Journal of Orthopaedics and Traumatology最新文献

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(pED) according to Phemister is an established treatment for leg length discrepancies (LLD) but has largely been replaced by less invasive techniques.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 (PI_95%: 1.1-1.4) in terms of RR in 2036, then decreasing to a RR equal to 1.2 (PI_95%: 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.

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.