Journal of Orthopaedics and Traumatology最新文献

Background: Diaphyseal leg fractures are common in pediatric age, and the most used treatment is surgery using elastic stable intramedullary nailing (ESIN). In the past, a cutoff of 50 kg was the limit of weight indication for the use of ESIN. In literature, the concept of BMI has recently been introduced to evaluate the results owing to an increase in the incidence of obesity in children; up to now, it has only been used in one study for the femur but never in the tibia, although more than one author suggests doing so. The objective of this study was to research a correlation between weight, BMI, and the results of ESIN treatment.

Materials and methods: A total of 84 patients treated with ESIN from 2013 to 2021 were included; the inclusion criteria were clinical and radiographic data until complete healing and the presence of weight and height data collection; patients with an exposed fracture or neurovascular injury were excluded. The following were evaluated: clinical healing time in terms of load resumption (CHT), radiographic healing time (RHT), anteroposterior (APA) and lateral (LA) radiographic alignment, surgical time (CT), nonunion (NU), and delayed union (DC). Patients were divided into two weight groups (< 50; > 50). The statistical analysis was performed using STATA (Stata, College Station, TX, USA), and a p-value less than 0.05 was considered statistically significant. The Shapiro-Francia test was used to check the normality of each variable. Pearson's correlation coefficient was calculated for the correlation between variables.

Results: A total of 84 patients with an average weight of 41.53 kg (18-85 kg) were included. Patients were divided into two groups; 62 patients weighing < 50 kg (GR1) and 22 patients weighing > 50 kg (GR2). We found a statistically significant correlation between weight and CHT, RHT, and ST and between BMI and CHT, RHT, and ST. Average results: GR1: CHT 55.84 days; RHT 48.79 days; ST 61.68 min and GR2: CHT 63.27 days; RHT 55.77 days, ST 79.32. We found no significant difference in CHT and RHT between the two groups, while a significant difference for ST was observed.

Conclusions: We confirm that ESIN nails can also be used in patients weighing > 50 kg affected by tibial shaft fractures; in fact, we found no statistical differences between the two groups' clinical and radiographic healing times. Moreover, we found no difference in results between weight and BMI for tibial shaft fracture. The statistical difference correlation in ST between GR1 and GR2 does not imply an important difference in clinical practice.

Background: The impact of tantalum (Ta) versus titanium (Ti) acetabular components on reinfection risk in periprosthetic joint infection (PJI) remains controversial. While prior studies have focused on two-stage revisions, this is the first comparative analysis of Ta versus Ti in single-stage revisions. This study aimed to compare all-cause rerevision and infection recurrence rates between Ta and Ti acetabular components in single-stage revision for chronic PJI.

Materials and methods: In this study, all patients underwent single-stage revision combined with intra-articular (IA) antibiotic infusion, with 56 receiving Ta acetabular components and 79 receiving Ti components. Both the Ta and Ti groups utilized acetabular reconstruction methods (including cups with and without augments) and cementless prostheses for all femoral components. We compared implant survivorship between the two groups, using implant survivorship free from reinfection and all-cause revision as the endpoints. Multivariate logistic regression (MVLR) was used to determine the independent predictive factors for septic failure.

Results: The implant survivorship free from reinfection of the Ta group (92.9%; 95% confidence interval (CI) 85.7~98.2%) was comparable to that of the Ti group (88.6%; 95% CI 81.0~94.9%; P = 0.391; log-rank test). The implant survivorship free from all-cause rerevision of the Ta group (91.1%; 95% CI 84.1~100%) was comparable to that of the Ti group (87.3%; 95% CI 78.9~94.4%; P = 0.323; log-rank test). MVLR did not identify the Ta acetabular component (P = 0.414) as a protective factor against septic failure in acetabular reconstruction. However, previous revision (P = 0.048) was identified as a risk factor.

Conclusions: Ta acetabular components exhibited a risk of all-cause rerevision comparable to Ti components in single-stage revision, with no significant protective effect against reinfection. These findings suggest that the notion of Ta components preventing infections should be viewed with caution.

Background: Distal humeral fractures accounted for ~1% of all fractures; however, they were prone to complications, including nonunion if left untreated or inadequately managed. Nonunion, which predominantly occurred at the supracondylar level, resulted in mechanical instability, functional impairment, and persistent discomfort. The most commonly employed surgical options included open reduction and internal fixation (ORIF), total elbow arthroplasty (TEA), and external fixation. This article provides a comprehensive assessment of these surgical procedures and shared clinical experiences related to these challenging cases.

Methods: A systematic review of literature was conducted using the PubMed database up to October 2024, with a focus on cases involving extraarticular distal humeral nonunions that were treated with ORIF, TEA, or Ilizarov techniques.

Results: A total of 25 studies involving 448 patients were encompassed in the review, with a mean patient age of 50 years and an average follow-up period of 48 months. Reported success rates for ORIF and TEA were 90% and 74%, respectively. A higher rate of fracture healing was demonstrated by ORIF, although functional outcomes were found to be comparable between the techniques. Complications such as infections and reduced range of motion (ROM) were documented.

Conclusions: The highest success rate in treating aseptic nonunions was associated with ORIF, highlighting the importance of stable fixation, bone grafting, and meticulous preoperative planning. TEA was regarded as a viable option, particularly for patients with poor bone quality or complex, unreconstructible fractures. To optimize outcomes, surgical techniques were required to be customized on the basis of patient-specific factors and surgeon expertise. Further research is recommended to facilitate the comparison of long-term functional outcomes across different surgical approaches.

Level of evidence: IV.

Background: Various augmentation choices have been reported to improve outcomes following locking plate fixation for proximal humerus fracture, but their effectiveness and safety are still under investigation. This study aims to investigate the effects of augmentation choices, including bone grafts, cement, and intramedullary plates, in locking plate fixation for proximal humerus fractures.

Methods: PubMed, Embase, and Cochrane Library were searched for studies up to April 2024. A random-effects meta-analysis was performed within a frequentist framework.

Results: A total of 35 studies, comprising 6 randomized controlled trials and 29 nonrandomized studies of intervention with a total of 37,494 patients, were included in this review. After adjusting for small-study bias, locking plate fixation with bone grafts or cement did not affect overall complication risk (risk ratio [RR]: 1.03, 95% confidence interval [CI] 0.74-1.45), the screw protrusion risk (RR: 0.74, 95% CI 0.45-1.13), and the avascular necrosis risk (RR: 0.98, 95% CI 0.73-1.32) compared with locking plates alone. Augmentation showed small-to-moderate effects on pain reduction and functional improvement and reduced changes in humeral head height and neck-shaft angle. In subgroup analyses, cement augmentation, while possibly inferior to bone grafts in pain relief and function, showed comparable effects on radiographic outcomes. No significant difference between strut fibular and non-fibular grafts was observed.

Conclusions: Augmentation with bone grafts or cement does not convincingly reduce complication risks or screw protrusion compared with locking plate fixation alone. However, it improves pain, function, and radiographic outcomes in osteosynthesis of proximal humerus fractures.

Level of evidence: II.

Registration: CRD42024500403.

Background: Ankle fractures are common in the pediatric population. Plain radiographs provide sufficient information for the diagnosis, but computed tomography (CT) can help to study the configuration of fracture and to plan fixation. Our study aims to study pediatric population with ankle fracture, understanding whether CT scans should be extended to all ankle fractures admitted to the Orthopaedic Department after a first radiographic evaluation, independent of the pattern of physeal plate fracture.

Materials and methods: Data about patients with ankle fractures admitted to the Orthopaedic Department were retrieved. The diagnosis and classification of ankle fractures obtained from plain radiographs were compared with those obtained from CT scans. For each patient, data about conservative or surgical management were retrieved. After collecting all the mentioned data, a survey with 61 plain radiographs of children's ankle fractures was proposed to 16 orthopedic surgeons of the department divided into three groups according to their years of experience in Paediatric Orthopaedics and Trauma. The survey consisted of five questions for each radiograph regarding Salter-Harris (SH) classification, management, indication for CT, number, and direction of screws (if needed).

Results: A total of 130 patients with ankle fractures satisfied the inclusion criteria and only 26 of them were classified according to the SH classification by orthopedic surgeons or radiologists after plain radiography. Almost all pediatric patients with ankle fractures admitted to the Orthopaedic Department, after evaluation of plain radiographs in the emergency department (ED), underwent CT with three-dimensional (3D) reconstruction to plan fixation or nonoperative management. CT may lead to reclassification of some fractures, showing that SHIV fractures may be more common than expected. A total of 6 orthopedic surgeons answered the survey on 61 ankle fracture plain radiographs. Independent of their experience, orthopedic surgeons tend to respond similarly to SH classification and fracture management, while they have contrasting opinions about performing CT scans. Analyzing their response to the number of screws, entry points, and directions and comparing them with postoperation radiographs, the results between responders were very discordant.

Conclusion: In children's ankle fracture involving the physeal plate, the SH classification, fracture management planning, the identification of the entry point and the direction of the screw could be more accurate using CT compared with plain radiographs.

Levels of evidence: Level IV, according to the Oxford 2011 Levels of Evidence.

Background: Few studies have investigated the relationship between the chronicity of anterior cruciate ligament (ACL) tears and the incidence of ramp lesion subtypes. The purpose of this study was to evaluate the relationship between the chronicity of ACL tears and the new subtypes of ramp lesions for treatment selection.

Methods: Between May 2015 and April 2023, 367 patients who underwent primary ACL reconstruction were evaluated. Meniscal repair was performed in cases where a ramp lesion was identified. According to the exclusion criteria, 96 patients who underwent repair of ramp lesion were divided into three groups (PR type: pure ramp lesion, RR type: red-red ramp lesion, and DL type: double longitudinal ramp lesion), and the groups were compared for chronicity of ACL tears and time from injury (TFI).

Results: Of the 30 patients classified as having PR type lesions, 11 (36.7%) had chronic ACL tears. Likewise, of the 37 patients classified as having RR type lesions, 14 (37.8%) had chronic ACL tears. In contrast, among the 29 patients classified as having DL type lesions, 20 (69.0%) had chronic ACL tears, indicating a statistically significant difference (p < 0.05). This distinction was significant up to 12 months after injury.

Conclusions: Pure ramp lesions accounted for only 31% of all ramp lesions in ACL tears. In addition, chronic ACL tears are more frequently accompanied by double longitudinal tears than by red-red zone longitudinal tears or pure ramp lesions of the meniscus posterior horn.

Study design: case series, level of evidence IV.

Introduction: The representation of women in the medical field has significantly increased in recent decades. However, their presence in surgical specialties, particularly in orthopedic surgery, remains disproportionately low. This study investigates gender discrimination and disparities in Italian orthopedic residency programs, expanding on existing literature, which indicates that female surgeons worldwide face challenges such as fewer promotions, lower salaries, and higher rates of harassment.

Materials and methods: From June to August 2024, the SIAGASCOT Junior Committee conducted a voluntary and anonymous survey among registered male and female orthopedic residents. The survey was distributed via email and social media and included 23 questions covering demographics, training opportunities, perceptions of gender discrimination, and experiences of physical or verbal harassment. Statistical analyses were performed using the Chi-squared test and Mann-Whitney U test to compare gender-based differences.

Results: A total of 394 residents were invited to participate in the survey, and 81 residents participated: 46 women (56.8%), 34 men (42%), and 1 respondent who preferred not to disclose his or her gender (response rate: 20.5%). While no significant gender disparities were observed in access to training opportunities, such as international experiences or professional memberships, significant gender differences emerged in perceptions of discrimination. Notably, 84.8% of female respondents reported being considered "unsuitable" for orthopedic surgery solely owing to their gender, compared with 0% of male respondents (p < 0.01). In addition, 85% of women reported experiencing verbal or physical harassment, primarily from male superiors or patients.

Conclusions: This study highlights the persistence of gender disparities in orthopedic surgery, with notable differences in perceived discrimination and harassment experiences between male and female residents. Although training opportunities appear to be equally distributed, the reported gender disparities seem to arise from subjective perceptions and cultural attitudes rather than measurable differences. Addressing these disparities requires cultural shifts, mentorship programs, and institutional policies aimed at eliminating harassment and promoting equity, ultimately fostering a more inclusive and supportive environment in orthopedic surgery.

Level of evidence: III.

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.