Bone & Joint Open最新文献

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.

Aims: Hip fractures are a leading cause of morbidity and mortality worldwide, particularly among older people. While early surgical management improves outcomes compared to non-surgical approaches, high costs of surgery pose significant barriers in low- and middle-income countries. A cost-utility analysis of hip fracture management was undertaken in Zimbabwe, to guide resource allocation and policy.

Methods: Patient-level data were obtained from a prospective cohort of adults aged 40 years and above with acute hip fractures presenting to hospital in Harare (two public; five private) between October 2021 and October 2022. Healthcare resource use and costs in 2023 USD$ were assessed from individual billing data, with imputed values used for missing resources. Health outcomes were measured in quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratios (ICERs), defined as the ratio of incremental costs to incremental QALYs, were estimated using a regression approach. Sensitivity analyses assessed the impact of different assumptions on cost-effectiveness.

Results: The cohort had 190 patients with an average age of 72 years (SD 14.3), and 51% (n = 97) were male; 61% (n = 116) had surgery for their hip fracture. Patients who underwent surgery had 0.17 (95% CI 0.10 to 0.25) additional QALYs and incurred substantially higher healthcare costs: $1,676 (95% CI 730 to 2,621) higher per patient. The ICER for the primary analysis was $9,647/QALY gained. Restricting the analysis to patients who did not experience extensive surgical delays resulted in smaller difference in costs and an ICER of $4,126/QALY gained. The results were sensitive to the exchange rate used to estimate costs.

Conclusion: Although patients who underwent surgery for hip fractures had higher costs, they had better health outcomes in terms of QALYs. Targeted improvements in provision of surgical care, particularly in minimizing surgical delays, could improve both patient outcomes and lower healthcare costs.

Aims: There are few reports of outcomes after reverse total shoulder arthroplasty (RTSA) with over ten years of follow-up. Further, there is a lack of reports on RTSA with trabecular metal (TM) implants with ten-year follow-up. We aim to assess the ten-year survival and minimum ten-year outcomes of TM-RTSA.

Methods: All RTSA procedures were performed between October 2007 and July 2013 in a single institution. A consecutive series of 206 RTSAs in 194 patients were included in the Kaplan-Meier survival analysis using revision or removal for any reason as the endpoint. We also investigated the clinical and radiological outcomes at a minimum follow-up of ten years.

Results: Out of 206 RTSAs, there were a total of 13 failures. The median time from surgery was 1.6 years (IQR 0.08 to 7.5). The five-year implant survival rate was 94.7% (95% CI 89.9 to 97.2; 102 RTSAs at risk), and the ten-year rate was 90.5% (95% CI 82.9 to 94.8; 62 RTSAs at risk). Minimum ten-year outcomes were available for 60 RTSAs, including 57 with ASES scores and 40 RTSAs with radiographs with a mean follow-up period of 11.3 years. The ASES score was a median pain score of 50 (IQR 45 to 50) and a median functional score of 36.7 (IQR 23.3 to 41.7) on the ipsilateral side. In radiological analyses for 40 RTSAs, scapular notching was observed in 31 RTSAs (77.5%) and classified as grade III or IV, as described by Sirveaux et al, in five RTSAs (12.5%). Glenoid radiolucency was observed in 11 RTSAs (27.5%) and loosening in three RTSAs (7.5%).

Conclusion: TM RTSA demonstrated a high ten-year survival rate of 90.5%. Although radiological findings increased over time, clinical outcomes remained favourable.

Aims: Adolescent idiopathic scoliosis (AIS) is considered a multifactorial disease, and proprioceptive deficit (PD) is evident as a potential associated factor. However, existing studies have indicated that only a subgroup of scoliotic adolescents would display PD. The aim of this cross-sectional clinical trial was to investigate the prevalence of, and relationship between, AIS and PD in spinal and peripheral regions.

Methods: A total of 166 participants aged ten to 25 years with AIS were assessed using 3D motion analysis to evaluate their spinal and peripheral proprioceptive abilities. Six proprioceptive tests were used to determine the presence of PD in the trunk, neck, elbow, and knee. PD was characterized by test results that were inferior to the established normative values.

Results: We found that the prevalence of trunk PD was 30.1%, while that of the neck, elbow, and knee was 19.3%, 32.5%, and 32.5%, respectively. We also revealed a correlation between spinal PD and curve magnitudes, suggesting a significant association between trunk PD and the severity of AIS. However, the presence of PD in different body parts was not significantly correlated with one another, indicating that PD may occur in the spine in isolation.

Conclusion: Overall, 50 subjects (30%) with AIS have truncal PD without necessarily the presence of peripheral PD. Moreover, their presence was associated with a larger curve magnitude. Future longitudinal studies are warranted to examine the causal relationship between PD and curve progression in AIS and vice versa.

Aims: The limited documentation on patients' perspectives on undergoing discharge on the day of surgery impedes its adoption as a standard of care. Hence, the aim of this study was to investigate whether patients were willing to repeat being discharged on the day of surgery if having a future hip or knee arthroplasty procedure.

Methods: This multicentre, prospective consecutive cohort study spanned from 1 September 2022 to 31 January 2024, and was conducted at six public arthroplasty centres adhering to the same published protocol for discharge on the day of surgery following hip and knee arthroplasty. Patients undergoing primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or medial unicompartmental knee arthroplasty (mUKA) were screened for eligibility and discharged when fulfilling predetermined discharge criteria. Patients discharged on the same calendar day of surgery were sent a questionnaire 30 days postoperatively.

Results: Of 9,542 primary hip and knee arthroplasties registered, 3,457 (36%) were eligible for discharge on day of surgery; 58% of eligible patients (n = 2,011) were discharged on day of surgery and therefore received the survey. Baseline characteristics were comparable across all arthroplasty groups. The survey response rate was 88% (n = 1,771). Overall, 90% (95% CI 88 to 91) were willing to repeat discharge on the day of surgery if having a future joint arthroplasty, with 91% (95% CI 88 to 93) after THA, 89% (95% CI 86 to 92) after TKA, and 90% (95% CI 86 to 92) after mUKA. The difference between centres ranged from 84% to 93%. Patients responding 'no' to repeat discharge on the day of surgery were more often female (55%, n = 95) compared to patients responding 'yes' (47%, n = 744); otherwise, the groups were comparable.

Conclusion: A total of 90% of patients (n = 1,590) discharged on the day of surgery following hip and knee arthroplasty expressed willingness to repeat discharge on the day of surgery. This supports further implementation efforts.