Bone & Joint Open最新文献

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.

Aims: Orthopaedic interventions in spinal dysraphism (SD) are frequently required to address a wide spectrum of musculoskeletal deformities. The outcomes used to assess treatment, however, are heterogeneous and most fail to incorporate patient/family perceptions. The aim of this study was to identify the minimum set of outcomes to be collected in clinical practice and research settings following orthopaedic intervention in ambulatory and non-ambulatory children with SD.

Methods: The study was based on Core Outcome Measures in Effectiveness trials (COMET) initiative. A list of individual clinical outcomes (ICOs) and outcome measurement tools (OMTs) were obtained from a systematic literature review (SR) and from patients and families through an interview and questionnaire. Core outcomes were rated for importance in a two-round Delphi process that included international orthopaedic surgeons, physiotherapists, orthotists, patients, and families. Outcomes that did not reach consensus during the Delphi process were resolved with a final consensus meeting.

Results: In total, 88 statements, including ICOs and OMTs, were scored during the Delphi process for ambulatory and non-ambulatory children. A total of 35 items were resolved in the final consensus meeting. The final core outcome set (COS) is goal-based and includes 28 outcome parameters to be collected a minimum of one year after any orthopaedic intervention and at subsequent set points during childhood. The COS incorporates clinical examination, mobility and functional assessment, patient-reported outcome measures, and investigations with the Goal Attainment Score recommended for goal setting.

Conclusion: A minimum set of outcomes to evaluate the orthopaedic treatment of SD was created thereby enabling consistency in reporting among centres and studies.

Aims: Knee osteoarthritis (OA) is a leading cause of pain and disability, impacting quality of life. There are various conservative (non-surgical, non-pharmacological) management approaches suggested to support those with knee OA and multiple international clinical practice guidelines to inform patient care. This study contrasts the consistency of these management recommendations across the currently available guidelines.

Methods: Systematic search of CINAHL, MEDLINE, Science Direct, and the Guideline International Network website applying PRISMA guidance. Clinical practice guidelines from representative bodies relating to the conservative management of knee OA were included. Quality assessment was completed using the International Centre for Allied Health Evidence (iCAHE) tool.

Results: The search returned 750 records, from which 13 current clinical practice guidelines from national and international medical, surgical, and professional associations were identified. Quality of guideline construction was high. Recommendations for core knee OA management were broadly consistent; entailing exercise, self-management advice and education, and weight management; however, detail as to the proposed delivery of these interventions was lacking. Notable variation was evident between guidelines recommendation for all other interventions, such as manual therapy, bracing/orthotics and acupuncture, related to how the guideline groups interpreted generally low levels of evidence.

Conclusion: There is broad consistency across clinical practice guidelines regarding core conservative management of knee OA which should direct and support patient care. Differences in evidence interpretation as to effect of alternative treatments result in different recommendations which may be confusing for patients, physiotherapists and medical personnel referring to these services.

Aims: Postoperative periprosthetic femoral fractures (POPFFs) following hip and knee arthroplasty are increasing. They often have poor outcomes. We have limited understanding of the predictors of these outcomes, which this study addresses.

Methods: We extracted administrative hospital data for patients aged 18 years and above with admissions to NHS hospitals in England with a primary diagnosis of POPFF between April 2016 and December 2022, including demographic characteristics, comorbidities, surgery for POPFF, admission source, outpatient department (OPD) appointments, and pre-POPFF admissions. Data were linked to the national death register. The most relevant available hospital-level key performance indicators (KPIs) were taken from the National Hip Fracture Database (NHFD). We used multilevel models with random intercepts for hospitals to predict in-hospital death, 30-day death, length of stay (LOS) above the upper quartile, and 30-day emergency readmission.

Results: A total of 33,728 patients were included, with a median age of 82 years (IQR 73 to 88); 65.9% were female. In total, 1,510 deaths occurred within 30 days of admission. In multiple regression models, age was associated with higher mortality and longer LOS. Females showed lower odds of mortality and 30-day readmission. Congestive heart failure and liver disease were more strongly linked to all adverse outcomes than were other comorbidities. Fixation (odds ratio (OR) 0.72, 95% CI 0.64 to 0.81) and revision (OR 0.78, 95% CI 0.68 to 0.91) were associated with lower 30-day mortality but longer hospital stays than having neither procedure. Previous hip fracture was associated with 30-day readmission and longer LOS but not with mortality. Admission from a care home was associated with higher 30-day mortality (OR 1.70, 95% CI 1.31 to 2.39), but shorter LOS. Previous any-cause emergency admissions and missed outpatient appointments were associated with worse outcomes. Hospital-level NHFD KPIs for POPFF and admission numbers for POPFF were not associated with any outcome.

Conclusion: We identified several patient factors, but no hospital factors, associated with adverse short-term outcomes following POPFF admission.

Aims: Varus ankle arthritis with excessive talar tilt (TT) angle often has unsatisfactory outcomes after supramalleolar osteotomy (SMOT) surgery. These patients have a 3D deformity involving the hind foot as well as the ankle. Thus, adjuvant correction of the hind foot component may contribute to the TT angle. This study aimed to explore whether calcaneal osteotomy combined with SMOT could effectively correct the hindfoot alignment to treat varus ankle arthritis with a large TT angle.

Methods: In total, 26 patients diagnosed with varus ankle arthritis with excessive TT angle were included in this study. Calcaneal osteotomy was combined with SMOT to correct the hindfoot alignment. Thus, a combination of supramalleolar and subtalar corrections was performed to improve the alignment of the lower limbs. Anterior and lateral radiographs of the weightbearing ankle were performed preoperatively and postoperatively. The tibial anterior surface angle, the tibial lateral surface angle, and TT angle were measured. The clinical efficacy was evaluated according to the American Orthopaedic Foot and Ankle Society scoring system and pain visual analogue scale.

Results: Preoperative varus hindfoot alignment was corrected to nearly normal via SMOT combined with calcaneal osteotomy. Radiological parameters demonstrated that SMOT combined with calcaneal osteotomy could significantly improve varus ankle arthritis and correct excessive TT angle. Moreover, the clinical outcomes of the patients were significantly improved and the pain was significantly relieved after the surgery.

Conclusion: We found that SMOT combined with calcaneal osteotomy significantly improved varus ankle arthritis with a significant reduction in TT angle. Therefore, with the correction of the subtalar alignment and the displacement of the talus centre, the hindfoot alignment can recovery effectively and the TT angle can be significantly reduced. This suggests that SMOT combined with calcaneal osteotomy is a practical surgical approach for varus ankle arthritis with excessive TT angle.