Journal of Orthopaedics and Traumatology最新文献

Background: Open reduction, superior plate (SP) fixation, and autologous cancellous granular bone grafting (ACGBG) are common strategies for treating clavicular midshaft atrophic nonunion (CMAN). We aimed to compare the radiological findings and clinical effects of two autologous cancellous bone grafts (ACBGs) and those of single SP fixation, to treat CMAN.

Methods: This retrospective study comprised 62 patients admitted to our hospital with CMAN (ACGBG with single SP fixation between March 2012 and October 2017, 32 patients; autologous cancellous structured bone grafting [ACSBG] with single SP fixation between November 2017 and May 2021, 30 patients). Patient visual analog scale (VAS) scores for pain and disability of the arm, shoulder, and hand (DASH) scores, obtained preoperatively and at final follow-up, were recorded and analyzed. Statistical differences between the ACGBG and ACSBG groups were assessed using Fisher's exact and two-sample independent t tests.

Results: No statistically significant differences were observed between the two groups in terms of patient demographics or the incidence of complications. VAS and DASH scores decreased significantly from the preoperative day to 9 months postoperatively in both groups, but this difference was not statistically significant at final follow-up. However, at 3 and 6 months postoperatively, compared with mean VAS and DASH scores in the ACGBG group, the ACSBG group showed lower pain and dysfunction scores (p < 0.05). The mean fracture healing times were 15.2 (range, 12-20) and 18.6 (range, 12-32) weeks in the ACSBG and ACGBG groups, respectively (p = 0.01). One case of plate breakage occurred in the ACGBG group at 5 months postoperatively, with recovery following ACSBG revision with single SP fixation.

Conclusions: ACSBG combined with single SP fixation is a promising and effective alternative technique for promoting bone union and postoperative early functional rehabilitation in treating CMAN.

Level of evidence: Level 3.

Background: In patients with cerebral palsy (CP), spastic hip is a prevalent complication. Various surgical approaches,, including pelvic osteotomy (PO), femoral osteotomy (FO), combined femoral and pelvic osteotomy (CFPO), and soft tissue surgery (STS), have been used to address this problem. This systematic review and meta-analysis was designed to compare the radiologic outcomes of these interventions for spastic hip in patients with CP.

Methods: To identify relevant studies, databases were searched using specific keywords. Initially, duplicates were removed, then the titles and abstracts were screened, followed by a comprehensive full-text review. Data extraction took place from the studies that met the inclusion criteria. Subsequently, a meta-analysis was conducted.

Results: The analysis of 6116 hips from 4546 patients across 81 studies demonstrated that PO significantly enhanced the center-edge angle (CEA), reduced the acetabular index (AI) and migration percentage (MP), and improved the Sharp and Tönnis angles. FO led to a substantial decrease in AI and MP, though CEA did not show a significant change, while CFPO resulted in significant improvements across AI, MP, neck-shaft angle (NSA), CEA, Sharp angle, and Tönnis angle. STS did not show significant changes in AI or CEA, but MP was notably reduced. Tone-decreasing procedures, such as selective dorsal rhizotomy and botulinum toxin injections, did not significantly alter MP, whereas guided growth techniques showed a significant reduction. MP improvements in FO decreased over time, with other radiologic parameters remaining relatively stable as follow-up increased. Age-specific trends indicated that children under 6 years primarily underwent tone-decreasing procedures and STS, while those around 7 years favored FO and guided growth, and older children (over 9 years) more commonly underwent PO, CFPO, or percutaneous osteotomy. Comparative analysis showed PO and percutaneous osteotomy were particularly more effective in reducing MP, with PO also being superior for AI improvement; whereas CFPO provided better outcomes for enhancing CEA. No significant differences were found among surgical methods for improving NSA.

Conclusions: This systematic review and meta-analysis underscores the superior efficacy of PO and CFPO in correcting spastic hip deformity in children with CP. Radiological outcomes demonstrate significant improvements following these procedures. The findings suggest that these approaches are particularly effective for complex cases where procedures such as FO, STS, or TDS may fall short. Future studies should focus on refining surgical protocols and exploring the long-term functional outcomes of these interventions.

Background: This retrospective analysis was performed to investigate the potential influence of intra-operative blood transfusion (IBT) in patients aged 65 years or older with intertrochanteric fractures (IF) who underwent intramedullary fixation.

Methods: The outcomes of interest included the incidence of postoperative delirium (POD), pain score at discharge, length of hospital stay (LOS), functional outcomes, and mortality. The study included all surgically treated patients with IF between Jan. 2018 and Dec. 2021. Data on patient demographics, injury-related factors, surgical procedures, intraoperative details, in-hospital information, and postoperative outcomes were collected. In order to mitigate potential confounding and selection bias, the researchers employed the propensity score matching (PSM) technique using a 1:1 ratio via the caliper matching method. Following PSM, the association between IBT and outcome analyses was assessed using McNemar's Chi-square tests. Additionally, the Spearman correlations between IBT, POD and postoperative functional outcomes were computed.

Results: Out of the initial 2159 consecutive patients screened, a final sample of 1681 individuals was included, consisting of 1278 in the non-IBT group and 403 in the IBT group. After PSM, each group comprised 298 participants. The disparities in POD rate and functional outcomes became significant after employing propensity score-based matching (P < 0.001 and 0.029, respectively), despite their lack of significance prior to matching. There were no notable distinctions observed in other operation-related data, LOS, and crude mortality rates at 30-day, 90-day, and 12-month intervals before and after PSM. Furthermore, incidence of POD (P = 0.006) and functional outcomes (P = 0.013) were significantly associated with IBT.

Conclusion: In conclusion, IBT significantly increases the incidence of POD and hinders postoperative functional recovery in elderly patients with hip fracture.

Background: Dynamic compression plate (DCP) osteosynthesis is the gold standard for treating forearm diaphyseal fractures, providing stability and promoting healing. Locking plates (LPs) are increasingly used in modern fracture management but may increase the risk of nonunion if applied with excessive rigidity and without proper fracture site compression. The purpose of this study is to compare the nonunion rate between LPs and DCPs.

Materials and methods: We conducted a retrospective study by reviewing the medical records and radiographs of 515 patients diagnosed with radial and/or ulnar shaft fractures at three trauma centers between 2014 and 2019. Inclusion criteria were patients treated with locking plates (LPs), locking compression plates (LCPs), or dynamic compression plates (DCPs) who had at least 9 months of outpatient follow-up and imaging assessments. Exclusion criteria included treatment with other methods, hospitalization for pathological fractures or implant removal, or incomplete surgical records. Data on patient demographics, injury details, and surgical outcomes were collected to compare nonunion rates, as well as early and late complications, between the LP and DCP groups.

Results: A total of 368 patients were included in the analysis. Among them, 132 (35.9%) had isolated radial shaft fractures, 116 (31.5%) had isolated ulnar shaft fractures, and 120 (32.6%) had both-bone fractures. Of these, 124 patients received LP implants, 98 were treated with LCPs, and 146 were treated with DCPs. Early complications were comparable among the groups; however, the nonunion rate was significantly higher in the LP group (18.5% versus 11.2% versus 6.2%, p < 0.007). Logistic regression identified LP use [odds ratio (OR): 3.05, 95% confidence interval (CI) 1.24-7.53] as a significant predictor of nonunion. Notably, LPs lacking dynamic compression functionality were associated with markedly higher odds of nonunion in radial shaft fractures (OR: 26.94, 95% CI 3.52-206.15). These findings collectively indicate that LPs increase the nonunion rate in forearm fractures.

Conclusions: Using LPs without compression functionality to treat forearm diaphyseal fractures increases the nonunion rate, particularly in radial shaft fractures. Therefore, we recommend using LCPs or DCPs for forearm diaphyseal fractures to ensure adequate compression at the fracture site during fixation, thereby promoting optimal bone healing rates.

Level of evidence: Level III: retrospective comparative therapeutic study.

Background: Anatomic stems for total hip arthroplasty (THA) have been developed to achieve a precise geometric fit between the implant and the surrounding femoral bone, aiming at the improvement of primary stability of cementless implants until osteointegration occurs. The aim of the current study is to go over the regional Registry of Orthopaedic Prosthetic Implants (RIPO) to analyze survivorship of THA implants when anatomic stems are used; moreover, separate analysis for modular and nonmodular stems, and in standard and short implants, is presented.

Materials and methods: This retrospective registry study involved the analysis of data collected by the RIPO registry between 2000 and 2019. The study focused on THAs performed for primary hip osteoarthritis (OA) between 2000 and 2019. All patients treated by THA within this time frame and officially registered in the RIPO registry were included in the study. Exclusion criteria were: revision THAs, cemented implants, hemiarthroplasties, resurfacing procedures, megaprostheses for neoplastic and non-neoplastic conditions, and THAs performed on patients residing outside the region.

Results: A total of 12,010 cementless primary THAs using curved anatomic stems were performed in Emilia-Romagna between 2000 and 2019 and formally registered in the RIPO registry. The overall survival rate for anatomic standard stems was 96.7% at 10 years (96.1-97.3%); at 15 from the surgery, the survival rate dropped to 95.1% (93.9-96.1%). A total of 473 out of 12,010 recorded THA with anatomic stems (3.93%) experienced failure requiring revision surgery. The fixed standard stem showed the lowest failure rate (0.6%), while modular short stems had the highest (7.4%) at long-term follow-up. The most common stem-related complication was periprosthetic fracture (PF) in short stems (2.0% of cases) while in standard stems it was implant breakage (0.9% of cases); PFs were significantly more frequent in female patients (p = 0.0082), with a relative risk (RR) of 1.59 compared with male patients. Implant breakage demonstrated the highest rate of incidence among standard-modular stems (1.1% of cases).

Conclusions: This registry-based study highlights that stem length and modularity significantly affect the long-term survival of anatomic femoral stems in THA. Fixed standard stems had the lowest failure rates, while modular short stems showed the highest failure rates and complications.

Level of evidence: 3:

Background: Osteochondral lesions of the talus (OLTs) with a large subchondral cyst have been shown to have inferior clinical outcomes after reparative techniques. Replacement techniques such as autologous osteoperiosteal transplantation (AOPT) and autologous osteochondral transplantation (AOCT) are indicated for large lesions. The aim of the study was to compare the short-term clinical and radiographic outcomes between patients undergoing AOPT and those undergoing AOCT for large cystic OLTs.

Methods: Patients who underwent AOPT or AOCT for medial large cystic OLTs between May 2019 and June 2023 were retrospectively evaluated. According to their characteristics, 1:1 propensity-score matching was performed, and 65 pairs of patients with ages ranging from 18 to 60 years old were recruited. Clinical outcomes were compared between both groups with the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and Visual Analogue Scale (VAS). The Ankle Activity Score (AAS), time to return to sports activity (RTA), rate of return to sports level, complications, and results of a subjective evaluation were also collected. The integrity of subchondral bone and the quality of repaired cartilage were evaluated using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score 12 months postoperatively. Second-look arthroscopy was performed 12 months postoperatively, and the cartilage repair was assessed with the criteria of the International Cartilage Repair Society (ICRS).

Results: The within-group comparison showed significant improvements in pain severity and function in both groups post-treatment compared with pre-treatment. Between-group analysis, however, showed no significant statistical difference between groups in any of the variables for clinical and radiographic outcomes, except for donor-site morbidity of the AOPT group, which showed a better outcome compared to the AOCT group.

Conclusions: In the treatment of large cystic OLTs, for patients with a chondral lesion of the patellofemoral joint that is unsuitable for AOCT, AOPT may be a safe and effective choice, with lower donor-site morbidity of the normal knee joint.

Background: Treatment of ankle osteoarthritis by total ankle replacement (TAR) is increasing worldwide. The aim of the study was to present the overall temporal trends of TAR throughout 22 years (2001-2022) in Italy, analyzing the distributions of hospitals by volume of activity and patients by age and sex, drawing on the National Hospital Discharge Record database. Furthermore, as a secondary aim, we compared these trends with those of ankle fusions.

Materials and methods: International Classification of Diseases, 9th Revision, Clinical Modification (ICD9-CM) codes of interest were identified to browse the Italian National Hospital Discharge Record database. Surgical volumes, trends over time, classes of hospital activity volume, sex and age of patients, and population incidence rates were described. The statistical significance of time series trends was assessed by the Cox-Stuart test with randomness as a null hypothesis.

Results: 20,248 ankle procedures (total ankle replacements 8853 and ankle fusions 11,395) were extracted from 231,601,523 admissions registered nationally from 2001 to 2022. The yearly total number of TARs significantly increased almost tenfold from 96 to 996 (p < 0.05), while the number of fusions exhibited a stationary behavior (p > 0.05). The increased trend in TAR procedures was concentrated mostly in the North of Italy, with predominantly males between 55 and 64 years of age. The analysis of the number of procedures performed on inhabitants by region and that performed by all the hospitals in the region showed a different pattern across Italy.

Conclusions: The substantial increase in TARs may be owing to improved implant designs and innovative surgical technologies, which allow the treatment of more severe cases and deformities, previously untreated or treated by a fusion. This trend highlights the need to invest in implementing high quality registries by promoting surgeons' participation in data collection.

Level of evidence: population based study, level 1 evidence.

Background: The need for anterior cervical discectomy and fusion (ACDF) for cervical degenerative disc disease (CDDD) will probably grow dramatically in the geriatric population. However, ACDF with self-locking standalone cages in patients over 80 years has not yet been investigated. This study aimed to assess the clinical and radiographic results in patients over 80 years treated by ACDF with self-locking standalone cages.

Methods: Between January 2018 and December 2019, patients with CDDD treated with ACDF were retrospectively stratified into two groups: the older group (≥ 80 years) and the younger group (< 65 years). The data collected included the demographics, preoperative comorbidities, intraoperative parameters, length of hospital stay, complications, clinical scores, and radiological parameters.

Results: A total of 123 patients were included in the study. The mean follow-up duration was 28.3 ± 2.4 months. The hospital stay was 5.3 ± 0.6 days and 3.8 ± 0.4 days, respectively, for the older and younger groups. Postoperative complication rate was found higher in the older group than that of the young group without significance. All the patient-reported outcome parameters had significant improvement at the final follow-up. The two groups had no significant differences in terms of the excellent and reasonable rates, fusion rate, and the C2-C7 Cobb angle.

Conclusions: Although a slightly higher incidence of complications, poorer recovery rate, and more extended hospital stay were found, without significant differences, satisfactory clinical and radiographic results were obtained in the older patients. The self-locking standalone cage is a safe and viable option for patients over 80 years who suffer from CDDD. Level of evidence Level IV.

Background: Various prediction models have been developed for extremity metastasis and sarcoma. This systematic review aims to evaluate extremity metastasis and sarcoma models using the utility prediction model (UPM) evaluation framework.

Methods: We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and systematically searched PubMed, Embase, and Cochrane to identify articles presenting original prediction models with 1-year survival outcome for extremity metastasis and 5-year survival outcome for sarcoma. Identified models were assessed using the UPM score (0-16), categorized as excellent (12-16), good (7-11), fair (3-6), or poor (0-2). A total of 5 extremity metastasis and 94 sarcoma models met inclusion criteria and were analyzed for design, validation, and performance.

Results: We assessed 5 models for extremity metastasis and 94 models for sarcoma. Only 4 out of 99 (4%) models achieved excellence, 1 from extremity metastasis and 3 from sarcoma. The majority were rated good (62%; 61/99), followed by fair (31%, 31/99) and poor (3%, 3/99).

Conclusions: Most predictive models for extremity metastasis and sarcoma fall short of UPM excellence. Suboptimal study design, limited external validation, and the infrequent availability of web-based calculators are main drawbacks.

Level of evidence: This study is classified as Level 2a evidence according to the Oxford 2011 Levels of Evidence. Trial registration This study was registered in PROSEPRO (CRD42022373391, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=373391 ).

Background: The Masquelet induced membrane technique is a surgical procedure that allows the reconstruction of segmental bone defects using a relatively simple approach that requires minimal resources from both the healthcare facility and the patient. Historically applied to the lower limb, this technique is gaining increasing attention in the literature for its use in the upper limb.

Methods: A systematic review of the literature was conducted using the PubMed and Google Scholar databases to identify all studies reporting the outcomes of the Masquelet induced membrane technique in the long bones of the upper limb (humerus, radius, and ulna) with a sample size of at least 3 patients. The papers had to include the length of the bone defect, a description of the protocol used for treatment, the complications of each case, and the anatomical location of the defect. The studies that did not meet the above inclusion criteria were excluded.

Results: The search identified 1044 studies, of which 15 met the inclusion criteria. These studies described a total of 156 patients with a mean age of 42 years. The affected bone segments included the humerus in 22 cases and the forearm in 134 cases. In 108 cases, the bone defect was septic. The average defect length was 4.5 cm. PMMA was used as a spacer in all cases, with antibiotics added in 77% of them. The average time interval between the first and second phases of the procedure was 9.5 weeks, and bone union took an average of 5.5 months. The mean follow-up duration was 48 months, and the complication rate was 21%, ranging from 0% to 75%.

Conclusions: The Masquelet induced membrane technique is a viable surgical option for managing segmental bone defects of the upper limb. However, the complication rate remains significant. Further research is needed to identify strategies to improve the outcomes of this technique.

Level of evidence: Level 2.