Journal of Orthopaedics and Traumatology最新文献

Introduction: Slipped capital femoral epiphysis (SCFE) is the most common hip disorder in adolescents and may lead to femoroacetabular impingement, early osteoarthritis, and long-term functional disability if inadequately treated. While in situ pinning remains the standard treatment for mild slips, it fails to correct the deformity in moderate and severe cases, potentially predisposing to degenerative changes. The modified Dunn procedure (MDP) was developed to restore proximal femoral anatomy through surgical hip dislocation while preserving vascular supply. The aim of the study is to evaluate the long-term radiological and functional outcomes of the MDP in patients with moderate (14 cases) and severe (10 cases) SCFE, and to assess the incidence of avascular necrosis (AVN), osteoarthritis, and other complications.

Methods: A prospective case series was conducted between August 2015 and January 2019 at a single tertiary institution. A total of 24 hips with moderate-to-severe SCFE and open physis were treated using the MDP via surgical hip dislocation. Mild and acute-only slips were excluded. MDP was used as a primary procedure, performed early in severe slips and in selected moderate slips after clinical assessment. Patients were followed clinically and radiologically for a mean duration of 84 ± 2.6 months (range 80-88 months). Functional outcomes were assessed using the Harris Hip Score (HHS) and Merle d'Aubigné and Postel score. Radiographic outcomes and complications, including AVN and secondary arthritis, were documented. Fixation was performed using Schanz screws, cannulated screws, or K-wires according to intraoperative findings.

Results: The mean preoperative slip angle (48.3° ± 7.2°) significantly improved postoperatively (11.4° ± 3.1°, p < 0.001). HHS improved from a preoperative mean of 70.4 ± 5.8 to 92.9 ± 4.2 at final follow-up (p < 0.001). The Merle d'Aubigné and Postel score improved from 13.8 ± 1.6 preoperatively to 17.5 ± 0.9 at final follow-up (p < 0.001). AVN developed in 4 out of 24 hips (16.7%). Arthritis developed in 2 out of 24 hips (8.3%, degenerative OA; no septic arthritis or chondrolysis), representing a total of 6 out of 24 hips (25%) with significant complications when combined with AVN. No cases of postoperative instability or wound infection occurred. Functional scores showed sustained improvement in the majority of patients.

Conclusions: MDP offers favorable long-term anatomical correction and functional recovery in moderate-to-severe SCFE. However, the risk of AVN and arthritis, particularly in unstable or severe cases, warrants careful patient selection and technical precision. Extended follow-up is essential to detect late complications and evaluate procedural durability.

Purpose: This study aims to investigate the extent of fat infiltration (FI) in the rotator cuff (RC) muscles in more medial slices from the Y-shaped view (Y-view) on shoulder magnetic resonance imaging (MRI) and assess whether these slices provide a more accurate prediction of the repairability of massive RC tears (massive RCTs).

Methods: The retrospective study included 57 patients with massive RCTs who successfully underwent arthroscopic surgery between 1 January 2023 and 31 December 2023. Patients were categorized into two groups: the irreparable group and the reparable group. All patients underwent shoulder MRI covering the region from the acromion to the medial border of the scapula in oblique coronal and oblique sagittal orientations. The FI stage of the RC was assessed across three different views to determine which view most effectively predicts the repairability of patients with massive RCTs.

Results: The FI stage of the infraspinatus (IS) muscle across three distinct views demonstrated a significant correlation with the repairability of massive RCTs. The FI stage was more severe in the irreparable group. Receiver operating characteristic (ROC) analysis revealed that the area under the curve for the 1/2 scapula view (0.737) and the most severe view (0.745) exceeded that of the traditional Y-view (0.644). Paired-sample ROC curve analysis revealed a significant difference between the most severe view and the traditional Y-view. The number of slices from the Y-view to the 1/2 scapula view was 5.89 ± 1.2. The most severe view of the IS was defined as the slice indicating the most severe FI stage, which was observed in at least two slices (84% probability) or exclusively in a single slice (16% probability).

Conclusions: This study's conclusions are based on the following findings: (1) Applying the Goutallier classification confirmed that FI in massive RCTs can extend medially to the Y-view, with the most severe FI not confined to a standard anatomical plane; (2) The concept of the "most severe view"-a nonstandardized, non-reproducible MR plane-reflects the area of peak FI. In predicting the reparability of massive RCTs, FI assessment of the IS muscle from this view demonstrates certain advantages over the traditional Y-view; however, its predictive value remains moderate. Future research should therefore focus on developing improved imaging strategies and clarifying the precise relationship between FI progression and clinical outcomes.

Level of evidence: Level IV; case-control study.

Background: Although reverse total shoulder arthroplasty (rTSA) with concomitant latissimus dorsi transfer (LDT) has been shown to effectively treat external rotation (ER) deficits, there are limited data regarding its outcomes with modern implants and its impact on activities of daily living (ADLs) requiring ER. The purpose of this study was to assess the mid-term clinical and radiographic outcomes of rTSA with concomitant isolated LDT in patients with an ER lag sign and posterior rotator cuff deficiency.

Methods: This retrospective cohort study with prospective follow-up included consecutive patients who underwent rTSA with concomitant isolated LDT between 2010 and 2022 with a minimum follow-up of 2 years. Primary outcomes included the resolution of ER lag sign, active ER, and the Activities of Daily Living and External Rotation (ADLER) score. Secondary outcomes included the Auto-Constant Score (CS), Subjective Shoulder Value (SSV), activities of daily living requiring internal rotation (ADLIR) score, visual analog scale (VAS) for pain, and radiographic analysis of standardized radiographs.

Results: In total, 32 procedures in 32 patients were identified. Of these, 22 procedures in 22 patients (68% female, 72.9 ± 8.4 years at surgery) were available for follow-up at 4.8 ± 2.2 years postoperatively (response rate 73%). The ER lag sign resolved in 95.5% of patients, the active ER improved significantly from -13° (-20-0°) preoperatively to 10° (0-20°) postoperatively (p = 0.002). The ADLER score increased from 20 (18-21.5) to 30 (28-30, p < 0.001). The CS improved from 32 (25-52) to 71 (67-75, p < 0.001) and the SSV from 30 (28-40) to 80 (65-100, p = 0.002), and low pain levels were reported. Internal rotation (p = 1) and the ADLIR score (p = 0.56) did not improve or decrease. No revisions or complications were observed.

Conclusions: rTSA with concomitant isolated LDT resulted in favorable clinical, functional, and radiographic mid-term outcomes, with a high rate of resolved external rotation lag sign and a significant improvement in activities of daily life that require ER. This procedure should be considered a viable treatment option in patients undergoing rTSA with posterior rotator cuff deficiency and an ER lag sign.

Level of evidence: IV, retrospective case series.

Background: Periprosthetic joint infection (PJI) is one of the most challenging complications following total hip arthroplasty (THA). Traditional management typically involves full revision to ensure comprehensive infection eradication. However, for patients with well-fixed implants, partial revision in a single-stage cementless approach may provide a viable alternative, potentially preserving bone stock and reducing operative time. The relative efficacy of this approach compared with full revision remains to be fully explored. This multicenter study aims to determine whether partial revision in cementless single-stage exchange surgery offers comparable infection control outcomes to full revision for select patients with well-fixed implants.

Methods: We conducted a retrospective, multicenter cohort study involving 226 patients who underwent cementless single-stage exchange hip arthroplasty for PJI between 1 October 2013 and 31 July 2022. Patients were divided into partial revision (n = 61) and full revision (n = 165) groups. The primary outcome was treatment success, defined as the absence of clinical symptoms and signs of infection at a minimum follow-up of 2 years.

Results: The success rates were 77.0% for the partial revision group and 80.0% for the full revision group, with no significant difference (p = 0.629). Both groups showed comparable 10-year survival rates for overall success and infection-free status. Patients with partial revision had significantly shorter operative times (137.3 versus 169.1 min, p < 0.001). Age ≥ 65 years (odds ratios (OR): 2.433, p = 0.003), American Society of Anesthesiologists (ASA) score ≥ 3 (OR: 1.778, p = 0.030), and chronic kidney disease (OR: 3.467, p = 0.053) were identified as independent risk factors for reinfection in the partial revision group.

Conclusions: Partial cementless single-stage revision may offer comparable infection control to full revision in selected hip PJI cases with well-fixed implants, while reducing operative time. Given the retrospective design, these findings should be interpreted with caution, and future prospective studies are needed to confirm long-term outcomes, assess implant survival, and evaluate functional recovery.

Objectives: This study aimed to analyze the radiologic characteristics of irreducible pediatric femoral head fracture-dislocations to prevent potential iatrogenic femoral neck fractures (FNF) or separation of the proximal femoral epiphysis (SPFE).

Methods: This is a retrospective review of patients who were skeletally immature and diagnosed with traumatic hip dislocations combined with femoral head fractures. The collected data included patient demographics, fracture classification, fragment ratio, combined injuries, urgent reductions, treatment strategies, complications, and final outcomes.

Results: We treated 12 patients with femoral head fractures and dislocations; 11 out of 12 patients underwent urgent closed reduction (91.7%). Six of the patients failed closed reduction and experienced FNF (n = 2, 33.3%) or SPFE (n = 4, 66.7%). Five patients presented with avascular necrosis of the femoral head after open reduction with internal fixation via a surgical hip dislocation approach, and two patients required further surgical treatment. Analysis of radiographs and computed tomography (CT) scans of irreducible femoral head fracture-dislocations revealed that the fractured femoral head was perched on the sharp angle of the posterior wall of the acetabulum, with a fragment ratio of 18-27%. After recognizing the irreducibility, one case with a fragment ratio of 26% underwent immediate open reduction without further attempts at closed reduction. This procedure preserved the natural hip joint, preventing FNF and SPFE.

Conclusions: For pediatric patients with irreducible femoral head fracture-dislocation injuries and a fragment ratio greater than 10%, repeated or forceful closed reduction may result in iatrogenic FNF or SPFE. Examining plain radiographs and CT images carefully before attempting reduction may help determine the safest treatment strategy.

Purpose: Late acute haematogenous total knee arthroplasty (LAH TKA) infections represent approximately 20% of all prosthetic infections. Debridement, antibiotics, and implant retention (DAIR) is a widely accepted treatment; however, it carries a significant risk of failure. The study aims to identify risk factors for DAIR failure in LAH TKA infections, focusing on blood cultures (BC) as a potential contributor.

Methods: A retrospective cohort study was conducted on 37 cases of LAH TKA infections from 2015 to 2023. Patients were divided into two groups: 20 in the success group (SG) and 17 in the failure group (FG). The study analyzes various factors, including demographics, comorbidities, serum and joint fluid biomarkers, blood and intraoperative cultures, prior infection or antibiotic use, and surgical and post-surgical variables.

Results: Positive BC were more frequent in the FG compared with the SG (P = 0.03), and were also more common in patients with a history of prior infection (P = 0.03). Logistic regression identified positive BC as the only significant predictor of DAIR failure (odds ratio (OR) 12, 95% confidence interval (CI) 1.1-18, P = 0.04), even after adjusting for other variables. Positive intraoperative cultures were more frequent in the FG, particularly in those with a prior infection history (P = 0.08), even if they were receiving antibiotics (P = 0.05).

Conclusions: Positive BC may be an additional risk factor for DAIR failure in LAH TKA. This highlights the importance of routinely performing BC during diagnosis.

Level of evidence: level III.

Background: There is debate regarding the optimal timing of bilateral total hip arthroplasty (THA), with simultaneous or staged approaches considered. Cost-effectiveness is an important factor that influences resource allocation. The main aim of this study was to assess the cost implications of bilateral simultaneous (sim-THA) versus staged (st-THA) total hip arthroplasty. The secondary objective was to evaluate the efficacy and safety of sim-THA compared those with of st-THA.

Methods: A systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing simultaneous and staged bilateral THA in terms of cost, complications, length of hospital stay, and patient outcomes were eligible. Odds ratios (ORs), mean differences (MD), and standard mean differences (SMD) with 95% confidence intervals (CIs) were calculated. The risk of bias was assessed using the Methodological Index for Non-randomised Studies (MINORS). Meta-analyses were performed using Review Manager version 5.4 (Cochrane, Oxford, United Kingdom).

Results: A total of 20 observational studies including 13,984 patients were included. Sim-THA was associated with significantly lower total costs (SMD -0.54, 95% CI -0.92 to -0.16; p = 0.005) and shorter hospital stay (MD -2.90, 95% CI -4.38 to -1.42; p = 0.0001) than those in the st-THA group. Revisions were less frequent in the sim-THA group (OR 0.44, 95% CI 0.36-0.53; p < 0.00001). No differences were observed in mortality (OR 1.01, 95% CI 0.31-3.28; p = 0.98) or readmission rates (OR 0.58, 95% CI 0.23-1.44; p = 0.24). The number of transfusions (OR 4.42, 95% CI 2.18-8.99; p < 0.0001) was lower in st-THA. Functionality (SMD 0.37, 95% CI 0.20-0.53; p < 0.0001) and pain scores (SMD 0.19, 95% CI 0.04-0.33; p = 0.01) favored sim-THA.

Conclusions: A meta-analysis of 20 studies demonstrated that sim-THA offers economical and clinical advantages, including reduced hospital expenses and improved patient quality of life, despite a higher number of transfusions, with comparable surgical blood loss to standard THA.

Background: Periprosthetic femoral fractures following hip arthroplasty (FH-PPF) represent a severe complication, especially in elderly patients with compromised health. Traditionally, revision arthroplasty is recommended for B2-B3 FH-PPF, yet internal fixation has emerged as a debated alternative in select patients. The hypothesis was that fixation, in selected patients with B2-B3 FH-PPF, decreases mortality and surgical complication rates with the same functional outcomes as revision arthroplasty.

Materials and methods: PIPPAS is a multicenter prospective observational study. This cohort substudy includes 485 patients across 57 hospitals with B2-B3 FH-PPF between January 2021 and May 2023. Management strategy, revision or fixation, was at the attending surgeon's discretion. Propensity score matching, controlled for age, age-adjusted Charlson Comorbidity Index (a-CCI), prefracture mobility, Pfeiffer scale, and ASA score, was done. Mortality risk factors were assessed using univariate and multivariate analysis.

Results: Out of 485 patients, 164 received fixation, and 321 underwent revision. Fixation patients were older (88 versus 82 years, p < 0.001) and frailer. Fixation was associated with shorter hospital stay (13 versus 15 days, p = 0.003) but higher 1-year mortality (25% versus 14.3%, p = 0.04). There were no differences in medical or surgical complications (p = 0.83 and p = 0.36) at any time, but dislocation rate was higher in the revision group (p = 0.001). The 1-year mortality rate in patients with no weight-bearing restrictions was higher for the revision group (p = 0.01). The propensity score matching showed higher 1-year mortality rate in the fixation group but no differences in functional outcomes, complications, or up to 6-months mortality. In the multivariate analysis a-CCI, cognitive impairment, B3 fractures, and prefracture independent walking impairment were independent mortality risk factors.

Conclusions: Revision arthroplasty showed less 1-year mortality rate and weight-bearing restrictions than fixation. However, frail patients with B2-B3 FH-PPF managed with fixation allowing full weight-bearing showed a lower 1-year mortality rate. Fixation in B2-B3 FH-PPF is a treatment option in frail patients, while aiming for stable constructions allowing full weight-bearing.

Level of evidence ii: prospective cohort study.

Trial registration: ClinicalTrials.gov (NCT04663893).

Background: Lumbar fusion is a common intervention for degenerative spinal conditions, with robotic-assisted techniques offering improved precision. However, evidence comparing robotic and conventional fusion in frail older adults is limited. This study evaluated short-term postoperative outcomes in this high-risk population.

Materials and methods: This retrospective study analyzed data from frail adults aged ≥ 60 years who underwent single-level lumbar fusion between 2016 and 2020 using the National Readmission Database. Frailty was assessed with the Hospital Frailty Risk Score (HFRS). Outcomes-including in-hospital mortality, complications, hospital charges, and length of stay (LOS)-were compared between robotic and conventional fusion groups using propensity score matching (PSM). Key covariates used in the matching process included age and severe liver disease. Logistic regression provided adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Results: Among 29,938 patients identified, 20,227 met inclusion criteria, and 3135 patients remained after PSM. Robotic surgery was associated with significantly higher hospital charges compared with the conventional approach (mean 203,700 USD versus 151,200 USD; β = 52.51, 95% CI 26.41, 78.60; p < 0.001). No significant differences were observed in in-hospital mortality (0.4% for both; OR 1.03, 95% CI 0.14, 7.79, p = 0.978), LOS (5.3 versus 5.6 days; β = -0.36, p = 0.263), or complication rates between groups.

Conclusions: Robotic-assisted lumbar fusion in frail older adults leads to higher total hospital charges without short-term clinical benefit compared with conventional techniques. Further research is needed to assess long-term outcomes and justify the use of robotic surgery in this population.

Level of evidence: 3: