Bone & Joint Open最新文献

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.

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.