Bone & Joint Open最新文献

Aims: This study aimed to assess the preoperative predictors of individual outcomes after surgery for lumbar disc herniation (LDH).

Methods: We conducted a retrospective cohort study using patients treated from 1 January 2009 to 31 December 2019 at a single hospital. We included patients aged between 18 and 65 years who underwent surgery for the first time for a specific level of herniation, where surgery consisted of lumbar discectomy or sequestrectomy. Fusion or central decompression procedures were excluded. Data were collected from electronic patient registries and paper questionnaires, when available. The study outcomes included postoperative emergency department visits, readmission, length of stay, postoperative Oswestry Disability Index (ODI) score after four weeks, additional surgery due to reherniation within 60 days, and postoperative infection. Logistic and ordinal regression analyses were used to develop a predictive model.

Results: The data included 882 patients, with a mean age of 41 years, and 56% of whom were male. The model for the length of stay showed the best performance parameters with a moderate fit (pseudo-R² 0.134, area under the curve (AUC) 0.682) if BMI as a variable was omitted. The results with BMI as a variable were similar (pseudo-R² 0.144, AUC 0.681). Emergency operation (χ = 17.4, p < 0.001) and surgery on multiple intervertebral discs (χ = 8.3, p = 0.001, or for multiple levels: 9.29, 95% CI 1.96 to 44.02) were the most efficient variables in prediction in these models, respectively. The model for postoperative ODI score showed similar performance (pseudo-R² 0.170, AUC 0.651); the most important variable was sex (χ = 6.5, p = 0.011).

Conclusion: Length of stay in hospital after LDH surgery was best explained by emergency surgery and surgery on multiple intervertebral discs. The models created were moderate at best, and future research with larger datasets is needed.

Aims: This study evaluates the effect of an orthopaedic department's full transition from the use of a cemented polished tapered stem (PTS) to a cemented composite beam femoral component (CB) on periprosthetic fracture rates up to ten years after primary surgery.

Methods: A ten-year, prospective observational study was conducted on patients undergoing cemented hip arthroplasty. There were 542 patients in the PTS group and 534 in the CB femoral component group. There were 333 and 285 hemiarthroplasties in the PTS and CB groups, respectively. The mean age of participants was 82 years (SD 8.1). The majority of patients were classified as American Society of Anesthesiologists (ASA) grade III to IV and were female, comprising 71.2% in the PTS group and 74.5% in the CB group. Most patients, 827, underwent hip arthroplasty due to fractures (76.9%). Cognitive dysfunction was present in 27% (n = 142) to 29% (n = 159) of patients. Cox regression analysis was performed to adjust for confounders such as age, sex, ASA grade, and cognitive dysfunction.

Results: The PTS group had a higher rate of periprosthetic fractures (6.5%) compared with the CB group (1.3%) over the study period from November 2011 to December 2015. The reoperation rate for the PTS groups was 9.7% and 5.2% for the CB group, respectively. The dislocation rates were 4.9% for the PTS and 1.3% for the CB group. The periprosthetic joint infection rate was 3.5% in the PTS and 2.0% in the CB group. In the regression model female sex (HR 2.0, 95% CI 1.2 to 3.1), ASA grade (HR 3.2, 95% CI 1.1 to 8.3), cognitive dysfunction (HR 1.9, 95% CI 1.2 to 3.2), and the type of femoral component (PTS vs CB, HR 0.2, CI 0.1 to 0.3) were correlated with outcome.

Conclusion: CB femoral components were associated with a reduction in adverse events compared with PTS in cemented hip arthroplasty in an older population. These findings support the use of CB femoral components in order to improve patient outcomes and minimize complications in selected cases.

Aims: Computer vision, automated interpretation of radiological images using AI algorithms, has seen considerable recent interest in the domain of musculoskeletal disease. The use of routinely collected healthcare data provides a significant potential source of information but is often complex and disorganized. We therefore set out to develop an AI-driven preprocessing pipeline for radiological hip and knee images taken from a regional NHS Picture Archiving and Communication System (PACS) system.

Methods: De-identified Scottish regional imaging data was ingested and stored in a specialist platform specifically designed for safe healthcare AI development as part of the AI to revolutionize the patient Care pathway in Hip and knEe aRthroplastY (ARCHERY) project. The preprocessing pipeline consisted of initial identification and sorting of anteroposterior (AP) hip and knee images using a semisupervised learning approach, followed by isolation of images with, and without, orthopaedic implants present. Successful execution was assessed through analysis on designated test sets using standard performance metrics.

Results: A total of 27,550 radiological images were available for inclusion. This comprised 10,111 designated pelvis and 6,496 knee radiographs, from 2,571 and 1,981 patients, respectively. Testing revealed perfect model performance for the identification of AP hip and knee images using a semisupervised ResNet model with a squeeze and excitation block (100% accuracy; recall/precision/area under receiver operating characteristic curve (AUROC) and kappa all 1.00). Implant identification model performance using a Vision Transformer architecture was excellent for both the hip (accuracy 99.3%, recall 0.99, precision 0.96, AUROC 0.99, kappa 0.97, F1 score 0.97) and knee (accuracy 96.3%, recall 0.86, precision 0.97, AUROC 0.93, kappa 0.89, F1 score 0.91).

Conclusion: We demonstrate successful development of an AI-driven preprocessing pipeline for musculoskeletal images collated from routine NHS data sources. Use of such 'real-world' data is likely key to development of clinically useful healthcare AI algorithms.

Aims: Anterior cruciate ligament reconstruction (ACLR) is a widely performed procedure, yet the clinical and functional outcomes of soft-tissue autografts compared with allografts remain unclear. While previous studies have focused on surgical techniques and failure rates, few have systematically analyzed functional outcomes following ACLR. This study aimed to assess medium-term functional patient-reported outcome measures (PROMs) as the primary outcome and clinical outcomes as the secondary outcome following ACLR.

Methods: A systematic review and meta-analysis followed PRISMA guidelines and was pre-registered on the Prospective Register of Systematic Reviews (PROSPERO). A comprehensive search of databases, including PubMed, Ovid MEDLINE, and Embase, was conducted up to June 2024. Eligible studies included skeletally mature patients undergoing primary ACLR, with reported clinical and functional outcomes at minimum 24 months. Data were analyzed using random-effects models to calculate standardized mean differences (SMDs) and odds ratios (ORs).

Results: Of 5,292 studies screened, 12 were included, encompassing 1,038 patients. Of the functional scores, International Knee Documentation Committee (IKDC) outcomes (n = 930; SMD = 0.27; 95% CI 0.14 to 0.39; p < 0.001) and Tegner activity scores (n = 646; SMD = 0.18; 95% CI 0.03 to 0.34; p = 0.021) significantly favoured autografts, with Lysholm scores (n = 643; SMD = 0.14; 95% CI -0.02 to 0.29; p = 0.078) showing no significant differences between graft types. For clinical outcomes, Lachmann's grades significantly favoured allografts (n = 346; SMD = -0.56; 95% CI -1.09 to -0.03; p = 0.037). Revision rates and graft re-tear rates did not differ significantly between graft types.

Conclusion: The study found that autografts and allografts yield variable functional and clinical outcomes in ACLR at minimum 24-month follow-up, with autografts showing modest yet statistically significant advantage in IKDC and Tegner activity scores, but not in Lysholm functional score at and beyond 24 months. However, Lachmann's scores suggested better stability with allografts.

Aims: The Superior Transverse Anatomic Reconstruction (STAR) approach for total hip arthroplasty (THA) is a modified posterior approach that preserves the piriformis and the quadratus femoris. This approach provides improved short-term outcomes, but few studies compare patients undergoing THA with STAR to the posterolateral approach (PA). The goal of this study is to compare the short-term perioperative outcomes of STAR with PA and evaluate the learning curve associated with the STAR approach.

Methods: A total of 561 consecutive patients who underwent primary THA from 1 August 2023 to 30 April 2024 were included in the STAR approach cohort. Patients in the PA cohort underwent primary THA from 1 January 2017 to 31 July 2023 and were matched 1:1 with STAR patients by age, sex, BMI, and surgeon. Continuous outcomes (change in Hip disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR), estimated blood loss (EBL), length of stay (LOS), operating time, opioid use, morphine milligram equivalents, and binary outcomes (transfusion, readmission, complications) were assessed with multiple linear regression at six weeks post operation.

Results: STAR cohort patients used less postoperative opiods in the immediate postoperative period and at six weeks (MME 65 (SD 58) vs 107 (SD 126); p < 0.001, and 258 (SD 273) vs 364 (SD 308); p < 0.001, respectively) and experienced less EBL (127 ml (SD 55) vs 162 ml (SD 87); p < 0.001), lower operating time (82 minutes (SD 24) vs 90 minutes (SD 27); p < 0.001), and shorter LOS (0.9 days (SD 1.2) vs 1.7 days (SD 1.3); p < 0.001). There were no differences in the change in HOOS, JR score from pre- to postoperative, the rate of blood transfusion, readmission, or postoperative complications requiring revision.

Conclusion: The STAR approach is a piriformis and quadratus preserving approach that can be used for primary THA and without a learning curve. The benefits of the STAR approach may include a shorter operating time, less EBL, shorter LOS, and less postoperative pain requiring opioids. Longer-term follow-up in necessary to determine if the STAR approach continues to be associated with a lower overall revision rate compared with the conventional posterior approach.

Aims: To evaluate the feasibility, radiological accuracy, and early clinical outcomes of robotic-assisted conversion of partial knee arthroplasty (PKA) to total knee arthroplasty (TKA) using the ROSA system. Feasibility was defined as successful robotic registration and completion of the procedure using standard primary components without femoral components or augments.

Methods: A retrospective cohort of 23 consecutive conversions (medial or lateral unicompartmental and patellofemoral arthroplasties) was analyzed. The minimum follow-up was 12 months. Clinical outcomes were assessed with the Oxford Knee Score (OKS), visual analogue scale (VAS) for pain, and patient satisfaction. Radiological accuracy was evaluated by comparing planned with achieved component alignment (medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), and hip-knee-ankle (HKA)) using paired t-tests, two one-sided tests for equivalence (SD 1.5°), and Bland-Altman analysis.

Results: All cases were successfully registered with the robot and completed without femoral components or augments; 22 of 23 used standard primary components. The mean OKS improved from 17.2 (SD 5.5) to 40.0 (SD 5.0) and VAS pain decreased from 6.7 (SD 1.5) to 1.6 (SD 1.6) (p < 0.001). The mean absolute error between planned and achieved alignment was 0.8° for MPTA and 0.3° for LDFA, confirming accurate restoration, while HKA showed greater variability (mean bias 1.37°; limits -4.1° to 6.9°). One secondary patellar resurfacing was required; no other complications occurred.

Conclusion: Robotic-assisted conversion of PKA to TKA was feasible, bone-preserving, and resulted in significant clinical improvement at 12 months, with precise component alignment but slightly more variation in overall mechanical axis restoration.

Aims: Periprosthetic femoral fractures (PFFs) have emerged as the leading cause of reoperation following total hip arthroplasty (THA). This study aimed to evaluate patient-reported outcomes following operative management of PFFs with either fixation or revision arthroplasty around Exeter femoral components.

Methods: From a trauma database, 112 patients with operatively managed postoperative PFFs involving Exeter femoral componentss were identified from 2017 to 2023 (minimum one year follow-up). Patients who responded (89/112, 79%: mean age 73.3 years (SD 10.1; 44 to 92; 35/89 female) completed validated patient-reported outcome measures (PROMs), including the EuroQol five-dimension three-level questionnaire (EQ-5D-3L), Oxford Hip Score (OHS), and Lower Extremity Functional Scale (LEFS), to assess both recalled prefracture and follow-up status.

Results: Fractures had been treated with fixation in 65/89 (73%) or revision THA (RTHA) in 24/89 (27%). There were no differences in patient demographic details between fixation and RTHA groups. Compared to recalled prefracture status, patients displayed significant postoperative declines across all PROMs (p < 0.001). The median EQ-5D declined by 0.106 following fixation and by 0.204 following RTHA, with no difference between groups (p = 0.500). Median OHS and LEFs declined by 3 and 2.5 points, respectively, in patients treated with fixation and by 5 and 8 points after RTHA. Overall, clinically meaningful declines in OHS of > 8 points were experienced by 34.8% (31/89) of patients and 62% of patients expressed satisfaction, with no significant differences between operative strategies (p = 0.621).

Conclusion: Health-related quality of life and joint-specific function declined significantly following Exeter femoral component associated postoperative periprosthetic fractures with comparable outcomes following RTHA or fixation of appropriately selected cases. Despite functional declines, most patients were satisfied with their outcome.

Aims: Impaction bone grafting of the acetabulum to treat segmental and cavitary defects has been shown to be successful for uncemented acetabular revisions. Concerns remain about graft integration and implant stability when severe bone defects require large amounts of bone graft. This study evaluates bone graft density and implant migration in patients undergoing uncemented acetabular revision with screw fixation and impaction bone grafting using large bone graft volumes.

Methods: In this exploratory study, nine patients undergoing acetabular revision surgery were evaluated to assess bone graft volume, bone mineral density (BMD), and implant migration using dual-energy CT and CT-based micromotion analysis, performed directly postoperatively and at 6, 12, and 24 months of follow-up.

Results: The mean volume of bone graft used was 64.0 cm³ (SD 36.9) and the BMD in the graft increased from a mean of 317 mg/cm³ (SD 96.4) postoperatively to 466 mg/cm³ (SD 104.2) at 24 months (p = 0.002), while iliac BMD changed from 96 mg/cm³ to 111 mg/cm³ (p = 0.258). The median total translation at 24 months was 1.6 mm (IQR 0.82 to 2.7). Cups with graft volumes ≥ 50 cm³ exhibited slightly larger proximal translation than those with < 50 cm³, with median 1.5 mm (IQR 1.4 to 1.6) compared with 0.6 mm (IQR 0.30 to 1.2).

Conclusion: Uncemented acetabular revisions using large allograft volumes exhibit a migration pattern that is consistent with other revision techniques. Despite the large amount of bone graft used, bone density increases over time.

Aims: Bone and joint infection in children can result in bone and joint damage, sepsis, and even death. Diagnosis is informed by the history, examination, and a suite of tests, including blood markers, radiographs, ultrasound, and MRI. This study aimed to identify the communication needs of families during diagnostic assessment of bone and joint infection.

Methods: This was a qualitative study involving semi-structured interviews with children and families who had experienced diagnostic tests for bone and joint infection, and health professionals experienced in the care of affected children. A total of 21 families (four children; 21 parents) and 11 health professionals from 11 English and Welsh hospitals were interviewed. Data analysis was informed by thematic analysis.

Results: Families often felt highly anxious during diagnosis. Some described a disorderly diagnosis process, gaps or inconsistencies in information, and insensitive communication that contributed to their anxiety. Other families described more positive experiences, indicating how health professionals helped them feel prepared by providing an outline of timelines, the rationale for tests, and the potential need to adjust plans as new information became available. Participants recognized the importance of age-appropriate communication with children, and the involvement of play specialists in this process.

Conclusion: The findings demonstrate the intense anxiety families experience during assessment of bone and joint infection, particularly when they are left to make sense of uncertainties by themselves, or when communication is unclear. Health professionals can support families during diagnosis by attending to both the information they provide and how it is provided, while acknowledging the uncertainties of the diagnosis process. Specifically, families valued explanations of the rationale for different clinical investigations and their timing, and advance discussion of the next steps and possible outcomes of diagnostic testing. When test results became available, families were also helped by clear follow-up plans, including in situations when the results were inconclusive.

Aims: Changes in both native and dynamic joint line obliquity may influence the pathogenesis of osteoarthritis (OA) and subsequent development of coronal limb alignment deformity. This study aimed to characterize joint line alterations relative to OA severity and constitutional alignment.

Methods: A retrospective, cross-sectional analysis of 3,320 preoperative weightbearing long-leg radiographs from patients undergoing total knee arthroplasty was performed using deep learning software. OA severity was assessed using the Kellgren-Lawrence (KL) grading system. Constitutional alignment parameters included lateral distal femoral angle (LDFA), medial proximal tibial angle (MPTA), arithmetic hip-knee-ankle (aHKA) angle, and arithmetic joint line obliquity (aJLO). Tibiofemoral joint line alterations were assessed using the mechanical hip-knee-ankle (mHKA) angle, tibial joint line angle (TJLA), femoral joint line angle (FJLA), and joint line congruence angle (JLCA). The primary outcome was the difference in the TJLA relative to the aJLO across KL grades, stratified for the presence of medial or lateral compartment OA.

Results: Alterations in TJLA were observed in moderate (KL Grade 3) and severe (Grade 4) OA for medial and lateral compartment OA (both p < 0.001). In medial OA, the TJLA reversed orientation at Grade 3 from medially declined to medially inclined relative to aJLO. The aJLO maintained its constitutional orientation until Grade 4, when non-clinically significant changes (< 1°) were observed (p < 0.001). In lateral OA, the TJLA became more medially inclined in moderate and severe OA, while the aJLO remained stable. Significant changes in aHKA were observed in moderate and severe OA, indicating an apparent change in constitutional limb alignment (p < 0.001 for both medial and lateral OA).

Conclusion: The tibiofemoral joint line angle changes dynamically with OA progression, while the constitutional aJLO remains stable until advanced disease occurs. Understanding this distinction between constitutional and dynamic joint line orientation is important when communicating and studying outcomes related to knee alignment.