Bone & Joint Open最新文献

Aims: The ability of a surgeon to provide accurate visual estimates of intraoperative gaps during total knee arthroplasty (TKA) is not well understood. This study evaluated: 1) the accuracy of gap estimation in extension and in flexion; 2) the accuracy of gap estimation in the medial and lateral compartments, also in extension and flexion; 3) the differences in accuracy among surgeons; and 4) the frequency of clinically significant errors in gap estimation, defined as greater than 1 mm.

Methods: A posterior stabilized TKA was performed on seven cadaveric knees. Five fellowship-trained arthroplasty surgeons and one orthopaedic resident manually stressed each knee, and visually assessed the medial and lateral gaps in full extension and 90° of flexion. Gaps were objectively measured via a motion capture system. Gap estimation error was calculated as the difference between the surgeons' visual assessment and the measured gaps.

Results: Across all surgeons and knees, the mean gap estimation error was -0.4 mm (SD 0.7), with the majority (72%) of gaps being underestimated. Errors were greater in extension (-0.7 mm (SD 0.8)) than in flexion (-0.2 mm (SD 1.0)) (p < 0.001). Lateral gap error was less in flexion (-0.1 mm (SD 1.0)) than extension (-0.7 mm (SD 0.8)). Gap estimation error pooled for all assessments differed between surgeons, ranging from a mean error of -0.8 mm (SD 0.8) to 0.2 mm (SD 1.2) (p < 0.001). Clinically significant gap estimation errors (> 1 mm) occurred in 33% of assessments in extension and 26% in flexion (p = 0.315, not statistically different). The frequency of such errors varied by surgeon ranging from 18% to 42% (p = 0.370).

Conclusion: Surgeons tend to underestimate intraoperative gaps during TKA, particularly in extension. Clinically meaningful gap estimation errors (> 1 mm) occurred in up to 33% (26/78) of exams, supporting the need to enhance gap assessment accuracy.

Aims: The morphology of the distal femur varies widely among individuals and has a direct impact on knee joint mechanics and function. Understanding this variability is essential in improving surgical planning and implant design, especially as current tools and approaches move toward more anatomically informed and personalized technique. This study sought to characterize the major modes of morphological variability in the adult human distal femur and to examine morphometric differences based on sex and ethnicity.

Methods: A dataset of 1,686 distal femurs from a CT scan-based database was analyzed. A total of 15 morphometric dimensional and angular variables were assessed, and principal component analysis (PCA) was employed to identify key modes of variability. Morphological differences were examined between male and female femurs and among self-identified Caucasian and Asian ethnic groups.

Results: Five principal components (PCs) explained over 90% of the total variance in the original morphometric variables. Male and Caucasian femurs were significantly larger than female and Asian femora respectively (PC1; 58.3% variability explained). There were characteristic variations in the trochlear anatomy, with female and Asian femurs exhibiting more elevated anterior distal femora (PC2; 13.6%). Variability in the intercondylar notch (PC3 11%) and femoral aspect ratio (PC5; 4.9%) were sex-specific, with female femora having relatively less anteriorly elevated medial condyles, larger AP height, and relatively narrower in the AP direction than male femora. However, variability in the condylar twist angles (PC4; 6.2%) was not different based on sex or ethnicity.

Conclusion: This study characterized morphological variability in a large sample of distal femora, with key differences noted based on sex and ethnicity. The results support further consideration of this variability in knee arthroplasty implant design options and surgical approaches.

Aims: The optimal duration of antibiotic therapy in joint infection remains controversial, particularly as native joint septic arthritis and periprosthetic joint infection (PJI) differ substantially in pathophysiology, surgical management, and prognosis. While short antibiotic courses have been advocated for native joints after adequate drainage, prolonged therapy is often recommended for PJIs due to biofilm-related infection. This systematic review and meta-analysis of randomized controlled trials (RCTs) aimed to compare short- with long-course antibiotic strategies in both native and prosthetic joint infections.

Methods: Following PRISMA guidelines, a systematic search was performed across PubMed, Embase, Web of Science, and the Cochrane Library. Only RCTs were included. Studies were assessed for inclusion using predefined population, intervention, comparison, outcomes, and study (PICOS) criteria. Meta-analyses were conducted using MedCalc, and treatment failures were analyzed using odds ratios (ORs) with 95% CIs.

Results: A total of 12 RCTs involving 1,414 patients (native 577; periprosthetic 837) were included, with six eligible for meta-analysis. For PJIs, long-course therapy (≥ 12 weeks) significantly reduced treatment failure compared with short courses (OR 2.04, 95% CI 1.18 to 3.54; p = 0.011), while complication and mortality rates were similar. In contrast, for native joints, short-course therapy (≤ four weeks) achieved comparable infection control with prolonged regimens (OR 1.347; p = 0.565) when combined with adequate surgical drainage, particularly in paediatric populations. Surgical strategy (e.g. debridement, antibiotics, and implant retention vs one- or two-stage exchange) influenced outcomes more than antibiotic duration alone.

Conclusion: Optimal antibiotic duration should be individualized based on joint type and surgical approach. Short courses are effective for native septic arthritis with proper drainage, whereas PJIs generally require extended therapy due to biofilm-related complexity. We propose the Age-Joint-Immunity-Surgery-Sensitivity (AJISS) score as a decision-making tool to guide treatment duration, warranting prospective validation.

Aims: To propose feasible and systematic surgical therapeutic algorithms for treatment of spinal pseudarthrosis caused by ankylosing spondylitis (AS) with diverse radiological patterns and clinical manifestations.

Methods: Retrospective analysis of AS patients with pre-existing pseudarthrosis was performed. All the patients were divided into six groups according to surgical procedures: anterior debridement and fixation (ADF), posterior fixation (PF), posterior laminectomy and fixation (PLF), osteotomy through pseudarthrosis (OTP), osteotomy skipping pseudarthrosis (OSP), and osteotomy skipping pseudarthrosis with laminectomy (OSPL). Sagittal parameters, pseudarthrosis characteristics, kyphosis apex location, and neurological status were assessed.

Results: Overall, 87 patients were evaluated (mean follow-up of 42.02 months (24 to 180)). Three cases with pseudarthrosis involving anterior-to-middle column and absence of local kyphosis underwent ADF. Conversely, PF was selected for eight cases with mild regional kyphosis and three-column involving lesions. For cases with pre-existing neurological deficit but without global kyphotic deformity, PLF was used (six cases). OTP was adopted in 16 cases with global kyphosis and identical location of apex and lesions. An additional five patients also underwent osteotomy at pseudarthrotic site with lesions located below the apex and severe spinal stenosis. Regarding 45 cases with global kyphosis, normal neurological function and absence of spinal stenosis, OSP was performed. Addtionally, if neurological deficit was complicated in the aforementioned situation, OSPL was chosen (four cases). Radiological assessment confirmed solid bony union at pseudarthrotic sites in all cases.

Conclusion: Developing a reliable therapeutic algorithm for AS-associated pseudarthrosis depended on its distinct radiological features and clinical manifestations. Key factors including presence of local and/or global kyphosis, extent of lesions, anatomical relationship between kyphosis apex and pseudarthrosis, and preoperative neurological status should be thoroughly evaluated to provide personalized treatment strategies.

Aims: Almost half of distal radius fractures (DRFs) lose threshold alignment (i.e. instability) after closed reduction and immobilization. This study aimed to investigate surgeons' ability to estimate secondary displacement by addressing three questions: 1) What is the diagnostic accuracy of surgeons to estimate instability of DRFs on pre- and post-reduction radiographs?; 2) What is the diagnostic accuracy of surgeons to estimate instability of DRFs on post-reduction CT imaging?; and 3) What patient factors are associated with estimating instability?

Methods: We performed a scenario-based, randomized experiment with two distinct online surveys. In Part I, 116 members of the Science of Variation Group assessed radiographs of 20 initially displaced DRFs (11 'stable', nine 'unstable'), and estimated the loss of threshold alignment after closed reduction. Half viewed pre- and post-reduction radiographs, while half viewed only post-reduction radiographs. In Part II, 115 participants assessed 15 DRFs cases (six 'stable', nine 'unstable') to estimate loss of alignment. Half of the participants evaluated pre- and post-reduction radiographs, and half also received post-reduction CT imaging.

Results: In Part I, diagnostic accuracy for estimating loss of threshold alignment on pre- and post-reduction radiographs was 54% (95% CI 51% to 57%), similar to 55% (95% CI 46% to 62%) when only viewing post-reduction radiographs (p = 0.063). In Part II, the accuracy was 70% (95% CI 64% to 77%) with both radiographs and CT, compared with 67% (95% CI 61 to 67) with radiographs alone (p = 0.240). Patient factors associated with estimating instability were female sex and higher age.

Conclusion: Surgeons' ability to detect DRF instability on both pre- and post-reduction radiographs, as well as post-reduction CT-scans, was limited, reflecting a restricted value of probability estimates for clinical decision-making. Given suboptimal estimations of alignment loss, it seems prudent to monitor adequately reduced fractures during initial immobilization. Future studies should focus on aids that can overcome this limited accuracy.

Aims: Recent years have seen increased interest in tissue-sparing approaches for total hip arthroplasty (THA), which has led to innovations in implant design. Short cementless femoral components have gained traction, and the inclusion of a medial calcar collar to improve stability may offset the risk of fracture. The aim of this current study is to report short-term outcomes and survivorship for a novel design of femoral component across four non-designer centres.

Methods: All patients undergoing primary THA across four centres from July 2020 to January 2025 were eligible for inclusion. Data were collected prospectively in a national arthroplasty register, with planned routine follow-up at six months and two years. Patient-reported outcome measures were assessed using the Oxford Hip Score (OHS) and EuroQol five-dimension questionnaire (EQ-5D) score.

Results: A total of 517 components in 489 patients were included in the dataset: three patients (0.6%) died by final follow-up, and of the remaining 514 components, 512 components (99.6%) remain in situ. For the two patients (0.4%) undergoing revision surgery, indications for revision were periprosthetic fracture (PPF) and large postoperative haematoma. PPF affected four patients (0.8%) in total: two intraoperative events were managed with cables, and one Vancouver C fracture was managed with plate and screw fixation. The mean preoperative OHS was 17 (95% CI 16.3 to 17.7) with a mean postoperative score of 40.7 (95% CI 39.7 to 41.5), and mean preoperative EQ-5D score was 0.36 (95% CI 0.34 to 0.38), with a mean postoperative score of 0.80 (95% CI 0.78 to 0.82).

Conclusion: This novel femoral component demonstrates excellent functional outcomes which are reproducible across multiple surgeons in non-designer centres, with low rates of revision surgery and PPF.

Aims: We assessed whether symptomatic end-stage hip and knee osteoarthritis (OA) are associated with poorer sleep quality and to what extent pain mediates these associations.

Methods: We included symptomatic end-stage hip- and knee OA participants from the Longitudinal Leiden Orthopaedics Outcomes of Osteo-arthritis Study (LOAS) and participants without OA from the Netherlands Epidemiology of Obesity (NEO) study. We assessed sleep with the Pittsburgh Sleep Quality Index (PSQI) and performed linear regression analyses to investigate the associations between OA and sleep and the potential mediating effects of pain-related sleep disturbances.

Results: Overall, 54% of the 922 hip OA and 48% of the 870 knee OA patients reported poor sleep (total PSQI > 5), compared with 21% of the 1,165 participants without OA. Both hip and knee OA were associated with worse subjective sleep quality (adjusted difference: 0.37 points (95% CI 0.29 to 0.44) and 0.23 points (95% CI 0.15 to 0.32), respectively) and pain-related sleep disturbances (adjusted difference: 1.75 points (95% CI 1.64 to 1.86) and 1.50 points (95% CI 1.38 to 1.62), respectively). The association of hip and knee OA and worse subjective sleep quality was fully mediated by pain-related sleep disturbances (112% (95% CI 90 to 145) and 123% (95% CI 90 to 191), respectively).

Conclusion: Symptomatic end-stage hip and knee OA are strongly associated with worse sleep quality, which is fully mediated by pain-related sleep disturbances. While the cross-sectional design limits causal inferences, these findings underscore the importance of improving both sleep quality and pain management strategies in symptomatic end-stage OA patients. Addressing sleep disturbances, which are often overlooked in clinical practice, could significantly enhance overall health and quality of life of patients with end-stage hip- or knee OA.

Aims: Objective and precise measurement of patellar instability (PI) parameters on CT images is essential for accurate diagnosis and treatment planning. However, manual assessment is tedious, time-consuming, and prone to error. This study aimed to develop and validate a deep learning model that automatically quantifies PI parameters on axial knee CT images.

Methods: CT scans of 1,125 knees were randomly divided into training, validation, internal test, and hold-out test sets. A deep learning-based model was trained to localize anatomical landmarks and calculate nine PI parameters: lateral patellar tilt (LPT), bisect offset ratio (BSO), congruence angle (CA), sulcus angle (SA), trochlear groove depth (TGD), lateral trochlear inclination (LTI), trochlear groove-transepicondylar axis (TG-TEA) distance, tibial tubercle-trochlear groove (TT-TG) distance, and tibial tubercle-Roman arch (TT-RA) distance. Model performance was compared with manual measurements using the successful detection rate, mean absolute error (MAE), intraclass correlation coefficient (ICC), and Pearson correlation coefficient.

Results: The model accurately predicted landmark locations (MAE 0.84 to 2.72 mm) and PI parameters (ICC 0.826 to 0.997, r 0.705 to -0.994, p < 0.001) except for SA (ICC 0.701 to 0.862, r 0.542 to 0.744, p < 0.001). On the hold-out test set, the model outperformed inexperienced radiologists for LPT, CA, SA, LTI, and TGD (model: ICC 0.701 to 0.996, r 0.542 to 0.992, p < 0.001; radiologists: ICC 0.413 to 0.959, r 0.281 to 0.923, p < 0.05).

Conclusion: The proposed deep learning model reliably automates PI measurement, reducing the time and variability associated with manual assessment and mitigating dependence on examiner experience.

Aims: Medial tibial plateau fractures are frequently due to high-energy injuries, and can be difficult to manage and associated with a significant rate of postoperative complications. The goal of the study was to evaluate the epidemiology and results of management of medial tibial plateau fractures, and ascertain the factors influencing its outcomes.

Methods: The patient cohort comprised 143 patients with medial tibial plateau fractures treated over a period of six years. The groups were divided into medial tibial plateau fractures (B-type) and bicondylar tibial plateau fractures (C-type), according to the AO/Orthopaedic Trauma Association (OTA) classification and Schatzker classification. Patient information, including basic demographic details, duration of follow-up, mechanism of injury, comorbidities, management, and postoperative complications, was recorded. Analysis of these data was performed to evaluate outcomes and compare both fracture groups.

Results: Among 143 patients, C-type fractures (43%) were more often linked to high-energy trauma and comorbidities, though not statistically significant (p = 0.051). Both groups were primarily managed with open reduction and internal fixation (ORIF; C-type: 88.5%, B-type: 85.4%, p = 0.582), with 7% managed conservatively. Complications were comparable, but deep infections (13.1% vs 4.9%, p = 0.079) and compartment syndrome (3.3% vs 0%, p = 0.099) were more frequent in C-type. Although C-type fractures demonstrated a trend towards higher complication rates and more complex management, none of the observed differences reached statistical significance. The overall risk of complications did not vary significantly between the two groups (p = 0.639). Logistic regression revealed no significant predictors of fracture type (R² = 0.050).

Conclusion: The outcomes of isolated medial tibial plateau fractures are comparable with those of bicondylar tibial plateau fractures, with similar complication rates. Although C-type fractures tended to be associated with higher-energy trauma and increased risks of deep infection and compartment syndrome, these differences were not statistically significant. While medial plateau fractures are often assumed to be less severe, they can be considered injuries of similar complexity to bicondylar patterns.

Aims: Cementless fixation is an alternative to cemented unicompartmental knee arthroplasty (UKA), with several advantages over cementation. This study reports on the 16-year survival and ten-year clinical and radiological outcomes of the cementless Oxford Unicompartmental Knee Replacement (OUKR).

Methods: This is a prospective study of the first 693 consecutive cementless medial OUKRs implanted in New Zealand.

Results: The 16-year survival was 89.2%, with 46 knees being revised. The most common reason for revision was progression of arthritis, which occurred in 24 knees. The other reasons for revision included ten bearing dislocations, eight of which were for trauma, one ruptured anterior cruciate ligament (ACL), two tibial plateau fractures, three cases of polyethylene wear, three cases of aseptic loosening, one impingement secondary to overhang of the tibial component, one deep infection, and one revision where the reason was not stated. At the 14 to 16 years survey, the mean Oxford Knee Score (OKS) improved from 23.3 (SD 7.4) to 40.59 (SD 6.8). Radiological analysis at ten years demonstrated no evidence of femoral loosening, subsidence, or radiolucent lines. There were 42 complete radiolucent lines in zone 7 around the tibial baseplate, and ten incomplete radiolucent lines seen in other tibial zones with no progression.

Conclusion: The cementless OUKR is a safe and reproducible procedure with excellent 16-year survival, clinical outcomes, and radiological outcomes in the hands of surgeons who are independent of the design centre.