Bone & Joint Open最新文献

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.

Aims: Acetabular fractures have major personal and societal impact. However, prospective longitudinal data about the patient's recovery trajectory is scarce. Therefore, we aimed to assess the course of the patient's functional recovery, up till five years post-injury. Additionally, predictors of no full recovery and patient's perception of most experienced difficulties were assessed.

Methods: A prospective longitudinal cohort study was performed, including adult patients treated for an acetabular fracture at a level 1 trauma centre between January 2017 and August 2023. Patient-reported outcome measures (PROMs) were used to assess functional status with the Short Musculoskeletal Function Assessment (SMFA) at baseline (recalled pre-injury), six weeks, three and six months, and one, two, and five years post-injury. We assessed whether patients had returned to their baseline level health status. Predictors for incomplete recovery were identified using logistic regression analysis. The most frequently experienced difficulties were presented by analyzing the highest reported scores on individual items of the SMFA.

Results: A total of 202 patients with an acetabular fracture filled out the PROMs. After two and five years of follow-up,109 out of 148 (74%) and 65 out of 83 (78%) of the patients fully recovered in terms of physical functioning, respectively. Patients with a posterior wall fracture had worse outcome compared to other Letournel fracture types. Enduring high-energy trauma and not being fully recovered on the SMFA emotion subscale at three months were independent predictors for incomplete recovery after two years on the SMFA function index. At two years, the most frequently reported severe difficulties were walking with a limp and feeling disabled.

Conclusion: Acetabular fractures significantly affect patient-reported functional status, with an initial decline until three months, followed by rapid improvement between three to six months, and gradual recovery up until five years following the injury. Patients with posterior wall fractures showed worse outcomes. High-energy trauma was the strongest predictor for incomplete recovery. The most frequently reported difficulties were walking with a limp and feeling disabled.

Aims: Muscle damage and inflammation after hemiarthroplasty (HA) for femoral neck fracture (FNF) could affect time to mobilization. Early mobilization is key in enhanced recovery and fast-track care systems. We have compared muscle damage and inflammation using creatine kinase (CK) and CRP as biomarkers in FNF patients operated on with the direct anterior (DA) and the sparing piriformis and obturator internus, repairing externus (SPAIRE) approach.

Methods: From January 2022, 158 eligible patients with a dislocated FNF were included in a randomized controlled trial comparing the approaches (n = 158). Hypothesis and planned statistical tests were pre-specified in this sub-group analysis and 100 patients were tested for CK, CRP, and haemoglobin (Hb) levels during hospital admission.

Results: Mean difference in CK between groups was, on postoperative day one, 45 u/l (95% CI -22 to 151, p = 0.290) and day two, 66 U/l (95% CI -42 to 185, p = 0.19). Mean difference in CRP was 3 mg/l (95% CI -23 to 19, p = 0.933) and Hb, 0.3 g/dl (95% CI -0.2 to 0.5, p = 0.388) on day two postoperatively. No correlation was found between CK/CRP and Timed Up and Go test and Harris Hip Score.

Conclusion: There were no differences in CK and CRP changes between the groups on day one and two after surgery. No correlation was found between CK and clinical outcomes in FNF patients operated with SPAIRE and the DA approach.

Aims: Periacetabular osteotomy (PAO) is a complex procedure for treating hip dysplasia by reorienting the acetabulum to slow osteoarthritis progression. This study aimed to assess the types and rates of complications after PAO and provide recommendations for prevention.

Methods: A total of 715 consecutive patients underwent unilateral PAO by a single surgeon between December 2006 and January 2024, with at least one year of follow-up. Indications included hip dysplasia, acetabular retroversion, and protrusio. Hip arthroscopy was performed concurrently in 325 cases. Demographic factors, perioperative data, and complications - graded using the modified Clavien-Dindo system - were analyzed. Risk factors and learning curves were also assessed.

Results: Of the 715 patients, 121 (16.6%) experienced 144 complications. There were 68 grade I, 52 grade II, 23 grade III, one grade IV, and 0 grade V complications. The 23 grade III complications requiring reoperations included four revision PAOs for overcorrection, three fixations for posterior column fracture, four neurolysis procedures for symptomatic lateral femoral cutaneous nerve (LFCN) dysesthesias, four heterotopic bone excisions, and eight wound debridements. All type I and II complications were treated without sequelae. The addition of hip arthroscopy did not increase complication rates. Age < 20 years was associated with a lower risk of complications (odds ratio (OR) = 0.53, 95% CI 0.33 to 0.84, p = 0.008), whereas smoking history (OR = 1.72, 95% CI 1.01 to 2.87, p = 0.040) and correction of both acetabular dysplasia and retroversion (OR = 2.46, 95% CI 1.08 to 5.24, p = 0.024) were linked to an increased risk of complications. The operating time and incidence of complications decreased with increasing experience.

Conclusion: PAO is an effective procedure with an acceptable complication rate. Risk factors should be discussed during preoperative counselling. While patient optimization may help to reduce complications, precise intraoperative technique remains critical for minimizing risk.

Aims: Fractures of the clavicle primarily occur in young males and constitute 2.6% to 5% of all fractures in adults. Distal clavicle fractures, where the outer end of the collarbone breaks, account for 20% to 25% of all clavicle fractures. These fractures can be called displaced if the ligaments connecting the collarbone to the shoulder blade (coracoclavicular complex) rupture. Such displaced fractures (Neer's type II and V) are currently treated with an operation involving fracture fixation or with sling immobilization. This protocol describes a randomized controlled trial that aims to evaluate the clinical and cost-effectiveness of these two types of treatment which are used for displaced distal clavicle fractures.

Methods: The DIsplaced DistAl Clavicle Fracture Trial (DIDACT) is a pragmatic, parallel, two-arm individually randomized non-inferiority trial of 214 adult patients with a radiologically confirmed diagnosis of a displaced distal clavicle fracture. Participants will be randomly allocated on 1:1 basis to surgery with locking plate fixation (with or without coracoclavicular (CC) sling, or CC reconstruction alone) or sling immobilization. In the sling immobilization group, if symptomatic nonunion occurs, participants would be offered surgical fixation (typically at the three-month follow-up). The primary outcome and endpoint will be the self-reported Disabilitities of the Arm, Shoulder and Hand questionnaire (DASH) at 12 months. The DASH will also be collected as a secondary outcome at baseline, six weeks, three, and six months after randomization. Other secondary outcomes include shoulder pain, EuroQol five-dimension five-level questionnaire (EQ-5D-5L), complications (e.g. infections, reoperations), fracture healing, healthcare costs, patient treatment preferences, satisfaction with appearance of their shoulder, sensitivity or pain to touch, and range of motion.

Conclusion: There is uncertainty around whether a sling immobilization pathway is non-inferior to surgery and which of these two treatments is cost-effective. The DIDACT trial is a sufficiently powered and rigorously designed study to inform clinical decisions for the treatment of adults with this injury.

Aims: Frailty has recently been associated with postoperative complications and clinical outcomes in various fields. This study aimed to assess the relationships between frailty and surgical outcomes of palliative surgery for spinal metastases and assess the usefulness of the modified five-item frailty index (mFI-5) in this population.

Methods: We prospectively evaluated 273 patients who underwent spinal metastasis surgery from June 2015 to December 2021. The mFI-5 was used to assess frailty, with a score of 0 defined as non-frailty, 1 as pre-frailty, and 2 or more as frailty. The following variables were assessed: background characteristics, complications (Clavien-Dindo grade 2 or higher), postoperative clinical outcomes, and life expectancy. The clinical outcomes compared between the three groups were the performance status (PS), Barthel index, and EuroQoL five-dimension questionnaire (EQ-5D) at six months postoperatively. A multivariate stepwise logistic regression analysis was performed of variables with values of p < 0.1 on the univariate analysis.

Results: The overall complication rate was 19% (52/273). The complication rate was significantly higher in the frailty group (p = 0.005), and patients with a greater mFI-5 score tended to have a higher incidence of postoperative complications. The Kaplan-Meier curve showed that the non-frailty group had a significantly longer survival time than the pre-frailty and frailty groups (p < 0.001). Multivariate logistic regression analysis suggested that mFI-5 is not predictive of postoperative complications and improvement of the EQ-5D, while is predictive of improvement of the PS (odds ratio (OR) 4.22) and Barthel index (OR 4.49).

Conclusion: The current study suggested that mFI-5 is not predictive of postoperative complications and improvement of the EQ-5D, while is predictive of improvement of the PS and Barthel index. Furthermore, palliative surgery for spinal metastases improved the PS, Barthel index, and EQ-5D, even in patients with frailty.

Aims: This study aims to evaluate the diagnostic performance of serum parameters, synovial fluid analysis, tissue and sonication fluid cultures, and histology to identify persistent infection, and to predict reinfection at reimplantation of two-stage exchange arthroplasty.

Methods: From January 2015 to January 2023, a total of 133 patients with completed two-stage exchange arthroplasty for periprosthetic joint infection (PJI) following total hip or knee arthroplasty were eligible for inclusion in this retrospective study. Diagnostic values of serum parameters (CRP, white blood cell count (WBC), differential, fibrinogen), synovial fluid WBC (SF-WBC), culture (synovial fluid, tissue, sonication fluid), and histology were evaluated prior to or at the second stage. Additionally, Kaplan-Meier curves were used to determine infection-free prosthesis survival rates for all parameters.

Results: Serum CRP showed the highest area under the receiver operating characteristic curve (AUC; 0.624) among all analyzed test methods (serum WBC: 0.501; serum % polymorphonuclear neutrophils (PMN): 0.605; fibrinogen: 0.533; SF-WBC: 0.601; SF culture: 0.566; tissue culture: 0.463; sonication fluid culture: 0.473; histology: 0.492). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CRP were 51.7% (95% CI 35 to 69), 73.1% (95% CI 64 to 81), 34.9% (95% CI 21 to 49), and 84.4% (95% CI 77 to 92), respectively. In 35% (n = 15/43) of patients with an elevated serum CRP (≥ 10 mg/l), reinfection occurred, while the reinfection rate was only 16% (n = 14/90) in patients with a normal CRP (< 10 mg/l, p = 0.012). Reinfection rates in patients with all-negative cultures at 23% were not significantly different from cases with positive cultures at 13% (p = 0.352).

Conclusion: Although CRP showed the best diagnostic value among all analyzed test methods, none of them could reliably identify persistent infection or predict reinfection. Additionally, a positive culture may not justify a further intervention (spacer exchange, prolonged antibiotics). In case of positive culture or elevated CRP, a further thorough debridement at the second stage is recommended to increase the chance of infection eradication.