Bone & Joint Journal最新文献

Aims: Some histological subtypes of soft-tissue sarcoma have an oedema tail evident on T2 hyperintensity in MRI scans at the time of presentation. The clinical and prognostic relevance of the infiltration of the oedema tail with tumour cells is not clear. The aim of this study was to determine the rate of contamination of the oedema tail with tumour cells in a series of sarcomas, the variables that affect the presence of tumour cells in the oedema, and the oncological relevance of the infiltration.

Methods: A total of 67 patients who had a primary appendicular soft-tissue sarcoma with an oedema tail at the time of presentation were treated in our tertiary referral centre between June 2017 and January 2022; 21 were excluded and 46 were included in this prospective study. We recorded epidemiological, radiological, and histological variables and investigated their correlation with infiltration of the oedema by tumour cells. Preoperative MRI scans were used to determine the presence and length of the oedema tail as assessed by an expert radiologist. The oedema was defined as a high-intensity signal in the edges of the sarcoma on a T2 STIR sequence. The oedema tail and the margins of the resection were measured and evaluated by an expert pathologist based on preoperative MRI scans. The overall survival and local recurrence-free survival were determined at a median follow-up of 36.8 months (IQR 17.4 to 50.7). Four patients were lost to follow-up.

Results: A total of 12 of the 46 patients (26%) showed infiltration into the oedema by > 2 mm from the pseudocapsule. The mean distance between the pseudocapsule and the tumour cells in oedema was 20 mm (2 to 40). The size and superficial location were independent variables for infiltration by tumour. The presence of tumour cells in the oedema was significantly associated with the overall survival (hazard ratio (HR) 0.299 (95% CI 0.104 to 0.999); p = 0.042).

Conclusion: The mean length of the oedema tail was 20 mm (2 to 40) and was infiltrated with tumour cells in 12 patients (26%). The overall survival was significantly poorer in those with, compared with those without, tumour cells in the oedema. Future studies should focus on the risk factors for the infiltration of the oedema with tumour cells, the association between the presence of infiltration and radiotherapy and chemotherapy, and whether it affects the prognosis in these patients.

Aims: The aim of this study was to evaluate the impact of peroneus longus tendon (PLT) harvest on gait biomechanics following anterior cruciate ligament (ACL) reconstruction. There is scarce evidence in the literature about the safety of PLT as a potential graft for ACL reconstruction, and no long-term studies with gait assessment exist. We analyzed changes in spatiotemporal parameters (STPs) using a computerized gait analysis system and assessed functional ambulation over time.

Methods: This prospective cohort study included 31 patients, including 23 males and eight females. The mean agewas 32.61 years (SD 10.60), with a mean clinical follow-up of 18.34 months (SD 6.25). The mean height, weight, and BMI were 160.23 cm (SD 8.08), 72.39 kg (SD 10.95), and 28.32 kg/m² (SD 4.74), respectively. Gait analysis was performed preoperatively and postoperatively at six months and one year. Various STPs along with Functional Ambulation Profile (FAP) scores were assessed. Comparison of study variables between different time intervals was done using repeated measures analysis of variance followed by Bonferroni post-hoc test. A p-value < 0.05 was considered statistically significant.

Results: Cadence, FAP score, single-leg support time, step time, and velocity increased significantly over different time intervals (p < 0.001). No significant difference in stride length, double support time, stance time, and swing time were noted over different time intervals.

Conclusion: Despite overall improvements in functional gait, PLT harvest for ACL reconstruction resulted in subtle gait alterations, notably prolonged single-leg support time. Although compensatory mechanisms help to preserve gait function, these changes require careful consideration, particularly in athletes. Incorporating targeted ankle rehabilitation may help to reduce potential long-term effects. Further research is necessary to evaluate its impact on foot biomechanics and stability.

Aims: The risk of surgical site infection (SSI) in hand trauma surgery is estimated to be approximately 5% to 10%. However, the severity of these SSIs remains unclear. We aimed to determine the risk of deep SSI, septic arthritis, and osteomyelitis following hand trauma surgery using Hospital Episode Statistics data, a source of routinely collected national healthcare data in England.

Methods: This was a national cohort study of hand trauma surgery in the NHS in England over 22 years, split into four sub-cohorts of the most common hand trauma operations: hand fracture fixation; flexor tendon repair; extensor tendon repair; and nerve repair. The primary outcome was readmission for deep SSI, septic arthritis, or osteomyelitis following hand trauma surgery at 30 and 90 days.

Results: There were 280,747 cases across the study period. A total of 4,013 postoperative infections, including deep SSI, septic arthritis, and osteomyelitis, occurred by 30 days, and 5,563 by 90 days. This corresponds to a severe SSI risk of 1.4% (95% CI 1.4 to 1.5) by 30 days and 2.0% (95% CI 1.9 to 2.0) by 90 days following common hand trauma surgery. Data for each cohort indicated a higher risk of osteomyelitis in fracture fixation and a higher risk of deep SSI in soft-tissue reconstruction.

Conclusion: The risk of readmission for deep SSI, septic arthritis, or osteomyelitis following hand trauma surgery is 1.4% at 30 days, rising to 2% at 90 days. These data can be used to inform patients of their risk and to guide future research in hand trauma surgery.

The incidence of anterior cruciate ligament (ACL) injuries in skeletally immature patients is rising, prompting a shift in management strategies. Historically, nonoperative treatment was favoured due to concerns about iatrogenic physeal injury and consequential growth disturbance. However, emerging evidence supports early ACL reconstruction to improve long-term outcomes and reduce complications such as instability, meniscal damage, and early onset arthritis. This review examines the unique anatomical, developmental, and biomechanical aspects of the paediatric ACL, emphasizing the need for early diagnosis and surgical treatment. Surgical management strategies, including physeal-sparing, physeal-respecting, and transphyseal reconstruction techniques are discussed, with particular attention to their application based on the patient's growth potential. Postoperative rehabilitation, tailored to the patient's developmental stage, is crucial for optimizing recovery and preventing long-term complications. A multidisciplinary approach, incorporating early diagnosis, specialist involvement, and collaboration with experienced paediatric physiotherapists, is essential to achieve optimal outcomes in this complex patient population.

Aims: A high rate of hip subluxation has previously been reported after implantation of a proximal femoral megaprosthesis in children. The primary aim of this retrospective study was to compare the incidence of acetabular dysplasia and hip subluxation, and the functional outcome and revision-free survival between children with open and closed triradiate physes at the time of implantation of their prostheses.

Methods: All patients were aged < 18 years and had a reconstruction with a non-extendable proximal femoral megaprosthesis. Extra-articular resections involving the acetabulum were excluded. Patients were classified into two groups: Group A with an open and Group B with a closed triradiate physis at the time of limb salvage surgery. A total of 36 patients were included; 15 in Group A and 21 in Group B. Their mean age at the time of surgery was nine years (2 to 13; SD 3.14) in Group A and 14 years (12 to 17; SD 1.57) in Group B, with a median follow-up duration of 103 months (IQR 54 to 110) and 58 months (IQR 38 to 106), respectively. Modes of failure and functional outcome were described using the modified Henderson classification and Musculoskeletal Tumor Society score, respectively. The two groups were compared using the Mann-Whitney U and chi-squared tests. The five-year revision-free survival was estimated using Kaplan-Meier and compared between groups using the log-rank test.

Results: Limb length inequality, hip subluxation, and acetabular dysplasia were significantly higher in Group A (p < 0.001, p = 0.032, and p = 0.007, respectively). There were no significant differences in functional outcome, revision-free survival, or time-to-resurfacing between groups (p = 0.076, p = 0.469, and p = 0.587, respectively).

Conclusion: Functional outcome and revision-free survival of proximal femoral megaprosthesis in children with an open triradiate physis are no different from those with closed physes, despite the high rate of acetabular dysplasia and hip subluxation.

Aims: Proximal humerus fractures (PHFs) often occur in a population at risk for complications following surgery. The purpose of this study is to assess the associations of frailty with complications of surgical intervention for PHFs.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried from January 2015 to December 2020 for patients aged ≥ 60 years who were undergoing surgery for PHFs. Tiered frailty scores were calculated by the revised risk analysis index (RAI-Rev) and the modified five-term frailty index (mFI-5) factor. Outcomes included 30-day mortality, readmission, length of stay, and complications. Analysis of variance and binary logistic regression were used to assess associations with odds ratio (OR) and 95% CI. Discriminatory accuracy was quantified by receiver operating characteristic curve analysis and C-statistics.

Results: A total of 6,020 patients with PHFs underwent surgical intervention (51% frail or severely frail). The use of reverse total shoulder arthroplasty (rTSA) for PHFs increased over time (OR 1.14 (95% CI 1.11 to 1.18)), whereas all other procedures decreased. Frail patients were more likely to experience a complication after surgery (OR 2.92 (95% CI 2.48 to 3.43)). Overall, rTSA had higher rates of complications (17% (OR 0.93 (95% CI 0.86 to 0.99)) and non-home discharge (32% (OR 0.84 (95% CI 0.79 to 0.90)). However, these decreased from 2015 to 2020. The RAI-Rev had superior predictability to mFI-5 for any complication (area under the curve (AUC) 0.674 vs 0.601), postoperative blood transfusion (AUC 0.704 vs 0.618), and non-home discharge (AUC 0.778 vs 0.637).

Conclusion: Frail patients have a three-times higher 30-day complication risk following proximal humerus surgery. rTSA is associated with higher rates of complications compared with internal fixation, but has steadily narrowed the gap over time. While the long-term outcomes and functional benefit should be considered, preoperative frailty assessment can be predictive of perioperative complications and disposition in this population.

Aims: The conclusion of the one-year analysis of the Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) was that initial cast immobilization with surgical fixation for nonunion was the optimal treatment for patients with a fracture of the waist of the scaphoid. However, there remained significant uncertainty about the medium-term outcomes and how these could influence the patient's health-related quality of life (HRQoL), care requirements, and costs. The aim of this study was to explore how additional data from the five-year follow-up influenced the cost-effectiveness of the treatment of these fractures.

Methods: The analysis presents the patient-reported HRQoL, measured with the EuroQol five-dimension three-level health questionnaire, and the use of healthcare resources at five years after randomization, and considers which factors influenced the results. The original analytical model, in which the implications of the different forms of treatment throughout the patient's life were estimated, was also updated.

Results: Five years after randomization, most patients in both groups returned to the HRQoL level which is consistent with age-adjusted norms and did not require further healthcare. In contrast, those who continued to have clinically relevant adverse events at five years reported significantly worse HRQoL scores and greater care needs. It was also confirmed in the updated model that initial cast immobilization was the most cost-effective strategy, with a mean cost to the health system of £1,606 less per eligible patient compared with those who initially underwent surgery, an annual saving of £7.5 million.

Conclusion: Most patients had no long-term impact from the injury regardless of the form of treatment. However, the few who had clinically defined adverse events at five years had poor HRQoL and greater care needs. The limited difference in these clinical outcomes between the two groups informed the findings of the decision model that, over the patient's lifetime, the small quality-adjusted life year gains for those who underwent surgery initially were not sufficient to justify the higher costs. These findings confirm that initial immobilization in a cast with fixation for nonunion is the optimal form of treatment for these patients.

Basal osteoarthritis of the thumb is extremely common and causes pain and difficulty with essential 'pinching' tasks such as writing and dressing. It has been shown, in high-quality studies, that physiotherapy can result in clinically important improvements in pain and function, but the delivery of nonoperative treatment currently varies considerably throughout the NHS in the UK. Trapeziectomy is an effective, simple, and low-cost procedure, and the most common of surgical treatment for basal osteoarthritis of the thumb in the UK. However, recovery can be lengthy and complications include subsidence of the thumb metacarpal, instability, and weakness. New designs of thumb carpometacarpal joint arthroplasty (CMCJA) show promising early results with low complication rates and a quick return to function, but the implants are expensive and high-quality evidence about the outcome is lacking. The Surgery versus Conservative OsteOarthritis of Thumb Trial (SCOOTT) is a multicentre, three-arm, randomized controlled trial which is currently being undertaken, comparing the clinical outcomes and cost-effectiveness of an enhanced package of non-surgical management, trapeziectomy, and thumb CMCJA.