Bone & Joint Open最新文献

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.

Aims: Understanding the factors contributing to pain and function limitation in knee osteoarthritis (OA) is crucial to optimize the individual patient's management. This study aimed to quantify the role of cartilage degeneration, as well as other intra- and extra-articular factors, in determining clinical symptoms in patients with advanced knee OA.

Methods: Subjects were selected from the Osteoarthritis Initiative database based on the criteria: Kellgren-Lawrence (KL) grades 3 to 4 and baseline clinical and MRI data. The analyzed data were: demographic parameters, KL grade, subchondral bone without cartilage coverage, anterior knee pain due to patellar quadriceps tendinitis, effusion, anserine bursa tenderness, meniscal extrusion, Hoffa's inflammation, bone marrow lesions (BMLs), visual analogue scale for pain, Western Ontario and McMaster Universities osteoarthritis index (WOMAC) total score, and WOMAC pain subscale.

Results: The multivariate analysis on 233 knees demonstrated that VAS was influenced by the percentage of femoral subchondral bone without cartilage coverage (p < 0.001/η² = 0.058), patellar quadriceps tendinitis (p = 0.004/η² = 0.036), BMI (p = 0.013/η² = 0.027), age (p = 0.026/η² = 0.022), and anserine bursa tenderness (p = 0.033/η² = 0.020). However, the WOMAC total score was influenced by patellar quadriceps tendinitis (p < 0.001/η² = 0.114), BMI (p = 0.001/η² = 0.045), female sex (p = 0.016/η² = 0.025), and medial compartment BMLs (p = 0.015/η² = 0.029), but not by the extent of cartilage damage.

Conclusion: The extent of cartilage degeneration influences the pain level, but is not the main factor driving the overall symptoms experienced in advanced knee OA. Other intra- and extra-articular factors, including patellar quadriceps tendinitis, anserine bursa tenderness, BMLs, and BMI have a greater impact on pain and functional impairment, and should be considered when choosing the most suitable treatment approach to manage knee OA patients.

Aims: For patients aged < 60 years with symptomatic medial compartment knee osteoarthritis (OA), there is uncertainty regarding the most effective management (surgical or non-surgical). Surgical realignment with a high tibial osteotomy (HTO) can relieve pain and improve function, while also potentially avoiding or delaying a knee arthroplasty. However, HTO has never been compared with non-surgical treatment in this patient group. MOTION (Medial Opening wedge high TIbial Osteotomy compared with Non-surgical treatment) aims to determine the relative clinical effectiveness and cost-effectiveness of HTO compared with non-surgical management for patients aged < 60 years with medial compartment knee OA.

Methods: MOTION is a pragmatic, multicentre, prospective randomized open blinded endpoint (PROBE) parallel group-controlled superiority trial. A total of 224 patients (112 per arm) will be recruited from approximately 20 UK sites. Patients aged < 60 years with moderate to severe symptomatic knee OA localized to the medial compartment, in whom surgical intervention is indicated, are eligible. The intervention is surgery with medial opening wedge HTO followed by standard postoperative rehabilitation, compared with a non-surgical intervention in the form of personalized knee therapy (PKT) focused on a structured, progressive, and tailored exercise programme of rehabilitation. Participants will be randomly assigned to one of the two treatment arms in a 1:1 ratio. The primary outcome is the Knee Injury and Osteoarthritis Outcome Score (KOOS) at 24 months post randomization. Secondary outcomes include the Oxford Knee Score (OKS), Forgotten Joint Score (FJS), EuroQol five-dimension questionnaire (EQ-5D), Sleep Problem Scale, return to work, need for secondary surgical intervention, and adverse events at 12 and 24 months. Health economic evaluation will determine the cost-effectiveness of the interventions. MOTION is funded by the National Institute for Health and Care Research (Ref: NIHR129820).

Discussion: MOTION aims to determine whether HTO is a superior option to non-surgical management (PKT) for patients aged < 60 years with medial compartment knee OA with regard to both the clinical benefit for patients and cost-effectiveness for the NHS.

Aims: Whether medial unicompartmental knee arthroplasty (mUKA) or total knee arthroplasty (TKA) are more suitable for patients with anteromedial osteoarthritis (AMOA) remains debated. We aimed to compare the development over time in patient-reported outcome measures (PROMs) between patients receiving mUKA and TKA.

Methods: We conducted a matched cohort study of patients receiving TKA or mUKA between March 2018 and February 2020. TKA patients were evaluated based on preoperative radiographs and excluded if not deemed eligible for mUKA. The PROMs (Oxford Knee Score (OKS), Forgotten Joint Score (FJS), and Activity and Participation Questionnaire (APQ)) were completed preoperatively, and at three, six, and 12 months postoperatively. Patients were propensity score matched in a variable 1:2 ratio using BMI, sex, age, and preoperative PROM scores. Area under the curve (AUC) was calculated using the trapezium rule to quantify the change from preoperative PROM scores to scores at three, six, and 12 months postoperatively. AUC differences were analyzed using linear regression.

Results: A total of 618 patients (242 mUKA, 376 TKA) were included. The AUC was significantly lower for TKA patients compared with mUKA patients across all three PROM scores (OKS: ∆AUC of -19% (95% CI -27% to -9 %); FJS: ∆AUC of -23% (95% CI -32% to -14%); APQ -22% (95% CI -32% to -12%). Median PROM scores at three months were 35 and 30 for OKS, 50 and 43 for FJS, 44 and 31 for APQ, for the mUKA and TKA groups, respectively. At six months, the median PROM scores increased to 39 and 35 for OKS, 62 and 50 for FJS, and 56 and 41 for APQ for the mUKA and TKA groups, respectively.

Conclusion: The AUC for PROM scores during the first year was 19% to 23% lower for TKA compared with mUKA. This contrast in development trajectories is present especially in the early recovery three to six months after surgery.

Aims: To elicit and quantify parental preferences for brace weaning strategies in the treatment of developmental dysplasia of the hip (DDH) and explore how parents trade between treatment burden and the risk of further intervention.

Methods: A discrete choice experiment (DCE) was developed to assess preferences for timing and duration of weaning, alongside trade-offs related to the risk of further treatment. Parents of infants treated for DDH were recruited via STEPS Worldwide, a patient charity. Parents completed 16 hypothetical scenarios comparing different weaning regimens with immediate cessation. Data were analyzed using conditional logit models. A secondary analysis excluded participants with irrational or disengaged responses. Subgroup analysis explored whether preferences varied by experience.

Results: A total of 195 respondents completed the survey. In the primary analysis, night-time brace wear was preferred over immediate cessation, even when risk remained equal. In the secondary analysis, which excluded internally inconsistent responses, all weaning strategies were significantly less preferred than immediate cessation under equal risk conditions. Parents were willing to accept longer durations of treatment in exchange for reduced risk of subsequent intervention. The minimum acceptable risk reduction required for parents to accept four additional weeks of brace wear, compared with immediate cessation, was 5.8% (night-time bracing), 7.5% (night-time and naps bracing), 8.4% (gradual brace reduction), and 10.0% (daytime bracing). Preferences varied by experience, especially age at diagnosis and prior weaning.

Conclusion: Night-time-only weaning was the most acceptable weaning strategy. Parents were willing to trade longer brace treatment for a lower risk of further intervention. We were able to quantify the size of the benefit required by families, which may inform research investigating the effectiveness of weaning strategies.