Bone & Joint Open最新文献

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.

The imprecise definition of terms used to describe pathological diagnosis in clinical medicine can lead to imprecise treatment concepts and inaccurate recording of outcomes. In this article, we explore the meaning of common terms applied to the pathology of the rotator cuff, and demonstrate how the imprecise use of words entails a risk of leading to a poor definition of the clinical condition being treated. We suggest improvements in the accuracy of the definition of what constitutes the rotator cuff. We suggest the use of 'defect' to describe the most common presentation of a degenerative lesion of the rotator cuff, rather than perpetuate the use of the term 'tear', which has a different, injurious aetiology. We suggest that the term 'repair' should be reserved for the condition in which an acutely injured tendon (with a 'tear') can be expected to heal, using the correct definition of the term 'to heal'. We recommend reserving the use of the term 'healed' for the condition of an acute lesion of the rotator cuff (a 'tear') to which the histological process of regenerating a near-normal enthesis can be reasonably applied. We further suggest that degenerative lesions ('defects') of the rotator cuff, which do not have the biological capacity to heal in the true sense when brought back to bone, should be described as having 'closure' of the defect.

Aims: This study was to propose novel measurements to assess severity of ligament injury in simple elbow dislocation using axial imaging. This study assessed inter- and intraobserver reliability of the proposed novel measurements and compared their application as measures of severity of medial collateral ligament (MCL) and lateral collateral ligament (LCL) injuries.

Methods: This retrospective study included patients diagnosed with simple elbow dislocations from January 2013 to December 2023. The degree of MCL and LCL injuries was assessed by four grades: (0 (normal); 1 (sprain); 2 (partial tear); and 3 (complete tear)) using MRI. Patients were classified into two groups according to the severity of MCL and LCL injuries (Group I (degree of MCL injury ≥ LCL injury); and Group II (degree of MCL injury < LCL injury)). The novel measurements were defined by measuring congruence angle (CA), medial ulnar translation (TRANS), and lateral ulnar tilt (TILT) as determined by axial MRI. Adjusted medial ulnar translation (ADJ-TRANS) was calculated. Two observers measured all parameters twice over four weeks.

Results: A total of 21 patients were analyzed. Interobserver reliability was moderate to good for CA and good for TRANS. Both CA and TRANS showed excellent intraobserver reliability. Grade 2 MCL injury had significantly higher ADJ-TRANS than grade 1, while grade 2 LCL injury had significantly higher TRANS than grade 1. Meanwhile, grade 3 LCL injury had significantly higher CA and TRANS than grade 2, and significantly higher CA, TRANS, and ADJ-TRANS than grade 1. Group II also had significantly higher CA, TRANS, and ADJ-TRANS than Group I.

Conclusion: Novel measurements using axial images of MRI scans achieved overall good inter- and intraobserver reliability. Higher grade LCL injury exhibited higher CA, TRANS, and ADJ-TRANS. Patients with LCL injury graded higher than that of MCL injury exhibited higher CA, TRANS, and ADJ-TRANS.

Aims: Patient satisfaction after total knee arthroplasty (TKA) is a key measure of clinical outcome. While preoperative pain catastrophizing is known to affect postoperative results, the impact of early postoperative catastrophizing remains unclear. This study aimed to evaluate whether early postoperative pain catastrophizing is associated with PS one year after TKA.

Methods: We evaluated 254 knees in 254 patients undergoing TKA, assessing the Pain Catastrophizing Scale (PCS) and visual analogue scale (VAS) one day before, as well as one, three, and seven days after TKA. The 2011 Knee Society Score (KSS) was assessed preoperatively and one year postoperatively. Based on PS scores in the KSS, patients were classified into satisfaction (PS > 20) and dissatisfaction (PS ≤ 20) groups. PCS and VAS scores were compared between groups using the Mann-Whitney U test. Spearman's rank correlation coefficient and multiple regression analysis were used to evaluate relationships among factors.

Results: Mean PCS scores were 22.8 (SD 12.6), 21.9 (SD 12.2), 18.3 (SD 10.8), and 15.2 (SD 10.5) one day before, as well as one, three, and seven days after TKA, respectively. PCS scores seven days after TKA were negatively correlated with patient satisfaction one year after TKA (ρ = -0.32, p < 0.001). The dissatisfaction group had significantly higher PCS scores at all postoperative timepoints (p = 0.010, p < 0.001, and p < 0.001, respectively.). There were no significant differences in VAS scores between groups at any timepoint. Multiple regression analysis revealed that the PCS score seven days after TKA was significantly associated with PS (β = -0.321, p < 0.001). The cutoff PCS score seven days post-TKA for the dissatisfaction group was 12 (area under the curve: 0.653).

Conclusion: Patients who were dissatisfied with TKA outcomes persistently exhibited high PCS scores immediately after surgery. Surgeons should consider not only preoperative PCS and VAS scores, but also postoperative PCS scores in order to enhance postoperative patient satisfaction following TKA.

Aims: In advanced medial knee osteoarthritis, lower limb alignment is assessed using weightbearing imaging, which reflects the joint line convergence angle (JLCA). However, successful lateral load transfer with open-wedge high tibial osteotomy (OWHTO) can reduce the JLCA by decreasing the lateral and increasing the medial joint space on weightbearing imaging, making the correction less predictable. This study aimed to demonstrate that OWHTO planning using preoperative supine imaging yields more reproducible correction than weightbearing imaging and to identify radiological predictors of excessive JLCA change (> 2°).

Methods: We retrospectively analyzed 115 knees of 96 patients who underwent OWHTO planned using supine imaging. Radiological parameters, including the hip-knee-ankle angle (HKAA) and arithmetic HKAA, were measured using preoperative and postoperative long-leg weightbearing radiographs. Knees were categorized into three groups by ΔJLCA: ΔJLCA < -2° (decreased); -2° ≤ ΔJLCA ≤ 2° (unchanged), and ΔJLCA > 2° (increased). Logistic regression and receiver operating characteristic curve analysis were used to determine radiological factors associated with ΔJLCA.

Results: The unchanged JLCA group comprised 84.3% of knees, with similar preoperative weightbearing and supine JLCAs (2.6° and 2.5°, respectively). The postoperative weightbearing JLCA was 2.5°. The decreased JLCA group included 11.3% of knees, and the postoperative weightbearing JLCA (mean 2.6°) was closer to the preoperative supine (mean 4.1°) than the weightbearing JLCA (mean 5.5°). Preoperative arithmetic HKAAs were identical in the unchanged and decreased JLCA groups (3.9° varus). The increased JLCA group comprised only 4.3% of knees. Preoperative weightbearing JLCA > 4.9° and varus HKAA > 8.8° were significantly associated with decreased JLCA, with areas under the curve of 0.86 and 0.72, respectively.

Conclusion: Postoperative weightbearing alignment following OWHTO is better predicted by preoperative supine than weightbearing imaging. Furthermore, large preoperative weightbearing JLCA (> 4.9°) and severe varus HKAA (> 8.8°) are associated with decreased postoperative JLCA.