Journal of Orthopaedics and Traumatology最新文献

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.

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.