Bone & Joint Journal最新文献

This aim of this annotation is to provide greater knowledge about Bayesian methodology when used in the design of clinical trials and in the analysis of the findings, including the potential benefits and limitations of this approach in Trauma and Orthopaedic surgery. We outline how adopting Bayesian methodology could serve as a feasible and potentially more relevant basis for the design and conduct of future randomized controlled trials in our specialty. It also provides background methodological context for the paper 'High-dose dual-antibiotic cement for hip hemiarthroplasty: a post-hoc Bayesian analysis of a randomized controlled trial', which is published in this issue.

Aims: The most appropriate management of patients who have undergone curettage for a suspected low-grade chondrosarcoma (CS), which has subsequently been found to be of grade 2, remains unknown. We aimed to assess whether these patients have an increased risk of local recurrence and distant metastasis if followed up over time, compared to those who undergo further treatment soon after the diagnosis has been established.

Methods: A retrospective study was undertaken which included 71 patients treated between January 2010 and December 2022 by intralesional curettage for a supposed low-grade CS, but who subsequently proved to have a histological grade 2 CS. Thereafter, patients either underwent further surgery (resection group) or follow-up (follow-up group).

Results: The estimated local recurrence rate was 36.8% at five (95% CI 35.6 to 38.0) and 48.1% at ten years (95% CI 46.4 to 49.8), and was significantly higher in the follow-up group (48.4%, 95% CI 45.4 to 51.4) than in the resection group (9.6%, 95% CI 8.1 to 11.1) at five years (p = 0.005). Locally recurrent CS, considered as a time-dependent covariate, had an increased risk of metastasis (36.8% vs 2.5% at five years; p < 0.001) and a worse disease-specific survival (81.3% vs 100% at five years; p = 0.007).

Conclusion: The optimal treatment strategy should be individualized based on the histological features of the tumour, tumour location, morbidity of resection, and patient-specific factors. We recommend that patients who have undergone unplanned surgery be treated in the standard manner. Observation may be appropriate in specific cases with a properly informed patient.

Aims: To map the Oxford Knee Score (OKS), OKS Activity & Participation Questionnaire, Forgotten Joint Score (FJS), and High Activity Arthroplasty Score to a common scale using principles of modern test theory. Using the common scale, we then aimed to build a computerized adaptive test (CAT) to reduce item burden.

Methods: Participants undergoing total knee arthroplasty provided preoperative and postoperative (six and 12 months) paired responses for four patient-reported outcome measure (PROM) instruments, with the OKS being the common linking instrument. After meeting assumptions (unidimensionality, monotonicity, local independence, and measurement invariance), a graded response model was fitted to the data. A CAT algorithm was developed.

Results: There were 6,301 paired responses included. Confirmatory factor analysis demonstrated that the four PROM instruments measured a similar or very similar latent construct, which we describe as 'knee health'. The combination of all four instruments resulted in higher test-level information than any individual instrument. The CAT reduced 36 items to a median of eight items, while maintaining high measurement precision (standard error of measurement 0.29).

Conclusion: The common metric provides a more precise measurement of knee health than any of the individual instruments, and avoids floor and ceiling effects inherent in individual scores. The CAT algorithm reduced the item burden to a median of eight items, which is lower than the FJS or OKS, when used as individual instruments. It will also allow for standardization of outcome reporting and pooling of results across databases that use any of the four instruments to facilitate individual and meta-analyses across different scores.

Aims: Short, uncemented hip stems might provide a favourable alternative in total hip arthroplasty (THA) by preserving proximal bone mass through reduced strain-adaptive remodelling. We evaluated and compared the migration and periprosthetic bone remodelling of a short stem with and without a collar, using radiostereometric analysis (RSA) to measure implant migration and dual-energy X-ray absorptiometry (DXA) to evaluate periprosthetic bone remodelling. In this study we present ten-year follow-up results, completing previously published two- and five-year RSA and DXA studies.

Methods: A total of 50 patients (34 males) underwent THA due to osteoarthritis and were randomized to either a collared or collarless short stem. Patients were followed for ten years with repeated RSA and DXA examinations. Patient-reported outcome measures (PROMs), Hip disability and Osteoarthritis Outcome Score, EuroQol five-dimension questionnaire, and Forgotten Joint Score were collected.

Results: A total of 45 patients remained at the ten-year follow-up. RSA showed early implant stabilization and osseointegration within three months after an initial subsidence of 0.62 mm (95% CI 0.33 to 0.91) for collared and 0.76 mm (95% CI 0.55 to 0.96) for collarless stems. Minimal further migration was observed up to ten years. Net bone mineral density at ten years was -3.3% (95% CI -9.2 to 2.7) and -2% (95% CI -7.3 to 3.4) in collared and collarless stems, respectively. The presence of a collar did not result in any statistically significant differences either for RSA or DXA results. PROMs improved as expected, and remained high up to ten years in both groups. None of the stems was revised.

Conclusion: The short stem remains stable at ten years and preserves bone mass, both with and without a collar. These findings support the continued use and further evaluation of this type of short, uncemented stem.

Aims: Inferior positioning of the calcar screw is important in the purchase of medial screws when treating proximal humeral fractures with a locking plate. However, the impact of the overall trajectory of the calcar screw has not been investigated. The aim of this study was to investigate whether the failure of a calcar screw to purchase both proximal and distal fragments would contribute to an increased risk of failure of fixation in these patients.

Methods: Patients who underwent locking plate fixation for a proximal humeral fracture between January 2012 and December 2022 were retrospectively reviewed. They were divided into two groups: a purchase group (P) in whom the calcar screw intersected the fracture line on postoperative anteroposterior radiographs, indicating purchase of both proximal and distal fragments; and a non-purchase group (NP) in whom the screw did not have purchase in both fragments. A total of 163 patients were included; 102 and 61 in the P and NP groups, respectively. We compared the rates of failure of fixation between these groups and performed a multivariable logistic regression analysis to identify the risk factors for failure of fixation.

Results: The rate of failure of fixation was significantly higher in the NP group (31.2%; 19 of 61) compared with the P group (3.9%; 4 of 102) (p < 0.001). There were no significant differences between the groups in terms of medical comorbidities, reduction of the fracture, or fixation status. Stepwise multivariable regression identified diabetes (odds ratio (OR) 4.36 (95% CI 1.23 to 16.78); p = 0.025), medial cortical translation of > 5 mm (OR 4.70 (95% CI 1.07 to 21.29); p = 0.039), and NP (OR 16.10 (95% CI 4.72 to 71.62); p < 0.001) as significant risk factors for failure of fixation.

Conclusion: Failure of the calcar screw to purchase both the proximal and distal fragments was associated with a significantly higher rate of failure of fixation in the surgical treatment of proximal humeral fractures using a locking plate.

Aims: Periprosthetic femoral fracture (PPFF) is a major complication following hip arthroplasty. This study examined the influence of femoral component design and fixation method on the risk of reoperation for PPFF.

Methods: We analyzed data on femoral component type use for primary hip arthroplasty stems reported to the Norwegian Arthroplasty Register and the Norwegian Hip Fracture Register from 1 January 2005 to 31 December 2023. The study included 187,576 well-documented femoral components used in hemi- and total hip arthroplasties which were assessed by Cox regression. The femoral components were categorized into five groups: 1) cemented composite beam (n = 30,415), and two types of cemented polished taper-slip components; 2) double-tapered (n = 52,255); 3) triple-tapered (n = 13,894), and two types of uncemented femoral components; 4) wedged collarless (n = 38,389); and 5) wedged collared (n = 40,853). Endpoint was reoperation for PPFF (revisions and osteosyntheses).

Results: A total of 1,398 femoral components (0.7%) were reported with a reoperation due to PPFF. The risk of reoperation was significantly higher for cemented double-tapered (adjusted hazard rate ratio (aHRR) 4.0 (95% CI 3.1 to 5.2), cemented triple-tapered (aHRR 4.0 (95% CI 2.9 to 5.6)), uncemented wedged collarless (aHRR 7.3 (95% CI 5.6 to 9.5)), and uncemented wedged collared (aHRR 3.5 (95% CI 2.6 to 4.6)) components compared to cemented composite beam components. Cemented triple-tapered prostheses exhibited a similar risk of reoperation (aHRR 1.0 (95% CI 0.8 to 1.3)) to cemented double-tapered components. Uncemented wedged collarless prostheses were associated with a higher risk of PPFF (aHRR 2.1 (95% CI 1.8 to 2.5)) compared to uncemented wedged collared designs.

Conclusion: To minimize the risk of PPFF, cemented composite-beam femoral components should be the surgeon's preferred choice. If cementing is not an option, uncemented wedged collared components are the best alternative. Opting for a cemented triple-tapered design does not improve outcomes compared to double-tapered component.

Aims: Dislocation arthropathy of the shoulder is an advanced arthritis resulting from recurrent glenohumeral dislocation with or without previous stabilization surgery. The aim of this study was to compare the clinical results of reverse total shoulder arthroplasty (RTSA) in patients with dislocation arthropathy with those with primary osteoarthritis (OA) and glenoid bone loss.

Methods: This was a retrospective matched cohort study including 22 patients with dislocation arthropathy who were treated by one surgeon between 2011 and 2021 and a matched group of 44 patients who were also treated with RTSA, for OA. All patients had a minimum follow-up of two years and were treated with one of two RTSA systems, both with a lateralized glenoid sphere, a 135° neck-shaft angle and an uncemented humeral component, but differing by inlay versus onlay humeral tray. The glenoids were reamed eccentrically until there was at least 90% cover of the baseplate. No bone grafting or augmented glenoid components were used. Range of motion (ROM) and patient-reported outcome measures (PROMs) were recorded preoperatively and at final follow-up.

Results: Implant survival at final follow-up was 100% in the dislocation arthropathy group and 98% in the OA group. Both groups showed significant improvements in all PROMs and all ROMs, and there was no significant difference in these improvements between the groups. The complication rate was similar in the two groups (9% in the dislocation arthropathy group and 11% in the OA group).

Conclusion: The clinical results of RTSA performed in patients with dislocation arthropathy were comparable to those in a matched group of patients with OA. Although these findings suggest that RTSA is a successful surgical treatment for patients with dislocation arthropathy, longer follow-up is needed.

Aims: Reverse total shoulder arthroplasty (RSA) is a well-established treatment for proximal humerus fractures in elderly patients. However, the clinical advantages of standard humeral components compared to fracture-specific components remain unclear. This meta-analysis compares the clinical outcomes and complication rates of standard compared with fracture-specific components in RSA.

Methods: A systematic review and meta-analysis were conducted according to the PRISMA guidelines. PubMed, Scopus, and Cochrane Library databases were searched from inception to 12 August 2024. Comparative studies reporting clinical outcomes between standard components and fracture-specific components in RSA for proximal humerus fractures were included. Data on functional scores, range of motion, tuberosity healing, and complications were extracted. Meta-analyses were performed using fixed or random-effects models based on heterogeneity, and risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and the Cochrane Risk of Bias Tool (RoB2). Weighted mean difference (WMD) was used as the effect size estimator for continuous outcomes, and risk ratio (RR) for dichotomous outcomes. Sensitivity analysis was performed to assess the robustness of the findings.

Results: Six studies involving 436 patients (142 with standard components and 294 with fracture-specific components) were included. The pooled analysis found no significant differences between the two component types in functional outcomes (visual analogue scale (VAS): WMD 0.22; American Shoulder and Elbow Surgeons (ASES): WMD -7.43; Constant score: WMD -3.08) or postoperative range of motion (abduction: WMD 1.08°; internal rotation: WMD 0.35°; external rotation: WMD -2.76°; forward flexion: WMD -4.27°). Complication rates, including tuberosity failure (RR 1.34), scapular notching (RR 1.09), and component loosening (RR 1.64), were also comparable.

Conclusion: This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. While the findings offer potentially useful insights, they should be interpreted in the context of the limited number of included studies and possible risk of bias.