Bone & Joint Open最新文献

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.

Aims: Tibial plateau fractures comprise 1% of all fractures, with a gold standard management of open reduction and internal fixation. Post-traumatic osteoarthritis is a common complication following fixation that can result in the requirement of a total knee arthroplasty (TKA). This study was designed to review the rate of TKA following surgical fixation of tibial plateau fractures. Primary outcome was the incidence of periprosthetic joint infection (PJI) and secondary outcome was function in these patients.

Methods: This retrospective multicentre study identified all patients with tibial plateau fractures that underwent surgical fixation within our health board over a 12-year period. The patients who then went on to require a TKA were identified.

Results: Between May 2008 and May 2021, 854 patients had a tibial plateau fracture managed surgically. Of these, 26 patients (3.04%; 1.89% to 4.20%) went on to require a TKA. Three of the 26 patients (11.54%; -0.74% to 23.82%) developed a PJI. The average increase in Oxford Knee Score was 14.3 for patients who did not go on to develop a PJI, compared with an increase of only 4 points in those that did develop a PJI. All patients in our study who had a TKA following fracture fixation had reduced postoperative patient-reported outcome measures when correlated to those reported in National Joint Registry data nationally for patients following both primary and revision TKA.

Conclusion: The rate of TKA following tibial plateau fracture fixation reflected that in the literature. The rate of PJI in our patients who had a TKA following a tibial plateau fracture fixation was found to be significantly higher (p < 0.0001) when compared with primary TKA. In an attempt to reduce the rate of PJI, we advocate for a two-stage approach in these patients. Patients should be counselled that the results of TKA following fracture fixation are inferior to primary TKA.

Aims: Weightbearing CT (WBCT) has set a new standard for the assessment of foot and ankle alignment in patients with progressive collapsing foot deformity (PCFD) under physiological loading conditions compared with conventional CT. Principal component analysis (PCA) models are currently used for a detailed 3D shape analysis, but are not able to take into account non-linear (e.g. rotational) anatomical variance, which is particularly relevant in PCFD. Innovative advances in geometrical morphometrics by principal polynomial shape analysis (PPSA) are now able to overcome this challenge. Therefore, the objective of this study was to evaluate the use of PPSA in identifying distinct morphological patterns in patients with PCFD under weightbearing conditions.

Methods: In this retrospective comparative study, 40 feet from 20 PCFD bilateral patients imaged by WBCT were confirmed eligible for analysis. Subsequently, matched controls were selected from a cohort of patients who underwent WBCT imaging for clinical follow-up of disorders unrelated to the foot. From the WBCT images, 3D models were reconstructed and registered. PPSA was applied to the 3D foot models to identify and delineate morphology variations in foot shape between the PCFD and control group.

Results: Automated classification of PCFD by linear discriminant analysis using the PPSA model yielded a sensitivity of 92.5% and specificity of 92.5%. Furthermore, PPSA revealed distinct foot morphology components in the PCFD group. Anatomical differences were significant and most pronounced at the level of the talocalcaneonavicular joint, with prominent internal and plantar rotation of the talar bone (p < 0.001).

Conclusion: This study is the first to apply PPSA in patients with PCFD. The findings validate distinct 3D spatial position alterations compared with control subjects. More specifically, they demonstrate that the talocalcaneonavicular joint complex is the most affected structure.

Aims: This study examines the prevalence and distribution of Modic changes (MCs) in the lumbar spine and the association with low back pain (LBP) across different age and sex categories.

Methods: A retrospective cross-sectional analysis was conducted based on MRI data from a UK orthopaedic centre of lumbar spine MRIs from January to December 2023. Demographics and clinical presentation, namely LBP, was analyzed for correlation with the presence of MC, which was categorized as Modic type I (M1) and II (M2), according to MRI signal intensity. Prior spinal surgery or spinal deformity were exclusion criteria.

Results: The results showed a high frequency of M1 and M2 changes at lower lumbar levels, particularly at L4/L5 and L5/S1, known to be subject to greater mechanical stresses (p < 0.001). MCs were highly correlated with LBP, as 66% of the patients had both conditions. Females were more affected with 72% of females with MC having LBP compared to 58% of males, (p < 0.001). M1 changes were also more frequently associated with LBP in young and old age groups.

Conclusion: These results show that not only are MC a common phenomenon, but that they are correlated with the presenting complaint of LBP in confirmation of previous studies. The work presented here adds to this by documenting the anatomical location, female predominance and age distribution where the presence of MC is more highly correlated with the presenting complaint of LBP.

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%.