictor (AUC = 0.817) with a clinically meaningful threshold (< 0.28 L/L). Combined rules showed moderate performance; the OR rule was ineffective.

Conclusion: Early postoperative hematocrit is a robust and clinically actionable marker associated with transfusion risk in primary THA. Cup inclination reflects the surgical technique rather than direct transfusion risk, and reoperation likely indicates underlying perioperative complexity. Transfusion strategies should prioritize hematocrit-based evaluation rather than inclination-based thresholds.

Level of evidence: III-retrospective single-center observational cohort study.

Objective: A comprehensive understanding of the anatomical structure of the femur is crucial for optimizing surgical approaches and improving prosthesis design. This study aims to conduct a thorough analysis of the anatomical structure of the Chinese femur using statistical shape models (SSM), thereby providing scientific evidence for clinical applications.

Method: In this study, the femoral CT data of 209 Chinese patients were collected for detailed 3D reconstruction to obtain a 3D model of the bilateral femur. Advanced 3D model alignment techniques and dense homologous mesh mapping methods were used to ensure the high accuracy and consistency of the models. Three-dimensional statistical shape modeling (SSM) and principal component analysis (PCA) methods were used to extract the main patterns of femoral morphology changes and further analyze the femoral morphology changes. On this basis, the effects of gender differences on femur morphology were further comparatively analyzed.

Results: This study successfully established a statistical shape model of the femur in the Chinese population and extracted patterns of femoral shape variation through principal component analysis. The first six principal components shape change patterns accounted for 82.7%, 3.4%, 2.7%, 2.5%, 2.0%, and 1.5% of the total change, respectively. The model of variation for each of the first six principal components accounted for more than 1% of the total anatomical variance and together explained 94.8% of the variance. PC01, PC02, PC03, PC04, and PC06 exhibited significant differences between sexes (p < 0.05).

Conclusion: By constructing a three-dimensional statistical shape model of the femur, this study reveals individual morphological variations as well as differences based on sex. This model not only deepens the understanding of the anatomical morphology of the Chinese femur but also provides an important scientific basis for the optimization of clinical surgical plans and the improvement of prosthesis design.

Objectives: Total hip arthroplasty (THA) is the gold standard for treating Crowe IV developmental dysplasia of the hip (DDH). However, its long-term effects on lower limb alignment, gait biomechanics, and plantar force in these patients remain underexplored, which is discussed in this article.

Methods: We conducted a retrospective cohort study that included 43 DDH Crowe IV patients who underwent THA between February 2008 and October 2019 and a control group of 43 matched healthy volunteers. Postoperative functional outcomes and quality of life were assessed using the Harris Hip Score, KOOS, AOFAS, and WOMAC scores. Lower limb alignment parameters (MAD, HKA, aTFA, mLDFA, mMPTA, and FO), knee alignment (HMFC, HLFC), and ankle alignment (mLDTA, FACO, and TT) were measured preoperatively, postoperatively, and at follow-up. Gait analysis and plantar force measurements were performed at the final follow-up.

Results: With an average follow-up of 10.2 years, patients showed significant improvement in functional and quality of life scores compared to pre-surgery. Preoperatively, all patients had knee valgus and ankle varus on the affected side. After THA, most parameters showed reduced valgus alignment, except for HKA and HLFC. On the unaffected side, MAD, aTFA, and HKA indicated preoperative valgus, which was fully corrected post-THA. Gait analysis revealed restricted lower limb motion and abnormal plantar force distribution that persisted postoperatively in Crowe IV DDH patients.

Conclusions: THA partially corrected abnormal lower limb alignment, gait parameters, and plantar force distribution in DDH Crowe IV patients over long-term follow-up.

Objective: Posteriorly tilted femoral neck fractures have been extensively studied, whereas anteriorly tilted fractures remain largely unreported. This study aims to characterize the clinical features, radiographic patterns, and postoperative outcomes of femoral neck fractures with anterior tilt.

Methods: This retrospective cohort study included adult patients with OTA/AO type 31B femoral neck fractures who underwent internal fixation within 36 h at a single orthopedic center from 2018 to 2022 and had ≥ 24 months of follow-up. Tilt angle was assessed using preoperative radiographs and CT. Associations between fracture characteristics and postoperative outcomes were examined using univariate and multivariable logistic regression, with covariates selected according to clinical relevance and univariate significance.

Results: Among 212 patients (median age: 55 years, 53.3% male), anterior tilt fractures were more common in females (57.6%) and those with valgus malalignment (69.7%). Anteriorly tilted femoral neck fractures required a distinct reduction technique compared to conventional femoral neck fractures. Displaced fractures were significantly associated with a higher risk of femoral head necrosis (adjusted odds ratio [aOR] = 4.16; 95% confidence interval [CI] 1.29-13.42; p = 0.017). Stratified analysis revealed that anteriorly tilted femoral neck fractures with varus malalignment-herein referred to as the "anterior-flexion/adduction" subtype-were significantly associated with increased risk of femoral head necrosis (aOR = 7.19; 95% CI 1.12-46.18; p = 0.038).

Conclusions: Anterior tilt alone is not a general prognostic risk factor; however, fractures characterized by anterior tilt combined with varus alignment represent a high-risk subtype requiring careful preoperative recognition and treatment planning. Further prospective studies are needed to validate these findings.

Introduction: Pelvic reconstruction following bone sarcoma resection presents significant challenges. This study evaluates the outcomes of using 3D-printed custom-made prostheses and cutting guides to improve surgical precision and functional results in periacetabular reconstructions. Therefore, in this study, we asked: (1) What is the cumulative incidence of reoperation for any reason following pelvic resection and reconstruction with a custom-made 3D-printed prosthesis involving the acetabulum in patients with primary bone sarcoma, and what factors contribute to an increased risk of reconstruction failure? (2) Does the use of 3D custom-made cutting guides, combined with a 3D custom-made hemipelvis prosthesis, ensure the attainment of safe resection margins and allow for anatomical reconstruction with optimal fit at the bone-prosthesis interface? (3) What were the observed outcome scores as measured by the Musculoskeletal Tumor Society (MSTS) Score? Additionally, how do the type of resection and the volume of the primary bone sarcoma affect the outcomes in relation to the type of reconstruction?

Materials and methods: We conducted a retrospective review of 24 patients treated for primary bone sarcomas at our institution from January 2013 to December 2023. Each patient received a 3D-printed cutting guide and a 3D-printed custom-made prosthesis tailored to their specific anatomical needs, based on high-resolution imaging and computer-aided design.

Results: The use of custom-made 3D prostheses resulted in a reoperation rate of 46%, primarily due to complications such as infection and mechanical failures. Specific complications included an 8% rate of deep infections and mechanical issues like aseptic loosening. Local recurrence was observed in 5 patients (21%) at a median time of 5 months post-surgery. Despite these challenges, the average MSTS score was 83.7%, indicating a high level of functional recovery post-surgery.

Conclusions: The integration of 3D printing in pelvic reconstructions for bone sarcomas significantly enhances anatomical and functional outcomes. However, the technology demands further refinement to reduce complication rates. Continued advancements in 3D-printing materials and techniques are crucial to maximizing the benefits of this innovative approach in orthopedic oncology.

Objective: The selection of the lowest instrumented vertebra (LIV) is crucial in the surgical treatment of adolescent idiopathic scoliosis (AIS), particularly for thoracolumbar/lumbar curves. While traditional LIV selection strategies primarily rely on weight-bearing radiographs, the utility of supine imaging remains unclear. This study aimed to evaluate the feasibility of using the last touched vertebra identified in the supine position (LTV-supine) as the LIV for Lenke-5 AIS.

Methods: We conducted a retrospective review of Lenke-5 AIS patients who underwent posterior spinal fusion at Peking Union Medical College Hospital from 2010 to 2017, with a minimum 5-year follow-up. All patients underwent distal fusion to the LTV-supine. Radiographic parameters, including coronal and sagittal alignments and LIV-related measurements (LIV tilt, translation, rotation, and the subjacent disc angle), as well as the Scoliosis Research Society-22 (SRS-22) scores were compared across preoperative, postoperative, and final follow-up time points using the paired t-tests. Based on the positional relationship between the LTV-supine (the selected LIV) and the LTV-upright, patients were categorized into two groups: the short-fusion group (LIV at the first vertebra proximal to the LTV-upright) and the non-short-fusion group (LIV at LTV-upright). Radiographic parameters, SRS-22 scores, and the incidence of radiographic complications were compared between groups using independent t-test.

Results: Forty-five consecutive patients were included. Radiographic outcomes demonstrated significant improvements: the thoracolumbar/lumbar curve Cobb angle was corrected from 49.2° ± 10.8° preoperatively to 8.3° ± 5.6° at final follow-up (correction rate: 83.4% ± 10.9%; p < 0.05), and the coronal balance decreased from 20.3 ± 10.0 mm to 11.2 ± 6.9 mm (p < 0.05). All LIV-related parameters showed significant improvement at the final follow-up compared to preoperative values (p < 0.05). SRS-22 scores showed notable enhancements in self-image/appearance and mental health domains at final follow-up (p < 0.05). Fusion to LTV-supine saved 0.3 ± 0.5 distal vertebrae compared to the LTV-upright strategy (p < 0.05), resulting in shorter fusions in one-third of the patients (15/45). No significant differences were observed between the short-fusion (n = 15) and non-short-fusion (n = 30) groups in the final follow-up Cobb angle, correction rate, SRS-22 domain scores, nor in the incidence of adverse radiographic outcomes, such as sloped LIV, subjacent disc wedging, or coronal imbalance.

Conclusions: Supine imaging serves as a valuable adjunct for LIV selection in AIS. For Lenke-5 AIS, adopting the LTV-supine can yield comparable radiographic outcomes while potentially sparing additional distal segments in a subset of patients compared to the conventional upright radiograph-based approach.

Study design: Retrospective cohort study.

Objective: Mono-segmental thoracic and lumbar nonfusion (MTLN) can occur during spinal fusion in patients with ankylosing spondylitis (AS). This study aimed to summarize the clinical characteristics of AS-MTLNs, identify correlative variables for their occurrence, and propose a new classification system.

Methods: We retrospectively reviewed the clinical materials of patients with AS diagnosed between 2008 and 2023 in our institution, and 803 patients were included. The patients were divided into an AS-MTLN group (n = 155, 19.3%) and a non-AS-MTLN group (n = 648, 80.7%). Fifteen variables were collected, and the differences between groups were compared. The proposed new classification system included three main types and seven subtypes, including noninflammatory nonfusion (Type 1), inflammatory nonfusion without intervertebral destruction (Type 2), and inflammatory nonfusion with intervertebral destruction (Type 3).

Results: The prevalence of AS-MTLNs in descending order was lower thoracic spine (n = 84, 54.2%), lumbar spine (n = 62, 40.0%), and upper thoracic spine (n = 9, 5.8%). The computed tomography (CT) Hounsfield unit (HU) of the L1 vertebra was the only variable that showed a significant difference between two groups (p = 0.007), and the binary logistic regression model further confirmed its correlation with the occurrence of AS-MTLN (p = 0.005, odds ratio = 0.993, 95%). Regarding the new classification system, the AS-MTLN numbers of three types were (1) Type 1: 53 cases, 34.2%; (2) Type 2: 31 cases, 20%; (3) Type 3: 71, 45.8%. Type 1 was more common in lumbar spine (33 cases, 62.3%), Type 2 was more common in lower thoracic spine (20 cases, 64.5%), and Type 3 was also more common in lower thoracic spine (52 cases, 73.2%).

Conclusion: This study systematically described the clinical characteristics of AS-MTLNs and recognized that the CT HU of the L1 vertebra was correlated with the occurrence of AS-MTLN. The newly proposed classification system includes all types of AS-MTLNs, with value for clinical applications and popularization.

Objective: Hip fracture causes significant morbidity and mortality, necessitating the identification of biomarkers for risk stratification. This study aimed to evaluate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and incidence of postoperative complications and the 2-year all-cause mortality among hip fracture patients.

Methods: This retrospective cohort study involved 2595 patients aged from 45 years who received surgery for hip fracture between 2000 and 2022. Preoperative NT-proBNP levels were used to divide patients into three groups: low (< 123.27 pg/mL), moderate (123.27-349.93 pg/mL), and high (> 349.93 pg/mL) NT-proBNP group. Multivariate logistic regression and Cox proportional hazards models were used to evaluate the odds ratio (OR) for postoperative complications and the hazard ratio (HR) for mortality, after adjusting for potential confounders.

Results: Post-operative complications were reported in 171 (6.59%) patients with mortality of 226 (8.71%) during the 2-year follow-up. Compared to patients with low NT-proBNP group, the adjusted odds ratio for postoperative complications was 1.21 (95% CI 0.69-2.15) for those in the moderate NT-proBNP group and 2.33 (95% CI 1.35-4.03) for those in the high NT-proBNP group. Similarly, the adjusted hazard ratio for 2-year all-cause mortality was 1.51 (95% CI 0.91-2.50) for those in the moderate NT-proBNP group and 2.66 (95% CI 1.63-4.32) for those in the high NT-proBNP group. Higher pre-operative NT-proBNP levels were associated with an increased risk for postoperative complications and 2-year all-cause mortality (both p for trend < 0.001) among hip fracture patients. The results were consistent across various subgroup and sensitivity analyses.

Conclusion: Preoperative NT-proBNP is strongly associated with both postoperative complications and 2-year all-cause mortality among patients received hip fracture surgery. Higher levels of NT-proBNP before surgery may serve as a useful biomarker for risk stratification and guiding treatment decisions for this patient subpopulation.

Objectives: Wide surgical resection is the standard for primary malignant soft tissue and bone tumors, especially when the knee's intra-articular space is involved. Extraarticular Knee Joint Resection (EKJR) aims to remove the knee joint while preserving function. Considering the lack of literature present on these aspects, the purpose of this study is to analyze the data of a series of 30 patients affected by benign aggressive or malignant bone and soft tissue tumors who underwent EKJR with two different resection techniques.

Methods: The study involved all patients treated with EKJR for tumors between October 2006 and March 2023. Two EKJR techniques were analyzed: Type-A (complete extensor mechanism excision) and Type-B (patellar coronal osteotomy sparing the extensor mechanism). Clinical outcomes, tumor characteristics, and complications were compared between the two techniques. For statistical analyses, the Mann-Whitney test or Kruskal-Wallis test was employed to explore differences between continuous variables. Relationships between categorical variables were assessed using Pearson's Chi-square test or Fisher's exact test. Correlations were evaluated using Spearman's correlation coefficient. Survival analyses were conducted using the Kaplan-Meier method.

Results: The cohort included 13 males and 17 females (16 Type-A, 14 Type-B resections). Histologically confirmed intra-articular involvement was found in 26.7% of cases. Late complications included infections and amputations, more frequently in Type-A resections. The 5-year Local Recurrence-Free Survival was 91.5%, Metastasis-Free Survival was 39.5%, and Overall Survival was 47.9%. Type-A resections lead to higher complication rates, including amputation, due to extensive vascular and tissue disruption. Type-B resections, preserving the extensor mechanism, result in better functional outcomes and faster recovery despite some residual weakness.

Conclusion: EKJR is oncologically effective but carries significant functional and complication considerations. Type-B resection balances oncological safety and functional preservation, especially for benign aggressive tumors.