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:
Background: Surgical site infections (SSIs) are an important postoperative complication in orthopedic surgery, resulting in increased morbidity, prolonged hospital stay, and higher healthcare costs. Negative pressure wound therapy (NPWT) has been proposed to reduce SSIs by facilitating wound healing by increased perfusion, edema reduction, and bacterial control. This systematic review and meta-analysis evaluate the effectiveness of NPWT compared with conventional dressings for prevention of surgical site infections in orthopedic and trauma surgery.
Methods: A comprehensive literature search was performed across PubMed, Web of Science, Scopus, and the Cochrane Library in December 2024. Only randomized controlled trials (RCTs) comparing NPWT with CD in patients undergoing joint replacement, trauma surgery, or spine surgery were included. Two independent reviewers conducted data extraction and assessed study quality using the Cochrane Risk of Bias 2 tool. Pooled outcomes were evaluated with odds ratios (ORs) computed for dichotomous variables and mean differences (MDs) for continuous outcomes. Heterogeneity was assessed via the I2 statistic and publication bias through Egger's test.
Results: Overall, 18 RCTs, comprising a total of 4585 patients, were included. Meta-analysis demonstrated that NPWT significantly reduced SSIs (pooled OR 0.64, 95% CI 0.50-0.82; p = 0.0005) and wound dehiscence (pooled OR 0.39, 95% CI 0.23-0.65; p = 0.0003). Additionally, NPWT was associated with a reduction in length of hospital stay by 0.87 days (MD -0.87, 95% CI -1.36 to -0.38; p = 0.0005) and fewer dressing changes compared with conventional methods. The quality of evidence for the primary outcome was rated as moderate based on the GRADE approach.
Conclusions: NPWT appears to offer a significant clinical benefit in reducing the incidence of SSIs in orthopedic and trauma surgery. Secondary analyses also demonstrated benefits for surgical wound dehiscence, length of hospital stay, and number of dressing changes. However, the certainty of evidence is moderate, and these findings should be interpreted with caution. Further well-designed, multicenter RCTs are warranted to confirm these benefits, assess long-term outcomes, and evaluate cost-effectiveness. Level of evidence Level I.
Registration: CRD42024624188.
Background: Permanent epiphysiodesis (pED) according to Phemister is an established treatment for leg length discrepancies (LLD) but has largely been replaced by less invasive techniques. Nevertheless, modern pED procedures based on the Phemister principle are still widely used in paediatric orthopaedics for LLD correction and treatment of tall stature. However, the long-term effects of pED on the knee joint remain unclear. This study aimed to evaluate the long-term outcomes of Phemister pED, specifically assessing secondary alterations in knee joint morphology and the incidence of pre-mature osteoarthritis. A clearer understanding of these sequelae may help guide treatment decisions in paediatric orthopaedic care.
Materials and methods: A retrospective review of our institution's longitudinal database identified 75 patients who underwent Phemister pED for LLD between 1980 and 2006. Of these, 20 patients met inclusion criteria and were available for long-term evaluation. Their clinical and radiographic outcomes were compared with those of an age- and sex-matched control cohort of ten untreated individuals. Clinical and radiographic assessments included LLD, mechanical axis deviation, joint orientation angles, central knee anatomy and osteoarthritis grading. Patient-reported outcomes were evaluated using the Oxford Knee Score (OKS), EQ-5D-3L and Knee Injury and Osteoarthritis Outcome Score (KOOS).
Results: The median follow-up was 37 years (interquartile range 33-39). The mean pre-operative LLD of 2.8 cm (standard deviation (SD) 0.7) was reduced to 1.1 cm (SD 0.6) at last follow-up, although 55% of patients had residual LLD > 1 cm. No relevant differences in joint alignment or central knee anatomy were found between patients and controls. Mild knee osteoarthritis (Kellgren-Lawrence grade 1) was observed in two patients and none in controls. Patient-reported outcomes showed lower OKS and EQ-5D-3L scores in the pED group, although KOOS scores were similar.
Conclusions: Phemister pED showed satisfactory long-term results for LLD correction, without secondary angular or intra-articular deformities or relevant knee osteoarthritis. Despite slightly lower function and more discomfort, findings support the use of modern pED techniques based on the Phemister principle. This is especially relevant for elective indications such as tall stature. Further comparative studies with percutaneous methods remain necessary to confirm these observations. Level of evidence Level IV, therapeutic study.
Background: The number of total hip arthroplasty (THA) procedures has been steadily increasing worldwide, driven by aging population, improvements in surgical techniques and implant design. This study aimed to analyze the temporal trends of elective THA in Italy since 2001-2023 and forecast THA volumes up to 2050 to provide insights for healthcare planning.
Materials and methods: International Classification of Diseases, 9th Revision, Clinical Modification (ICD9-CM) coding system was used to extract records of interest (elective THA) from the Italian National Hospital Discharge Record database. Six statistical models were applied to forecast future THA volumes: logistic regression; Poisson regression; logarithmic regression; inverse/power regression; Poisson log-normal regression; and hierarchical Poisson regression with temporal effects (HPTE). Model performances were assessed by using error metrics and internal validation on the basis of a rolling-origin approach. An out-of-sample validation was conducted to ensure a robust assessment of forecasting reliability. THA volume forecasts were provided with 95% prediction intervals.
Results: A total of 1,318,400 records for primary elective THAs performed in Italy since 2001-2023 were analyzed. The number of THAs increased by approximately 80%, rising from 68.270 in 2001 to 122.777 in 2023. Among the tested models, HPTE generally showed the best fitting and forecasting performances. By using the HPTE model, the forecasts showed an increase in THA volumes up to a maximum rate ratio (RR) of 1.3 (PI95%: 1.1-1.4) in terms of RR in 2036, then decreasing to a RR equal to 1.2 (PI95%: 1.1-1.4) by 2050 with respect to 2019.
Conclusions: Our findings forecast a steady increase between 10% and 40% in THA, driven by demographic and epidemiological trends. These projections are essential for anticipating future surgical demand and guiding healthcare system planning. Without adequate investment and strategic planning, rising volumes may strain service capacity and sustainability.
Level of evidence: population based study, level 1 evidence.
Coronoid fractures are rarely isolated and are much more frequently associated with other osseous or ligamentous structures injuries. On the basis of the coronoid fracture patterns, described by the O'Driscoll classification, it is possible to recognize three main patterns of injury that differ on traumatic mechanism and on associated lesions: posterolateral rotatory instability, posteromedial rotatory instability, and axial load injuries. The management of coronoid fractures is challenging and varies according to characteristics of the fracture, associated lesions, and amount of elbow instability. In general, operative treatment is indicated in every case the fracture is at least 50% of the whole coronoid, whether the sublime tubercle is involved, and whether the ulno-humeral joint is not perfectly reduced. In conclusion, the correct management of the coronoid, especially in the setting of complex elbow instability, represents a predictive factor for patient outcomes and functional results. The stability of the elbow, rather than the size of the coronoid fragment, is the main parameter for surgical indication, aimed to fix the coronoid and/or repair the associated lesions.
Background: Robotic-assisted unicompartmental knee arthroplasty (UKA) has gained popularity for its potential to improve implant precision and reduce surgical errors. However, comparative evidence on short-term outcomes versus conventional UKA is lacking. Thus, the purpose of this study was to compare the short-term outcomes of robotic-assisted versus conventional UKA using a nationally representative database.
Methods: The Nationwide Readmissions Database 2016-2020 was retrospectively examined to identify adult patients who received an elective UKA. After applying exclusion criteria and 1:2 propensity score matching (PSM), 8310 patients were included in the analysis. Outcomes included in-hospital complications, implant malposition or failure, perioperative fracture, length of hospital stay (LOS), hospital costs, and 30- and 90-day readmission rates. Multivariable regression analyses were performed to adjust for residual confounding factors.
Results: Robotic-assisted UKA was associated with significantly lower complication rates compared with conventional UKA (3.7% versus 13.2%, p < 0.001). Specifically, robotic-assisted procedures had reduced risks of implant malposition or failure (odds ratio [OR] = 0.08; 95% confidence interval [CI]: 0.05-0.13; p < 0.001) and perioperative fracture (OR = 0.18; 95% CI 0.04-0.76; p = 0.020). No significant differences were observed in LOS, total hospital costs, or readmission rates at 30 and 90 days.
Conclusions: Robotic-assisted UKA is associated with improved short-term surgical safety, including fewer complications, particularly, reduced implant malposition and perioperative fractures. However, broader hospital metrics such as LOS, cost, and readmissions were comparable between the two approaches. Further prospective studies are needed to validate these findings and assess long-term outcomes and cost-effectiveness.
Level of evidence: Level III.
Clinical trial registration number: Not applicable.
Background: Acute compartment syndrome (ACS) following lower extremity arterial injuries necessitates urgent fasciotomy to prevent limb loss, yet current diagnostic tools lack specificity for ischemia-reperfusion pathophysiology. Our study aimed to develop a nomogram combining biomarkers and clinical indicators to predict fasciotomy risk, enhancing early risk stratification and optimizing surgical decision-making.
Materials and methods: In this retrospective case-control study (2010-2024), data were sourced from a tertiary hospital in China. A total of 146 patients with traumatic femoral or popliteal artery injuries were stratified into fasciotomy (n = 45) and non-fasciotomy (n = 101) groups. Adhering to the events-per-variable (EPV) principle (10:1), predictors were selected via least absolute shrinkage and selection operator (LASSO) regression and bootstrap validation. A multivariable logistic regression model was internally validated using tenfold cross-validation and 1000 bootstrap replicates.
Results: Four independent predictors were retained: limb ischemia severity (odds ratio [OR] = 4.25, 95% confidence interval [CI]: 1.97-10.02), K+ (OR = 6.99, 95% CI: 2.60-21.73), creatine kinase (CK; OR = 1.18, 95% CI: 1.08-1.30), and neutrophils (NEU) with a nonlinear threshold effect (OR = 1.20, 95% CI: 1.10-1.33). The nomogram demonstrated excellent discrimination (area under the curve [AUC] = 0.877, 95% CI: 0.819-0.934), precise calibration (Hosmer-Lemeshow P = 0.417), and broad clinical utility (net benefit threshold: 3-87%).
Conclusions: This study integrated accessible clinical and laboratory data and identified limb ischemia severity, K+, CK, and NEU as factors associated with fasciotomy risk. A nomogram based on these variables demonstrated reliable predictive performance and strong clinical applicability, enabling timely risk assessment and early intervention in patients with lower extremity arterial injuries.
Level of evidence: Level 4.
Objective: This study aimed to investigate the indications and clinical effects of the Frosch approach versus the supra-fibular head approach in the treatment of posterolateral tibial plateau fractures combined with lateral column fractures (PTPL) on the basis of the morphological classification of the posterolateral cortex.
Methods: A retrospective analysis was conducted on patients treated between June 2018 and January 2024 for PTPL using either the Frosch approach (group A, n = 23) or the supra-fibular head approach (group B, n = 21). Fractures were classified according to the morphology of the posterolateral cortex into two types: intact cortex (type I, n = 24) and disrupted cortex (type II, n = 20). Patients with type I fractures were further divided into subtypes IA (Frosch, n = 12) and IB (supra-fibular head, n = 12), and those with type II fractures into IIA (Frosch, n = 11) and IIB (supra-fibular head, n = 9). Baseline characteristics and perioperative parameters were compared. Clinical effects was assessed using the Rasmussen radiological score, and knee function was evaluated using the Rasmussen functional score.
Results: The operative time was significantly longer in group A than in group B (130.0 ± 19.1 versus 110.1 ± 13.7 min, P < 0.05). In the type I subtype, operative time was longer in IA than in IB (138.3 ± 19.5 versus 111.9 ± 17.4 min, P < 0.05). In the type II subtype, operative time was significantly longer in IIA compared with IIB (120.9 ± 14.5 versus 107.8 ± 6.7 min, P < 0.05). Rasmussen radiological scores were significantly higher in IIA than IIB (17.6 ± 1.2 versus 17.0 ± 0.9, P < 0.05); similarly, functional scores were higher in IIA than IIB (29.1 ± 1.8 versus 27.7 ± 1.7, P < 0.05).
Conclusions: Morphology-based classification of PTPL-according to the integrity of the posterolateral cortex-can provide valuable guidance for surgical decision-making. For fractures with cortical disruption, the Frosch approach offers superior reduction and enhanced stability. In contrast, for fractures with intact cortical continuity, the supra-fibular head approach is a less invasive and technically straightforward alternative with favorable clinical outcomes.
Level of evidence: III, retrospective study.
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