Journal of Orthopaedics and Traumatology最新文献

Background: Patients typically follow a 7-9-month return to play (RTP) protocol following anterior cruciate ligament reconstruction (ACLR); however, much of these data have been based on non-elite athletes. The purpose of this study is to understand whether professional soccer players returning to competition < 6-months following ACLR will have an increased risk of graft failure, play fewer seasons postoperatively, and have lower volume of play compared with those returning > 6 months.

Materials and methods: A total of 180 male professional European soccer players were enrolled and underwent ACLR with a single surgeon between April 2008 and December 2016 and returned to sport < 6 months (early RTP group, n = 92) or > 6 months (standard RTP group, n = 88). Time from intervention to RTP (days), same season returns, total games and average minutes played in return season, seasons played after surgery, and playing status were recorded.

Results: The early RTP group returned to soccer sooner (142.8 ± 21.4 days) than the standard RTP group (276.2 ± 118.9) (p < 0.01), and more players returned the same season as the injury in the early RTP group (n = 55/92, 62.5%) than the standard RTP group (n = 18/88, 20.5%) (p < 0.01). The difference in average minutes per game in the first season back was not statistically significant (early RTP, 56.7 ± 22.3 min; standard RTP 49.9 ± 29.8 min, p = 0.094). The early RTP group had significantly longer careers following ACLR (5.7 ± 2.2 seasons) than the standard RTP group (4.7 ± 2.4 seasons) (p = 0.005). The early RTP group sustained more reruptures (n = 4, 4.4%) than the standard RTP group (n = 1, 1.1%).

Conclusions: Professional European soccer players returning to competition < 6 months following ACLR did not have poorer outcomes than those who returned > 6 months despite the fact that there were three more failures. However, the early RTP group players were more likely to return during the same season, had longer careers after ACLR, and played a similar number of games and minutes per game, but had more graft failures.

Level of evidence: Retrospective cohort study level IV.

Trial registration: Retrospectively registered according to prot. Professionisti_OSS_22.

Background: The risk factors related to delayed union in humeral diaphyseal fractures (HDFs) following surgical osteosynthesis remain unclear. Therefore, this study aimed to evaluate radiological outcomes and the risk factors associated with delayed union in a retrospective cohort of patients who underwent open reduction and plate fixation (ORPF) for acute HDFs.

Materials and methods: Consecutive patients with AO/OTA 12-A and AO/OTA 12-B fractures who underwent ORPF using standard compression techniques between 2017 and 2020 were enrolled in the study. Demographic data, along with serial medical records and radiographs, were collected. The included patients were divided into two groups: the timely union (union occurring within 6 months postoperatively) and the delayed union group (union occurring between 6 and 12 months postoperatively). Differences between the groups were examined, and logistic regression was subsequently applied for risk factor analysis.

Results: Sixty-five cases were included in the study, consisting of 34 males and 31 females, with a median age of 38.9 years. Among these, 45 cases (69.2%) were classified in the timely union group, while 20 cases (30.8%) were classified in the delayed union group. Overall, 30 cases (46.2%) demonstrated secondary bony union. Significant differences were observed between groups in terms of fracture pattern, immediate postoperative fracture gap, union pattern, and complication rate (p < 0.05 for all comparisons). Multivariate logistic regression analysis revealed that the use of interfragmentary screw and the presence of postoperative complications were independent predictors of delayed union, with an adjusted odds ratio of 0.14 and 5.76, respectively.

Conclusions: In ORPF for acute HSFs, 30 out of 65 cases demonstrated secondary bone union despite the use of standard compression techniques. The application of interfragmentary screws significantly reduces the risk of delayed union. Conversely, the presence of postoperative complications is associated with an increased likelihood of delayed union.

Level of evidence: 3 Trial Registration All procedures were approved by the institutional review board of the authors' hospital (IRB nos. A-ER-112-395 and IRB20230089).

Background: Advancements in diagnostic and therapeutic modalities for giant cell tumors of bone (GCTB) have introduced molecular and radiological tools that refine clinical decision-making. H3.3 G34W immunohistochemical staining has become a routine diagnostic marker, while H3F3A mutational analysis enhances prognostic insights. Treatment primarily involves surgical methods such as curettage or en bloc resection, with denosumab serving as an adjunct in high-risk or inoperable cases.

Methods: We retrospectively analyzed 55 patients with GCTB, focusing on clinicopathologic and radiological findings. Tumors were evaluated using the Campanacci grading system. Immunohistochemical analysis with H3.3 G34W antibody and next-generation sequencing (NGS) were performed to detect H3F3A mutations. A subgroup of nine patients treated with denosumab was further analyzed for clinical outcomes and histological changes.

Results: The cohort had a mean age of 37.7 years, with tumors most commonly affecting the knee joint (55%). All tested tumors demonstrated positive H3.3 G34W staining, with eight exhibiting H3F3A G34W mutations. Recurrence rates were 32% following curettage and 18% after en bloc resection. Denosumab treatment, administered for an average of 14.6 months, facilitated tumor downsizing and new bone formation without major side effects. Histologically, treated tumors showed a depletion of giant cells and increased bone matrix deposition.

Conclusions: Surgery remains the cornerstone of GCTB treatment, with curettage or resection tailored to tumor characteristics. Denosumab offers a valuable adjunct in high-risk cases, enhancing surgical feasibility and promoting joint preservation. The Campanacci grading system continues to be a crucial tool for prognostication and treatment planning, particularly when complemented by molecular and radiological diagnostics. Future research should focus on integrating advanced imaging and artificial intelligence for personalized GCTB management.

Level of evidence: Level 4.

Background: Intravenous tranexamic acid (TXA) dosing regimens differ substantially across studies, varying from fixed doses (e.g., 1-2 g) to weight-based protocols (e.g., 10-20 mg/kg). This study aimed to compare postoperative blood loss, transfusion rates, in-hospital mortality, and complications between fixed-dose and weight-based TXA regimens in revision total knee arthroplasty (rTKA).

Materials and methods: This retrospective comparative study included 298 patients who underwent rTKA between June 2004 and May 2024. Patients were divided into three groups: (1) the no TXA group; (2) the fixed-dose TXA group, in which patients received an intravenous infusion of 1 g TXA before skin incision and a topical application of 1 g; and (3) the weight-based TXA group, in which patients received a weight-adjusted dose of 20 mg/kg/h TXA intravenously and a topical application of 1 g. We analyzed the maximum decrease in hemoglobin (Hb) levels, postoperative transfusion rate, and the incidence of in-hospital mortality and complications.

Results: The weight-based TXA group demonstrated a lower maximal decrease in Hb compared with both the no TXA (18.22 g/L versus 26.09 g/L, p < 0.001) and fixed-dose TXA (18.22 g/L versus 24.69 g/L, p < 0.001) groups. Both the fixed-dose TXA and weight-based TXA groups exhibited lower postoperative transfusion rates compared with the no TXA group (p < 0.001). The weight-based TXA group showed a lower postoperative transfusion rate compared with the fixed-dose TXA group (p = 0.022). Although the incidence of deep vein thrombosis (DVT) among the three groups was statistically significant (p = 0.038), pairwise comparisons between groups did not reveal statistically significant differences (all p > 0.05).

Conclusions: Weight-based dosage of TXA significantly reduced postoperative blood loss and transfusion requirements in rTKA compared with fixed-dose TXA regimen. A weight-based TXA regimen should be considered to effectively minimize postoperative blood loss and decrease transfusion requirements.

Level of evidence: Level 3, non-randomized observational study.

Background: The factors predicting the development of heterotopic ossification (HO) of the elbow in children with untreated chronic Monteggia fractures (UCMFs) remained unclear. This multicentre study was designed to evaluate the radiographic data from paediatric patients with UCMFs and to identify the risk factors for HO formation and their radiographic characteristics.

Materials and methods: We retrospectively reviewed 274 patients (mean age at injury: 5.82 ± 2.62 years) with UCMFs with all types of anterior (group A) and non-anterior (group B) radial head (RH) dislocations. Radiographs were used to assess the presence, size and bone density of HO. The risk factors evaluated included age at injury, sex, laterality, interval from injury to diagnosis, presence of radial or median nerve injury, immobilization of the fractured ulna after injury, direction of RH dislocation and distance of RH dislocation (DD-RH). The results were compared with 76 patient demographics-matched paediatric acute Monteggia fractures (PAMFs) undergoing surgery within 48 h after injury.

Results: The HO rate (13.1%) in children with UCMFs was significantly higher than that (0%) in children with PAMFs (P = 0.001). The incidence of HO (14.5%) in group A was significantly higher than that (0%) in group B (P = 0.032). Age at injury and DD-RH were confirmed as risk factors for HO in patients with UCMFs by both univariate and logistic regression analyses (P < 0.05). Receiver operating characteristic curve analysis and chi-squared analysis indicated that age at injury > 6.78 years and DD-RH < 1.59-fold of the narrowest radial neck width were the cut-off values for an increased HO rate in patients with UCMFs (P < 0.05). Increased age at injury (P = 0.041) and interval from injury to diagnosis (P = 0.006) were associated with high-bone density HO.

Conclusions: Patients with UCMFs with anterior RH dislocations, age at injury > 6.78 years, and DD-RH < 1.59-fold of the narrowest radial neck width were more likely to develop HO. The bone density of HO increases with age at injury and interval from injury to diagnosis. Timely RH reduction after acute injury may prevent HO.

Level of evidence: III.

Background: The management of osteofibrous dysplasia (OFD) is controversial, with limited reports on combining non-radical resection with internal fixation. This study evaluates optimal treatments for patients with OFD aged < 15 years, with attention to the limitations of the small sample size.

Materials and methods: This retrospective analysis included 28 patients (30 extremity) with severe pain, pathological fractures, angular deformities, or extensive cortical bone involvement. On the basis of the surgical approach, patients were divided into four groups: group 1, curettage, allograft, and plate fixation for six patients (six extremity); group 2, elastic stable intramedullary nailing fixation for six patients (six extremity); group 3, Fassier-Duval telescopic system fixation for eight patients (nine extremity); and group 4, interlocking intramedullary nail for eight patients (nine extremity).

Results: All patients achieved bony union and pain alleviation with no recurrence of deformities. The refracture rate during the follow-up was zero cases (0%; group 1) versus one (16.7%; group 2) versus zero (0%; group 3) versus zero cases (0% group 4) (p > 0.05). Instances of internal fixation loosening were zero cases (0%; group 1) versus zero (0%; group 2) versus five (55.6%; group 3) versus zero cases (0%; group 4) (p < 0.05). The musculoskeletal tumor society (MSTS) scores of the four groups were 27.5 (group 1) versus 27.7 (group 2) versus 26.3 (group 3) versus 28.7 (group 4) (p < 0.05).

Conclusions: Selecting different treatment strategies for patients of various ages and locations with OFD is vital. Surgical intervention for patients with persistent pain, pathological fractures, extensive cortical bone involvement, or significant tibial deformities can significantly improve their quality of life. The encouraging MSTS scores also support this conclusion. However, given the study's single-center design and small sample size, further research with larger, multicenter studies is necessary.

Level of evidence: Level IV.

Objectives: The purpose of this study was to provide thorough, understandable and precise evidence for the clinical use of antibiotic-loaded bone cement (ALBC) in preventing periprosthetic joint infection (PJI).

Methods: We evaluated the effectiveness of ALBC in preventing PJI by conducting an umbrella review of existing meta-analysis. Four databases, PubMed/MEDLINE, Cochrane Library, Embase and Web of Science, were searched until May 2024. Two reviewers were reviewers for literature screening, and data were extracted independently. AMSTAR 2 guideline and GRADE were also used for quality evaluation. The clinical outcomes were evaluated for effectiveness by several indicators, including surface infection rate (SIR), deep infection rate (DIR), total infection rate (TIR), unadjusted/adjusted all-cause revision rate, and revision rate for PJI.

Results: We synthesized the results of ten meta-analyses. Two meta-analyses had high AMSTAR 2 scores, two had moderate AMSTAR 2 ratings, three had critically low AMSTAR 2 scores, and the remaining meta-analyses had low AMSTAR 2 ratings. In terms of postoperative surgical site infection and revision rate, SIR (OR 1.50, 95% CI 1.14, 1.99, P = 0.004, I² = 0%), unadjusted all-cause revision rate (RR 1.44, 95% CI 1.08, 1.90, P = 0.011, I² = 91.8%) and adjusted all-cause revision rate (HR 1.21, 95% CI 1.12, 1.31, P < 0.001, I² = 0%) in ALBC group were significantly higher than those in non-antibiotic-loaded bone cement (NALBC) group. ALBC group was significantly lower than NALBC group in DIR (OR 0.53, 95% CI 0.39, 0.70, P < 0.0001, I² = 57%), (RR 0.506, 95% CI 0.341, 0.751, P = 0.001, I² = 0%) and revision for PJI (RR 0.721, 95% CI 0.628, 0.828, P = 0, I² = 53%). There was no statistical difference in total infection rate (TIR) between the ALBC group and the NALBC group (OR 0.81, 95% CI 0.51, 1.28, P = 0.37, I² = 73%).

Conclusions: On the basis of the results of our analysis, we do not believe that ALBC is more effective than NALBC in preventing PJI after primary total joint arthroplasty (PTJA). No statistically significant difference was found on TIR between the two groups, although it was lower in the ALBC group. In addition, the DIR and revision for PJI are significantly lower in the ALBC group, but the results are of low quality, which calls for high-quality and large-sample studies in the future.

Background: Distal femur fractures present a significant challenge for orthopedic surgeons, accounting for approximately 5% of all femoral fractures. Among the most commonly reported combined techniques in the literature are the double-plate technique and the retrograde nailing plus lateral plating, the nail-plate construct (NPC). The aim of our study is to compare surgical data, quality of life, and functional outcomes in 33-C fractures treated with either double-plate constructs or a retrograde nailing plus lateral plate.

Materials and methods: A multicenter retrospective observational study was conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Diagnoses were made on the basis of the AO classification, utilizing traditional radiological assessments. Patients were categorized into two groups on the basis of the surgical treatment they received: The NPC group comprised patients who underwent surgery with nail-plate construct, while the Plate group consisted of those who had surgery with double plating.

Results: A total of 42 patients were included in the study. The NPC group comprised 26 patients with a mean age of 58.4 ± 18.8 years, while the Plate group consisted of 16 patients with a mean age of 61.3 ± 16.4 years. Significant differences were observed in knee extension recovery (p = 0.010) and lateral distal femur angle (LDFA) (p < 0.001). Linear regression showed a significant influence from treatment choice on all the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, as well as in all domains of the European Quality of Life Five Dimensions Five-Level Version (EQ-5D-5L), except for the Daily Self-Care domain.

Conclusions: Nail-plate constructs seems to lead to significantly better outcomes in AO type C distal femur fractures, compared with double plating, in terms of knee function and quality of life. Significant differences are shown also in anatomical outcomes, especially in extension gap, and LDFA.

Level of evidence: III.

Background: Large bone defects resulting from trauma, disease, or resection often exceed the intrinsic capacity of bones to heal. The current gold standard addressing these defects is autologous bone grafting (ABG). Procedures such as reamer-irrigator-aspirator (RIA) and conventional bone grafting from the iliac crest are widely recognized as highly effective interventions for critical-size bone defects. The early phase of fracture healing is particularly crucial, as it can determine whether a complete bony union occurs, or if delayed healing or non-unions develop. The initial composition of the bone marrow (BM)-rich ABG transplant, with its unique cellular (e.g., leukocytes, monocytes, and granulocytes) and acellular (e.g., growth factors and extracellular proteins) components, plays a key role in this process. However, despite many successful case reports, the role of ABG cells, growth factors, and their precise contributions to bone healing remain largely elusive.

Materials and methods: We characterized the native cellularity of both solid and liquid RIA-derived ABG by analyzing primary, minimally manipulated populations of monocytes, macrophages, and T cells, as well as hematopoietic, endothelial, and mesenchymal progenitor cells by flow cytometry. Growth factor and cytokine contents were assessed through antibody arrays. Possible functional and immunomodulatory properties of RIA liquid were evaluated in functional in vitro assays.

Results: Growth factor and protein arrays revealed a plethora of soluble factors that can be linked to specific immunomodulatory and angiogenic properties, which were evaluated for their potency using functional in vitro assays. We could demonstrate a strong M2-macrophage phenotype inducing the effect of RIA liquid on macrophages. Additionally, we observed an increase in anti-inflammatory T cell subsets generated from peripheral blood mononuclear cells and BM mononuclear cells upon stimulation with RIA liquid . Finally, in vitro endothelial tube formation assays revealed highly significant angiogenic properties of RIA liquid, even at further dilutions.

Conclusion: The cytokine and protein content of RIA liquid exhibits potent immunomodulatory and angiogenic properties. These findings suggest significant therapeutic potential for RIA liquid in modulating immune responses and promoting angiogenesis. Anti-inflammatory and angiogenic properties demonstrated in this study might also help to further define and understand its particular mode of action while also providing explanations to the excellent bone-healing properties of ABG in general.

Level of evidence: Case-series (Level 4).

Background: Current literature on ultra-distal tibial fractures (UDTF) is relatively limited, particularly regarding the outcomes and complications of different treatment strategies, with data being notably scarce. This study aimed to compare the clinical outcomes of intramedullary nailing (IMN) and distal tibial plate (DTP) fixation in the treatment of UDTF.

Methods: A total of 48 eligible patients were retrospectively reviewed and divided into two matched groups based on age, gender, injury severity score, and fracture type. The IMN group comprised 21 patients, and the DTP group included 27 patients. All patients were followed up to assess both clinical and radiological outcomes.

Results: The IMN group demonstrated significantly shorter surgery time (P = 0.043) and fracture healing time (P = 0.002) compared with the DTP group. However, no significant differences were found between the two groups in terms of time from fracture to admission (P = 0.740), preoperative hospital stay (P = 0.310), postoperative hospital stay (P = 0.379), infection rates (P = 1.000), or rates of nonunion (P = 0.822). Postoperative malalignment occurred in three patients in the IMN group and one patient in the DTP group (P = 0.430). The mean postoperative angulation in both groups was similar in the coronal plane (P = 0.101) and sagittal plane (P = 0.334). The mean Olerud-Molander Ankle Score (OMAS) was 88.62 ± 5.24 in the IMN group and 85.85 ± 8.39 in the DTP group (P = 0.169).

Conclusion: Both implants are effective in treating UDTF. However, IMN offers advantages in reducing surgical time, accelerating fracture healing, and promoting early recovery. Therefore, IMN may represent a superior surgical option for managing UDTF.