Bone & Joint Open最新文献

Aims: Hip fracture patients have a significant mortality risk. Risk stratification tools are important in guiding management and family discussions. Aims were to assess the associations and validity of the Clinical Frailty Scale (CFS) in predicting mortality and return to original residence within 30 days using national hip fracture registry data.

Methods: Routinely collected clinical registry data for all patients presenting with a hip fracture in Scotland aged 50 years and over between February 2022 and December 2023 with a completed CFS score were analyzed. The association of frailty with mortality and return to original residence was assessed using multivariable Cox regression and logistic regression analysis, respectively, adjusting for confounders to present adjusted hazard (aHRs) and odds ratios (aORs).

Results: Of 15,546 patients, 8,573 had completed the CFS. Exclusion for missingness gave a final sample of 8,092. Most (71.4%) were female with a median American Society of Anesthesiologists (ASA) grade of 3 (IQR 3 to 3) and CFS of 5 (IQR 4 to 7). Vulnerable and frail patients (CFS ≥ 4) were older, more likely to be admitted from a higher care setting, and had increased mortality risk on the same admission. Higher CFS scores were associated with increased mortality risk: mildly frail (CFS 4 to 5), aHR 1.67 (95% CI 1.53 to 1.87); and frail (CFS 6 to 8), aHR 3.01 (95% CI 2.59 to 3.50). CFS and ASA grade showed similar performance in predicting one-year mortality (CFS area under curve (AUC) 0.72, 95% CI 0.71 to 0.73; ASA AUC 0.66, 95% CI 0.65 to 0.67) and return to residence (CFS AUC 0.63, 95% CI 0.62 to 0.65; ASA AUC 0.61, 95% CI 0.60 to 0.62).

Conclusion: The CFS is a pragmatic and validated tool for assessing frailty, which has a strong association with mortality risk in patients with hip fractures. Its predictive accuracy supports its integration into national hip fracture registries. While its utility in predicting return to pre-injury residence is moderate, it remains a valuable component of comprehensive patient assessment.

Aims: Total hip arthroplasty (THA) failure occurs more frequently in patients with abnormal pelvic version and kinematics, as these individuals are at greater risk of impingement and dislocation. This scoping review summarizes current classification systems for hip-spine and spine-hip issues in THA, defines specific patterns of pelvic version and kinematics, and integrates recommendations to optimize outcomes.

Methods: An extensive literature review was carried out in October 2024 on MEDLINE, Cochrane, ProQuest, and PubMed medical databases, reporting classification systems with specific diagnostic recommendations and treatment strategies. The search included articles published in English language from January 2016 until September 2024. Search keywords included 'Total hip arthroplasty' or 'total hip arthroplasty' in combination with 'hip-spine', 'spine-hip', 'lumbopelvic', 'spinopelvic', 'pelvic version', 'pelvic kinematic', and 'pelvic mobility'. Seven eligible articles were selected and analyzed.

Results: Current hip-spine classifications characterize groups of patients based on specific parameters. Available classifications were summarized in a nomogram illustrating all combinations of pelvic version and kinematics, and that provides recommendations to minimize the risk of complications following THA for each pattern. Specific recommendations are provided for patients with abnormal pelvic version and kinematics. Notably, for patients presenting stiff, stuck-standing, or stuck-standing pelvis, the surgeon should increase cup inclination and anteversion and also consider an anti-dislocation implant design and offset femoral component. Conversely, if lumbopelvic mismatch is present in stiff, stuck-sitting patients, cup anteversion must be reduced.

Conclusion: This review provides an integrated and comprehensive overview of the current literature on spinopelvic issues in THA patients. It highlights the complexity of the issue and the need for a unified understanding of the different classifications. The review also provides robust and consistent recommendations for managing patients with abnormal pelvic version and kinematics. Further studies are required to validate the efficacy of the recommendations proposed by current available classification systems.

Aims: Two preoperative risk models have been designed to predict debridement, antibiotics, and implant retention (DAIR) failure: KLICC and CRIME-80 scores. However, external validation of both scores is scarce. We aimed to validate these scores in an external cohort and to create a new model with additional risk factors.

Methods: We retrospectively evaluated 96 patients with early acute periprosthetic hip infection treated with DAIR. At a two-year cut-off, failure was defined as the need for second DAIR, implant removal, or 90-day infection-related death. Association between demographic variables and failures was tested. The model discriminatory performance was measured using the time-dependent receiver operating characteristic (ROC) curve and Harrell concordance index (C-index). The 'calibration in the large' (CITL) was calculated as the logistic regression model intercept. A modified KLICC score was created by adding the variable time from onset of symptoms to DAIR.

Results: The 24-month cumulative incidence of failure was 23.96% (95% CI 15.9 to 32.8). KLICC's area under receiver operating characteristic (AUROC) was 0.79 (95% CI 0.67 to 0.90), with a CITL of -0.57 (95% CI -1.16 to -0.01) and a slope of 0.68 (95% CI 0.35 to 1.02). CRIME-80's AUROC was 0.63 (95% CI 0.51 to 0.76), with a CITL of -1.66 (95% CI -2.13 to -1.19) and a slope of 0.35 (95% CI -0.14 to 0.85). The difference between both AUROCs was statistically significant (p = 0.0138), with the KLICC score performing better. As compared with the original KLICC score, the modified-KLICC improved the AUROC to 0.85 and the beta-slope and α intercept to 1.24 and -0.07, respectively (p = 0.020).

Conclusion: KLICC was superior to CRIME-80 in predicting DAIR failure. The modified-KLICC score improved the model prediction and could be useful to help indicate alternatives to DAIR when the predictive failure is high.

Aims: Various reconstructions of the distal radius after tumour resection have been proposed. Osteoarticular allografts can restore a functional joint, but the long-term durability of this reconstruction has been questioned. Data on long-term results are scarce in the literature. The aim of our study was to answer the following questions: What is the long-term survival of osteoarticular distal radius allografts with a minimum follow-up of ten years? What is the long-term patient satisfaction?

Methods: From 1999 to 2013, we performed 23 reconstructions with osteoarticular allografts after distal radius resection. Patients had a mean age of 36 years (14 to 69); 17 had giant cell tumour, three Ewing's sarcoma, two osteosarcoma, and one osteoblastoma. All patients were evaluated for allograft survival and functional outcome (Musculoskeletal Tumor Society (MSTS) score and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score).

Results: One patient was lost to follow-up at 53 months. One patient died for concomitant disease at 44 months. Of the remaining 21 patients, one underwent revision arthrodesis at 48 months. A total of 20 allografts remained in situ at follow-up for a mean of 213 months (22 to 293). The mean MSTS was 25.7 (18 to 30), and the mean DASH was 10.4 (0 to 30). According to the MSTS parameter of emotional acceptance, all patients with a surviving allograft scored still satisfied or higher.

Conclusion: In our experience, osteoarticular allografts in distal radius reconstruction can be a long-lasting procedure with long-term patient satisfaction. Few and conflicting results are reported in the literature; even when comparing series, it is difficult to clearly identify factors that may explain the differences in reported results.

Aims: The reconstruction of Paprosky type III bone defects remains a challenge. Although biological fixation materials are currently dominant, cage continues to play a role in resource-poor settings. The aims of this study are to report the long-term follow-up survivorship of the combination of cage and morselized allograft in Paprosky type III bone defects and evaluate allografts' incorporation.

Methods: We retrospectively analyzed 208 patients with Paprosky type III acetabular bone defects who underwent revision with a combination of cage and morselized allografts between January 2007 and January 2019. In total, 43 patients were followed up, with an mean follow-up of 10.6 years. There were 19 Paprosky type IIIA bone defect patients and 24 Paprosky type IIIB bone defect patients; seven patients of the 24 also had pelvic discontinuity (PD). Clinical assessment included Harris Hip Score (HHS) and 12-Item Short-Form Health Survey questionnaire (SF-12). Radiological assessment included cage stability, survivorship, and allograft incorporation.

Results: There were two re-revisions, one at 5.1 years postoperatively, another at 13.6 years postoperatively. The calculated survival rate of cages was 97.7% at ten years (95% CI 84.6% to 99.7%) and 85.5% at 15 years (95% CI 42.6% to 97.1%), with clinical failure as the endpoint. The calculated survival rate of cages was 94.2% (95% CI 78.1% to 98.6%) at both ten years and 15 years, with radiological failure as the endpoint. Cage remained stable in 39 patients (90.7%), and the cage in two patients was classified as possibly loose at the last follow-up. Allografts of 40 cases (93%) incorporated fully. HHS and SF-12 showed significant improvement at the last follow-up compared to the preoperative value (p < 0.05).

Conclusion: The combination of cage and morselized allografts is an alternative option for acetabular revision with Paprosky type III bone defects, with a satisfactory ten-year clinical survivorship of 97.7% and radiological survivorship of 94.2%.

Aims: Pain and poor health-related quality of life measures serve as the primary indication for primary elective total hip arthroplasty (THA). It remains challenging to predict whether THA delivers the patient-anticipated improvements. Our study aimed to develop and validate statistical and machine learning prediction models of one-year clinical improvement in patient-reported outcome measures (PROMs) after elective THA.

Methods: We included 82,526 patients with primary elective THAs from the Swedish Arthroplasty Register (SAR) for forecasting one-year improvements in the EuroQol five-dimension questionnaire (EQ-5D) index, EQ-visual analogue scale (VAS), and combined EQ-5D/EQ-VAS scores. Two minimal clinically important difference (MCID) thresholds were applied for the EQ-5D index score based on the approaches of standardized response mean (SRM) of 0.196 and capacity of benefit (CoB) of 0.428. MCID cutoff for the EQ-VAS was set to 7.81. A total of 21 features were used to feed the models. To avoid estimates bias, we eliminated missing data. Model performance was tested using the area under the receiver operating characteristic curve (AUC), and importance of features was identified in the best performing algorithm.

Results: Applying the SRM MCID, approximately two-thirds of patients reported one-year improvements in EQ-5D index (66.3%) and EQ-VAS (69.1%). The improvement rate decreased to 51.7% when we combined improvements in both outcomes. A higher CoB cut-off for EQ-5D index yielded lower rates (~40% for the EQ-5D index and 31.3% for the combined measure). The gradient boosting machine (GBM) consistently outperformed other models by a narrow margin in predicting significant clinical improvements in one-year PROMs and achieved a good to excellent binary discriminative power (AUC range 0.80% to 0.97%). Preoperative PROMs, EQ-5D index, EQ-VAS, and Charnley Hip Score, along with age, collectively contributed to over 80% of the algorithmic power in the ensemble GBM model.

Conclusion: We developed an interpretable machine learning model on a Swedish cohort that may facilitate personalized assessment of meaningful clinical improvement after elective THA.

Aims: Following resection of a primary bone tumour, reconstruction is commonly performed using either a megaprosthesis or biological reconstruction. Periprosthetic joint infection (PJI) remains one of the most frequent complications. Various treatment strategies exist for PJI, including debridement, antibiotics, and implant retention (DAIR), and single- and two-stage revision, although consensus on optimal management remains elusive. This study aimed to investigate the global practices regarding DAIR in tumour cases through an electronic survey among orthopaedic oncology surgeons.

Methods: A global cross-sectional observational survey study was distributed to 272 orthopaedic oncology surgeons who attended the BOOM Consensus Meeting in January 2024. The survey contained 19 multiple choice questions focusing on DAIR practices. Responses were collected anonymously and analyzed using descriptive statistics.

Results: The survey was completed by 173/272 surgeons (64%) from 44 countries. While 62% (169/272) routinely performed radical soft-tissue debridement in DAIR, only 39% exchanged all modular components, indicating variability in surgical approaches. DAIR was more commonly performed in acute rather than chronic infections, with 55% finding it very useful in acute cases. The use of local antibiotic delivery was supported by 56%, although only 49% found antibiotic cement coatings beneficial. Systemic antibiotic duration post-DAIR varied, with 39% favouring six weeks and 35% preferring three months.

Conclusion: The study highlights global inconsistencies in DAIR practices for PJI in orthopaedic oncology, with financial disparities impacting modular component exchange. Standardized definitions are lacking, and we propose that if only polyethylene is changed, then the procedure is referred to as 'poly exchange'; we recommend defining the procedure as DAIR when extensive debridement, lavage, and removal, wash, and reimplanting of all modular components is done while retaining stable stems, followed by suppressive antibiotic therapy; and finally, we recommend that if all the modular components are changed for new ones, the procedure is referred to as 'DAIR plus'.

Aims: To identify or develop a patient-reported outcome measure (PROM) aligned with the family-centred core outcome set (COS) for infants with developmental dysplasia of the hip (DDH) treated in a brace.

Methods: This study was conducted in five phases: 1) identification of relevant PROMs through two systematic literature reviews; 2) assessment of identified PROMs for content validity and relevance to the COS; 3) a consensus meeting with key stakeholders, including parents and clinicians; 4) development of a novel PROM; and 5) pilot testing with parents of infants treated in a brace. PROMs were assessed according to COSMIN criteria, and development was guided by stakeholder feedback.

Results: The systematic reviews identified two relevant PROMs: the Hip Worries Inventory (HWI) and the Infant and Toddler Quality of Life Questionnaire (ITQOL). Neither tool fully aligned with the COS, nor was considered suitable for comprehensive assessment in this population. The HWI was judged to lack domain coverage and negatively framed items, whereas the ITQOL was lengthy and burdensome. A consensus meeting supported the development of a new, concise PROM. The resulting Evaluation Measure for BRACe Experience (EMBRACE) includes eight items, scored using a Likert scale, across caregiver and infant domains. Pilot testing confirmed acceptability, clarity, and relevance.

Conclusion: The EMBRACE is a concise, family-centred PROM developed to reflect the core domains that were prioritized by families and clinicians for children undergoing DDH brace treatment. It enables the impact of treatment to be captured on both infants and caregivers.

Aims: To evaluate the incidence, timing, and capture of surgical site infections (SSIs) following hip fracture surgery using routinely collected primary and secondary care datasets, and to assess the limitations of using such resources to identify SSIs.

Methods: We conducted a retrospective cohort study using linked Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) data from 1999 to 2013. Patients with a hip fracture were identified and compared with age- and sex-matched controls. SSIs were defined using diagnostic codes and categorized as 'definite' or 'possible'. Timing of diagnosis was evaluated, and risk factors for developing infection assessed, using Cox regression.

Results: Among 13,920 hip fracture patients, 192 developed definite a SSI (n = 192, 2.4%) or possible SSIs (n = 15, 0.1%). Most infections were recorded in CPRD, with limited overlap between CPRD and HES. Median time to diagnosis was 130 days, with 43% of cases identified more than 90 days postoperatively. Charlson Comorbidity Index ≥ 3 was significantly associated with increased risk. Reoperation for infection occurred in 1.2% of cases (n = 37).

Conclusion: Routinely coded data sources likely under-capture SSIs after hip fracture surgery. Poor agreement between primary and secondary care records, combined with delayed identification, limits the utility of routinely collected administrative datasets to accurately identify postoperative infection.