Bone & Joint Open最新文献

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.

Aims: The classic, widely accepted approach for one-stage hip revision arthroplasty in patients with periprosthetic joint infection (PJI) is the cemented exchange. This approach provides stable implant anchoring despite bone defects after removal of infected components, and facilitates local antibiotic delivery. This study aims to investigate the efficacy of cementless one-stage hip revision arthroplasty using a gentamicin-eluting bone graft substitute (GBGS) to address both bone defect filling and antibiotic elution.

Methods: We conducted a prospective analysis of 20 patients with confirmed PJI undergoing cementless one-stage hip revision arthroplasty using GBGS. The GBGS was used to fill femoral and acetabular defects during implantation. Clinical outcomes, radiographs, adverse events, and patient-reported outcome measures (PROMs) including Harris Hip Score (HHS) and EuroQol five-dimension five-level questionnaire (EQ-5D-5L) were assessed. Patients received 12 weeks of systemic antibiotics and were followed up for at least 24 months.

Results: The mean age of the cohort was 66.3 years (SD 8.4; 46 to 80), with ten female and ten male patients. On average, 13.2 ml (SD 3.9; 5 to 17) of GBGS was applied to bone defects. No reinfections occurred during the follow-up period of 3.3 years (SD 0.92; 2.1 to 4.8). We observed 15 serious adverse events (SAEs), none of which were associated with the product. All cases showed good bony consolidation and prosthesis integration at 12 months. Significant improvements were seen in HHS (preoperative mean: 47.7; final visit mean: 80.1; p < 0.001) and EQ-5D-5L score (preoperative mean: 0.43; 12-month mean: 0.88; p < 0.001).

Conclusion: This prospective pilot study is the first to demonstrate the safety and feasibility of single-stage cementless hip exchange arthroplasty using GBGS in managing PJI and associated bone defects. The technique resulted in significant improvements in functional outcomes and quality of life, with a good safety profile. Further studies with larger cohorts are warranted to validate these findings.

Aims: Soft-tissue sarcoma (STS) is a rare, aggressive malignancy with a high risk of recurrence when invading surrounding structures, and the optimal treatment strategy for safe surgical margins is still unclear. This study aimed to evaluate the safety and efficacy of combined local inactivation by ablation in STS during limb-sparing surgery in high-risk STS patients.

Methods: A retrospective cohort study was conducted on 44 patients between 1 January 2018 and 31 December 2022, at a tertiary medical centre. The patients were divided into two groups based on whether combined microwave in situ ablation (MWA) was performed during surgery (MWA group, n = 24 vs Control group, n = 20). The two groups were compared for postoperative complications, local disease-free survival (DFS), overall survival (OS), and progression-free survival (PFS).

Results: At the last follow-up, 12 patients in the Control group and eight patients in the MWA group experienced local recurrence. The MWA group showed longer local DFS than the Control group (48.02 (SD 4.70), 95% CI 38.81 to 57.23 vs 33.91 (SD 6.54), 95% CI 21.10 to 46.71; p = 0.047). Postoperative complications showed no significant difference (MWA: 33.3% vs Control 25%, p = 0.143). No significant differences were observed in the median OS (MWA: 53.10 (SD 6.91), 95% CI 39.55 to 66.75) compared with Control (58.30 (SD 4.66), 95% CI 49.16 to 67.44; p = 0.512) and median PFS (MWA: 16.67 (SD 3.75), 95% CI 9.32 to 23.97) compared with Control (12.62 (SD 5.88), 95% CI 1.10 to 24.09; p = 0.691) between the two groups.

Conclusion: The combined in situ ablation inactivation in high-risk STS during limb-sparing surgery can improve local tumour control and prolong local disease-free survival.

Aims: We aimed to determine if a home-based hip exercise programme, designed to use strength and flexibility exercises to modify pelvic positioning, is superior to usual care in reducing pain and improving function and quality of life in patients with symptomatic femoroacetabular impingement (FAI).

Methods: This was a single-blind parallel-group randomized controlled trial. Eligible participants were aged ≥ 16 years and diagnosed with symptomatic cam FAI. A sample size of 94 was needed to detect a clinically important difference. Participants were randomly allocated to: 1) an eight-week home-based exercise programme focused on posterior pelvic tilt supervised by a physiotherapist every two weeks in addition to usual care; and 2) usual care. The primary outcome measure was function (patient-reported 33-Item International Hip Outcome Tool (iHOT-33)) and secondary outcome measures were quality of life (EuroQol five-dimension five-level questionnaire (EQ-5D-5L)), and pain (visual analogue scale (VAS)) at baseline, nine weeks, and six months. The Mann-Whitney U test was used to test between-group differences in scores using a two-tailed level of significance of p < 0.05.

Results: A total of 95 participants were recruited (48 intervention, 47 control), 55 were males (57.9%), the mean age was 32 years (SD 8.5), and both groups were similar at baseline. There were no statistically significant differences in the primary outcome measure between groups at nine weeks and six months for function (nine weeks: p = 0.394, 95% CI -15.5 to 6.5; six months: p = 0.526, 95% CI -8.8 to 13.7). There were no statistically significant differences in the secondary outcome measures between groups: pain (nine weeks: p = 0.153, 95% CI -0.4 to 2.4; six months: p = 0.743, 95% CI -1.1 to 1.7), and quality of life (quality of life VAS nine weeks: p = 0.877, 95% CI -10.0 to 6.0; six months: p = 0.269, 95% CI -15.0 to 5.0; index value nine weeks: p = 0.815, 95% CI -0.067 to 0.052; six months: p = 0.217, 95% CI -0.099 to 0.020).

Conclusion: Our results demonstrated no statistical differences in pain, function, and quality of life for participants following an eight-week home-based exercised programme supervised by a physiotherapist compared to usual care.

Aims: With the increasing burden of arthroplasty waiting lists within Northern Ireland, this study aims to evaluate the safety, efficacy, and postoperative outcomes following the introduction of a high-volume day-case arthroplasty unit in a district general hospital (South West Acute Hospital (SWAH)), with no previous routine orthopaedic service.

Methods: An independent company was contracted to provide high-volume, day-case arthroplasty. Standardization of care, enhanced recovery after surgery (ERAS) principles, and recruiting experienced staff were important steps in the set-up. This study includes the first 244 total hip arthroplasty (THA) cases performed. A matched cohort of 43 THA patients was compared with patients from the largest elective unit in Northern Ireland (Musgrave Park Hospital) to ensure satisfactory outcomes in the 90-day postoperative period.

Results: Same-day discharge was achieved in 83.7% of cases performed in SWAH which compared with 4.7% of MPH patients (p < 0.001). There was no significant difference in rates of attendance to an out of hours general practioner (7% vs 9.3%, p = 0.693) or emergency department (11.6% vs 16.3%, p = 0.757). Readmission rates (2.3% vs 11.6%) and reoperation rates (2.3% vs 0%) also did not show any significant difference (p = 0.202 and p = 0.500, respectively). No patient in either matched cohort had a venous thromboembolism diagnosed. Between the matched cohorts, there was a significantly higher number of American Society of Anesthesiologists grade I and II patients performed at SWAH (p = 0.003); however, this was likely due to the strict exclusion criteria necessary for the safe implementation of a day-case arthroplasty unit.

Conclusion: An arthroplasty day-case service was safely set up in a district general hospital without a previous orthopaedic unit. More than 80% of these patients were discharged on the same day of surgery. With the ever-increasing pressure, demand, and waiting lists for arthroplasty, this model could prove an important adjunct to existing services.