Bone & Joint Journal最新文献

Aims: Osteonecrosis of the femoral head (ONFH) after femoral neck fracture poses challenges in children, particularly at Ficat stage III. Limited effective treatments are available. This study explores basicervical femoral neck rotational osteotomy (BFNRO) for ONFH following fracture of the femoral neck in children and adolescents, and evaluates its outcomes.

Methods: Children and adolescents with ONFH (Fiat stage III) following fracture who underwent BFNRO at our centre from June 2017 to September 2022 were included. Follow-up exceeded one year, with data on modified Harris Hip Score (mHHS), range of motion (ROM), patient satisfaction, femoral head collapse, necrotic area repair, leg length, and osteoarthritis (OA) progression recorded.

Results: This study included 15 patients (15 hips; eight male and seven female) with a mean age of 12.9 years (10 to 17). Nine patients had BFNRO alone, and six had combined periacetabular osteotomy. Rotation angles varied from 70° to 90° for anterior rotation and 110° to 135° for posterior rotation. Nine patients had femoral neck fixation in a varus position (10° to 30°). The postoperative contour of the weightbearing area of the femoral head has significantly improved in all patients. At a mean follow-up of 28.6 months (12.2 to 72.7), mean mHHS significantly improved (65.2 (SD 8.6) to 90.2 (SD 5.8); p < 0.001). Only one patient showed femoral head further collapse. Patients experienced no/mild hip pain (visual analogue scale 0 to 3), slight restriction in ROM, and mild limb shortening. Two patients had OA progression. No infections or nerve injuries were observed, and no arthoplasies undertaken.

Conclusion: Even with late stage ONFH after fracture, BFNRO in children and adolescents can provide positive early to mid-term results by relocating the necrotic area and restoring the integrity of the anterior-lateral column of the femoral head, thereby preventing femoral head collapse and delaying the onset of severe OA.

Aims: This study aims to determine the outcomes of distal femoral replacements (DFRs) for nononcological conditions.

Methods: This was a multicentre retrospective cohort study across five UK centres between 1 August 2009 and 1 April 2023. The primary outcome was the local complication rate. Secondary outcomes assessed were blood transfusion rate, critical care requirements, return to baseline mobility and residence status, systemic complication rates, reoperation rate, and mortality rates. Implant survival analysis was performed using Kaplan-Meier methodology with local complication as the endpoint. Binary logistical regression was performed to identify risk factors for developing local complications. The study included 227 DFRs with a median age of 78.2 years (IQR 70.1 to 84.0). Indications were periprosthetic femoral fracture (PFF) (n = 74; 33%), aseptic revision arthroplasty (n = 45; 20%), acute trauma (n = 42; 19%), infected revision arthroplasty (n = 40; 18%), chronic/failed trauma (n = 14; 6%), and complex primary arthroplasty (n = 12; 5%). Median follow-up was 3.9 years (IQR 1.5 to 7.1).

Results: The local complication rate was 21% (48 cases). The most common local complications were periprosthetic joint infection (n = 22; 10%), PFF (n = 7; 3%), and aseptic loosening (n = 7; 3%). Blood transfusion was required in 57 patients (25%), while 67 (30%) required critical care facilities. A return to baseline mobility and residence was observed in 94 (50%) and 183 (83%) patients, respectively. The six-month systemic complication rate was 12% (n = 27) and the reoperation rate was 16% (n = 36). The 30-day and one-year mortality rates were 3% (n = 6) and 9% (n = 21), respectively. The two-year implant survival rate was 80.9% (SE 2.8). Binary logistic regression demonstrated surgery for infected revision arthroplasty, an increasing construct:stem ratio, and increasing operating time were associated with a higher risk of failure (p < 0.05).

Conclusion: This is the largest study of DFR for nononcological conditions. Due to high local complication and reoperation rates, it should be considered as a salvage option for complex knee reconstruction and patients should be counselled appropriately.

Aims: In the surgical treatment of a periprosthetic joint infection (PJI), traditional mechanical debridement can only remove visibly infected tissue; not all of the biofilms can be removed. The aim of this study was to report the results of a single-stage revision using non-contact low-frequency ultrasonic debridement (NLFUD) in the treatment of chronic PJIs.

Methods: This was a prospective study of patients undergoing single-stage revision for chronic PJI, between August 2021 and June 2022. After mechanical debridement, an 8 mm handheld non-contact low-frequency ultrasound probe was used for debridement at a frequency of 25 ± 5 kHz and power of 90%, for five minutes. Each debridement lasted for ten seconds, with three-second intervals. The probe repeatedly sonicated all soft-tissue and bony surfaces. Before and after NLFUD, 25 ml of fluid was extracted from the surgical field for bacterial culture and counting. Chemical debridement was then used to irrigate the whole field. The bacteriological findings, recurrence of infection, and complications were recorded.

Results: A total of 45 patients (25 infected total hip arthroplasties (THAs) and 20 infected total knee arthroplasties (TKAs)) were included. Overall, 43 patients (95.6%) were free of infection at a mean follow-up of 29 months (24 to 33). There were no complications relating to the ultrasonic debridement, with no neurovascular or muscle injury, no poor wound healing, and no fat liquefaction. The rate of positive culture in the fluid from the surgical field before ultrasonic debridement was 40.0% (18/45), and it significantly increased to 75.6% (34/45) after ultrasonic debridement (p = 0.001). The median number of colony-forming units (CFUs) before debridement was 307 CFU/ml (IQR 225 to 585) significantly improved to 2,372 CFUs/ml (IQR 2,045 to 2,685; p < 0.001) after debridement.

Conclusion: We found that a favourable short-term control of infection can be achieved in these patients by a single-stage revision using NLFUD, without associated complications. However, further robust evidence is required to confirm the clinical benefits of using NLFUD under these circumstances.

Aims: The Paprosky acetabular defect classification and associated algorithms cannot adequately guide cementless acetabular reconstruction when using porous metal augments. We aimed to introduce a rim, points, and column (RPC)-orientated cementless acetabular reconstruction algorithm, and hypothesized that patients undergoing this treatment would demonstrate satisfactory mid-term clinical and radiological outcomes.

Methods: We enrolled 114 patients (119 hips) who underwent revision total hip arthroplasty between April 2014 and November 2017 by a single surgeon. A minimum five-year radiological follow-up was available for 90 hips (75.6%), with mean clinical and radiological follow-up durations of 6.8 years (SD 0.9) and 6.3 years (SD 1.9), respectively.

Results: Harris Hip Scores improved from 35.4 (SD 10.2) preoperatively to 86.0 (SD 10.3) postoperatively (p < 0.001). Fixation modes included rim fixation (33 hips; 27.7%), three-point fixation without point reconstruction (42 hips; 35.3%), three-point fixation with point reconstruction (40 hips; 33.6%), and three-point fixation with pelvic distraction (four hips; 3.4%). Medial wall reconstruction was performed in 20 patients (16.8%). All acetabular components were radiologically stable. Nine-year Kaplan-Meier survival rates for periprosthetic joint infection, any reoperation, and dissatisfaction were 98.28% (95% CI 88.38 to 99.76), 94.37% (95% CI 81.93 to 98.33), and 95.10% (95% CI 84.64 to 98.50), respectively.

Conclusion: Acetabular component stability in cementless acetabular reconstruction relies on rim or three-point fixation, with anterior and posterior column continuity providing essential stability. Medial wall reconstruction complements fixation in the RPC algorithm, yielding satisfactory mid-term outcomes.

Aims: The results of revision surgery to correct leg-length discrepancy (LLD) after total hip arthroplasty (THA) are not clear. Only two previous small series have been published dealing with this issue. The aim of this retrospective study of revision THAs for LLD was to determine the postoperative change in LLD, the functional outcomes, and whether obtaining equal leg lengths influenced function, as well as to report the complication rate and survival.

Methods: This multicentre study included 57 patients: 42 revisions for limb shortening and 15 for limb lengthening. LLD was measured on conventional radiographs. The Oxford Hip Score (OHS) and Forgotten Joint Score (FJS) were collected, along with the number of patients achieving the minimal clinically important difference (MCID) for the OHS.

Results: Revisions were carried out at a mean of 2.8 years after the initial THA. The median LLD decreased significantly from 7.5 mm (IQR 5 to 12) to 1 mm (IQR 0.5 to 2.5) at a mean follow-up of two years (SD 2.4) (p < 0.001). A total of 55 patients (96%) had < 5 mm LLD at follow-up and 12 (21%) had equal leg lengths. The complication rate was 26%. There were 13 mechanical complications (eight periprosthetic femoral fractures, two stem loosenings, two acetabular loosenings and one dislocation), and one periprosthetic infection. Patient satisfaction was high, with a median FJS of 79% (IQR 64 to 98), and 37/48 patients (77%) reached the OHS MCID. Lengthening procedures had significantly worse function postoperatively than shortening procedures (38% vs 91% of patients achieving the OHS MCID (p < 0.001)). Survival was 85% (95% CI 77.9 to 92.5) at two years and 77% (95% CI 66.3 to 87.1) at 4.6 years using re-revision as the endpoint.

Conclusion: When LLD after THA remains symptomatic after conservative management, revision THA should be considered. Revision THA for LLD improved the medium-term functional outcomes with a high patient satisfaction rate, especially for shortening procedures. However, the complication rate, particularly of periprosthetic femoral fracture, was high.

Aims: Upper limb fractures in children are often managed in casts. Waterproof casts which allow safe immersion in water may be used. These may improve comfort, convenience, and satisfaction when compared with standard casts. The aim of this review was to compare the efficacy, safety, and satisfaction of waterproof casts with standard casts in the management of upper limb fractures in children.

Methods: A systematic review of randomized controlled trials (RCTs) was conducted in September 2024. Comprehensive searches of Medline, PubMed, Cochrane CENTRAL, and EMBASE databases were performed. Studies were included which recruited children aged 0 to 18 years with upper limb fractures, which were managed in waterproof or standard casts. Patient-reported outcomes, functional outcomes, and complication rates were assessed.

Results: A total of five studies involving 390 children were included. Those managed with a waterproof cast reported significantly superior satisfaction with regard to comfort (mean difference (MD) 1.92 (95% CI 0.15 to 3.69); p = 0.034), itchiness (MD 0.21 (95% CI 0.00 to 0.43); p = 0.047), and overall child and parent satisfaction (MD 0.53 (95% CI 0.01 to 1.05); p = 0.048). Those managed with a waterproof cast also had significantly improved functional outcomes as measured by the Activities Scale for Kids-Performance (ASK-P) score, with a MD of 16.90 (95% CI 6.87 to 26.93; p = 0.001). There were no significant differences regarding heat or sweatiness, pain, return to recreational activities, unexpected returns for cast maintenance, radiological deformity, or skin problems.

Conclusion: Waterproof casts seem to provide an alternative to standard casts in the management of upper limb fractures in children. There were improved functional outcomes at the time of removal of the cast, improved comfort, and less itching. Pooling of the studies was limited due to the heterogeneity of the reporting of outcomes and the small sizes of the studies. Neither long-term outcomes, nor economic analysis based on healthcare-related quality of life, are available. A definitive RCT based on a core outcome set is required to confirm the efficacy and investigate the cost-effectiveness of waterproof casts in children.

Aims: The aim of this study was to determine the success of an algorithm designed to guide the choice of bearing based on gluteus medius deficiency to be used in revision total hip arthroplasty (THA).

Methods: Dislocation following revision THA remains a leading cause of failure, and while bearings which offer enhanced stability are available, the indications for their use remain unclear. The integrity of the abductor muscles is a major contributor to stability. We describe the use of an algorithm based on gluteus medius deficiency to determine the choice of bearing in revision THA. The default choice in patients with no damage to gluteus medius was a large head, defined as one with a diameter of ≥ 36 mm. Those with gluteus medius deficiency but with preservation of the posterior muscle and tendon were treated with a dual-mobility bearing. A constrained acetabular liner was used in those with complete gluteus medius deficiency. This was a series of consecutive revision THAs undertaken by a single surgeon using this algorithm. The patients were followed to report the rates of dislocation, all-cause re-revision, and Oxford Hip Score (OHS).

Results: A total of 311 revision THAs were performed in 259 patients (26 were bilateral) with a mean age of 70 years (32 to 95). At a mean follow-up of 4.8 years (1.0 to 9.0), the dislocation rate for the whole cohort was 4.1% (95% CI 2.4 to 7.0), and Kaplan-Meier survival analysis revealed a 96.1% (95% CI 93.0 to 97.8) dislocation-free survival at 60 months. A large diameter head was the most commonly used bearing, in 164 revisions (53%). There was no significant difference in the dislocation-free survival between the bearings (p = 0.46). The survival free of all-cause re-revision for the whole cohort was 94.2% (95% CI 96.3 to 91.0). The mean OHS improved from 19.6 (2 to 47) preoperatively to 33.9 (4 to 48) at the final follow-up.

Conclusion: The findings suggest that the algorithm which we describe, based on soft-tissue deficiency at the time of surgery, can allow the successful choice of bearing to be used in revision THA.

Aims: Performance indicators are increasingly used to improve the quality of healthcare provided to hip fracture patients. Joint care, under orthopaedic surgeons and physicians with an interest in older patients, is one of the more common indicators of high-quality care. In this systematic review, we investigated the association between 'comprehensive geriatric assessment' and patient outcomes following hip fracture injury.

Methods: In total, 12 electronic databases and other sources were searched for evidence, and the methodological quality of studies meeting the inclusion criteria was assessed. The protocol for this suite of related systematic reviews was registered with PROSPERO (ID: CRD42023417515).

Results: A total of 24,591 articles were reviewed, and 39 studies met the inclusion criteria for the review, involving a total of 25,363 patients aged over 60 years with a hip fracture. There were five randomized clinical trials, three quasi-experimental studies, two non-randomized parallel group control trials, 22 pre-/post-intervention studies, and seven retrospective cohort studies, conducted between January 1992 and December 2021. The timing and content of a comprehensive geriatric assessment was ill-defined in many studies and care pathways were heterogeneous, which precluded meta-analysis of the data. Early comprehensive geriatric assessment was associated with improved outcomes in 31 of the 36 (86%) patient-reported outcomes, including improved mobility (acute/long-term), functional status, and better quality of life. In total, 155 out of 219 (70.78%) clinical outcomes derived from hospital records showed a positive association with early comprehensive geriatric review, including reduced preoperative time and length of hospital stay, reduced incidence of postoperative complications, fewer hospital readmissions, and lower mortality.

Conclusion: Early comprehensive geriatric assessments after hip fracture in older people is associated with improved patient-reported outcomes and better clinical outcomes such as reduced incidence of complications, length of hospital stay, preoperative waiting time, and mortality. Standardization of the definitions of 'early' and 'comprehensive' geriatric assessments and consistent reporting of care pathway models would improve future evidence synthesis.