Bone & Joint Open最新文献

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.

Aims: Coronal Plane Alignment of the Knee (CPAK) phenotyping is gaining momentum in research and clinical practice to understand individualized knee alignments and predict knee balance in total knee arthroplasty (TKA). The nine CPAK classes are based on joint line obliquity (JLO) and arithmetic hip-knee-ankle angle (aHKA), which are calculated using the medial proximal tibial angle (MPTA) and lateral distal femoral angle (LDFA). This study aims to assess CPAK classification reproducibility, and analyze what level of angular error is associated with CPAK misclassification.

Methods: Two readers labelled 75 long-leg radiographs (LLRs) from the Osteoarthritis Initiative database for analyses of CPAK inter-reader reproducibility. A single reader then labelled and classified phenotypes for an aggregate total of 1,128 LLRs. Finally, Monte Carlo simulations were run based on 1,128-patient phenotype distribution and the inter-reader reproducibility statistics to understand how CPAK agreement rates were affected by the reproducibility of MPTA and LDFA measurements.

Results: There was excellent reproducibility in MPTA and LDFA measurements (mean absolute error: 0.41°/0.71°; and intraclass correlation coefficient: 0.96°/0.91°, respectively). These small angular deviations led to one-in-five disagreement in CPAK classification (20.0%; 95% CI 10.9% to 29.1%). An aHKA mean absolute error of < 0.1°, which is potentially unattainable, would be required to reduce inter-reader CPAK disagreement to below 95%.

Conclusion: CPAK phenotyping from long-leg radiographs may result in clinically significant rates of misclassification. CT imaging may improve reliability, particularly in cases where aHKA and JLO are near to discriminatory values.

Aims: Heterotopic ossification (HO) is a recognized complication following periacetabular osteotomy (PAO), but its patterns, incidence, and clinical relevance remain poorly defined. The commonly used Brooker classification, developed for total hip arthroplasty, is not fully applicable to HO after PAO. This study aimed to propose a new classification system specific to HO after PAO, evaluate its clinical relevance, and report the cumulative probabilities of radiological and symptomatic HO.

Methods: This retrospective study included 643 patients who underwent PAO between January 2006 and July 2024. A total of 308 patients (47.9%) had concomitant arthroscopic procedures. Radiographs were analyzed to identify HO using both the Brooker classification and a newly developed system. The cumulative probabilities of radiological and symptomatic HO were calculated using Kaplan-Meier analysis. Difference of variables between patients with and without HO was analyzed. Receiver operating characteristic (ROC) curve analysis was used to compare the predictive performance of the two classification systems.

Results: The cumulative probabilities of radiological and symptomatic HO at five years post-PAO were 30.4% and 3.8%, respectively. The probabilities were 41.9% in males and 29.2% in females. Four patients (2.8%) required surgical excision of HO, all classified as type 3 or 4 under the new system. The ROC analysis demonstrated superior predictive performance for the new classification system (AUC = 0.928) compared to the Brooker classification (AUC = 0.697; p = 0.007). No significant differences were found between the patients with and without HO in terms of age, sex, concomitant arthroscopic procedures, or receiving prophylaxis in addition to low-dose aspirin.

Conclusion: This study highlighted the cumulative probabilities of HO following PAO and introduced a new classification system that improved clinical relevance and predictive accuracy. These findings have provided insights into the incidence and management of HO after PAO, and laid the groundwork for standardized reporting and future research.

Aims: This study compares functional outcomes and patient experience between cast immobilization and early mobilization in a removable boot after ankle fracture fixation, with early weightbearing encouraged in both groups.

Methods: This pragmatic multicentre randomized controlled trial with qualitative component and economic evaluation was conducted across eight UK NHS hospitals. Adults with acute ankle fractures were randomized to receive a plaster cast or removable support boot two weeks post-surgery. The primary outcome was ankle function measured by the Olerud and Molander Ankle Symptom Score (OMAS) seven weeks post-surgery. Secondary outcomes included function at 12 weeks, mechanistic measures, quality of life, complications, and resource use. Subgroup analyses included fracture complexity and age. Patients' views on both treatments were collected through semi-structured telephone interviews.

Results: In total, 243 participants consented to be randomized (120 cast; 123 boot), of whom 173 (71.2%) completed the primary outcome. The mean difference in OMAS at seven weeks between groups was 4.9 points favouring the boot (95% CI -1.0 to 10.7), which is below the minimal clinically important difference, and failed to detect a difference between groups. Boot participants had better dorsiflexion, particularly those with comminuted fractures, and better plantarflexion, particularly older patients. Complication rates were low, albeit higher in the boot group (cast eight/112; boot 18/117); all were minor, except one case of deep vein thrombosis in the boot group. Overall, we found low wound complication rates (7%). There were no differences for all other secondary measures. Patients expressed preference for boots at randomization, point of withdrawal from the trial, and during interviews.

Conclusion: Patients managed in casts and boots had similar functional outcomes following ankle fracture fixation. Boots provided improved dorsiflexion and plantarflexion for some subgroups, but higher complication rates. Treatment modality decisions could therefore be informed by individual patient preference.

Aims: Periprosthetic joint infections (PJIs) are devastating complications. Our knowledge of hip fracture-associated hemiarthroplasty PJI (HHA-PJI) is limited compared to elective arthroplasty. The goal of this study was to describe the epidemiology, risk factors, management, and outcomes for HHA-PJI.

Methods: A population-based (465,000 patients) multicentre, retrospective analysis of hip hemiarthroplasty (HHA) between January 2006 to December 2018 was conducted. PJI was defined by international consensus and treatment success as no return to operating room and survival to 90 days after the initial surgical management of the infection. Univariate, survival, and competing risk regression analyses were performed.

Results: In total, 1,852 HHAs were identified (74% female; mean age 84 years (SD 7); 90-day mortality 16.7%). A total of 43 patients (2.3%) developed PJI at aged 77 years (SD 10) (56% female; 90-day-mortality 20.9%; hazard ratio (HR) 1.6; 95% CI 1.1 to 2.3; p = 0.023). The incidence of HHA-PJI was 0.77/100,000 population/year and 193/100,000 HHAs/year. The median time to PJI was 26 days (IQR 20 to 97), with 53% polymicrobial growth and 41% multidrug-resistant organisms (MDRO). Competing risk regression identified younger age (subdistribution hazard ratio (SHR) 0.86; 95% CI 0.8 to 0.92; p < 0.001), chronic kidney disease (SHR 3.41; 95% CI 1.36 to 8.56; p = 0.013), BMI > 35 kg/m² (SHR 6.81; 95% CI 2.25 to 20.65; p < 0.001), perioperative urinary tract infection (SHR 1.89; 95% CI 1.02 to 3.5; p = 0.042), and dementia (SHR 9.4; 95% CI 2.89 to 30.58; p < 0.001) as significant risk factors for developing HHA-PJI. When infection treatment was successful (n = 15, 38%), median survival was 1,632 days (IQR 829 to 2,084), as opposed to 215 days (IQR 20 to 1,245) in those who failed, with a 90-day mortality of 30% (n = 12). There was no significant difference in treatment success between debridement, excision arthroplasty, or revision arthroplasty.

Conclusion: HHA-PJI is an uncommon complication, but is significantly associated with mortality. All currently identified predictors are nonmodifiable. Due to the common polymicrobial and MDRO infections, our standard antibiotic prophylaxis may not be adequate. HHA-PJI is a different disease compared to elective PJI with distinct epidemiology, pathogens, risk factors, and outcomes, which require targeted research specific to this unique population.

Aims: Cirrhosis is a known comorbidity that may influence outcomes following total joint replacement (TJR). This meta-analysis evaluates the impact of cirrhosis on postoperative complications and mortality after TJR.

Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Four databases were searched up to February 2025. Studies comparing the outcomes of TJR in cirrhotic versus non-cirrhotic patients were included. Data were analyzed using a random-effects model, and subgroup and sensitivity analyses were performed.

Results: A total of 12 studies, including 12.8 million TJR cases, were analyzed, with 111,011 cirrhotic patients. Cirrhosis was significantly associated with higher rates of mortality (odds ratio (OR) = 4.67, 95% CI 2.58 to 8.43), revision surgery (OR = 2.13, 95% CI 1.60 to 2.83), periprosthetic joint infection (OR = 2.61, 95% CI 2.11 to 3.21), implant failure (OR = 1.86, 95% CI 1.58 to 2.18), prosthetic fracture (OR = 1.89, 95% CI 1.19 to 3.01), transfusion (OR = 1.73, 95% CI 1.56 to 1.92), pneumonia (OR = 1.35, 95% CI 1.17 to 1.56), acute renal failure (OR = 2.16, 95% CI 1.35 to 3.46), readmission (OR = 1.93, 95% CI 1.70 to 2.20), and extended hospital stay (SMD = 0.49, 95% CI 0.28 to 0.69). Gastrointestinal complications (OR = 0.72) and pulmonary thromboembolism (OR = 0.25) were significantly lower. No significant differences were observed for wound complications, bleeding volume, operating time, venous thromboembolism, or cardiac events.

Conclusion: Cirrhotic patients undergoing TJR are at greater risk for mortality, complications, and healthcare resource use. These findings underscore the need for multidisciplinary preoperative evaluation and careful risk-benefit assessment to improve outcomes in this vulnerable population.

Aims: To improve functional outcomes following total knee arthroplasty (TKA), robotic systems have been introduced such as the MAKO (Stryker), the most widely used system globally at present. This systematic review aimed to compare the patient-reported outcome measures (PROMs) of robotic TKA (RTKA) to manual TKA (MTKA).

Methods: Five electronic databases were systematically searched for eligible articles that used PROMs to compare MAKO RTKA to MTKA. The primary outcome was the Forgotten Joint Score (FJS). We defined follow-up periods as short (up to three months), medium (three months to one year), and long term (beyond one year). We pooled outcomes combining the Knee Society Scoring System (KSS), Oxford Knee Score (OKS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Meta-analyses were conducted using a random-effects model and reported using mean difference (MD) or standardized mean difference (SMD) and 95% CI.

Results: In total, 22 articles evaluating 3,738 TKAs were included: 1,835 MTKAs and 1,903 RTKAs. The evidence level for most studies were IIa, due to few high-level studies. Using FJS, meta-analysis showed little difference at short-term follow-up (MD 11.49, 95% CI -5.62 to 28.59), but found a difference at medium-term follow-up (MD 5.50, 95% CI 2.19 to 8.81). This was not sustained at long-term follow-up (MD 23.89, 95% CI -16.50 to 64.27). Pooling all PROMs showed no difference in the short term (SMD 0.27, 95% CI -0.05 to 0.59), but results favoured RTKA at medium- (SMD 0.46, 95% CI 0.22 to 0.70) and long-term follow-up (SMD 0.40, 95% CI 0.13 to 0.66).

Conclusion: There are few high-level studies, but based on current data MAKO RTKA may result in improved functional outcomes compared to MTKA. Further randomized controlled trials are required to provide robust data and to assess clinical and cost-effectiveness as well as a wider spectrum of early and late outcomes.