Journal of Orthopaedics and Traumatology最新文献

Background: Leg length discrepancy (LLD) has been implicated as a biomechanical factor contributing to hip osteoarthritis (OA), yet the extent of its influence remains unclear. This study examines the correlation between moderate LLD (≥ 10 mm) and hip OA progression, focusing on asymmetrical OA distribution in patients over 65 years old.

Materials and methods: A retrospective analysis was conducted from a database of 1672 full-length standing X-rays. Patients under 65 years, with deformities, unilateral limb issues, or prosthetics, were excluded; therefore, the study group was composed of 220 patients. Tibial and femoral lengths were measured bilaterally, and hip OA severity was assessed using the Tönnis classification. Statistical analyses included Pearson's Chi-squared test and linear regression to explore correlations between LLD and OA distribution.

Results: Among the sample, 18% showed an LLD ≥ 10 mm. A significant correlation was found between LLD and the asymmetrical distribution of hip OA (p = 0.002), with higher OA severity observed in the hypometric limb. Linear regression analysis suggested that each millimeter of LLD corresponded to a 0.74-unit change in OA severity difference between hips.

Conclusions: This study highlights a significant association between moderate LLD and contralateral hip OA in the elderly, emphasizing the biomechanical impact of asymmetrical joint loading. Findings suggest the need for early identification and targeted management of LLD to mitigate OA progression.

Level of evidence: III.

Background: The purpose of this study was to describe a novel, simple, and implant-free arthroscopic soft-tissue tenodesis technique of the long head of the biceps tendon (LHBT) to the rotator cuff using an absorbable monofilament suture and to evaluate its clinical and functional outcomes at a minimum 1-year follow-up.

Methods: A retrospective case series of 23 patients (mean age 58.0 ± 7.8 years) who underwent arthroscopic rotator cuff repair with concomitant LHBT soft-tissue tenodesis between June 2021 and June 2023 was analyzed. Functional outcomes were assessed using Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, and the Long Head of Biceps (LHB) score. Supination strength was measured with a handheld dynamometer and compared with the contralateral side. Incidence of Popeye deformity and tenderness over the bicipital groove were recorded.

Results: Objective Popeye deformity was observed in 13% of patients, with subjective concern reported by only 4.3%. Supination strength and LHB scores were similar to the contralateral side (means of 104.65 versus 104.64 N; LHB 93.7 versus 94.6 points). The mean CMS and ASES scores were 90.3 ± 12.4 and 89.6 ± 15.9 points, respectively. The SANE score averaged 87.4 ± 20.9, and the VAS for pain was low (1.65 ± 2.59 cm).

Conclusions: This implant-free, arthroscopic LHBT soft-tissue tenodesis technique is technically simple, cost-effective, and yields excellent clinical and functional outcomes with minimal cosmetic concerns. It represents a reliable option for patients undergoing rotator cuff repair with concurrent LHBT pathology.

Level of evidence: Level IV.

Background: The aim of this study was to compare clinical outcomes and complication rates during long-term follow-up (≥ 6 years) after treatment for three- and four-part proximal humeral fractures using two different types of locking plates.

Materials and methods: A total of 113 patients with three- and four-part proximal humeral fractures who underwent surgery between September 2012 and January 2019 were enrolled retrospectively. Data for 49 patients [ 9 males, 40 females; mean age [standard deviation] (SD ) 68.9 (5.8) years} treated with a PGR (intrauma) plate (group A) and 51 patients [10 males, 41 females; mean age (SD): 66.0 (7.5) years] treated with a PHILOS humeral plate (PHP, group B) were available at the last follow-up. The mean follow-up periods in groups A and B were 10.8 and 10.2 years, respectively, with a minimum follow-up of 6 years. At the final follow-up evaluation, functional outcomes were assessed using the Oxford Shoulder Scale (OSS), Simple Shoulder Test (SST), and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. X-ray evaluation was also performed, and complications were recorded.

Results: The mean OSS score in the PGR and PHP groups at follow-up was 42.9 and 39.1, respectively (p > 0.05). The SST score (PGR: 7.5 ± 2.0; PHP: 7.3 ± 4.0) and DASH score (PGR: 22.1 ± 5.5; PHP: 20.5 ± 4.0) were similar in both groups (p > 0.05). In our series, 6% of patients had complications; these included avascular necrosis of the humeral head (two cases in the PGR group and three in the PHF group) and one case of periplate fracture in the PGR group.

Conclusions: Among patients with three- and four-part proximal humeral fractures, both PGR plate and PHP treatment achieved comparable functional outcomes and demonstrated similarly low complication profiles. These results reinforce the appropriate clinical utility of either implant for fixation in the treatment of this fracture pattern.

Level of evidence: 3:

Introduction: Transcervical femoral neck fractures (TFNFs) are among the most devastating fragility fractures in the elderly. TFNF are associated with excess 1-year mortality rates ranging from 15% to 30%. Treatments include conservative methods, internal fixation, and arthroplasty (partial or total hip arthroplasty). This study aims to analyze the changes in incidences of TFNF in the Italian population between 2001 and 2023 and the evolution of the choices of treatment.

Materials and methods: Using hospital discharge record (HDR) data from 2001 to 2023, records with ICD9-CM codes for femoral neck fractures (820.0 and 820.1) among diagnoses were selected and categorized into four treatment groups: total arthroplasty, partial arthroplasty, fixation, and conservative. Time series were analyzed with stratification by sex and age.

Results: The extracted data included 1,120,724 records of TFNFs, with 871,161 cases treated surgically (total or partial arthroplasty or internal fixation) and 249,563 treated conservatively; the average patient age was 79.1 years, with a higher proportion of women (72.8%). Partial hip arthroplasty was the preferred treatment overall. For younger patients, in the age classes < 45 and 45-54 years, fixation was the most chosen treatment. Over time, the use of the conservative treatment decreased from 27.5% in 2001 to 14.6% of cases in 2023. The use of partial and total hip arthroplasty increased from 40% and 13.3% in 2001 to 44.5% and 24.3% in 2023, respectively.

Conclusions: Over the past two decades, Italy experienced declining age-adjusted incidence rates of TFNF despite persistent crude numbers (approximately 50,000 cases per year) owing to demographic aging. Partial hip arthroplasty (PHA) remained the preferred treatment, while total hip arthroplasty (THA) went from being the least used to the second-most performed treatment through the 23 observed years. Level of evidence level 1, population-based study.

Background: Posterosuperior massive irreparable rotator cuff tears (PMIRT) are rare and disabling conditions. When conservative treatment fails, latissimus dorsi tendon transfer (LDTT) is a viable surgical option for symptom relief in carefully selected patients. However, its effectiveness in restoring glenohumeral function and its influence on scapulothoracic rhythm remain subjects of ongoing debate.

Purpose: The purpose of this study was to evaluate the clinical outcomes of LDTT and assess its impact on scapulothoracic rhythm using kinematic and electromyographic analysis.

Material and methods: A total of 18 patients with PMIRT underwent LDTT. Functional scores consisted of Constant-Murley score (CMS), America Shoulder and Elbow Surgeons (ASES) score, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Electromyography (EMG) activity of the latissimus dorsi muscle was evaluated in conjunction with three-dimensional (3D) kinematic tracking system. Differences in external rotation strength were compared with and without active adduction.

Results: The mean age was 55.9 years (range 40-69 years), with a mean follow-up of 20.4 months (range 6-39 months). At final follow-up, the mean CMS was 68.2 (95% CI 64.9-71.5), ASES was 76.9 (95% CI 66.1-87.6), and QuickDASH was 17.6 (95% CI 9.5-25.6). A significant difference in external rotation strength was observed with and without active adduction (p < .0005). EMG confirmed latissimus dorsi activation in all patients, with no significant differences between rotation conditions (p > .05). Kinematic analysis showed an overall normal scapulothoracic rhythm, with significant differences only in scapular tilting during elevation and external rotation with the shoulder in adduction (p = 0.044 and p = 0.023, respectively).

Conclusions: LDTT provides satisfactory clinical outcomes in patients with PMIRT, enhancing external rotation strength when the latissimus dorsi is actively recruited and contributing to near-normal scapulothoracic rhythm restoration. A structured, targeted postoperative rehabilitation protocol is essential to optimize outcomes.

Level of evidence: IV.

Background: Different approaches have been proposed to treat patients with pulseless supracondylar humeral fractures (SHF). We aim to analyze the current outcomes of patients who have undergone different treatment options for pulseless SHF, namely watchful waiting versus urgent surgical exploration.

Methods: Electronic databases including PubMed, Embase, and Cochrane Library were explored. Our study included patients from all age groups but only included English-language articles. Single case reports and case studies with adequate description of patient population, injury, and outcomes were included. An individual patient data meta-analysis was done to evaluate key outcomes of surgical exploration versus no surgical exploration in pulseless patients with SHF.

Results: Overall, the data for 1070 individual patients from a total of 48 studies were included. Patients with pulseless SHF with open fractures have a higher probability of requiring vascular intervention (p < 0.001) as they are more likely to have disrupted arteries (p = 0.050) and more likely to require vascular repairs (p < 0.001) than patients with closed fractures. Similarly, patients with pulseless SHF with pucker sign (p = 0.003) and ecchymosis (p = 0.002) were more likely to undergo surgical exploration. However, the neurological status had no relation to them undergoing surgical exploration (p = 0.382), and also does not affect complication outcomes (p = 0.326) nor the need for vascular intervention (p = 1.00). However, patients with pale pulseless SHFs were more likely to undergo surgical exploration (p < 0.001), were more likely to have disrupted arteries (p < 0.001), required more vascular intervention (p < 0.001), and had a higher likelihood of complications (p < 0.001). Notably, there is no significant difference in overall complications between those who underwent exploration of arteries and those who did not among patients with pink pulseless SHF (p = 0.230).

Conclusions: Significant predictors for arterial injury requiring intervention include a pale pulseless limb, open fracture, pucker sign, and ecchymosis; expedient surgical exploration is recommended in these scenarios. However, for patients with pink pulseless SHF, watchful waiting is a viable strategy. Our meta-analysis found no significant difference in overall complication rates between patients with pink pulseless who underwent exploration and those who did not.

Level of evidence: Level II.

Registration: The review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines CRD.

Background: Distal humerus fractures in adults are rare but complex injuries, particularly AO type C3 fractures, often involving comminution, instability, and osteoporotic bone. Demographic trends indicate rising incidence, especially among elderly patients, with increasing functional demands challenging modern osteosynthesis. Open reduction and internal fixation (ORIF) with bicolumnar plating remains the preferred reconstructive approach, although complications remain substantial. This study aimed to evaluate trends in fracture complexity, patient demographics, and functional outcomes over five decades, focusing on the most recent cohort (2009-2018, series E) and comparing with historical cohorts (series A-D, 1969-2008).

Methods: This retrospective analysis included five consecutive 10-year institutional cohorts (series A: n = 43; B: n = 29; C: n = 47; D: n = 58) of 233 patients with 235 supradiacondylar distal humerus fractures (AO type C1-3) treated with ORIF. Functional outcome parameters (Jupiter and Cassebaum Scores) and demographic data were available for all cohorts; additional parameters (range of motion (ROM), QuickDASH Score) were available for series D and E, Mayo Elbow Performance Score (MEPS), Short Form (SF)-36, and strength were assessed specifically in series E (n = 56; follow-up n = 21). Cross-cohort comparisons of categorical variables used chi-square tests; continuous outcomes were summarized descriptively. Historical cohort means served as a basis for comparison, and analysis of variance (ANOVA) with Tukey Honestly Significant Difference (HSD) was applied for within-series analyses.

Results: Mean patient age increased to 62.6 (range 19-89, SD ± 18.1) years in series E. The proportion of AO type C3 fractures rose significantly from 11.6% (series A) to 71.4% (series E) (p ≤ 0.05). In series E (n = 56, follow-up n = 21), ORIF with bicolumnar plating was performed in 94.6% of cases and the overall complication rate was 16.4%, with mean hospitalization time of 11.1 (range 1-40, SD ± 10.1) days, mean extension deficit of 23° (range 0-90°, SD ± 26.4°), strength loss of 25.5 N (range 0-64.7 N, SD ± 19.1 N), QuickDASH Score of 23.3 (range 0-61.4, SD ± 21.2), and mean MEPS of 83.2 (range 45-100, SD ± 17.0). Good-to-excellent results were observed in 52.6% (Jupiter) and 73.7% (Cassebaum). Subjective satisfaction remained high.

Conclusions: Over five decades, distal humerus fractures increasingly involved older patients and more complex AO type C3 patterns. While ORIF continues to provide satisfactory outcomes, persistent deficits in motion and plateauing functional scores indicate that reconstructive limits may be approached in this evolving patient population.

Level of evidence: Level IV; Case series, treatment study.

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.