Bone & Joint Open最新文献

Aims: This systematic review and meta-analysis aimed to compare the patient-reported outcomes of operative and nonoperative management in adults with a fracture of the distal radius, with a focus on the outcomes in older patients (aged ≥ 65 years).

Methods: Randomized controlled trials comparing operative and nonoperative management of patients aged ≥ 18 years with dorsally displaced distal radius fractures were included. Operative management included open reduction and internal fixation (ORIF), manipulation and Kirschner-wiring, or external fixation. Nonoperative management included cast/splint immobilization with or without closed reduction. Primary outcome was the 12-month Patient-Rated Wrist Evaluation (PRWE). Additional outcomes included the Disabilities of Arm, Shoulder and Hand (DASH), pain, complications, and radiological parameters. A sub-group analysis was undertaken for studies that reported outcomes in older adults (aged ≥ 65 years).

Results: After screening 1,635 studies, 19 trials with 2,178 patients (mean age 63 years (18 to 98), 74% female) were included. Seven studies reported outcomes in older patients (n = 773). There were statistical but not clinically significant differences favouring surgery for PRWE at three months (mean difference (MD) -8.70, 95% CI -14.45 to -2.95; p = 0.003) and 12 months (MD -2.96, 95% CI -5.15 to -0.77; p = 0.008). There was a statistical but not clinically significant difference in DASH at three months (MD -10.58, 95% CI -13.15 to -8.01; p < 0.00001) and 12 months (MD -4.17, 95% CI -6.05 to -2.30; p < 0.001) favouring surgery. There was no difference in complications (odds ratio (OR) 0.95, 95% CI 0.52 to 1.76; p = 0.880). For older adults, there was no difference in the PRWE at three months (MD -8.53, 95% CI -18.13 to 1.07; p = 0.080) or 12 months (MD -2.13, 95% CI -4.60 to 0.33; p = 0.090), with no difference in complications (OR 0.73, 95% CI 0.21 to 2.49; p = 0.620).

Conclusion: Operative management of adult dorsally displaced distal radius fractures was associated with superior functional outcomes according to the PRWE and DASH, but whether these are clinically meaningful is debatable. However, in older adults there was no significant or clinically meaningful benefit of surgery.

Aims: To evaluate the accessibility and utility of current radiation personal protective equipment (PPE) provision and understand the experiences and radiation protection practices offered to all levels of Trauma & Orthopaedic (T&O) surgeons in the UK.

Methods: An incentivized electronic survey was sent to all UK T&O surgeons during a six-week period in 2024. Responses to 27 multiple-choice questions were collected and free-text responses analyzed by theme.

Results: A total of 677 responses from 196 UK NHS hospitals were received: 228 recepients (33%) were female, 455 (67%) were resident doctors, and 222 (33%) were consultants, representing a response rate of 38% (341/897) for trainees and 11% (222/2114) for consultants. Overall, 171 (25%) agreed they could find appropriate lead gown PPE; 80 (12%) had been given dosimeters, although few had received feedback; 173 (26%) received mandatory training, but many more (328, 48%) had sought training individually. When undertaken, it was felt useful. Symptoms attributed to ill-fitting PPE were common and more likely to be reported by females (odds ratio 2.5). In total, 372 (55%) did not feel protected by their current PPE, and 569 (84%) were concerned about the effects of ionizing radiation (IR) on their health. Thematic analysis confirmed concerns relating to PPE availability, education, and inconsistent advice and guidance across hospitals. Health concerns and poor morale were also highlighted.

Conclusion: Employers must address the lack of compliance with the UK legislation, IR Regulations 2017 (IRR17), in relation to access to PPE, training, and monitoring. There is a need for standardized national guidelines and training.

Aims: The aim of this study was to compare the direct lateral approach (DLA) with the anterolateral approach (ALA) and posterior approach (PA) using data on hemiarthroplasties (HAs) reported to the Norwegian Hip Fracture Register. The primary endpoint was reoperations within 12 months post-surgery. Secondary endpoints included mortality, patient-reported outcome measures (PROMs; EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and EuroQol visual analogue scale (EQ-VAS)), and intraoperative complications.

Methods: A total of 39,905 HA patients aged 60 years or older who were operated on using DLA from January 2005 to December 2023 were compared to 2,813 patients operated on with ALA and 5,504 with PA in the same period. Hazard rate ratios (HRRs) for reoperations and mortality were calculated using Cox regression adjusted for age, sex, American Society of Anesthesiologists classification, cognitive status, and fixation method. Patients reported EQ-5D-3L and EQ-VAS 12 months postoperatively.

Results: The reoperation rate was 3.7% for DLA, 3.0% for ALA (HRR 0.79 (0.64 to 0.99)), and 5.9% for PA (HRR 1.54 (1.37 to 1.74)). PA was associated with an increased dislocation rate compared to DLA (HRR 3.92 (3.28 to 4.67)). Fewer infections were observed with ALA (1.5%, HRR 0.68 (0.50 to 0.93)) and PA (1.6%, HRR 0.74 (0.59 to 0.92)) compared to DLA (2.2%). Similar 30-day mortality rates were found for all approaches and marginally lower one-year mortality was found for the PA. Patients operated on with the DLA reported significantly lower EQ-5D-3L index score and EQ-VAS at 12 months post-surgery compared to ALA and PA. Fewer intraoperative fractures were found using the PA.

Conclusion: This study indicates that PA is associated with a higher reoperation rate after HA compared to the two other approaches. This is primarily due to high dislocation rate, despite a higher infection rate with DLA. EQ-5D-3L and EQ-VAS appear to favour ALA and PA 12 months post-surgery. Based on this study, traditional PA should be avoided in this patient group. ALA seems to be a safe alternative to the DLA.

Aims: The WHiTE3:HEMI trial recruited patients with an intracapsular hip fracture to be randomized to receive the Thompson hemiarthroplasty or the Exeter stem and Unitrax modular head. Results demonstrated no difference in mortality or health-related quality of life at four months. The aim of this study was to review outcomes at eight years for patients recruited into the WHiTE3:HEMI trial at our institution.

Methods: Dates of readmission, reoperation, and death were recorded from our local Trust universal clinical system for clinical noting, results, and radiology imaging. These data are concordant with the NHS Spine Personal Demographic Service and those submitted to the National Hip Fracture Database. Patient characteristics, incidence of periprosthetic fracture (PPF), reoperation, revision, and mortality were compared between the two groups. Patients were analyzed 'as randomized'.

Results: In total, 135 Thompson patients were compared with 143 Exeter Unitrax patients. There were no differences in age, sex, American Society of Anesthesiologists grade, Abbreviated Mental Test Score, Nottingham Hip Fracture Score, grade of operating surgeon, or residence on admission. In the Thompson group, there were 13/135 (9.6%) surgical complications, 6/135 (4.4%) reoperations, and 1/135 (0.7%) PPF. In the Exeter Unitrax group, there were 10/143 (7.0%) surgical complications (p = 0.425), 5/143 (3.5%) reoperations (p = 0.685), and 2/143 (1.4%) PPFs (p = 0.596). Eight-year Thompson cumulative implant survivorship was 96.9% (95% CI 90.4 to 99.0) and Exeter Unitrax 96.5% (95% CI 90.6 to 98.7) (p = 0.954). There were no differences in 30-day or four-month mortality rates. One-year mortality rates were 37.0% in Thompson and 20.3% in Unitrax (difference 16.7%, 95% CI 1.1 to 31.8, p = 0.002). Pooled mortality at eight years was 86.3% with no difference between the two groups (p = 0.612).

Conclusion: At one year, a significantly higher mortality rate was noted in the Thompson group. At long-term follow-up, Thompson and Exeter Unitrax demonstrated equivalent and low reoperation rates and excellent implant survivorship. Further studies may look to validate these findings.

Aims: Nonunion after foot and ankle arthrodesis is a major complication, which can lead to revision arthrodesis with increased risk of morbidity. Multiple factors can contribute to developing a nonunion, including a low-grade infection. The aim of this study is to investigate the rate of unsuspected low-grade infection in revision surgery for nonunion after foot and ankle arthrodesis. We also analyzed the difference in outcome of revision arthrodesis for patients with or without infection.

Methods: We conducted a retrospective study in the Sint Maartenskliniek, the Netherlands. All patients who underwent a revision arthrodesis (index surgery) for assumed aseptic nonunion after foot and ankle arthrodesis between January 2019 and July 2021 were included. Patients were excluded if fewer than five tissue samples were obtained during index surgery, or if infection was suspected before or during the index surgery. The causative microorganisms, antibiotic susceptibility, treatment, and outcome were assessed.

Results: In total, 105 revision arthrodeses due to nonunion were performed, of which 77 patients were included. In 17 patients (22.1%), an infection was diagnosed based on culture results of tissue samples taken during index arthrodesis. The causative bacteria identified were Cutibacterium acnes (n = 11), Staphylococcus spp. (n = 7), and Acinetobacter spp. (n = 1). After two years of follow-up, the success rate of the infection group was 77% compared with 88% for the patients with negative cultures (p = 0.451).

Conclusion: Low-grade infection should be considered as a possible explanation of a nonunion, despite the lack of local inflammatory signs. As 22% of the nonunions were unexpectedly caused by low-grade infection, we strongly recommend obtaining at least five tissue samples for culture during revision arthrodesis. The success rate of revision surgery followed by targeted antibiotics in patients with a low-grade infection is 77%, which is lower than the outcome in revision surgery for patients without infection (88%), although not significant (p = 0.451).

Aims: The aim of this study was to determine the early stability of acetabular components of total hip arthroplasty (THA) treating acute acetabular fractures through a replace-in-situ technique, using standard radiological assessment techniques as well as radiostereometric analysis (RSA), the gold standard for assessment of implant stability.

Methods: We prospectively investigated 29 patients who underwent THA to manage an acute acetabular fracture in which patients underwent postoperative in-clinic radiological assessment of acetabular component stability, and detailed measurements using both RSA and manual techniques. The latter were performed based on pelvic reference landmarks located below and above the fracture. Greater than 3 mm of proximal translation and/or 5° of rotation around the sagittal axis were considered diagnostic of a loose acetabular component.

Results: The median proximal translation and sagittal rotation of the cohort was 0.5 mm (IQR 0.3 to 0.9) and 0.8° (IQR -0.6° to 1.1°), respectively, as measured by RSA at two years. Acetabular components in the most unstable acetabular fracture patterns were found to migrate more immediately post-surgery. There was a disparity between different measurement techniques. Accurate RSA measurements correctly identified two components that were deemed to be clinically loose, and the diagnostic performance of RSA migration measurements was improved when migration within the first six months was excluded. Visual assessment of radiographs in clinic underestimated - and manual radiological measurements overestimated - acetabular component loosening in these complex cases.

Conclusion: The replace-in-situ technique led to acceptable early acetabular component stability in the majority of cases (27/29, 93%), a good result considering the complexity of these reconstructions. Accurate measurements of acetabular component migration are recommended in these cases, as pelvic landmark identification on consecutive plain radiographs is influenced by both pelvic projection on plain radiographs and fracture fragment migration during healing.

Aims: To assess the rates of relapse and risk factors for release and surgical intervention in patients with idiopathic clubfoot.

Methods: A retrospective review of all patients with idiopathic clubfoot and initiation of Ponseti treatment between February 2005 and December 2015 was conducted. All patients with successful initial Ponseti casting treatment at the study institution and one year of follow-up were included. Rates of relapse, surgery, and types of surgical procedures performed were collected.

Results: The final cohort included 268 children with 397 idiopathic clubfeet, consisting of 98 females (36.6%) and 170 males (63.4%). The successfully Ponseti-treated group without relapse was composed of 171 children with 252 feet (63.5% of total cohort). A total of 97 patients (36.2%) had a relapse and required further intervention (relapse group). There was a greater proportion of patients with complex-type clubfoot in the relapse group (18.6% vs 4.7%, p = 0.001). Patients who never relapsed presented at a median age of 33.7 days (IQR 40.8), while those who relapsed presented at a significantly younger age, at a median of 25.1 days (IQR 17.2) (p < 0.001). Children in the no-relapse group required significantly fewer casts to achieve correction, with a mean of 4.3 compared with 5.2 in patients with relapse (p < 0.001). Children in the no-relapse group showed a significantly higher rate of good adherence compared with those in the relapse-group (94.9% vs 62.3%, p < 0.001). In total, 24 children (23 feet, 5.8% of total cohort) underwent surgery, whereas 74 had a relapse but did not require surgery. The most common surgical procedures performed were tibialis anterior tendon transfer (n = 25) and open tendoachilles lengthening (n = 21).

Conclusion: We confirm that a higher number of casts to achieve correction in the initial Ponseti series, younger age at presentation, complex clubfoot features, and poor brace adherence may be correlated with risk of relapse and surgery. The need for joint invasive surgery is rarely indicated.

Aims: The aim of this study was to explore the relationship between the femoral head diameter (FHD) and the degree of subluxation in developmental dysplasia of the hip (DDH) patients, and develop a machine-learning model for predicting acetabular component size in total hip arthroplasty (THA) according to demographic data and FHD.

Methods: The FHD of 469 DDH patients from Longwood Valley medical database was measured, after excluding those with severe femoral head destruction, bone grafting, or augments. Its distribution and difference across Crowe and Hartofilakidis classifications were also assessed. Five machine-learning algorithms were developed to predict the size of the acetabular component, and the best model was determined according to the mean square error (MSE), root mean square error (RMSE), and R-squared values. The accuracy of the best model's cup size prediction was validated by comparing it with acetate templating and CT-based planning in a consecutive cohort from an independent institution.

Results: The FHD gradually decreased with increasing Crowe and Hartofilakidis classifications. The Pearson correlation coefficient between FHD and the size of the acetabular component was 0.60, indicating a moderate correlation. In the test set, the random forest model outperformed the other four models in terms of MSE (0.904), RMSE (0.951), and R-squared (0.919). In the external validation, the accuracy of this model was not significantly different from CT-based planning (80.0% vs 87.5%, p > 0.05), but outperformed acetate templating (80.0% vs 52.5%, p < 0.05), particularly for Crowe Type IV (81.8% vs 27.3%, p < 0.05).

Conclusion: The FHD decreases with increasing degree of subluxation in DDH patients. The machine-learning model constructed by combining demographic parameters and FHD demonstrates significantly higher accuracy in acetabular component size planning compared to templating methods. This approach serving as an effective auxiliary tool or alternative when CT is unavailable.

Aims: This research aims to review the long-term outcomes of CT-guided radiofrequency thermal ablation (RFA) in managing patients with osteoid osteoma (OO).

Methods: A total of 210 patients, with a mean age of 16.6 years, treated with CT-guided RFA between January 2005 and December 2022, were retrospectively studied. The research assessed patients' post-procedure clinical follow-up, recording treatment success and complications. Cox regression analysis, conducted in both univariate and multiple models, examined the impact of independent variables on recurrence time.

Results: The average follow-up was 103.7 months. In the first 24 hours after the treatment, all patients had less OO pain. Successful outcomes without recurrence were achieved in 200 out of 210 patients (95.2%). Univariate analysis indicated that sex did not have a significant impact on recurrence (p = 0.657); however, recurrence was significantly associated with younger age (p = 0.004).

Conclusion: This research shows that CT-guided RFA for OO patients relieves pain quickly, has low recurrence rates, and minimal complications. Younger patients should be monitored for an extended duration due to the influence of age on recurrence rates.

Aims: Osteomyelitis and infected nonunion cause devastating morbidity and are difficult to treat. Antimicrobial resistance further complicates musculoskeletal infection and is a significant global problem, including in low- and middle-income countries. Extensively drug-resistant bacteria and high rates of musculoskeletal infection have been identified during the Russian-Ukrainian war. Biomaterials with antimicrobial properties unrelated to antibiotics represent a potential solution. Bioactive glass, for example, has shown promise as a bone void filler. It binds to bone, stimulates bone formation, causes no harmful immune response, and has antimicrobial properties. This systematic review appraises the evidence for bioactive glass as a treatment for osteomyelitis and infected nonunion.

Methods: A comprehensive search of MEDLINE and EMBASE was performed with research librarian guidance. Articles were screened and assessed for risk of bias by two blinded authors. No date limitations were used. Methodology was guided by the Cochrane Handbook and the PRISMA statement. Data were compiled and narratively synthesized.

Results: We included 24 observational studies on 957 patients. Reported outcomes were heterogeneous, with patient-reported outcome measures available in only one study. Most studies were small and at considerable risk of bias. Studies supported bioactive glass use with high rates of bone healing and infection resolution. Comparative studies found non-inferiority with established treatments such as antibiotic-containing calcium sulphate and polymethylmethacrylate cement spacers. Few significant bioactive glass-related complications were reported.

Conclusion: This review demonstrates the potential of bioactive glass as a treatment for osteomyelitis and infected nonunion. Widespread uptake over established treatments is likely to require further supporting evidence, such as high-quality randomized controlled trials, to understand the role of biomaterials in treating these challenging conditions. Future work should examine 3D-printed bioactive glass hybrids, which may have biomechanical advantages for large bone defects.