Bone & Joint Open最新文献

Aims: To compare the outcomes of robotic arm-assisted (rUKA) and manual unicompartmental knee arthroplasty (mUKA) during the learning phases of a single surgeon. Previous comparisons have not accounted for the recognized learning curve of mUKA.

Methods: This retrospective study included 109 patients (n = 37 rUKA, n = 72 mUKA) treated by a single surgeon during their learning curve at two centres during the same period. Inclusion criteria encompassed isolated medial compartment osteoarthritis with correctable deformities. Outcomes included patient-reported outcome measures (PROMs), implant positioning accuracy and precision, operating time, complications, and implant survival. Learning curves for both groups were analyzed using cumulative sum (CUSUM) analysis and breakpoint detection using piecewise linear regression.

Results: There were no differences in baseline characteristics between groups, except for American Society of Anesthesiologists (ASA) grade I, which was more prevalent in the rUKA group (p = 0.017). While both groups achieved similar PROMs postoperatively, the rUKA group showed greater improvement in Oxford Knee Score, being significantly more likely to achieve the minimal important change and/or patient-acceptable symptom state (p = 0.014). No learning curve was seen for PROMs in either group. The learning curve to competency for operating time was shorter for rUKA (13 cases) compared with mUKA (45 cases). rUKA demonstrated significantly higher accuracy and precision across all radiological planes (p ≤ 0.005) with no observable learning curve, whereas the mUKA group had a learning phase for implant positioning that took 25 cases, and competency was not reached until case 55. Tibial overhang occurred in eight mUKA cases and none in rUKA (p = 0.033). At a median follow-up of over six years, all four revisions occurred in the mUKA group, however this was not statistically significant (p = 0.141).

Conclusion: rUKA demonstrated a greater likelihood of achieving clinically meaningful outcomes, a shorter learning curve, and improved implant positioning accuracy and precision, compared with mUKA, when performed during the surgeon's learning phase.

Aims: High-quality clinical trials in adolescent idiopathic scoliosis (AIS) are needed to guide decision-making but progress is hindered by suboptimal selection of outcome measures. Identifying meaningful outcomes for consistent measurement across clinical trials and routine practice is critical. However, there is currently no understanding of which treatment outcome domains are considered important by adolescents, their parents, and healthcare professionals (HCPs). This study is the first to address this gap internationally.

Methods: This study represents the first stage of core outcome set (COS) development, following gold-standard guidance. A cross-sectional qualitative interview study with 40 participants (adolescents with AIS, their parents, and HCPs) was conducted. Semi-structured interviews were analyzed to identify and categorize important AIS treatment outcomes. Analytical rigour was ensured through coder agreement and stakeholder consultation.

Results: A total of 91 important outcome domains were identified; 53 outcome domains applying to both bracing and surgery, with 15 additional outcome domains for bracing only, and 23 additional outcome domains for surgery only. Of the 91 outcome domains, more than three-quarters (71/91, 78%) related to life impact, with smaller proportions relating to physiological/clinical outcomes (13/91, 14%), resource use (4/91, 4%), and adverse events (1/91, 1%).

Conclusion: The current study highlights treatment outcomes considered important by adolescents with AIS, their parents, and HCPs. These findings will inform outcome selection in clinical trials and routine practice, as well as facilitating an ongoing programme of research to develop a COS for evaluating treatment of AIS.

Aims: Fragility hip fractures are a growing concern, increasing year on year by just over 1%. These injuries carry high mortality rates and often result in poor functional outcomes, especially in frail patients. Early mobilization after surgery has been linked to better survival and shorter hospital stays. While Enhanced Recovery After Surgery (ERAS) protocols are well established in elective orthopaedics, their application in hip fracture care remains limited due to the frailty of this patient group.

Methods: The Cardiac Chair Position (CCP), originally used in cardiac surgery, may support early mobilization by helping patients transition from supine to standing. This study evaluated the impact of incorporating CCP into day 1 rehabilitation for hip fracture patients. This observational cohort study compared two six-month periods: June to November 2019 (standard care) and June to November 2021 (standard care plus CCP). A total of 270 patients aged 65 years and older with neck of femur fractures from low-energy trauma were included.

Results: Patients were divided into two groups: those who received standard bed exercises, and those who also used the CCP. Researchers collected data on day 1 mobility, postural hypotension, inpatient mortality, 30-day survival, length of hospital stay, and discharge destination. No significant differences were observed in postural hypotension, mortality, length of stay, or discharge destination. However, the CCP group showed significantly improved day 1 mobility with an increased proportion of patients demonstrating the ability to push-off the bed, stand and step, transfer to a chair, and walk.

Conclusion: Although CCP did not affect survival or hospital stay, it did enhance day 1 mobility. Given its simplicity, CCP is a promising addition to hip fracture rehabilitation. Further studies, including randomized trials and cost-effectiveness assessments, are needed to confirm its broader benefits. This research underscores the importance of early mobilization in elderly patients with fragility fractures.

Aims: Perthes' disease is a childhood hip condition that requires prolonged management, which often includes physiotherapy and education. Families and clinicians have highlighted a need for optimized self-management. The NON-STOP app was developed as a digital self-management intervention. The app incorporates exercises, educational content, and a reward system including a customisable avatar to motivate children to engage. This study assessed the usability and acceptability of the NON-STOP app in preparation for a definitive clinical trial.

Methods: A mixed-methods study was undertaken, involving an observational before-and-after study, with a nested focus group study. Children with Perthes' disease from three UK NHS centres were recruited and used the Non-Surgical Treatment of Perthes' (NON-STOP) app for six weeks. Quantitative data included app engagement metrics, quality of life and function (for follow-up completion rates), physical activity levels (Children's Physical Activity Questionnaire), and app-usability (Health Information Technology Usability Evaluation Scale (Health ITUES)). Following this, focus groups with participating families explored their experiences to explore usability and acceptability in more detail and also inform refinement of the app.

Results: A total of 31 children were recruited, 20 of whom completed post-trial data. Health ITUES scores demonstrated high usability, with particularly high scores in 'perceived ease of use' and 'usefulness'. Engagement was highest in the first three weeks, with a decline thereafter. Focus group participants described the app as more engaging than previous self-management tools (e.g. paper handouts), citing rewards, avatars, and a user-friendly layout as positive elements. Suggested improvements included further personalization and inclusion of videos in the education section of the app.

Conclusion: The NON-STOP app was found to be both usable and acceptable by children with Perthes' disease and their families. Insights from this study have informed further refinements to the app in preparation for its integration in Op NON-STOP trial, the first randomized clinical trial comparing surgical and non-surgical treatment in Perthes' disease.

Aims: Obesity is associated with increased surgical complexity and poorer postoperative outcomes after primary total hip arthroplasty (THA), yet its impact on revision THA remains unclear. This study evaluates the relationship between BMI and outcomes following revision THA.

Methods: We analyzed prospectively collected data from patients who consented to participation in the Perioperative Quality Improvement Programme (PQIP) research study. All patients undergoing revision THA from May 2018 to December 2022 were included. Patients were stratified into BMI categories, and outcomes were assessed using the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) at baseline, six, and 12 months postoperatively. Statistical comparisons were performed to evaluate differences in health-related quality of life (HRQoL) between BMI groups.

Results: Higher BMI was associated with lower preoperative EQ-5D scores. However, all BMI groups demonstrated significant postoperative improvement, with the greatest gains observed in patients with a BMI > 40 kg/m². At six and 12 months, HRQoL improvements were comparable across BMI groups, with no significant difference in long-term outcomes between those living with and without obesity.

Conclusion: Despite potentially increased intraoperative risks, high BMI patients experience meaningful functional improvement following revision THA. These findings challenge the rationale for BMI-based surgical restrictions, suggesting that high BMI alone should not be a contraindication for revision THA.

Aims: This study aimed to evaluate the effect of lipped liners (LL) on implant survival in primary total hip arthroplasty (THA), focusing on mechanical complications such as dislocation and aseptic loosening. Given the conflicting evidence on LL performance, we conducted a large-scale registry analysis to clarify their long-term safety and effectiveness compared to flat liners (FL).

Methods: We analyzed 15,222 primary THAs performed in 13,989 patients between 1 January 2000 and 31 December 2021, using data from the Emilia-Romagna Registry of Orthopaedic Prosthetic Implants (RIPO). Patients were allocated into two groups: 7,619 received FL and 7,603 received LL. The primary outcome was implant survival, with mechanical complications as key endpoints. Kaplan-Meier survival analysis and multivariate Cox regression were employed to assess the revision risk, adjusted for age, sex, type of stem fixation, femoral head material, and liner design.

Results: Overall, no significant difference in revision rates was observed comparing groups when all the causes of revisions were considered (log-rank p = 0.088); at 15 years, cumulative implant survival was 96.9% for FL and 96.4% for LL. Revisions for dislocation (28.2% vs 19.0%) and aseptic acetabular loosening (19.2% vs 13.8%) were more frequent in the LL group. When considering mechanical complications alone, 15-year survival was 98.9% for FL versus 98.1% for LL; a similar trend was observed at 20 years (98.9% vs 96.2%; p = 0.002). In multivariable analysis, LL use was independently associated with an increased hazard of revision (HR 1.53, 95% CI 1.05 to 2.23; p = 0.026).

Conclusion: LL use in THA is linked to a higher risk of mechanical complications and implant revision compared to FL. Although LL may provide enhanced stability in select cases, optimal outcomes depend on patient-specific factors and precise implant positioning, warranting a cautious approach to their widespread use.

Aims: Patients with rare diseases, such as osteosarcoma, often experience diagnostic delays, and clinicians have limited evidence-based guidelines to inform care. Time to treatment initiation (TTI), the interval between a definitive diagnosis and the start of a definitive treatment, has emerged as a prognostic factor for various cancer types. However, the relationship between TTI and survival outcomes has not been established in patients with high-grade, localized osteosarcoma. The aim of this study was to evaluate the impact of TTI on overall survival in patients with this aggressive bone sarcoma.

Methods: The National Cancer Database was queried from January 2004 to December 2021 to identify all patients with histologically confirmed high-grade, localized osteosarcoma. Survival analysis was conducted using Kaplan-Meier curves and Cox regression modelling controlling for clinically pertinent covariates.

Results: A total of 3,750 patients were included. Overall survival was significantly higher in the cohort that experienced TTI of less than four weeks in Kaplan-Meier analysis (p < 0.001, log-rank test). Univariable Cox regression conveyed a significant association between prolonged TTI and overall survival (hazard ratio (HR) 1.03 per week of delay; 95% CI 1.02 to 1.04; p < 0.001). However, there was no statistically significant relationship following multivariable Cox regression (HR 1.01; 95% CI 0.99 to 1.02; p = 0.284).

Conclusion: Prolonged TTI was associated with increased mortality, although not independently. Multicollinearity between covariates and TTI complicates the interpretation, making it unclear whether TTI itself or related factors primarily influence survival. Nevertheless, prompt treatment initiation remains a reasonable clinical goal to help minimize avoidable delays and support coordinated, timely care.

Aims: To explore the lived experiences of patients with periprosthetic infection in a mega prosthesis reconstruction after sarcoma resection.

Methods: Sarcoma patients treated between January 2016 and May 2023 with a surgical bone sarcoma resection and reconstruction with a mega prosthesis and a subsequent treatment for a deep periprosthetic infection, at one of three sarcoma centres in Sweden, were enrolled post-completion of sarcoma and infection therapies. Data were collected using semi-structured interviews, verbatim transcribed, and analyzed using a qualitative phenomenological method. The interviews were conducted from November 2022 to November 2023.

Results: Eight interviews, lasting 33 to 68 minutes, were conducted. Seven participants (three females) with a mean age of 29 years (22 to 59), were interviewed once. One participant experienced a reinfection, necessitating a second interview. The study's findings indicate that participants lacked awareness of periprosthetic infection risk and severity, with concerns regarding tumour recurrence outweighing these risks. Infection treatment was described as more tolerable than the tumour treatment. Despite positive previous encounters with medical personnel, the hospital, the same as for the cancer treatment, evoked negative emotional responses. All participants reported a decline in joint function post-infection compared with pre-infection, and all experienced changes in their self-perception.

Conclusion: Improvements are needed in the communication of potential complications related to bone reconstruction; patients exhibit significant anxiety regarding tumour recurrence; and the patient's relationship with medical personnel and family significantly influences their ability to manage further extensive medical treatment.

Aims: Although therapies for rheumatoid arthritis (RA) have advanced, it remains unclear whether RA continues to carry an elevated risk for revision surgery after total hip arthroplasty (THA). Therefore, the aim of this study was to compare revision rates of patients with RA undergoing primary THA with those of patients with osteoarthritis (OA).

Methods: This observational cohort study was based on data from the German Arthroplasty Registry from November 2012 to March 2024. Primary THA procedures in RA patients were compared with those in OA patients. Cumulative revision rates over nine years were calculated using Kaplan-Meier estimations. Differences by type of revision (major/minor), cause (aseptic/septic), and implant fixation were tested using the log-rank test and multivariate Cox proportional hazard analyses.

Results: A total of 12,750 THAs in RA patients were compared with 528,435 in OA patients. Overall, 17,434 revisions were recorded (RA 604; OA 16,830). At nine years, higher cumulative revision rates were observed in RA patients for major (5.1% vs 3.1%; p < 0.0001) and minor revisions (1.7% vs 1.1%; p < 0.0001), regardless of cause. After adjustment for demographic characteristics and fixation type, RA was associated with increased risk of major (hazard ratio (HR) 1.48, 95% CI 1.34 to 1.63; p < 0.001) and minor revision (HR 1.62, 95% CI 1.40 to 1.88; p < 0.001). In RA patients, hybrid fixation was linked to lower major revision risk compared with uncemented fixation (HR 0.56, 95% CI 0.42 to 0.74; p < 0.001). Cementless fixation predominated in both groups (RA 69%, OA 78%).

Conclusion: An increased risk of major and minor revision after primary THA was found in RA patients compared with OA patients, independent of cause. Although hybrid fixation was linked to lower major revision risk than uncemented fixation, cementless fixation remained the most common method in RA patients.

Aims: Postoperative periprosthetic femoral fractures (POPFF) are a recognized complication following total hip arthroplasty (THA). The primary aim of this study was to compare the survivorship and POPFF rate of a composite beam (CB) femoral component with a polished taper slip (PTS) femoral component as part of THA.

Methods: Between January 2008 and December 2013, 3,198 consecutive THAs were performed using either the Exeter V40 (PTS, n = 2,177) or the Lubinus SP II (CB, n = 1,021) femoral component within two separate arthroplasty centres. Patient demographic details and operative details were collected prospectively. Patient records and radiological archives were reviewed at minimum ten years following surgery to identify subsequent revision surgery, dislocation, or POPFF.

Results: At a median 12-year follow-up (IQR 11.1 to 12.7), 2,214 patients (2,214/3,198) remained alive. The mean patient age at surgery was 67.6 years (SD 11.2). Analysis of all-cause THA failure demonstrated PTS femoral component survivorship of 96.6% (95% CI 95.8 to 97.4) while CB femoral component survivorship was 99.5% (95% CI 98.7 to 100) (log rank (Mantel Cox) p = 0.001) at ten years. POPFF accounted for 13% of reoperations in the CB group (n = 2/16) compared with 48% of reoperations (n = 34/71) in the PTS group (p = 0.001), where 85% of POPFFs underwent ORIF. Multivariate analysis found that PTS femoral components (hazard ratio (HR) 5.17, p = 0.003) and older patient age at surgery (HR 3.18, p = 0.002) were associated with an increased risk of POPFF. Risk of dislocation was higher in the CB group (relative risk 2.1, 95% CI 1.0 to 4.3; p = 0.030).

Conclusion: PTS femoral components were associated with a significantly higher risk of POPFF. When including patients treated with open reduction and internal fixation (ORIF), this resulted in reduced PTS survivorship compared with CB femoral components at follow-up. This should be considered alongside the established benefits of PTS femoral components when used in THA.