Bone & Joint Open最新文献

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.

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.