Bone & Joint Journal最新文献

Aims: The TARIC total ankle prosthesis is a low-profile, mobile-bearing implant. To date, no outcomes of this implant have been reported. This study evaluated the early clinical and radiological outcomes of this implant with a minimum follow-up of two years.

Methods: We retrospectively reviewed 85 consecutive cases (79 patients) of TARIC total ankle arthroplasty (TAA) performed by two surgeons between January 2021 and December 2022. The mean age of the cohort was 68.5 years (41 to 83), with a minimum follow-up of 24 months (mean 33.2 months (24 to 44)). The primary clinical outcome was the Ankle Osteoarthritis Scale score measured over the two-year follow-up. Radiological outcomes were assessed by measuring coronal plane alignment, identifying periprosthetic radiolucent lines or areas, and evaluating component subsidence or loosening. Postoperative complications and concomitant procedures at index surgery were also recorded.

Results: All clinical outcome variables significantly improved, with three patients who underwent implant removal excluded from the analysis (p < 0.001). The mean tibiotalar and talar tilt angles improved to 4.9° (SD 2.8°) and 1.8° (SD 2.4°), respectively (p < 0.001). Radiolucent lines were most frequently observed at the bone-tibial component interface (38.8% (33/85)) and the fin of the tibial component (15.3% (13/85)). Periprosthetic radiolucent areas ≥ 5 mm were observed in 17 ankles (20.0%), and 16 ankles (16.5%) exhibited subsidence < 5 mm, which is relatively higher than previously reported rates in other implant systems. Three cases required implant removal, resulting in an implant survival rate of 96.5% at 24 months.

Conclusion: Early clinical outcomes and survivorship of TARIC TAA were comparable to previous reports on other total ankle systems. However, the relatively high rate of periprosthetic radiolucency and component subsidence warrants careful long-term monitoring.

Aims: The reporting of patient-reported outcome measures (PROMs) has become essential to the assessment of the outcome of treatment in many branches of medicine and surgery. However, missing PROM scores often present practical and statistical difficulties. The aim of this study was to investigate the missingness mechanism of PROM scores in patients who underwent hip or knee arthroplasty at three fast-track centres in Denmark by comparing demographics, mortality, the risk of revision, and PROM scores between responders and non-responders.

Methods: This population-based cohort study included 6,300 primary hip and 4,964 primary knee arthroplasties from three fast-track centres in Denmark between January 2016 and September 2021 using the Danish arthroplasty registries. The Oxford Hip/Knee Score (OHS/OKS), EuroQol five-dimension three-level/five-level questionnaire, and EuroQol visual analogue scale scores were collected before and one year after surgery. Unadjusted relative risks (RRs) of death and revision were estimated with 95% CIs using binary regression. Median differences (MDs) in PROM scores with 95% CIs were calculated using bootstrapping.

Results: Patients with and without baseline and follow-up scores had similar age, sex, Charlson Comorbidity Index, and BMI data. However, hip and knee patients with missing baseline scores had significantly increased RRs of death within one year of 6.5 (95% CI 3.8 to 11.0; p < 0.001) and 6.2 (95% CI 3.7 to 10.5; p < 0.001), respectively. Yet, missing baseline was not significantly associated with the risk of revision. Finally, missing follow-up was significantly associated with lower baseline OHS and OKS with MDs of -3 (95% CI -4.0 to -2.0; p < 0.001) and -3 (95% CI -4.3 to -1.7; p < 0.001), respectively.

Conclusion: Non-responders had significantly increased mortality and significantly worse baseline scores despite similar demographics and revision risk. Thus, PROM scores may have been 'missing not at random' given our covariates, indicating that multiple imputation and/or multilevel models may not be sufficient to overcome the problem of missing PROM scores.

Aims: In the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT), surgical fixation was compared with cast immobilization using the Patient-Rated Wrist Evaluation (PRWE) score at one year as the primary endpoint. The aim of this longer-term study was to assess the clinical effectiveness of the two treatment pathways at a five-year follow-up.

Methods: Patients who had not withdrawn from the trial were invited for a clinical assessment at five years after randomization and asked to complete a patient-reported questionnaire in the clinic, or by post or telephone. The PRWE was collected along with the grip strength, range of motion (ROM), imaging data, EuroQol five-dimension three-level questionnaire (EQ-5D-3L) score, and the use of health resources. The repeated measures analysis model used at one year was repeated to include the five-year timepoint.

Results: A total of 344 patients provided a valid PRWE score at five years (78.4% of the original cohort). There was no significant difference between the groups at five years (mean difference 0.6 (95% CI -2.4 to 3.6); p = 0.709). These results were robust to sensitivity analyses, restricting data collection windows. Neither the pain and function subscales of the PRWE score nor the overall estimate of the treatment effect showed a significant difference between the groups. Neither non-compliance with allocation of treatment, the displacement of the fracture, nor the patient's preferred treatment at baseline had an effect on the PRWE scores between groups. Only seven patients for whom imaging was collected at five years had a nonunion, three of 146 (2.1%) in the fixation group and four of 121 (3.3%) in the immobilization group. Grip strength and ROM were similar between the groups.

Conclusion: The clinical effectiveness of the two forms of treatment remained similar at five years. The recommendation that adult patients with a fracture of the waist of the scaphoid which is displaced by ≤ 2 mm should be treated inially with immobilization in a cast, followed by early fixation of a nonunion, is further corroborated by these findings.

Aims: Total elbow arthroplasty (TEA) has shown favourable outcomes in the management of severely comminuted distal humeral fractures in low-demand elderly patients, leading to its increased use in recent years. Less is known about the outcomes of TEA when used for the failure of either internal fixation or conservative management, particularly whether not performing TEA acutely influences the options for further management if fixation fails. This systematic review aimed to assess the clinical and functional outcomes following TEA when used for the post-traumatic sequelae of a distal humeral fracture, and to compare these outcomes with those in patients with a distal humeral fracture who undergo TEA acutely.

Methods: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Scopus databases were searched from January 2000 to September 2024 for studies reporting complications, reoperations, the range of motion of the elbow, or functional outcomes following the use of TEA in the management of the post-traumatic sequelae of distal humeral fractures, including those due to failed fixation, nonunion, and post-traumatic arthritis. Demographic and clinical data were collected, descriptive statistics were summarized, and meta-analyses were undertaken to compare the outcomes between salvage and acute TEA.

Results: A total of 16 studies were included, with a total of 380 patients who underwent salvage TEA and 251 who underwent TEA as the initial management. Salvage TEA was associated with a significantly higher overall risk of complications (odds ratio (OR) 2.5 (95% CI 1.0 to 5.9)), though the rate of reoperations did not differ from those who underwent TEA acutely (OR 1.4 (95% CI 0.8 to 2.4)). Pooled analyses revealed a similar postoperative range of flexion (mean difference (MD) -2.4° (95% CI -9.1 to 4.3)) and extension of the elbow (MD 1.1° (95% CI -2.3 to 4.5)) and pronation (MD 0.0° (95% CI -1.1 to 1.1)) and supination (MD -0.0° (95% CI -1.0 to 0.9)) of the forearm. However, salvage TEA showed significantly inferior functional outcomes, as assessed by the Mayo Elbow Performance Score (MD 9.7 (95% CI -18.8 to -0.6)).

Conclusion: These findings indicate that salvage TEA represents a viable option for the management of post-traumatic sequelae following the teatment of a distal humeral fracture, although patients who underwent salvage TEA had a significantly increased rate of complications and significantly inferior functional outcomes compared with those who underwent TEA acutely.

Aims: Hip arthroscopy is the treatment of choice for patients with femoroacetabular impingement (FAI), and it has been shown that outcomes are dependent upon symptom duration. However, the relationship between symptom duration and intra-articular injury pattern at time of arthroscopy has not previously been studied.

Methods: A retrospective review was conducted of all patients undergoing hip arthroscopy for FAI between January 2017 and December 2023, who were identified from the institutional database of Queen Elizabeth University Hospital, Glasgow, a tertiary referral, university-affiliated hospital. Times from referral and review to surgery, patient demographics, and intraoperative findings (Beck and University College London Hospitals (UCLH) classifications) were assessed. Multivariate and univariate linear regression analyses were performed to determine if there was a correlation between severity of cartilage injury and waiting time or patient demographics.

Results: A total of 307 patients were eligible for inclusion. The mean age was 34 years (SD 9.2) and mean BMI 26.6 kg/m² (SD 4.5). Time from surgeon review to surgery, patient age, and α angle independently influence the severity of cartilage damage. All cartilage damage scores were significantly correlated to waiting times in males (Beck (r = 0.325; p < 0.001), UCLH (r = 0.248; p = 0.006), UCLH size of lesion (r = 0.197; p = 0.044)). Beck (2.88 vs 2.56; p = 0.027) and UCLH (2.50 vs 2.23; p = 0.038) scores were significantly higher in patients waiting > two years from referral to surgery compared to those who waited < two years. This was more apparent when male patients were analyzed separately (Beck (3.51 vs 2.66; p < 0.001) and UCLH (3.03 vs 2.29; p = 0.001)). Male patients waiting > six months from review to surgery also had significantly worse Beck scores than those waiting < six months (2.98 vs 2.33; p = 0.028).

Conclusion: Increasing waiting times are resulting in increased severity of intra-articular damage in patients undergoing hip arthroscopy for FAI. For the first time, longer waiting times have been correlated with worse cartilage injuries, independent of the size of the cam lesion, particularly in male patients.

Aims: Total excision of the femur and its reconstruction pose a substantial challenge in children. We present the long-term results of total femoral excision and type BIIIa rotationplasty in children.

Methods: A total of 18 patients who had undergone a type BIIIa rotationplasty over a period of 20 years were included in the study. Their mean age at the time of surgery was 7.1 years (3.3 to 11). Two patients underwent a hip disarticulation in the perioperative period. Five died in the first two years from surgery. The mean follow-up of the remaining 11 patients was 124 months (24 to 244). We evaluated their long-term radiological, functional, and oncological outcomes and measured any limb length discrepancy at final follow-up.

Results: The hip was stable in eight of 11 patients. Radiologically appreciable remodelling of the proximal tibia was seen in all patients. At final follow-up, four patients had reached skeletal maturity, five were adolescents (aged 12 to 17 years), and two were still pre-adolescent (aged < 12 years). The mean shortening in the skeletally mature patients was 2.25 cm (0 to 4). Limb length was measured in four of the five adolescent patients: the mean shortening was 0 cm (-1 to +1). Other than the two patients who underwent a hip disarticulation in the immediate perioperative period, no patient needed a subsequent surgical procedure. None of the patients had a local recurrence. The five-year probability of overall survival was 70% (95% CI 51 to 96). The mean Musculoskeletal Tumor Society score was 23 (22 to 23). The mean Toronto Extremity Salvage Score calculated in nine patients was 91 (82 to 100).

Conclusion: A type BIIIa rotationplasty is a reliable option for reconstruction after total femoral excision in children. Long-term follow-up shows good functional and oncological outcomes, without the need for additional surgical procedures.

Aims: Articular impaction in olecranon fractures has been under-recognized. This study aimed to evaluate the clinical implications of articular impaction, and to identify factors associated with poor postoperative outcomes following open reduction and internal fixation (ORIF).

Methods: Patients who underwent ORIF for olecranon fractures were retrospectively reviewed. Articular impaction was assessed using preoperative CT scans, and articular impaction reduction quality was categorized based on residual depression. Functional outcomes were assessed using the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder and Hand (DASH) score, and range of motion. Multivariable regression analysis was performed to identify independent predictors of poor outcomes.

Results: Of 122 patients with olecranon fractures, 41 (33.6%) demonstrated articular impaction on CT. Patients with articular impaction exhibited significantly worse functional outcomes, including higher DASH scores (p = 0.018), lower MEPS (p = 0.021), and increased incidence of post-traumatic arthritis (p = 0.048). In the total cohort, step-off > 2 mm was the only independent predictor of poor outcomes (adjusted odds ratio (OR) 12.338 (95% CI 3.082 to 49.391); p < 0.001). Within the impaction group, both step-off > 2 mm (adjusted OR 5.793 (95% CI 2.954 to 8.524); p < 0.01) and poor impaction reduction (> 3 mm residual depression) (adjusted OR 5.487 (95% CI 1.313 to 731.824); p = 0.033) were significant predictors of worse functional outcome.

Conclusion: Articular impaction in olecranon fractures is associated with worse postoperative outcomes, with inadequate impaction reduction contributing to increased step-off and poorer function. Achieving optimal impaction reduction and minimizing residual step-off are critical to improving clinical and radiological outcome.

Aims: In the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT), surgical fixation was compared with cast immobilization, with the primary endpoint being the outcomes at one year. The aim of the current study was to assess the radiological outcomes (union and the development of osteoarthritis (OA)) of the two forms of treatment at five years.

Methods: Patients who remained in the trial at five years after randomization were invited to have plain radiographs and a CT scan of the injured wrist, and a posterior-anterior radiograph of the contralateral wrist. This imaging was reviewed by three observers independently for union of the fracture and the distribution and severity of OA. This analysis followed a pre-specified statistical analysis plan. The relationship between OA and the Patient-Rated Wrist Evaluation (PRWE) scores at five years was assessed.

Results: Of the 439 patients who were randomized, 267 (60.8%) provided imaging at five years. Their characteristics were similar to those of the original cohort. A total of 182 patients (68.2%) (n = 92 fixation, n = 90 cast) had complete union and seven had a nonunion (2.6%; n = 3 fixation, n = 4 cast). Fractures with a minimum of 20% union at one year consolidated with the passage of time without intervention. Progression of OA in the joints around the scaphoid was seen in both groups from baseline to five years. By five years, 140 patients (52.4% of those with imaging at five years) had OA in at least one joint with similar prevalences in both groups. The prevalence of OA, the number of arthritic joints and the maximum severity of OA, was similar in the two groups. A total of 344 of the initial cohort of 439 patients (78.4%) provided a valid PRWE score at five years and the mean score was higher in those with more severe OA, indicating worse pain and function.

Conclusion: Between one and five years after randomization, union consolidated in those with > 20% bridging without intervention. The proportion of patients with full, almost full, partial, slight, and nonunion for the two forms of treatment remained similar at five years. The prevalence and severity of OA increased during the five years but was similar in both groups.