Orthopaedics & Traumatology-Surgery & Research最新文献

Background: Currently, there is limited information regarding postoperative adherence to surgeon recommendations following hallux valgus surgery. This prospective study aimed to assess early postoperative ambulation and adherence to recommendations using a GPS-enabled wearable device during the postoperative period.

Hypothesis: We hypothesized that patients undergoing hallux valgus surgery would exhibit high postoperative activity levels and poor adherence to surgeon recommendations.

Patients and methods: A prospective, single-center cohort study was conducted from February to July 2024, including 24 consecutive patients (8 males, 16 females; mean age 53.2 ± 8.3 years) undergoing minimally invasive hallux valgus surgical correction (distal chevron osteotomy, and Akin). A GPS tracker with a 3-axis accelerometer was incorporated into the postoperative dressing, recording step count, movement duration, and location from postoperative Days 1 to 5. Patients were recommended home rest for the first five postoperative days and to limit ambulation using a postoperative shoe, restricted to essential activities. Adherence to recommendations was assessed based on recorded activity levels and distances traveled. Pain was monitored using a visual analog scale.

Results: Patients exhibited high postoperative ambulation. In total (17/24) 70% engaged in outdoor activity beyond 1 km, and (11/24) 47% walked more than 2000 steps per day. Step count increased significantly from 1797 ± 2397 on Day 1 to 2937 ± 2140 on Day 5 (p = 0.002). Activity duration also increased from 164 ± 88 minutes on Day 1 to 222 ± 95 minutes on Day 4 (p = 0.002). Pain levels exhibited a significant inverse relationship with activity duration (ρ = -0.26 (p = 0.01)). No postoperative complications were observed at follow-up.

Discussion: Our study showed high activity levels and poor compliance with postoperative recommendations following hallux valgus surgery during the early postoperative phase. Despite the absence of complications, these findings do not support relaxing postoperative activity restrictions based on this limited cohort. GPS-based wearable tracking might have a potential role in improving postoperative surveillance and refining patient care guidelines.

Level of evidence: IV; prospective case series.

Introduction: Surgical management of anterior cruciate ligament (ACL) injuries in skeletally immature patients remains challenging due to the presence of open growth plates and the higher risk of graft failure compared to adults. The addition of an anterolateral ligament (ALL) reconstruction could improve stability and reduce failure risk, but concerns about growth disturbances persist.

Objective: To determine the graft failure rate, growth safety, and return-to-sport outcomes after combined ACL-ALL anatomic reconstruction using a hamstring graft in skeletally immature patients. We hypothesized that this combined technique would be associated with a low graft failure rate while preserving growth safety and satisfactory functional outcomes.

Methods: We conducted a retrospective monocentric study including 39 patients (bone age < 14 years for boys, < 12 years for girls) who underwent combined ACL-ALL reconstruction using hamstring graft. The tibial tunnel was transphyseal, and the femoral tunnel was unique epiphyseal and performed under fluoroscopic control. The Pedi-IKDC, Lysholm, and Tegner scores were recorded before surgery and at final follow up. Graft rupture, surgical complication and growth disturbance were also assessed at final follow up.

Results: After a mean follow-up of 3,6 years (1,9-5,3), only one graft failure (2.6%) and one growth disturbances (2.6%) were observed without clinical consequence or need for additional surgical treatment. No postoperative complications occurred. The mean Pedi-IKDC and Lysholm scores were 98.2 (range, 70-100) and 98.6 (range, 70-100), respectively. All patients returned to sport and only eight resumed at a lower level, with no cases of instability or significant growth discrepancy.

Conclusion: Combined ACL-ALL reconstruction using hamstring graft and a unique epiphyseal femoral tunnel provides excellent functional outcomes with low rates of rerupture and growth disturbance in skeletally immature patients.

Level of evidence: IV; retrospective case series.

Background: Meniscal deficiency after discoid lateral meniscus resection often leads to early lateral compartment degeneration. Clarifying the impact of lateral femoral condyle (LFC) squaring on graft behavior and outcomes may help optimize lateral meniscal allograft transplantation (MAT) results.

Purpose: This study aimed to compare LFC morphology, specifically the presence of condylar squaring, with meniscal graft extrusion, radiological structural characteristics, and clinical outcomes following lateral MAT.

Methods: A total of 108 patients undergoing lateral MAT were retrospectively divided into two groups based on LFC squaring: Group S (n = 57) and Group N (n = 51). Comparisons included radiographic indices, MRI-based graft extrusion, graft signal intensity, and cartilage status graded by the International Cartilage Repair Society (ICRS) system, SPECT/CT subchondral metabolic activity, and clinical outcome scores at pre- and postoperative follow-up. All surgeries followed a uniform technique and rehabilitation protocol, with blinded radiologic assessments.

Results: Group S demonstrated narrower lateral-edge joint-space width both preoperatively (3.5 ± 1.7 mm vs 4.2 ± 1.5 mm; p = 0.004) and at final follow-up (4.1 ± 1.9 mm vs 4.9 ± 1.7 mm; p = 0.023). High-grade cartilage lesions (ICRS ≥ 3) were more frequent in Group S before surgery (33.3% vs 11.8%; p = 0.008). At 1 year, graft extrusion was greater in Group S (3.5 ± 0.8 mm vs 2.2 ± 0.6 mm; p < 0.001), with a higher proportion of extrusion ≥3 mm (40.4% vs 7.8%; p < 0.001). Group S showed a significantly larger increase in coronal extrusion (2.6 ± 0.9 mm vs 1.2 ± 0.7 mm; p < 0.001). Graft signal intensity did not differ between groups. In the SPECT/CT subgroup, SUVmax at LFC was higher in Group S (7.8 ± 5.8 vs 4.3 ± 3.1; p = 0.012). At ≥2-year follow-up, Lysholm and IKDC scores and isokinetic extensor strength recovery showed no significant between-group differences.

Conclusion: In this observational study, LFC squaring was associated with narrower lateral joint-space width and greater meniscal graft extrusion after lateral MAT. Despite these structural differences, short-term patient-reported outcomes and muscle strength recovery did not differ between groups. These findings suggest that while LFC squaring reflects a less favorable biomechanical environment, its clinical significance requires further evaluation in longer-term follow-up studies.

Level of evidence: III; retrospective comparative study.

Background: Extra-articular distal femoral fractures typically occur in younger adults following high-energy trauma and are commonly treated with antegrade nailing, retrograde nailing, or plate fixation. In this study, we asked three key questions: Do these surgical methods result in different clinical and functional outcomes in patients under 60 years? If differences exist, do they persist at mid-term follow-up? How does each technique influence patients' quality of life?

Patients and methods: To address this question, we conducted a retrospective case-control study of 117 patients treated between January 2015 and December 2022. Patients were allocated to three groups: AIMN (n = 38), RIMN (n = 39), and locking plate fixation (n = 40). Demographic and clinical data were analyzed, and functional and quality-of-life outcomes were assessed using the Lysholm and EQ-5D scales.

Results: The mean follow-up was 70.76 ± 30.54 months (median: 76; range: 24-119). Knee flexion at final follow-up differed significantly among groups (p = 0.007). Functional outcomes measured by the Lysholm score also showed significant intergroup differences at both the first postoperative year and final follow-up (p = 0.030). Quality of life, assessed using the EQ-5D scale, showed no group differences at one year (p > 0.05). However, at final follow-up, the RIMN group had significantly poorer scores (p = 0.001).

Discussion: In conclusion, all three surgical methods appeared to offer acceptable management options for extra-articular distal femur fractures in patients under 60 years of age. The comparatively lower functional and quality-of-life outcomes observed with retrograde nailing may point to certain limitations, though these findings should be interpreted with caution.

Level of evidence: III.

Background: Surgical planning for adolescent idiopathic scoliosis (AIS) is complex. Large language models (LLMs) like DeepSeek Reasoning Model R1 (DeepSeek-R1) offer potential for decision support, but their accuracy in determining fusion levels is unproven.

Hypothesis: The DeepSeek-R1 model could generate surgically reasonable fusion levels for AIS with clinically acceptable accuracy.

Patients and methods: This study enrolled 203 consecutive AIS patients meeting surgical indications. Comprehensive clinical and radiological data, including Lenke classification, were structured into standardized prompts. DeepSeek-R1 was tasked with determining the upper and lower instrumented vertebrae (UIV, LIV) for each case. Its outputs were evaluated independently by three experienced spinal surgeons using a 5-point Likert scale (≥3 defined as reasonable). Inter-rater reliability was assessed using Intraclass Correlation Coefficient (ICC). Performance across Lenke subtypes was analyzed using Fisher's exact test with Monte Carlo simulation.

Results: DeepSeek-R1 generated surgically reasonable fusion levels (Likert score ≥3) in 70.9% (144/203) of cases, with excellent inter-expert agreement (ICC = 0.840, 95% CI [0.798, 0.875]). Performance varied significantly by Lenke subtype, demonstrating high reasonable rates for types 1A (87.0%), 1B (82.9%), 5C (81.1%), and 6C (87.5%). However, suboptimal performance was observed for types 1C (19.0%), 2A (42.9%), and 2C (25.0%).

Conclusion: DeepSeek-R1 demonstrated clinically acceptable accuracy in planning AIS fusion levels overall, particularly excelling in specific Lenke curve patterns (e.g., 1A, 1B, 5C, 6C). Its performance, however, was inconsistent across all subtypes, highlighting limitations in complex curve scenarios (notably 1C, 2A, 2C). While promising as a decision-support tool, further refinement and validation are necessary before clinical implementation.

Level of evidence: III.

Background: The hip‒spine relationship (HSR) plays a crucial role in the outcomes of total hip arthroplasty (THA) as it influences spinopelvic mobility and the risk of prosthetic impingement. Traditional preoperative assessments, which rely on static spinopelvic parameters, often fail to predict postoperative changes. To overcome this limitation, we developed an unsupervised machine learning model on the basis of an archetype analysis that revealed seven distinct lumbopelvic profiles, independent of modifiable postoperative factors. The aim of this study was to apply the trained model to a new patient cohort and analyse the postoperative spinopelvic mobility patterns across archetypes.

Hypothesis: Our hypothesis was that the use of an archetypal approach would allow us to anticipate patients with changes in lumbopelvic mobility and those at risk of adverse spinopelvic mobility.

Methods: The clinical data of 108 patients who underwent THA via the anterior approach by a single surgeon were analysed retrospectively. The preoperative spinopelvic parameters-age, standing pelvic tilt (SPT), lumbar lordosis (LL), pelvic incidence (PI), lumbar flexion (LF), and PI‒LL mismatch-were input into the previously trained archetype analysis model. Patients were classified into one of seven archetypes on the basis of their highest archetype score (summing to 1.0 per patient). Spinopelvic mobility (ΔSPT) and the pelvic femoral angle (ΔPFA) were assessed from standing and flexed-seated lateral radiographs preoperatively and three months postoperatively. Adverse spinopelvic mobility was defined as a ΔSPT ≥ 20°. Associations between archetypes and postoperative mobility were evaluated via logistic regression.

Results: The mean postoperative ΔSPT increased by 9.53 ° (-34.4 ° to 50.3 °), with the rate of a postoperative ΔSPT ≥ 20° increasing significantly in archetypes associated with sagittal imbalance and lumbar stiffness: A4 (63.33%), A5 (60%), A6 (62.5%), and A7 (87.5%) (p = 0.01). Logistic regression confirmed that these archetypes were associated with the highest risk of postoperative adverse mobility (adjusted ORs ranging from 3.2 to 7.5; p < 0.05).

Conclusion: This AI-driven archetypal classification demonstrates an association with adverse spinopelvic mobility, suggesting potential value for risk stratification, identifying high-risk profiles that may benefit from personalized surgical strategies, including implant orientation modifications.

Level of evidence: IV; retrospective study.

Background: Septic nonunion of tibial plateau fractures is an exceptionally rare and severe complication for which long-term outcomes and the need for definitive salvage procedures are poorly documented. The juxta-articular location, limited bone stock, and frequent soft-tissue compromise make management particularly challenging, even in specialised centres.

Hypothesis: It was hypothesised that most patients with septic nonunion of the tibial plateau ultimately require non-reconstructive salvage procedures and experience poor long-term functional outcomes.

Methods: A retrospective cohort study was conducted at a national referral centre for complex osteoarticular infections (CRIOAC). All adults treated for septic nonunion of the tibial plateau between 2002 and 2023 were included, with a minimum follow-up of two years. Septic nonunion was defined by absent healing after ≥6 months combined with microbiologically confirmed deep infection according to Fracture-Related Infection (FRI) criteria. Demographic data, fracture characteristics, microbiology, surgical management, and long-term outcomes were collected. The primary outcome was the rate and type of non-reconstructive salvage procedures (arthrodesis, transfemoral amputation, or delayed total knee arthroplasty). Functional outcomes (KSS, KOOS, VAS, range of motion) were assessed when applicable.

Results: Twenty-eight patients were included (mean age 45 ± 15 years; mean follow-up 8.1 ± 6.3 years). Only 5 of 28 patients (18%) achieved both union and infection remission without salvage surgery. Salvage procedures were required in 23 of 28 patients (82%), including total knee arthroplasty in 14 (50%), femorotibial arthrodesis in 4 (14%), and transfemoral amputation in 5 (18%). Persistent infection at final follow-up was recorded in 6 of 28 patients (21%). Functional outcomes were generally poor, with KSS 46.1 ± 12.2 and KOOS 41.4 ± 9.6 among patients retaining a mobile joint. Numerical trends suggested that diabetes, immunosuppression, open fractures, and polymicrobial infection may be associated with failure.

Conclusion: Septic nonunion of the tibial plateau is associated with extremely limited reconstructive potential and a high likelihood of salvage procedures, even within a specialised multidisciplinary centre. These results provide essential data for prognosis assessment and transparent patient counselling in this complex clinical scenario.

Level of evidence: IV; retrospective cohort study.

Background: Adductor canal block (ACB) offers opioid-sparing analgesia after total knee arthroplasty (TKA), with limited quadriceps weakness. A practical alternative is a surgeon‑performed intraoperative ACB. This study aimed to evaluate: (Q1) Does surgical ACB (S-ACB) reduce pain at rest 24 h after TKA versus anesthesiologist‑performed ultrasound‑guided ACB (US‑ACB)?, (Q2) Does S-ACB reduce 24‑h opioid consumption?, (Q3) Are there differences in early pain, rescue blocks, or adverse events?, (Q4) Does S-ACB impact length of stay (LOS)?

Hypothesis: We hypothesized that S-ACB would be superior to US-ACB in reducing rest pain at 24 h after TKA.

Material and methods: Single-center, randomized, open-label trial of adults undergoing unilateral primary TKA (January 2025-June 2025). Patients were randomized 1:1 to S‑ACB (intraoperative injection into the adductor canal using predefined anatomical landmarks) or US‑ACB (preoperative in‑plane injection adjacent to the femoral artery, beneath vastus medialis). Both groups received 15 mL ropivacaine 0.475% for ACB and 40 mL ropivacaine 0.2% posterior capsular infiltration. The primary outcome was NRS pain at rest 24 h.

Secondary outcomes: included 24-h morphine consumption, NRS in post-anesthesia care unit (PACU), at post-operative day 3 (POD3), last in-hospital, rescue block, adverse events, and length of hospital stay (LOS). Intention‑to‑treat analyses were performed.

Results: Fifty‑one TKAs were analyzed (S‑ACB n = 27; US‑ACB n = 24). Baseline characteristics were balanced except for diabetes (more frequent in US-ACB).

Primary outcome: mean 24‑h NRS was 1.6 ± 1.8 (S‑ACB) vs 2.0 ± 2.2 (US‑ACB); mean difference -0.33 (S‑ACB-US‑ACB), 95% CI -1.44 to 0.78; not statistically significant. 24‑h morphine: 5.6 ± 4.0 mg (S‑ACB) vs 5.8 ± 3.7 mg (US‑ACB); difference -0.16 mg, 95% CI -2.67 to 2.37 mg; not significant. No block‑related adverse events occurred. Rates of rescue block were low (two in US‑ACB). LOS was similar (6.5 ± 3.1 vs 6.7 ± 2.4 nights). Across timepoints (PACU, POD3, discharge), NRS and opioid use did not differ.

Discussion: Surgical ACB did not provide superior analgesia compared to US-ACB at 24 h, with low pain scores and opioid needs overall and no safety issue. Larger multicenter trials are warranted to confirm equivalence and explore functional recovery.

Level of evidence: II; Randomized trial.