Journal of Orthopaedics and Traumatology最新文献

Background: Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome.

Material and methods: Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated.

Results: 51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030).

Conclusion: This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes.

Level of evidence: III, retrospective cohort study.

Background: Lateral, All-Round and All-Inside (LARAI) portal is a viewing or working portal for observing and repairing the lesions of the lateral meniscus. However, there are safety concerns about popliteal artery (PA) injuries during the procedure. This study aimed to assess the safe distance between the trajectory of the LARAI portal and PA.

Materials and methods: Both three-dimensional computed tomography (3D-CT) and cadavers were used to simulate the LARAI portal trajectory. In the 3D-CT study, between January 2020 and September 2020, 45 participants who underwent computed tomography angiography were included in the study. The shortest distance from the PA to the simulated trajectory needle (PS) was measured using 3D-CT. Mean -3SD -2 was calculated to assess the safety of the LARAI portal trajectory. If this value was more than zero, the trajectory was considered "safe." In the cadaveric study, lower limbs from seven fresh-frozen cadavers were used to establish the "safe" trajectories of the LARAI portal, and the PS was measured.

Results: In the 3D-CT study, the longest PS (P < 0.001) was found 20 mm lateral to the edge of the patellar tendon trajectory at 0 mm from the posterior cruciate ligament (PCL). Safe trajectories were also found 10 mm, 15 mm, and 20 mm lateral to the edge of the patellar tendon at 0 mm from the PCL, as well as the 20 mm lateral to the edge of the patellar tendon at 3 mm from the PCL. The cadaveric study showed that the average PS of all safe trajectories closely adjoined to PCL was greater than 14 mm.

Conclusions: The LARAI portal trajectory in the "figure of four" is safe, and the optimal insertion point is 10-20 mm lateral to the edge of the patellar tendon and closely adjoined to the posterolateral margin of the PCL at knee joint line level.

Level of evidence: Level IV.

Background: Percutaneous iliosacral (IS) screw fixation and trans-iliac trans-sacral (TITS) screw fixation are clinically effective treatments of posterior pelvic sacroiliac fractures. In order to accurately assess the sacrum position relative to the pelvis, pelvic incidence (PI) is a commonly utilized radiographic parameter in sagittal view. This study aimed to investigate and compare the surgical outcomes and radiographic parameters of IS or TITS screw fixations for the treatment of posterior sacroiliac complex fractures with different PI values.

Materials and methods: The data on patients with posterior pelvic sacroiliac fractures who underwent percutaneous IS or TITS screw fixations, or both, at a single level I trauma center between January 2017 and June 2020 were reviewed. We documented the patient characteristics and fracture types, reviewed surgical records, and measured the radiographic parameters via plain films and multi-planar computed tomography (mpCT) images. Radiographic variations in PI, sacral slope, pelvic tilt, sacral dysmorphism, pelvic ring reduction quality, screw deviation angles, screw malposition grading, and iatrogenic complications were documented and analyzed.

Results: A total of 85 patients were included, and 65 IS and 70 TITS screws were accounted for. Patients were divided into two groups according to screw fixation method and further divided into four sub-groups based on baseline PI values. The PI cutoff values were 49.85° and 48.05° in the IS and TITS screw groups, respectively, according to receiver operating characteristic analysis and Youden's J statistic. Smaller PI values were significantly correlated with sacral dysmorphism (p = 0.027 and 0.003 in the IS and TITS screw groups, respectively). Patients with larger PI values were at a significantly increased risk of screw malposition in the TITS screw group (p = 0.049), with no association in the IS screw group. Logistic regression confirmed that a larger PI value was a significant risk factor for screw malposition in the TITS screw group (p = 0.010). The post-operative outcomes improved from poor/fair (at 6 months) to good/average (at 12 months) based on the Postel Merle d'Aubigné and Majeed scores, with no significant differences between subgroups.

Conclusions: Both percutaneous IS and TITS screw fixations are safe and effective treatments for posterior pelvic sacroiliac fractures. Due to the higher risk of screw malposition in patients with larger PI values, it is crucial to identify potential patients at risk when performing TITS screw fixation surgery.

Level of evidence: Level III.

Background: While clinical and patient-reported outcomes have been investigated in patients after InternalBrace™-augmented anterior cruciate ligament repair (ACL-IB), less is known regarding restoration of functional performance. We aimed to determine differences in functional performance within and between patients 2 years after ACL-IB, patients 2 years after ACL reconstruction (ACL-R), and healthy controls.

Materials and methods: A total of 29 ACL-IB, 27 ACL-R (hamstring autograft), and 29 controls performed single-leg hop (maximum forward distance hop, SLH; side hop > 40 cm in 30 s, SH), proprioception (knee joint position sense at 30° and 60° flexion), and dynamic postural balance (Y Balance) tests. Differences were calculated within groups (side-to-side difference) and between the involved leg of patients and the non-dominant leg of controls, and were evaluated to predefined statistical (P < 0.05), clinically relevant, and methodological (smallest detectable change) thresholds. The number of exceeded thresholds represented no (0), small (1), moderate (2), or strong (3) differences. In addition, the relative number of participants achieving leg symmetry (≥ 90%) and normal performance (≥ 90% of the average performance of the non-dominant leg of controls) were compared between groups (chi-squared tests, P < 0.05).

Results: We observed no-to-moderate leg differences within ACL-IB (moderate difference in hops) and within ACL-R (moderate difference in knee proprioception), no leg differences between patient groups, no-to-small leg differences between ACL-IB and controls, and no leg differences between ACL-R and controls in functional performance. However, two patients in ACL-IB and ACL-R, respectively, passed the hop pretest only with their uninvolved leg, and fewer patients after ACL-IB and ACL-R than controls reached a leg symmetry and normal leg performance of controls in SLH (P < 0.001).

Conclusions: Functional performance seems to be comparable 2 years postoperatively between ACL-IB and ACL-R for a specific subgroup of patients (i.e., proximal ACL tears, moderate activity level). However, the presumed advantage of comparable functional outcome with preserved knee structures after augmented ACL repair compared with ACL-R, and the tendency of both patient groups toward leg asymmetry and compromised single-leg hop performance in the involved legs, warrants further investigation. Level of Evidence Level III, case-control study. Trial registration clinicaltrials.gov, NCT04429165 (12/09/2020). Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04429165 .

Background: Both modular and monoblock tapered fluted titanium (TFT) stems are increasingly being used for revision total hip arthroplasty (rTHA). However, the differences between the two designs in clinical outcomes and complications are not yet clear. Here, we intend to compare the efficacy and safety of modular versus monoblock TFT stems in rTHA.

Methods: PubMed, Embase, Web of Science, and Cochrane Library databases were searched to include studies comparing modular and monoblock implants in rTHA. Data on the survivorship of stems, postoperative hip function, and complications were extracted following inclusion criteria. Inverse variance and Mantel-Haenszel methods in Review Manager (version 5.3 from Cochrane Collaboration) were used to evaluate differences between the two groups.

Results: Ten studies with a total of 2188 hips (1430 modular and 758 monoblock stems) were finally included. The main reason for the revision was aseptic loosening. Paprosky type III was the most common type in both groups. Both stems showed similar re-revision rates (modular vs monoblock: 10.3% vs 9.5%, P = 0.80) and Harris Hip Scores (WMD = 0.43, P = 0.46) for hip function. The intraoperative fracture rate was 11.6% and 5.0% (P = 0.0004) for modular and monoblock stems, respectively. The rate of subsidence > 10 mm was significantly higher in the monoblock group (4.5% vs 1.0%, P = 0.003). The application of extended trochanteric osteotomy was more popular in monoblock stems (22.7% vs 17.5%, P = 0.003). The incidence of postoperative complications such as periprosthetic femoral fracture and dislocation was similar between both stems.

Conclusions: No significant difference was found between modular and monoblock tapered stems as regards postoperative hip function, re-revision rates, and complications. Severe subsidence was more frequent in monoblock stems while modular ones were at higher risk of intraoperative fracture.

Level of evidence: Level III, systematic review of randomized control and non-randomized studies.

Trial registration: We registered our study in the international prospective register of systematic reviews (PROSPERO) (CRD42020213642).

Background: Surgery involving implantable devices is widely used to solve several health issues. National registries are essential tools for implantable device surveillance and vigilance. In 2017, the European Union encouraged Member States to establish "registries and databanks for specific types of devices" to evaluate device safety and performance and ensure their traceability. Spine-implantable devices significantly impact patient safety and public health; spine registries might help improve surgical outcomes. This study aimed to map existing national spine surgery registries and highlight their features and organisational standards to provide an essential reference for establishing other national registries.

Methods: A scoping search was performed using the Embase, PubMed/Medline, Scopus, and Web of Science databases for the terms "registry", "register", "implantable", and all terms and synonyms related to spinal diseases and national registries in publications from January 2000 to December 2020. This search was later updated and finalised through a web search and an ad hoc survey to collect further detailed information.

Results: Sixty-two peer-reviewed articles were included, which were related to seven national spine registries, six of which were currently active. Three additional active national registries were found through the web search. The nine selected national registries were set up between 1998 and 2021. They collect data on the procedure and use patient-reported outcome measures (PROMs) for the follow-up.

Conclusion: Our study identified nine currently active national spine surgery registries. However, globally accepted standards for developing a national registry of spine surgery are yet to be established. Therefore, an international effort to increase result comparability across registries is highly advisable. We hope the recent initiative from the Orthopaedic Data Evaluation Panel (ODEP) to establish an international collaboration will meet these needs.

Background: This study aimed to analyze the clinical efficacy of one-stage anterior debridement of lower cervical tuberculosis using iliac crest bone graft fusion and internal fixation.

Materials and methods: A retrospective analysis was performed on 48 patients with lower cervical tuberculosis admitted to multiple medical centers from June 2018 to June 2021. Among them, 36 patients had lesions involving two vertebrae and 12 patients had lesions involving more than three vertebrae. All patients were treated with quadruple antituberculosis drugs for more than 2 weeks before the operation, and then treated with one-stage anterior debridement and autogenous iliac bone graft fusion combined with titanium plate internal fixation. After the operation, antituberculosis drugs were continued for 12-18 months. The patients were followed-up to observe the improvement in clinical symptoms, bone graft fusion, Cobb angle, visual analog score (VAS), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), wound healing, and neurological function.

Results: The patients were followed-up for 13-43 months, with an average of 21.46 ± 1.52 months. The clinical symptoms significantly improved after the operation. The bone graft was completely fused in all patients, and the bone fusion time was 3-6 months, with an average of 4.16 ± 0.47 months. At the last follow-up, the Cobb angle, VAS, ESR, and CRP level were significantly lower than those before surgery (P < 0.05). None of the patients had loosening, detachment, or rupture of the internal fixation, and no recurrence occurred. All surgical incisions healed in one stage without infection or sinus formation. The preoperative Frankel neurological function classification was grade B in 7 cases, grade C in 13, grade D in 18, and grade E in 10. At the last follow-up, 8 cases recovered to grade D and 40 recovered to grade E.

Conclusions: For patients with lower cervical tuberculosis, based on oral treatment with quadruple antituberculosis drugs, direct decompression through anterior debridement, followed by autologous iliac bone graft fusion combined with internal fixation can completely remove tuberculosis foci, rebuild the stability of the cervical spine, and obtain good clinical efficacy. Level of evidence Level 3.

Background: Knee osteoarthritis (OA) is a chronic disease associated with a severe impact on quality of life. However, unfortunately, there are no evidence-based guidelines for the non-surgical management of this disease. While recognising the gap between scientific evidence and clinical practice, this position statement aims to present recommendations for the non-surgical management of knee OA, considering the available evidence and the clinical knowledge of experienced surgeons. The overall goal is to offer an evidenced-based expert opinion, aiding clinicians in the management of knee OA while considering the condition, values, needs and preferences of individual patients.

Methods: The study design for this position statement involved a preliminary search of PubMed, Google Scholar, Medline and Cochrane databases for literature spanning the period between January 2021 and April 2023, followed by screening of relevant articles (systematic reviews and meta-analyses). A Società Italiana Ortopedia e Traumatologia (SIOT) multidisciplinary task force (composed of four orthopaedic surgeons and a rheumatologist) subsequently formulated the recommendations.

Results: Evidence-based recommendations for the non-surgical management of knee OA were developed, covering assessment, general approach, patient information and education, lifestyle changes and physical therapy, walking aids, balneotherapy, transcutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, pharmacological interventions and injections.

Conclusions: For non-surgical management of knee OA, the recommended first step is to bring about lifestyle changes, particularly management of body weight combined with physical exercise and/or hydrotherapy. For acute symptoms, non-steroidal anti-inflammatory drugs (NSAIDs), topic or oral, can be used. Opioids can only be used as third-line pharmacological treatment. Glucosamine and chondroitin are also suggested as chronic pharmacological treatment. Regarding intra-articular infiltrative therapy, the use of hyaluronic acid is recommended in cases of chronic knee OA [platelet-rich plasma (PRP) as second line), in the absence of active acute disease, while the use of intra-articular injections of cortisone is effective and preferred for severe acute symptoms.

Background: There is no evidence in the current literature about the best treatment option in sacral fracture with or without neurological impairment.

Materials and methods: The Italian Pelvic Trauma Association (A.I.P.) decided to organize a consensus to define the best treatment for traumatic and insufficiency fractures according to neurological impairment.

Results: Consensus has been reached for the following statements: When complete neurological examination cannot be performed, pelvic X-rays, CT scan, hip and pelvis MRI, lumbosacral MRI, and lower extremities evoked potentials are useful. Lower extremities EMG should not be used in an acute setting; a patient with cauda equina syndrome associated with a sacral fracture represents an absolute indication for sacral reduction and the correct timing for reduction is "as early as possible". An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an indication for laminectomy after reduction in the case of a displaced sacral fracture in a high-energy trauma, while a worsening and progressive radicular neurological deficit represents an indication. In the case of a displaced sacral fracture and neurological deficit with imaging showing no evidence of nerve root compression, a laminectomy after reduction is not indicated. In a patient who was not initially investigated from a neurological point of view, if a clinical investigation conducted after 72 h identifies a neurological deficit in the presence of a displaced sacral fracture with nerve compression on MRI, a laminectomy after reduction may be indicated. In the case of an indication to perform a sacral decompression, a first attempt with closed reduction through external manoeuvres is not mandatory. Transcondylar traction does not represent a valid method for performing a closed decompression. Following a sacral decompression, a sacral fixation (e.g. sacroiliac screw, triangular osteosynthesis, lumbopelvic fixation) should be performed. An isolated and complete radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. An isolated and incomplete radicular neurological deficit of the lower limbs does not represent an absolute indication. A worsening and progressive radicular neurological deficit of the lower limbs represents an indication for laminectomy after reduction in the case of a displaced sacral fracture in a low-energy trauma associated with imaging suggestive of root compression. In the case of a displaced sacral fracture and neurological deficit in a low-energy trauma, sacral decompression followed by surgical fixation is indicated.

Conclusions: This consensus collects expert opinion about this topic and may guide the surgeon in choosing the

Background: Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus.

Methods: This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications.

Results: Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60-200) versus 500 (350-600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6-8) versus 6 (5-7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27-29) versus 27 (26.5-28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery.

Conclusions: Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients. Level of evidence Level II. Trial registration statement Not applicable.