Journal of Orthopaedics and Traumatology最新文献

Background: The etiology of serious life-threatening events after total joint arthroplasty (TJA) is poorly elaborated and understood in literature. The purpose of this study was to identify independent predictors of postoperative intensive care following total hip arthroplasty (THA) and total knee arthroplasty (TKA) and to clarify the circumstances leading to these transfers.

Material and methods: A total of 142 patients suffering from postoperative intensive care-dependent serious adverse events (Clavien-Dindo classification Grade IV, CD°IV) after THA or TKA were matched 1:1 with non-CD°IV patients using propensity score matching for age, sex, comorbidity (Charlson Comorbidity Index, CCI), and year of treatment. Possible predictive factors for the need of postoperative intensive care were initially evaluated using univariate tests, followed by multivariate regression analyses to identify independent predictors.

Results: CD°IV transfers correlate with higher Hospitality Frailty Risk Score levels (HFRS) [mean 4.4 (standard deviation, SD 3.8) versus mean 3.0 (SD 3.0); p < 0.001], higher American Society of Anesthesiologists Physical Status Classification System (ASA) Scores [mean 2.5 (SD 0.6) versus mean 2.3 (SD 0.7); p = 0.02], a greater proportion of octogenarians [35.9% (n = 51) versus 23.9% (n = 34); p = 0.028] and a higher incidence of medical complications [97.9% (n = 139) versus 60.6% (n = 86); p < 0.001] compared with an adjusted control group after total joint arthroplasty (TJA). Multivariate regression analysis confirmed "Frailty" (odds ratio, OR 1.14, 95% confidence intervals, CI 1.05-1.23, p = .002), preexisting cardiological (odds ratio, OR 2.0, 95% confidence intervals, CI 1.004-4.1, p = 0.049) and gastrointestinal secondary diagnoses (OR 3.0, 95% CI 1.3-6.9, p = 0.01), and intake of anticoagulants (OR 2.7, 95% CI 1.6-4.6, p < 0.001) as independent risk factors for CD°IV intensive care unit (ICU) transfers after TJA.

Conclusions: Patients with CD°IV events after THA and TKA represent a complex, vulnerable, and multimorbid patient population. There is a need for a multidisciplinary approach that integrates prehabilitation and perioperative risk assessments to reduce the occurrence of severe, life-threatening events requiring ICU care.

Level of evidence: Level III-retrospective cohort study.

Trial registration: Retrospectively registered.

Background: Displaced intraarticular calcaneal fractures (DIACFs) remain a complex challenge in orthopedic practice due to their complexity and the intricate nature of surgical interventions. While surgical techniques have evolved, postoperative rehabilitation is equally crucial for achieving optimal outcomes. This systematic review evaluates the effects of early weight bearing (EWB) in surgically treated patients with unilateral DIACFs on patient-reported outcomes, health-related quality of life, postoperative pain, differences in Böhler's angle, and complication rates.

Methods: A systematic literature search was performed across PubMed, Embase, and Cochrane Library up to January 2025. Eligible studied included adults (≥ 18 years) who underwent surgery for unilateral DIACFs (Sanders type II-IV), implemented an EWB protocol, reported at least one patient-reported outcome, and were published from 2000 onward. Data extraction and quality assessment were conducted using the Newcastle-Ottawa Scale.

Results: From 1007 identified records, 20 studies (n = 1051 DIACFs) met the inclusion criteria. Pooled results showed a mean American Orthopedic Foot and Ankle Society (AOFAS) Score of 85.7, Maryland Foot Score of 91.1, and visual analog score of 1.9. The analysis revealed a decline of 0.4 degrees in Böhler's angle from postoperative to last follow-up. The overall complication rate was 13.9%.

Conclusions: EWB protocols appear to be safe and beneficial in the postoperative management of DIACFs, yielding favorable outcomes without increased complication rates. These findings support the reconsideration of current conservative weight-bearing guidelines. Future research should focus on the development of standardized, evidence-based after-treatment guidelines. Level of evidence Level I. Trial registration PROSPERO CRD42022280985.

Background: Minimally invasive plate osteosynthesis (MIPO) has become an effective option for tibial shaft fracture surgery owing to its protection of the osteogenic microenvironment. However, the nonexposure of the fracture site also makes satisfactory reduction challenging. In this study, we designed a strategy of percutaneous clamping reduction assisted by the implanted plate as a template.

Method: A retrospective analysis of patients with tibial shaft fractures who underwent percutaneous clamping reduction using a plate as a template was performed. From March 2017 to April 2022, a total of 110 patients (mean age: 30.3 years) were included. The reduction time, intraoperative blood loss, the effect of reduction, and postoperative radiographs were recorded and evaluated. The healing time, recovery of limb function, and complications were also assessed.

Results: The average reduction time was 8.3 ± 5.8 min. The average intraoperative bleeding was 20.6 ± 5.9 ml. The radiographs after reduction showed most patients achieved near-perfect alignment with the average coronal varus or valgus angulation of 1.8° ± 0.7° and the average sagittal anterior/posterior angulation of 2.9° ± 0.9°, and one (0.9%) patient had malreduction due to improper plate shaping. Bone healing was achieved in all patients, with an average fracture healing time of 3.8 ± 1.4 months. Complications included one case of bone nonunion (0.9%) and one case of postoperative infection (0.9%), both of which achieved bone union after secondary treatment. Additionally, there was one patient with extensor hallucis longus tendon contracture and one patient with flexor hallucis longus tendon contracture. Both cases had minimal functional impact. Importantly, there were no neurovascular injuries or hematomas.

Conclusions: By using the plate, which can perfectly match the anatomical structure, as a positional template to assist the percutaneous clamp reduction, a more accurate and reliable reduction was achieved with minimal surgical disturbance. It is a key advancement in clinical practice with promising applications for more complex fractures and diverse anatomical locations. Level of evidence Therapeutic level III.

Background: This study aimed to assess the most appropriate thresholds for albumin-to-globulin ratio (AGR) in patients who had a suspected periprosthetic knee infection. Furthermore, the diagnostic accuracy of the proposed threshold was evaluated.

Materials and methods: Between January 2020 and April 2022, patients with failed or painful knee arthroplasty who were admitted to a tertiary referral institution undergoing the standardized diagnostic protocol to identify those with a periprosthetic joint infection (PJI) were analyzed. The 2018 International Consensus Meeting (ICM) criteria were used to classify patients with PJIs and aseptic joints. Sensitivity, specificity, positive predictive value, negative predictive value, and the area under the receiver operating characteristic (ROC) curve (AUC) of AGR were calculated to define the test's diagnostic accuracy.

Results: The ROC curve showed that the optimal cutoff value of AGR was 1.43. AGR registered a sensitivity of 95% (95% CI 91-197%), a specificity of 63% (95% CI 56-69%), a positive predictive value of 75% (95% CI 69-81%), and a negative predictive value of 91% (95% CI 86-94%). Receiver operator curve analysis demonstrated an AUC of 0.85 (95% CI 0.77-0.88). Although body mass index (BMI), uremia, glutamic-oxaloacetic transaminase (GOT), international normalized ratio (INR), and alkaline phosphatase showed significant differences between the false positive cases and those cases affected by aseptic failure with AGR higher than 1.43, indicating potential confounding effects (p < 0.05), no parameter was found to be a significant predictor of false positives cases (p > 0.05).

Conclusions: For its high sensitivity, AGR showed potential as a screening tool for detecting infections in PJI diagnostics.

Level of evidence: III.

Purpose: To investigate the effect of arthroscopic reduction combined with robot-guided screw placement on Hawkins type II fractures of the talus neck.

Methods: Clinical data from 42 patients with talus neck Hawkins type II fracture treated in the institution from November 2019 to January 2021 were selected. According to the blind envelope method, 21 patients were enrolled in the study group, and 21 patients were enrolled in the control group. The patients in the study group underwent arthroscopy-assisted reduction combined with orthopedic robot navigation screw placement surgery, while those in the control group underwent open reduction surgery.

Results: All 42 patients were followed up. The patients in the study group were followed up for a mean of 14.76 (range, 12-17) months. No talus avascular necrosis or fracture nonunion were observed. Subtalar arthritis was reported in two cases. Patients in the control group were followed up for an average of 14.52 (ranging from 12 to 17) months, and no talus avascular necrosis or fracture nonunion was found. Incisional infection occurred in one case and subtalar arthritis in three cases. The difference between the two groups was statistically significant (P < 0.05) in the duration from injury to surgery, operation time, blood loss, incision length, and number of guide pin insertions. There was no significant difference between the two groups in ankle joint range of motion, the American Orthopedic Foot and Ankle Society ankle-hindfoot score at the last follow-up, and visual analogue scale of pain before operation and at the last follow-up (P > 0.05).

Conclusions: The management of Hawkins type II fracture of the talus neck using arthroscopy-assisted reduction combined with robot navigation screw placement yields satisfactory results and represents a viable treatment alternative that warrants consideration.

Background: The impact of systemic lupus erythematosus (SLE) on total shoulder arthroplasty (TSA) outcomes is unclear. This study investigated the association between SLE and short-term TSA outcomes.

Methods: Data from the Nationwide Readmission Database (NRD) 2016-2020 of patients ≥ 20 years old who underwent primary TSA were included. SLE was identified by International Classification of Diseases, Tenth Revision, and Clinical Modification (ICD-10-CM) codes. Outcomes were compared between patients with and without SLE, and propensity-score matching based on age and sex was performed.

Results: This study included 1960 matched TSA patients (980 with SLE and 980 without SLE). The mean patient age was 65.7 years, and 92% were female. After adjusting for covariates, SLE was significantly associated with a higher risk of surgical complications (odds ratio [OR] = 1.48, 95% confidence interval [CI]: 1.13-1.93), acute postoperative hemorrhagic anemia (OR = 1.48, 95% CI 1.05-2.09), and increased 30-day (OR = 2.11, 95% CI 1.30-3.40) and 90-day (OR = 1.59, 95% CI 1.11-2.26) readmission rates. Patients with SLE with Charlson Comorbidity Index scores of 0 or > 1 had a significantly higher 90-day readmission rate (OR = 2.45 and 1.48, respectively). Additionally, patients with SLE ≥ 65 years old had a significantly higher risk of complications (OR = 1.56). Patients with SLE undergoing reverse TSA also exhibited a significantly increased 90-day readmission risk (OR = 1.71).

Conclusions: SLE significantly increases the risk of postoperative complications and readmissions following TSA, especially in older patients and those undergoing reverse TSA. However, the lack of data on immunosuppressive therapy, laboratory tests, and disease activity may weaken the strength of the evidence.

Background: Historically, anatomical total shoulder arthroplasty (ATSA) has been the standard intervention for primary osteoarthritis in patients with an intact rotator cuff. However, there is an increasing trend towards utilizing reverse total shoulder arthroplasty (RTSA) as an alternative in specific cases. The aim of this study is to investigate the influence of the degree of retroversion, percentage of subluxation and age on the surgeon's decision-making in the choice between ATSA and RTSA in patients with primary osteoarthritis with an intact rotator cuff.

Methods: Attendees of a large international congress on (live) shoulder surgery were requested to complete a questionnaire consisting of closed and open questions regarding shoulder arthroplasty and clinical scenarios. Participants were divided into high- and low-volume surgeons (< 30 cases per year).

Results: A total of 166 responses were collected. In total, 37 different nationalities from all six continents were represented among the respondents. The included participants had a median experience of 11 years (interquartile range, IQR: 6-18). In total, 56 (39%) participants were considered high-volume surgeons. The median degree of retroversion, the median percentage of posterior subluxation and the median age for which participants still considered performing ATSA rather than RTSA were respectively 20° (IQR: 10-20.75), 70% (IQR: 60-80) and 70 years (IQR: 65-75). Furthermore, a low degree of consensus was observed for the choice of treatment in the ten case vignettes with these factors combined. In case of significant disagreement, RTSA was preferred more often by high-volume surgeons compared with low-volume surgeons.

Conclusions: This case-vignette study highlights that the degree of retroversion, percentage of subluxation of the humeral head and the patient's age are important factors to consider in the surgeon's decision-making between ATSA and RTSA. However, our findings indicate limited consensus among orthopaedic surgeons concerning the precise impact of these patient-specific factors. Despite the lack of consensus, some trends can be identified. Overall, participants preferred treatment with RTSA in patients with a high degree of retroversion and older age. Treatment with ATSA was preferred in patients with a younger age, without severe glenoid retroversion and a posterior subluxation of < 80%. The level of evidence is Level V, expert opinion.

Background: Surgical site infection (SSI) is a major postoperative complication following internal fixation or arthroplasty for proximal femoral fracture (PFF). Few studies have examined the potential risk factors for SSI; therefore, we conducted this matched-pair analysis.

Materials and methods: This single-centre study was based on a retrospective database of patients treated for PFF with internal fixation or arthroplasty between 2006 and 2024. Patients with revision for SSI were enrolled and matched with an uneventfully treated group at a 1:3 ratio. Matching was performed on the basis of sex, age, body mass index, diagnosis and treatment. The primary outcomes were risk factors for SSI. The secondary outcomes were risk factors for mortality, as determined by multivariate Cox regression analysis.

Results: Initially, a total of 5000 patients were enrolled. The mean follow-up was 11.7 years. The total SSI rate was 2.8% (140/5,000). Ultimately, 130 patients with confirmed SSI and 390 matched patients were enrolled in this study. Most of the SSIs were Staphylococcus aureus, followed by Staphylococcus epidermidis. The factors that significantly influenced SSI were female sex, American Society of Anaesthesiologists (ASA) score of 4, dementia, atrial fibrillation, and the number of red blood transfusions (≥ 3 units). The mean survival duration of the total cohort was 4.2 years (SD ± 3.38). The 30-day, 3-month and 1-year all-cause mortality rates of patients with SSIs were 5.4%, 25.4%, and 40%, respectively. Multivariate Cox regression revealed that SSI was an independent risk factor for mortality (hazard ratio 1.59; 95% confidence interval 1.28-1.98; p < 0.001), Further risk factors for mortality were living in a retirement home, reduced mobility, anaemia at admission, elevated C-reactive protein, ASA score 3 or 4, intraoperative blood loss greater than 400 ml, Charlson comorbidity index score above ≥ 1, dementia and renal insufficiency.

Conclusions: In this study, patients with SSI following surgery of PFF had a significantly shorter survival time than patients in the uneventfully treated matched-pair group. Most risk factors associated with SSI are unaffected. Fortunately, the rate of SSI was low and decreased significantly within the study period.

Lever of evidence: III; clinical case series with matched pair controls.

Background: The transfibular fracture region (TFFR) approach can be utilized for managing posterior pilon fractures associated with intercalary fragments. However, its long-term outcomes remain unreported. This study aimed to compare the long-term clinical outcomes of the TFFR approach and the posteromedial approach for posterior pilon fractures (Klammer type 2/3, Danis-Weber type B) associated with displaced intercalary fragments over an average 8 year follow-up.

Method: From 2012 to 2018, a cohort of consecutive patients who underwent open reduction and internal fixation surgery via either the TFFR approach or the posteromedial approach for posterior pilon fracture associated with intercalary fragments were enrolled for this study. Clinical outcomes were evaluated over an average 8 year (range 5-12 years) follow-up. The surgical duration, number of intraoperative fluoroscopies, and postoperative complications were recorded. Functional outcomes were assessed using the Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), and Short Form-36 (SF-36) score at last follow-up.

Results: Seventy-nine patients were included in the final analysis, including 43 in the TFFR group and 36 in the posteromedial group. No significant differences between the two groups were observed in the FAOS (p = 0.679) or its specific components for symptoms (p = 0.264), pain (p = 0.963), activities of daily living (ADL, p = 0.102), sports (p = 0.156), or quality of life (p = 0.859). There was also no significant difference between the two groups in the FAAM-ADL (p = 0.408), FAAM-Sport (p = 0.617), and SF-36 scores (p = 0.757). Nevertheless, the surgical duration was shorter in the TFFR group (p < 0.001).

Conclusion: The TFFR approach is not inferior to the posteromedial approach. For posterior pilon fractures with lateral malleolar fractures in the same plane, the TFFR approach may be preferred owing to its potential to reduce surgical time and the use of a single incision. Level of Evidence Level III, retrospective cohort study.

Background: Gluteus medius tendon tears lead to considerable functional limitations and a high level of suffering in affected patients. In cases where the symptoms are severe, surgical intervention is indicated. A range of techniques are used to repair the tendon, with the primary aim being to achieve the highest possible primary stability in order to minimise the risk of re-rupture. This biomechanical study compares two different refixation techniques in terms of their stability in an ovine model.

Material and methods: The gluteal tendons of sheep hips (n = 17) were meticulously prepared and detached from the femoral insertion. To reattach these tendons at their original anatomical footprint, either the sole double-row transosseous-equivalent technique (DR) or the DR supplemented by a proximal suture insertion (augmentation) of the tendon (DR +) was used. Pull-out tests were performed until failure using a uniaxial material testing machine, with a tensile force applied along the physiological tensile direction of the hip abductors. The data obtained (force at failure, linear stiffness) were compared between the groups using the Mann-Whitney U test.

Results: The augmentation of the proximal tendon portion resulted in a substantial increase in force at failure, exceeding 450% (698 ± 80.3 N DR + compared with 155.9 ± 53.9 N DR technique). In addition, augmented tendons exhibited a notable enhancement in stiffness, with an average increase of 31.3 ± 15 N/mm in DR + compared with 12.4 ± 4.8 N/mm in DR. Furthermore, the DR + method resulted in a substantial reduction in the incidence of slippage of the tendon fibres out of the sutures and tendon bundles when compared with the DR suture.

Conclusions: The clinical problem of suture knots becoming loose within the tendon stump, leading to the failure of the tendon sutures, could be mitigated by additional augmentation, resulting in a substantial increase in ultimate load at failure. The benefits of the double-row transosseous-equivalent technique, which facilitates the pressing of the tendon stump against the footprint, are maintained. Level of Evidence Level of Evidence 5.