Journal of Orthopaedics and Traumatology最新文献

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.

Background: Hemiarthroplasty (HA) is a salvage option in revision shoulder arthroplasty when reimplantation (aTSA/rTSA) or secure glenoid fixation is not feasible. This systematic review evaluates indications, clinical outcomes, and complications after conversion to HA using an indication- and implant-stratified synthesis.

Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), PubMed/MEDLINE, Embase/Scopus, and Web of Science were queried to 15 March 2024. Studies reporting revision of any shoulder arthroplasty to HA with ≥ 12-month follow-up were included. Owing to heterogeneity in measures and implant types, a descriptive analysis stratified by initial implant × indication was performed; primary endpoints were postoperative functional scores, with complications and reoperations as secondary endpoints.

Results: Of 580 identified studies, 20 met inclusion criteria, totaling 268 patients. Glenoid component loosening was the most frequent indication (≈59%), followed by soft-tissue insufficiency (≈11%) and infection (≈9%). Postoperative function varied: ASES 48.2-66, constant 22-37, SANE 54-70. Complications occurred in 29%, and 15.7% underwent reoperation. Outcomes were indication-dependent: the highest scores were observed after humeral loosening (small subgroup), whereas glenoid loosening after aTSA or rTSA showed moderate, clinically meaningful improvements, particularly when bone loss could be reconstructed (e.g., grafting). Instability yielded modest gains, and infection was associated with the poorest results. Preoperative values were inconsistently reported, limiting Δ estimates.

Conclusions: HA remains a salvage solution with indication-dependent effectiveness: best after humeral/glenoid loosening when reconstruction is feasible, modest in instability, and poor in infection. While HA can relieve pain and provide moderate functional improvement, it does not restore normal function. Selection should be deliberate and indication-specific, and future studies should adopt standardized reporting and prospective, indication-stratified designs.

Purpose: This study was to evaluate the efficacy of soft tissue reconstruction using synthetic mesh and a medial gastrocnemius flap in patients who underwent proximal tibial hemiarthroplasty after resection of proximal tibial bone sarcomas.

Methods: A retrospective cohort study was conducted on 102 skeletally immature children (58 males, 44 females) who underwent proximal tibial Hemiarthroplasty between January 2005 and December 2023. The most common diagnoses were osteosarcoma (95%), Ewing's sarcoma (4%), and chondrosarcoma (1%). The mean age was 11 years (7-14 years) and the mean follow-up was 85 months (12-233 months). We reported complications according to the modified Henderson classification. The functional outcomes were evaluated by Musculoskeletal Tumour Society Score (MSTS-93) and the Toronto Extremity Salvage Score (TESS).

Results: Patients in the combined reconstruction group had higher MSTS-93 and TESS scores (MSTS-93, 83% versus 72%, p = 0.023; TESS, 85% versus 74%, p = 0.041). The mean 2-year postoperative Insall-Salvati ratio (ISR), the Blackburne-Peel index (BPI), and the Caton-Deschamps index (CDI) for patients who underwent combined reconstruction were 1.18 ± 0.32, 0.98 ± 0.22, and 1.21 ± 0.28, respectively. While, The mean 2-year postoperative ISR, BPI, and CDI of patients without combined reconstruction were 1.42 ± 0.39, 1.25 ± 0.29, and 1.61 ± 0.41, respectively (p < 0.05). The combined reconstruction group had a lower mean extensor lag (4.3° versus 11.3°, p < 0.001). In total, 33 patients had at least one complication and 27 patients underwent surgical revision, including 13 infections, 8 local recurrences, 3 soft tissue failures, 2 aseptic loosening, and 1 implant failure. The combined reconstruction group had a lower rate of knee dislocation (2.7% versus 21.4%, p = 0.002).

Conclusions: Soft tissue reconstruction of the proximal tibia using synthetic mesh combined with a medial gastrocnemius flap improves the postoperative efficacy of tumor-related proximal hemiarthroplasty and is expected to reduce the incidence of postoperative knee dislocation and periprosthetic infection.

Level of evidence: Level III case control study.

Background: Rheumatoid arthritis (RA) affects ankle joints in up to one half of patients with established disease, causing inflammation and damage. Arthroscopic synovectomy removes inflamed tissue to improve joint function, but long-term outcomes and the potential role of adjunctive therapies are limited.

Materials and methods: A total of 176 patients who had a preoperative diagnosis of RA according to the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria, radiographic Larsen grade ≤ 3, and who underwent arthroscopic synovectomy from May 2013 to May 2019 were prospectively enrolled. Weight-bearing anteroposterior and lateral plain radiographs of the ankle were performed annually after initial surgery. The Larsen grade was used to evaluate the progression of ankle joint damage in RA, and patient-reported outcomes (American Orthopaedic Foot and Ankle Society [AOFAS] Ankle-Hindfoot Scale and the Foot and Ankle Outcome Score [FAOS]) were collected annually. The primary outcome measure was 5-year AOFAS score. Baseline characteristics, including age, body mass index (BMI), duration of symptoms before surgery, Larsen grade before surgery, and other potentially related factors, including number of platelet-rich plasma (PRP) injections and change in BMI from baseline, were recorded.

Results: There were 138 patients included, all with minimum 5-year follow-up data. The overall reoperation rate was 13% (95% confidence interval [CI] 6.8-18.9%; 18 of 138). According to multivariable analysis, 5-year AOFAS scores were associated with number of PRP injections (correlation coefficient = 2.09 [95% CI 1.47-2.71]; P < 0.001), duration of symptoms before surgery (correlation coefficient = 0.42 [95% CI 0.14-0.70]; P = 0.01), Larsen grade before surgery (correlation coefficient = 0.28 [95% CI 0.06-0.49]; P = 0.034), and mean BMI change from baseline (correlation coefficient = -1.23 [95% CI -1.57 to -0.89]; P < 0.001). When comparing the number of PRP injections (0, 1-2, or ≥ 3), patients who had serial PRP injections (≥ 3) had diminished functional and radiographic deterioration over time.

Conclusions: Arthroscopic synovectomy improves symptoms for ankle RA and appears to slow-but not halt-radiographic deterioration over 5 years. Serial PRP injections and reduction in BMI from baseline could be associated with better clinical outcomes and slower joint degeneration, which needs to be verified by randomized controlled trials.

Level of evidence: Level II, prospective cohort study. Trial registration Research Registry, researchregistry10878. Registered 24 November 2024-retrospectively registered, http://researchregistry.knack.com/researchregistry10878.