Arthroplasty最新文献

Introduction: Periprosthetic joint infections (PJI) pose significant clinical challenges due to biofilm formation and antibiotic resistance. Standard treatment often involves implant removal and prolonged antibiotic therapy. Novel strategies target intracellular pathogens and biofilm-associated bacteria, including liposomal antibiotics, antimicrobial peptides, and bacteriophage therapy. Bacteriophages offer specificity and minimal disruption to human microbiota but remain experimental in PJI. Combining phages with targeted antibiotics shows promising results in preclinical models, though further research is needed to confirm efficacy in human PJI and optimise delivery methods.

Objectives: This study updates the current evidence on the use of bacteriophages for patients with PJI, proposing guidelines for their clinical application.

Method: PubMed was searched for articles containing phage therapy in revision arthroplasty. No additional filters or time constraints were used. All eligible studies were accessed by hand.

Results: A total of 39 studies (20 clinical, 19 reviews) on phage therapy for PJI were analysed, covering 56 patients. Of those, negative outcomes were only reported in five. Most studies involved elderly patients with periprosthetic infections of the knee or hip and showed high success rates when combined with antibiotics and surgery. Phage therapy was well tolerated, with only mild adverse effects, such as fever and reversible transaminitis, occurring predominantly with intravenous administration. Review articles reveal that despite promising outcomes, challenges remain, including a lack of standardisation, limited clinical data, and regulatory hurdles.

Conclusion: This study highlights the potential of phage therapy for PJI, emphasising its high specificity, ability to target antibiotic-resistant bacteria, and capacity to disrupt biofilms, and provides a guideline for its clinical administration. Clinical adoption, however, remains limited by regulatory barriers, lack of standardised protocols, and insufficient trial data. Key steps for implementation include establishing regulatory frameworks, developing academic-industrial partnerships and reference centres, and identifying indications supported by controlled trials. With these in place, phage therapy could become a promising adjunct in managing periprosthetic joint infections. Video Abstract.

Background: Accurate femoral component alignment in the sagittal plane is crucial for total knee arthroplasty (TKA) success. In manual TKA, sagittal alignment is typically guided by the intramedullary axis (IMA) determined on lateral radiographs. However, due to femoral bowing, the IMA varies along the femoral shaft, raising the question of the optimal level for referencing this axis. As short-segmented knee radiographs (SSKR) are increasingly used in clinical practice, it is unclear whether they introduce systemic deviations in IMA determination. This study aimed to compare the IMA derived from SSKR and conventional lateral radiographs (CLR), and to assess whether axis deviation increases with femoral shaft length.

Methods: This retrospective analysis included 153 patients undergoing primary TKA. The femoral IMA was determined using a two-circle method on both the full CLR and a 12.5 cm distal segment simulating SSKR. For the CLR axis, one circle was positioned at the most proximal point of the femoral shaft visible on the radiograph, and the second circle was placed 5 cm proximal to the distal femoral joint line. For the SSKR-based axis, the distal circle remained identical, while the proximal circle was repositioned 12.5 cm proximal to the joint line. Measurements were performed twice by two observers. The angular deviation between CLR- and SSKR-based axes was reported in degrees. A one-sample t-test was used to test for statistical significance. Clinically relevant deviation was defined as ≥ 2°, and the number and percentage of such outlier cases were reported. Correlation between femoral shaft length and angular deviation was analyzed using Pearson correlation. A multivariable regression tested whether femoral length independently predicted angular deviation after adjusting for age, sex, BMI, and side.

Results: The IMA on SSKR was significantly more posterior than on CLR, with a mean angular deviation of 2.3° ± 1.1° (95% CI: 2.2-2.5; P < 0.001; Cohen's d = 2.1). In 57 cases (38%), deviation exceeded the clinically relevant threshold of ≥ 2°. A significant positive correlation was found between the visible femoral shaft length and the angular deviation between CLR and SSKR axes (r = 0.504, P < 0.001). In multivariable regression, femoral length remained an independent predictor of angular deviation after adjustment for age, sex, BMI, and side (P < 0.001).

Conclusion: Referencing the IMA on SSKR results in a significantly more posterior axis compared to CLR, which may lead to increased femoral component flexion in TKA. Given the high incidence of outlier cases and their association with femoral shaft length, surgeons should be cautious when relying on short radiographs for preoperative planning of sagittal femoral alignment. Video Abstract.

Purpose: To evaluate the accuracy of two-dimensional (2D) digital templating in primary total knee arthroplasty (TKA) and assess whether surgical training level affects templating accuracy.

Methods: A total of 424 patients who underwent primary TKA with preoperative 2D digital templating using the Attune system were retrospectively analyzed. Templating was performed in TraumaCad (Brainlab AG) by junior residents (< 3 years of training), senior residents (≥ 3 years), or board-certified orthopaedic surgeons. Planned and implanted component sizes were compared, and accuracy was assessed as exact matches and deviations of ± 1, ± 2, and ± 3 sizes. Pearson correlation analysis was used to assess the association between planned and implanted sizes. One-way ANOVA was used to compare mean absolute deviation across training levels. Additionally, the proportion of cases with a deviation greater than ± 1 size was calculated for both components across experience levels and compared using chi-square tests.

Results: A total of 424 patients (61% female) were included. The median planned component sizes were 6 (IQR, 5-7) for the femoral and 6 (IQR, 5-7) for the tibial component; the median implanted sizes were 6 (IQR, 5-7) and 6 (IQR, 4-7), respectively. Planned and implanted sizes were very strongly correlated for both femoral (r = 0.864; P < 0.001) and tibial components (r = 0.841; P < 0.001). Templating accuracy was high, with 92.7% of femoral and 88.7% of tibial components within ± 1 size. No significant differences in correlation strength or mean absolute deviation were observed across training levels (P > 0.05). The proportion of cases with > ± 1 size deviation was low across all groups and did not differ significantly between training levels for either component (femoral: P = 0.874; tibial: P = 0.791).

Conclusion: 2D digital templating for primary TKA demonstrated high accuracy, with reliable prediction within a ± 1 size range and no significant influence of surgical training level. These findings support its continued clinical use and confirm that templating can be reliably performed by residents at all stages of training. Video Abstract LEVEL OF EVIDENCE: Level III, diagnostic study.

Background: This study compared transverse and longitudinal skin incisions in anterolateral supine (ALS) total hip arthroplasty (THA), focusing on cosmetic and sensory outcomes using the Patient Observer Scar Assessment Scale (POSAS).

Methods: A retrospective analysis was conducted on 132 hips that underwent primary ALS THA performed by a single surgeon between 2019 and 2024. Longitudinal incisions were used until December 2022, and transverse incisions aligned with relaxed skin tension lines were used thereafter. POSAS 3.0 was used to evaluate scar quality across satisfaction, appearance, and sensory domains.

Results: Baseline characteristics were similar between groups, except for follow-up duration and incision length. No significant differences were found in POSAS scores. However, regression analysis revealed that transverse incision significantly improved satisfaction (P = 0.04) and appearance (P < 0.05). Sensory scores were significantly affected by follow-up duration (P < 0.001).

Conclusion: Transverse incisions in ALS THA may enhance cosmetic satisfaction without compromising sensory outcomes. These findings support the potential role of personalized incision planning for improving patient-reported outcomes following THA. Video Abstract.

Objective: To review and synthesise the existing evidence on the effects of peripheral nerve block (PNB) compared with no nerve block on the incidence of postoperative delirium (POD) in adults undergoing hip fracture repair.

Methods: A systematic search of electronic databases (PubMed, Web of Science, EMBASE, and the Cochrane Library) for relevant literature published from database inception to 1st May 2025 was conducted. Randomised controlled trials with PNBs as an intervention in adults undergoing surgery for hip fractures were selected. Studies that excluded patients with preoperative cognitive dysfunction and observed POD as an outcome were eligible.

Results: Twelve randomised controlled trials, involving a total of 1157 participants, 602 in the control group and 555 in the intervention, were included for quantitative analysis. The meta-analysis revealed that PNBs significantly reduced the incidence of POD (RR: 0.68, 95% CI [0.50 to 0.91], P = 0.009, I² = 43%).

Conclusion: In patients without pre-existing cognitive impairment, the perioperative use of PNBs can reduce the occurrence of POD. However, substantial variation in study design and heterogeneity of PNB approaches limit the certainty of these findings. Future research calls for well-designed, standardised, and stratified clinical trials to compare the efficacy of each PNB approach and to evaluate their potential benefits in those at greater risk of POD, including those with baseline cognitive impairment and preoperative delirium. Video Abstract.

Purpose: Accurate prediction of postoperative coronal alignment is essential for successful outcomes following medial unicompartmental knee arthroplasty (UKA). Traditionally, valgus stress femorotibial angle (FTA) has been used to estimate the correctability of varus deformity; however, its reliability is limited by dependence on soft tissue behavior and examiner technique. In contrast, the arithmetic hip-knee-ankle angle (aHKA), calculated from bony anatomy, offers an objective and reproducible measure of constitutional limb alignment. While early studies suggest aHKA correlates well with postoperative alignment, direct comparison with valgus stress FTA has been lacking. This study aimed to compare the predictive accuracy of aHKA and valgus stress FTA for postoperative alignment and alignment correction (ΔHKA) in medial UKA.

Methods: This retrospective study included 125 knees undergoing medial fixed-bearing UKA. Preoperative aHKA was calculated from long-leg radiographs, and valgus stress FTA was measured using a Telos arthrometer. Postoperative hip-knee-ankle angle (HKA) was obtained from standardized radiographs. Correlation analyses were performed between postoperative HKA and both aHKA and 360°-valgus stress FTA. Similarly, correlations were assessed between ΔHKA and (aHKA-preoperative HKA) as well as (360°-valgus stress FTA-preoperative HKA). Fisher's Z-test was used to assess differences in correlation strengths.

Results: Postoperative HKA showed stronger correlation with aHKA (R² = 0.5003, P < 0.001) than with 360°-valgus stress FTA (R² = 0.1157, P < 0.001), with a statistically significant difference (Z = -4.12, P < 0.001). ΔHKA was more strongly associated with aHKA-preoperative HKA (R² = 0.3805, P < 0.001) than with 360°-valgus stress FTA-preoperative HKA (R² = 0.1111, P < 0.001) (Z = -2.92, P = 0.0036).

Conclusion: aHKA demonstrated superior predictive accuracy for both postoperative alignment and alignment correction compared to valgus stress FTA. As a bone-based and examiner-independent parameter, aHKA is a valuable tool for preoperative planning in medial UKA and may reduce the need for stress radiography. Video Abstract.

The implantation of total knee replacements is an effective treatment for advanced degenerative knee joint diseases. Implant positioning relative to the bones affects the loads occurring in the artificial joint, joint stability, and postoperative functionality. Variance in implant positioning during the surgical implantation of a total knee replacement cannot be entirely ruled out. By simulating implant malpositioning in an experimental setting, particularly critical cases of malalignment can be identified, from which guidelines for orthopedic surgeons can be derived. The AMTI VIVO™ six degree of freedom joint simulator allows reproducible preclinical testing of joint endoprostheses under specific kinematic and loading conditions. It features a virtual ligament model that defines up to 100 ligament fibers between the articulating components. This paper presents a method to investigate the effect of different implant positions on the biomechanics of the knee after total knee arthroplasty. For this, the VIVO joint simulator requires no modification of the physical setup by moving virtual ligament insertion points relative to the bone. As a proof of concept, exemplary shifts and rotations of the femoral and tibial implant components are performed, and dynamic results are compared to a musculoskeletal multibody digital twin and findings from the literature. Video Abstract.

Background: Vertebral compression fractures (VCFs) can impair posture, gait, and daily activities in patients undergoing total hip arthroplasty (THA). However, limited data are available regarding the incidence, risk factors, and impact of VCFs on sagittal spinal alignment following THA. Therefore, the purpose of this study was to investigate the incidence and risk factors of VCFs after THA, and to evaluate their impact on sagittal spinal alignment and clinical outcomes.

Methods: This retrospective cohort study included 220 patients (243 hips) who underwent primary THA, with a mean follow-up period of 6.1 years. Data collected included patient demographics, Fracture Risk Assessment Tool (FRAX) scores, lumbar bone mineral density measured before THA, sagittal spinal alignment parameters, Harris Hip Score (HHS), and the occurrence of new VCFs. We analyzed changes in spinal alignment and identified risk factors associated with incident VCFs.

Results: VCFs occurred in 20% of hips during the follow-up period. Patients who developed VCFs demonstrated a significantly increased sagittal vertical axis, reduced lumbar lordosis angle, and lower postoperative HHS compared to those without VCFs. Preexisting VCF and higher preoperative FRAX scores were significantly associated with the development of new VCFs. Multivariate logistic regression analysis identified the FRAX score as an independent predictor of incident VCFs.

Conclusions: In this 6.1-year retrospective cohort study, 20% of hips developed new VCFs after THA, which were associated with worsened spinal alignment and hip function. The higher FRAX score, calculated prior to THA surgery, is a useful predictor of VCF risk and may help identify individuals who require closer monitoring or preventive interventions during follow-up after surgery. Video Abstract.

Background: The management of retro-acetabular osteolysis in revision hip arthroplasty with acetabular component retention remains controversial and challenging due to limited access to the area.

Surgical technique and methods: Fourteen patients with well-fixed and well-aligned acetabular components underwent revision surgery and a retained shell. A vinyl urinary catheter and syringe were used to deliver demineralized bone matrix putty to the bone defect after debridement. Clinical outcome and radiographic follow-up were scheduled at a minimum of 2 years.

Results: The revision arthroplasty survivorship rate with this technique was 85.7% (12 of 14 patients) at a median follow-up of 6 years. One cup failed due to an aseptically loosening cup, and another from late septic loosening. Significant improvement of the University of California Los Angeles (UCLA) score, Harris Hip Score (HHS) pain subscale, and Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) were observed at a median 6-year follow-up.

Conclusions: Management of retro-acetabular osteolysis with injected demineralized bone matrix using a syringe and vinyl urinary catheter is a reliable, easy, low-cost method with satisfactory mid-term clinical outcome improvement. Video Abstract.

Background: Hemophilia A (HA) arthropathy poses a significant clinical challenge, particularly in achieving perioperative hemostasis and surgical precision. Accounting for the majority of hemophilia cases, HA frequently leads to severe secondary joint damage. Although gene therapy holds promise, its clinical application in HA remains limited by challenges to durable efficacy. Crucially, the transient efficacy and unpredictable pharmacokinetics of gene therapy have not been evaluated in major orthopedic surgeries with a high potential for bleeding, such as total hip arthroplasty (THA).

Case presentation: To our knowledge, this is the first documented case of robot-assisted (RA)-THA performed after gene therapy for severe HA-associated hip arthropathy, including a detailed surgical protocol and a postoperative follow-up of over six months. The patient received hemophilia gene therapy 56 weeks prior to surgery. Crucially, no exogenous FVIII supplementation was required preoperatively or intraoperatively. A minimal amount of FVIII was administered postoperatively. No abnormal bleeding events occurred throughout the perioperative period. The patient maintained normal coagulation status, achieved excellent wound healing, and demonstrated excellent functional recovery.

Conclusion: This pioneering case demonstrates the potential safety and efficacy of combining gene therapy with minimally invasive RA-THA for HA hip arthropathy. The integrated approach significantly reduced dependence on exogenous FVIII and enabled precise anatomical reconstruction.