Journal of Orthopaedics and Traumatology最新文献

Musculoskeletal infections remain among the most challenging conditions in orthopaedic practice, often requiring prolonged antibiotic therapy, repeated surgical interventions, and extensive rehabilitation. The emergence of antimicrobial resistance and the persistence of bacterial biofilms further complicate management, particularly in chronic osteomyelitis, infected fracture fixations, and periprosthetic joint infections. In this context, bacteriophage therapy has re-emerged as a promising adjunctive strategy. Bacteriophages offer targeted antibacterial activity, including the ability to disrupt biofilms and self-replicate at the site of infection. Contemporary approaches, such as phagograms, customised phage cocktails, and local delivery techniques, have addressed many historical limitations related to phage specificity and accessibility. A growing number of case reports and small clinical series have documented successful applications of phage therapy in orthopaedic infections, with encouraging safety profiles and infection resolution in refractory cases. Early-phase clinical trials are now systematically evaluating the feasibility, pharmacokinetics, and immunogenicity of phage therapy in musculoskeletal settings. Furthermore, synergistic effects with antibiotics and the potential to overcome biofilm-related antibiotic tolerance highlight the added therapeutic value of this approach. While regulatory and manufacturing challenges persist, the integration of bacteriophages into multidisciplinary orthopaedic care marks a paradigm shift toward precision microbiology. Rather than replacing conventional treatment, phage therapy complements surgery and antibiotics, offering a biologically rational and patient-specific adjunct in the fight against recalcitrant infections.

Background: Talocalcaneal (TCC) and calcaneonavicular (CNC) coalitions are the most common cause of rigid symptomatic flatfoot in children. After resection, calcaneal lengthening osteotomy or arthrodesis are usually reported as second step surgery for correction of the most frequent valgus hindfoot deformity. More recently, coalition resection and minimally invasive subtalar extraarticular screw arthroereisis (SESA) for hindfoot valgus correction in one step have been described. We report the functional mid-term results of patients treated in adolescence with resection and valgus correction with SESA.

Methods: Between 2008 and 2024 data were collected from 25 patients (18 M, 7 F) affected by TCC (n = 16, 7R, 9L) and CNC (n = 16, 8R, 8L), all with symptomatic rigid flatfeet (n = 32). Average age at surgery was 12.8 ± 1.4 years (9.8-16.4 years, median 12.8). All patients underwent resection and SESA for correction of residual hindfoot valgus deformity; 31/32 feet had postoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Mann-Whitney test was used for comparison between TCC and CNC outcomes.

Results: Average follow-up (FU) was 4.7 ± 3.2 years (6 months-11.9 years, median 3.7) with a mean age at FU of 17.5 ± 3.3 years (13.2-25.4 years, median 16.8). Overall average AOFAS Ankle-Hindfoot score was 95.6 ± 5.7 and 94.3 ± 6.6 for TCC and 96.7 ± 4.6 for CNC, respectively. Subgroup scores for pain, function, and alignment were 37.3 ± 4.6, 48.7 ± 2.4, and 8.3 ± 2.4 for TCC and 38.1 ± 4.0, 48.6 ± 6.2, and 10.0 for CNC, respectively, showing a statistically significant difference between TCC and CNC only for alignment (p = 0.014). No patients had additional surgery for complications or valgus recurrence.

Conclusions: Symptomatic rigid flatfeet affected by TCC and CNC and treated in adolescence with coalition resection and SESA for residual hindfoot valgus correction achieved good to excellent results in all cases. Further surgery to correct malalignment was avoided.

Level of evidence: Level IV, retrospective study.

Background: Loss of lumbar lordosis after spinal fusion can lead to complications such as chronic low back pain, abnormal sagittal balance, and accelerated adjacent segment degeneration. This study aims to evaluate a novel intraoperative positioning technique for lumbar spondylodesis, involving hip hyperextension in the prone position with an inflatable bladder under the thigh to preserve lumbar lordosis.

Materials and methods: This prospective, pilot, interventional study included 100 patients undergoing monosegmental lumbar fusion at L4 or L5. Patients with degenerative disc disease and no prior spine surgery were enrolled. Lateral X-rays were obtained preoperatively, intraoperatively, and postoperatively, measuring sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and distal lordosis (DL). Spine types were categorized using the Roussouly classification. Data were analyzed using multivariate regression, accounting for age, body mass index (BMI), and spine type, with subgroup and sensitivity analyses.

Results: The mean patient age was 68.1 years, with 54% classified as overweight (mean BMI: 26.6 kg/m²). Significant improvements in distal lordosis were noted: preoperative (16.68° ± 8.85), intraoperative before reduction (17.60° ± 8.80), after reduction (21.44° ± 10.19), and postoperative (22.23° ± 10.13) (Z = -7.757, p < 0.005). The Sacral Slope increased postoperatively by 2.67° [t(99) = 2.671, p = 0.009]. The hip hyperextension technique improved lordosis independently of age, BMI, and spine type (p < 0.05). Patients with higher BMI (p < 0.01) and Roussouly type 3 (p < 0.05) benefited the most.

Conclusions: This study introduces a novel positioning technique that effectively preserves lumbar lordosis during spinal fusion without additional implants or complex procedures. The technique shows promise for optimizing outcomes and warrants further investigation with larger cohorts and extended follow-up. Trial Registration Retrospectively registered with the institutional ethics committee (Approval No. F-2023-073). Informed consent was obtained from all participants. Level of Evidence Level IV, case series.

Background: The presence of chondral lesions in patients with chronic ankle instability is common and has been suggested as a possible cause of persistent pain in some cases, even after successful ligament reconstruction. For this reason, some authors have proposed combining ankle stabilization with cartilage microfracture; however, the results reported in literature are contradictory.

Materials and methods: The study was designed as a prospective randomized clinical study with two parallel arms. Patients with an anterior talofibular ligament tear causing pain and instability, associated with a Berndt-Harty stage I-IIb talar osteochondral lesion of < 150 mm² that had not responded to conservative treatment, were blindly assigned to either isolated ligament reconstruction (REC) or reconstruction plus microfracture (REC + MIC). Evaluators were also blinded.

Results: A total of 71 patients were included in the study, with 36 in the REC group and 35 in the REC + MIC group. The groups were comparable in terms of anthropometry and pathology. The operating time was significantly longer in the REC + MIC group (48.0 ± 4.5 min) compared with the REC group (24.9 ± 3.9 min; p < 0.001). At the end of follow-up, both patient groups showed similar results on the American Orthopaedic Foot and Ankle Society (AOFAS) score (p = 0.755), Self-Reported Foot and Ankle Score (SEFAS) (p = 0.862), Karlsson score (p = 0.993), and visual analog scale (VAS) (p = 0.870). However, the time to recovery differed between the groups, with patients in the REC group recovering faster from before the operation (pre-op) through the third month after the operation (post-op). The difference in recovery at 3 months post-op was statistically significant on the AOFAS (p < 0.001), SEFAS (p < 0.001), and Karlsson (p < 0.001) scores. No statistically significant difference was observed in terms of pain (p = 0.342). The failure rate was also comparable between the groups, with four (11.1%) reoperations in the REC group and five (14.3%) in the REC + MIC group (p = 0.735).

Conclusions: At 2 years post surgery, no differences were observed in function (according to the AOFAS, SEFAS, and Karlsson scores), pain, or complications in patients with ankle instability and associated chondral damage treated with or without microfractures. However, patients who underwent microfractures experienced a significantly slower recovery of function.

Level of evidence: Level 1.

Trial registration: ClinicalTrials.gov Identifier NCT06947317 (retrospectively registered). Date: 1 May 2025. ( https://clinicaltrials.gov/study/NCT06947317 ).

Background: Chronic low back pain (cLBP) is common. Physiotherapy is frequently indicated as a non-pharmacological management of these patients. This Bayesian network meta-analysis compared active versus passive physiotherapy versus their combination in terms of pain and disability in patients with mechanical and/or aspecific cLBP.

Methods: In June 2025, the following databases were accessed: PubMed, Web of Science, Google Scholar and Embase. All the randomised controlled trials (RCTs) which evaluated the efficacy of a physiotherapy program in patients with LBP were accessed. Data regarding pain scores, the Roland-Morris Disability Questionnaire (RMQ) and the Oswestry Disability Index (ODI) were collected. The network meta-analyses were performed using the STATA (version 14; StataCorp, College Station, TX, USA) routine for Bayesian hierarchical random-effects model analysis, employing the inverse variance method. The standardised mean difference (STD) was used for continuous data.

Results: Data from 2768 patients (mean age 46.9 ± 10.9 years, mean BMI 25.8 ± 2.9 kg/m²) were collected. The mean length of follow-up was 6.2 ± 6.1 months. Between groups, comparability was found at baseline in terms of mean age, proportion of women, mean BMI, symptom duration and patient-reported outcome measures (PROMs). By the end of the follow-up period, the active group evidenced the lowest pain scores (SMD 1.00; 95% CI -3.28 to 5.28). The active group evidenced the lowest RMQ score (SMD 0.94; 95% CI -4.96 to 3.09). The active group evidenced the lowest ODI score (SMD -1.23; 95% CI -9.83 to 7.36).

Conclusion: Active physiotherapy showed better results than passive physiotherapy and a combination of both for the management of mechanical and/or non-specific cLBP.

Level of evidence: Level I, Bayesian network meta-analysis of RCTs.

Purpose: Adductor lesions (ALs) frequently coexist with osteitis pubis (OP) in athletes, yet the prevalence and clinical impact of different AL types have not been comprehensively evaluated. This study aimed to determine the frequency of various AL types using magnetic resonance imaging (MRI) and to investigate their association with clinical outcomes in athletes with OP.

Materials and methods: This retrospective cross-sectional study included male athletes aged 18-45 years with MRI-confirmed OP. ALs were classified into four types on the basis of MRI: type 1 (strain), type 2 (tendon avulsion), type 3 (tendinopathy), and type 4 (secondary cleft sign). Types 1-2 were considered acute, and types 3-4 chronic lesions. The relationships between AL types, age, symptom side, return to sport (RTS), and hip outcome score (HOS) were analyzed.

Results: Among 132 athletes with OP, 90% had concurrent AL, while 10% had isolated OP. Type 3 AL was the most frequent type (77.3%), followed by type 4 (23.5%), type 1 (15.9%), and type 2 (2.3%). Logistic regression revealed that type 3 was more likely to be found in younger athletes, while types 1 and 4 were found in older athletes. Although 95% of athletes had bilateral OP, 72% reported unilateral symptoms. The symptom side showed better consistency with the AL side than the OP side (Cohen's kappa = 0.489 versus 0.057). All athletes were treated conservatively, 50 chronic AL cases were applied also injection (31 corticosteroid-CS, 19 platelet reach plasma-PRP). Athletes with isolated OP achieved a higher RTS rate than those with AL (100% versus 75%, p = 0.033). RTS rates were higher in acute AL cases than in chronic cases (91% versus 72%) and in CS injections than in PRP injections (80% versus 63%), but without statistical significance. HOS scores were comparable across groups.

Conclusions: Adductor lesions, particularly chronic types, are highly prevalent in athletes with OP. While age influences the type of AL, the symptom side is compatible with the AL side, regardless of the type. RTS rates are more satisfactory in isolated OP and acute AL cases, but chronic AL cases were less successful in RTS outcomes despite injection treatments. These findings underscore the importance of identifying and classifying ALs for prognosis and treatment strategy in athletic groin pain.

Level of evidence: level IV, retrospective cohort study.

Purpose: This study aimed to evaluate the clinical outcomes, failure rates, and complications associated with a second revision anterior cruciate ligament reconstruction using an Achilles tendon allograft in a mono-loop fashion, which allows simultaneous reconstruction of the anterior cruciate ligament and the anterolateral ligament. The hypothesis was that this combined technique is safe and leads to satisfactory clinical outcomes at mid-term follow-up.

Methods: A retrospective analysis was conducted on 20 patients who underwent a second revision ACL reconstruction between January 2018 and December 2022. All patients received an Achilles tendon allograft with a bone plug, used in a mono-loop technique to reconstruct both ACL and ALL. Exclusion criteria included multi-ligament injuries, posterior tibial slope > 12°, or follow-up shorter than 24 months. Clinical evaluation included pre- and postoperative scores: Tegner, subjective IKDC, Lysholm, and KOOS, as well as physical examination and Rolimeter testing. Mean follow-up was 32.2 months.

Results: The mean patient age was 36.8 ± 6.3 years. All clinical scores improved postoperatively: Tegner (from 64.3 to 87), subjective IKDC (55.1 to 64.4), Lysholm (58.2 to 76.9), and KOOS (59.7 to 70.1). Anteroposterior laxity decreased from 7.2 ± 2.1 mm preoperatively to 1.2 ± 1.3 mm postoperatively. A total of 55% of patients returned to their desired sports level, 25% to a lower level, and only one patient (5%) did not return owing to residual laxity. No postoperative complications or re-revisions were reported.

Conclusions: The mono-loop technique for simultaneous ACL and ALL reconstruction using an Achilles tendon allograft during a second revision procedure is safe and effective. It results in satisfactory mid-term outcomes, low failure rates, and no significant complications, providing a viable single-stage alternative for complex revision cases.

Study design: Cohort study; Level of evidence, 3.

Objective: Avulsion fracture of the anterior inferior tibiofibular ligament (AITFL) combined with ankle fracture compromises the integrity of the ankle and affects its outcome. This study aimed to determine the incidence of AITFL fractures in surgically treated ankle fractures and to identify its related risk factors.

Methods: In this study, we enrolled a total of 156 patients with surgically treated ankle fractures. We extracted information from medical records on patients' demographic characteristics, body mass index, trauma mechanism, medical history, American Society of Anesthesiologists grade, and trauma mechanism. Ankle fractures were classified on X-ray images, and AITFL fractures according to the original or modified Wagstaffe classification based on radiographs and computed tomography (CT) images. The diagnostic capability of radiographs and risk factors for AITFL fractures were determined.

Results: Patients were divided into two groups: (1) with and (2) without AITFL avulsion fractures. Of the 156 cases, 77 (49.4%) anterior malleolar injuries were identified from CT images. Among these cases, 49 (63.6%) were solely Wagstaffe fractures, 18 (23.4%) were solely Chaput avulsion fractures, and 10 (13.0%) had both avulsion lesions. In 9 of the 10 cases with both avulsion fractures were supination-external rotation (SER) fractures. Moreover, there are 30 cases (39.0%) of AITFL avulsion fractures unidentifiable on the basis of plain radiographs. Age (OR 1.04, p < 0.001) and posterior Pilon fracture (OR 3.52, p = 0.002) were risk factors of AITFL avulsion fractures.

Conclusions: AITFL injuries appeared more commonly in ankle fractures than previously thought, and were frequently overlooked clinically. Recognizing AITFL fractures associated with ankle fractures through CT imaging is imperative, and timely repair is crucial for optimizing functional outcomes. Our findings provide clinicians with insights on such injuries for better surgical management.

Background: Chronic lateral ankle instability (CLAI), frequently resulting from ankle sprains, is often associated with undiagnosed hindfoot varus deformities, specifically subtle cavus foot (SCF). While ligament reconstruction remains the standard treatment for CLAI with SCF, there is ongoing debate regarding the need for adjunctive calcaneal osteotomy to correct the underlying malalignment. Our study aims to evaluate the clinical efficacy and necessity of minimally invasive calcaneal osteotomy combined with arthroscopic modified Broström procedure in patients with CLAI with SCF.

Materials and methods: A retrospective analysis of 102 patients with CLAI and SCF was conducted from November 2016 to November 2022. Patients undergoing arthroscopic modified Broström procedure were assigned to the control group, while those receiving arthroscopic modified Broström procedure with minimally invasive calcaneal osteotomy were placed in the experimental group. General data and complications were documented. Preoperative and postoperative imaging included calcaneal pitch angle, Meary's angle, arch height, and calcaneus valgus angle. Clinical outcomes were measured using the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and visual analogue scale (VAS).

Results: A total of 81 patients with 2-year follow-up were included, with 46 in the experimental group and 35 in the control group. Significant differences in imaging indicators were observed in the experimental group at all follow-up points (P < 0.001), while no significant changes were noted in the control group (P > 0.05). Both groups demonstrated improvements in AOFAS and VAS scores (P < 0.001), with differences between 3- and 24-month follow-up (P < 0.001). Significant differences in imaging indicators and AOFAS scores were found between groups at both follow-up intervals (P< 0.01). The complication rate was 6.52% in the experimental group and 11.43% in the control group.

Conclusions: For patients with CLAI with SCF, arthroscopic modified Broström procedure with minimally invasive calcaneal osteotomy is an effective treatment that minimizes bone and soft tissue damage. Our study suggests that it is necessary to correct hindfoot alignment while stabilizing the ankle joint to enhance function and reduce recurrence of chronic ankle instability.

Level of evidence: Level III, retrospective comparative study.

Background: Anterior cruciate ligament (ACL) injuries are common and can lead to significant knee instability and an increased risk of long-term cartilage damage. Given the emerging role of internal brace ligament augmentation (IBLA) in treating these injuries, this systematic review aimed to evaluate the collective evidence on the safety and effectiveness of IBLA in patients with anterior cruciate ligament injury.

Methods: We systematically searched the PubMed, Embase, Cochrane Library, and Web of Science databases until July 2025. The literature was screened according to the inclusion and exclusion criteria, and data were extracted. The extracted key data included the International Knee Documentation Committee score (IKDC), Tegner score, Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index score (WOMAC), Marx Activity Scale, visual analogue scale (VAS), and the Veterans RAND 12-Item Health Survey (VR-12). The quality of nonrandomized trials was assessed using the Newcastle-Ottawa Scale (NOS).

Results: Systematic screening identified 11 studies (n = 676 patients) for analysis. Patient-reported outcomes demonstrated significant improvements post-intervention. Meta-analyses demonstrated statistically significant increases in KOOS (MD = 36.86, 95% CI: 32.51-41.20, p < 0.01), VR-12 (MD = 16.62, 95% CI:14.75-18.49, p < 0.01), and decreases in visual analog scale (VAS) (MD = -2.82, 95% CI: -3.40 to -2.25, p < 0.01). Lysholm (postoperative 89-94) and IKDC scores (postoperative 85-91) approached or exceeded pre-injury levels. Tegner scores remained stable near pre-injury levels (5.33-6.4). Marx activity scores showed a significant decrease (MD = -3.84, 95% CI: -6.19 to -1.49, p < 0.01), potentially indicating postoperative activity adaptation. Study heterogeneity was noted. All included studies demonstrated mild to high quality.

Conclusions: IBLA appears to be a promising technique for improving functionality, stability, and pain management in anterior cruciate ligament injury. However, the current evidence is significantly constrained by small sample sizes, a predominance of low-quality studies, and a lack of long-term comparative data. Therefore, further rigorous, high-quality research is required to definitively establish the safety and long-term effectiveness of IBLA.

Level of evidence: III.