Orthopaedics & Traumatology-Surgery & Research最新文献

Introduction: Osteogenesis imperfecta (OI) is a rare genetic bone disorder, mainly caused by autosomal dominant mutations of the COL1A1 or COL1A2 genes that encode the alpha chains of type 1 collagen. In severe forms and in nonambulatory patients, for whom physical exercise is difficult, exposing the bone to mechanical stimuli by promoting movement, especially with physiotherapy and mobility aids, is an essential part of clinical practice. However, the effects of mechanical stimulation at the cellular level remain unknown for this disease.

Hypothesis: The study hypothesis was that human mesenchymal stem cells (hMSCs) from patients with OI were as sensitive to mechanical stimulation as those from healthy patients, validating the current clinical practice.

Materials and methods: hMSCs were harvested from 3 healthy control subjects and 3 patients with OI during an elective osteotomy of a long bone of the lower limb. The healthy and OI hMSCs were then exposed to mechanical stimuli, such as intermittent shear stress of 0, 0.7, 1.5, and 3 Pascal (Pa) at a frequency of 2.8 Hertz (Hz) for 30 min using a commercial ibidi system. The immediate early gene expression of themechanosensitive prostaglandin-endoperoxide synthase 2 (PTGS2) was examined 1 h after stimulation to determine the best level of mechanical stimulation. The expression of 7 other mechanosensitive genes was also examined for this level of mechanical stimulation after applying intermittent shear stress at 1.5 Pa.

Results: In all hMSCs, mechanical stimulation induced PTGS2 gene overexpression with a maximum after exposure to intermittent shear stress of 1.5 Pa and without significant differences between OI and healthy donors. Except for fibroblast growth factor 2, gene expression in OI donors was found to be significantly different from that in hMSCs not exposed to shear stress. Moreover, the relative expression associated with mechanical stimulation was not significantly different between healthy and OI donors for most other genes.

Discussion: This is the first study to demonstrate that hMSCs from patients with OI are as sensitive to mechanical shear stress as those from healthy donors. The mechanical stress that resulted in the greatest change in the expression of PTGS2 in patients with OI was similar to that previously reported in the literature for healthy subjects. These findings are an important step toward further fundamental research aimed at confirming the effects of mechanical stress at the cellular level over the long term and, more importantly, toward developing clinical protocols for delivering mechanical stimuli to these patients.

Level of evidence: III; comparative case-control study.

Ruptures of the quadriceps tendon (QT) are rare but serious injuries accounting for less than 2% of all tendon injuries around the knee. These injuries, often occurring in individuals over 40, are leading to a loss of active extension and a significant impact on knee function. While the treatment of acute QT ruptures through various reinsertion techniques has shown excellent outcomes, managing chronic injuries and failed primary repairs remains challenging due to tendon retraction and difficulties in repositioning the tendon stump. This study introduces a novel approach associating direct tendon reinsertion with metal frame reinforcement, aiming to effectively lower the retracted tendon to the proximal pole of the patella. This technique offers a promising alternative that addresses the limitations of traditional methods and potentially improves patient outcomes by providing a safe primary fixation and protection of the repair, enabling early rehabilitation and reducing the need for subsequent interventions. LEVEL OF EVIDENCE: IV; case series study.

Background: Although virtual reality (VR) simulators have demonstrated their efficiency for basic technical skill training of healthcare professionals, validation for more complex and sequential procedures, especially in arthroscopic surgery, is still warranted. We hypothesized that the VR-based training simulation improves arthroscopic cuff repair skills when transferred to realistic visual and haptic conditions.

Hypothesis: VR-based training simulation improves arthroscopic cuff repair skills when transferred to realistic visual and haptic conditions.

Study design: This study is prospective, multicentric and randomized.

Methods: Thirty orthopedic surgery residents were enrolled in the study and randomized in two groups: VR training (VR+) and no VR training (VR-). Only the VR+ group underwent a monthly VR-based training program for rotator cuff repair. The 1-h VR training sessions were standardized and supervised by the same instructor. After six months, all participants performed a double-row arthroscopic rotator cuff repair procedure on a benchtop shoulder model providing realistic visual and haptic conditions with implants. Two independent surgeons with expertise in shoulder repair and blinded to the randomization rated the participants' performance using the Arthroscopic Surgical Skill Evaluation Tool (ASSET).

Results: Demographic characteristics and surgical experience were comparable between the two groups. The ASSET global rating score was higher in the VR+ group than in the VR- group (34.4 ± 3.1 and 30.5 ± 5.7, respectively; p = 0.046) and the VR+ group performed the procedure faster than the VR- group (27.3 ± 3.6 vs. 31.7 ± 0.4 min, respectively; p = 0.003).

Discussion: This study demonstrated that a monthly VR-based program for 6 months was better than standard peer training alone for mastering a complex and sequential rotator cuff repair when using the validated ASSET Score. Overall, nonspecific arthroscopic skills were also higher in the VR+ group.

Level of evidence: II, therapeutic study.

Background: The medial collateral ligament (MCL) and lateral collateral ligament (LCL) are paramount for joint stability. Their elongation patterns may change during fixed-bearing and mobile-bearing unicompartmental knee arthroplasty (FB and MB UKA). This study aims to explore the relationship between the elongation of MCL, LCL, and changes in joint space, as well as their correlation with functional scale scores during FB and MB UKA.

Hypothesis: We hypothesize that MCL and LCL have different elongation patterns in UKA patients, and there is a correlation between elongation and joint space and functional scores.

Materials and methods: The study recruited 24 patients undergoing UKA on a unilateral knee (13 FB and 11 MB). A dual fluoroscopic imaging system was employed to assess in-vivo knee kinematics during static standing and single-leg lunge. The superficial and deep MCL (sMCL, dMCL) and LCL were divided into anterior, medium, and posterior portions. The virtual ligament method quantified in-vivo ligament lengths. Analysis focused on the correlation of normalized ligament lengths with functional scores and joint space.

Results: 1. LCL Elongation in FB UKA: There is a significant increase in LCL elongation during early and mid-flexion of the single-leg lunge (p < 0.05). 2. MCL Elongation in MB UKA: Both sMCL and dMCL exhibit significant elongation during early and mid-flexion of the single-leg lunge (p < 0.05). 3. Correlation with Functional Scores: Differences in collateral ligament elongation in FB UKA are significantly correlated with the OKS and KSS, highlighting the impact on functional outcomes. In MB UKA, differences in ligament elongation are significantly correlated with the FJS. 4. Joint Space Correlation: There is a significant correlation between the elongation of the anterior and medium portions of dMCL and joint space in the surgical compartment during mid- and deep flexion (30-100°, p < 0.05, r > 0.64).

Conclusion: The study reveals distinct ligament elongation patterns between UKA and native knees in LCL for FB UKA and MCL for MB UKA. These patterns are associated with knee functional scores. Moreover, dMCL elongation correlates significantly with the joint space for MB UKA during middle and deep flexion phases.

Level of evidence: III; prospective retrospective cohort study.

Introduction: Dupuytren's disease is a benign disorder leading to flexion contracture of the fingers and functional disability. Many treatments have been described. Open fasciectomy is the gold standard; however percutaneous needle fasciotomy (PNF) is a reliable option for uncomplicated primary contracture but it has a high rate of recurrence.

Hypothesis: A history of PNF treatment before open fasciectomy is a risk factor for postoperative complications.

Material and methods: A retrospective single-center study was conducted involving 56 patients (62 hands) who were operated for Dupuytren's contracture by open fasciectomy between November 2016 and November 2020. We compared the outcomes of patients with history of prior PNF on the same finger (group A) to patients without history of PNF (group B). There was no significant difference between the two groups in the severity, comorbidities or preoperative finger mobility. The primary outcome was the complication rate during surgery or during the follow-up period (mean follow-up of 2 years).

Results: The intra- and postoperative complication rate was 26% (n = 9) in group A (history of PNF) versus 9% (n = 4) in group B (no PNF) (p = 0.0482), corresponding to a relative risk for complications of 2.8 (95% CI: 1.2-6.4) in case of previous PNF. Tourniquet time per operated ray was higher in group A than in group B (34.1 min versus 24.9 min, p = 0001).

Discussion: A history of PNF for Dupuytren's disease can lead to a higher rate of major intraoperative or postoperative complications when open fasciectomy is performed compared to open fasciectomy as a first-line therapy.

Level of evidence: III; retrospective comparative study.

Introduction: Osteoarticular infections (OAI) after prosthetic surgery have serious functional and economic consequences. Rapid tests for alpha-defensin (TAD) and leukocyte esterase (TLE) are two intra-articular markers involved in the diagnosis of OAIs. TLE cannot be applied in the presence of blood unless centrifugation is used, but the rate of "non-application" of the test for this reason is unknown in complex microbiological situations (discordant or negative puncture, ongoing antibiotic treatment). We therefore conducted a prospective study to determine: 1) the performance of the TAD and TLE rapid tests in diagnosing complex OAI, 2) the rate of non-application of the TLE due to hemarthrosis, and 3) the concordance between the two tests.

Assumption: These two diagnostic tests had a negative predictive value (NPV) ≥ 90% for the diagnosis of complex OAI.

Materials and methods: A total of 79 suspected OAI patients with complex microbiological diagnoses were included between 2018 and 2023. They were 52 men (66%) for 27 women (34%), with a mean age of 66 ± 13.5 years. The hip (n = 41, 52%) and knee (n = 36, 46%) were the most represented, followed by the elbow (n = 1, 1%) and shoulder (n = 1, 1%). These patients were suspected of having an OAI that required joint puncture, but with a complex microbiological diagnosis due to discordant punctures (n = 21, 27%) or sterile punctures despite strong suspicion of infection (n = 50, 63%), or in case of ongoing antibiotic treatment (n = 8, 10%). All patients underwent joint fluid puncture followed by TAD (Synovasure™, Zimmer, Warsaw, IN, USA) and, when the macroscopic appearance of the sample allowed (clear fluid group), TLE (Multistix 8SG, Siemens Healthcare GmbH, Erlangen, Germany). The results of both tests were compared with Musculoskeletal Infection Society (MSIS) criteria.

Results: Of the 79 patients included, 27 (34%) were considered infected according to the MSIS. In 30% of cases (n = 24), TLE was not feasible due to the presence of blood in the joint fluid. In the "clear fluid" group, the NPV was equal to 90% for both TAD (sensitivity 87%, specificity 88%) and TLE (sensitivity 87%, specificity 81%). The two parameters showed almost perfect agreement (κ = 0.927).

Conclusion: TAD and TLE are two rapid, reliable tests with near-perfect concordance and high NPV, even in situations of complex microbiological diagnosis. They are particularly useful for deciding on a therapeutic strategy for patients with complex OAI. The TLE cannot be used in 30% of cases due to hemarthrosis, but centrifugation can correct this defect.

Level of evidence: III; Prospective comparative diagnostic accuracy study.

Introduction: Quantitative Gait Analysis (QGA) is the gold-standard for detailed study of lower-limb movement, angles and forces, especially in pediatrics, providing a decision aid for treatment and for assessment of results. However, widespread use of QGA is hindered by the need for specific equipment and trained personnel and high costs. Recently, the OpenPose system used algorithms for 2D video movement analysis, to determine joint points and angles without any supplementary equipment or great expertise. The present study therefore aimed to validate application of OpenPose for gait analysis in children with locomotor pathology, thereby circumventing the limitations of QGA.

Hypothesis: The OpenPose system is as precise as QGA for measuring lower-limb angles in gait in children.

Materials and methods: Gait analysis was studied prospectively, between January and July 2023, in 20 children: 13 boys, 7 girls; mean age, 13 years. There was no selection for pathology or use of walking aids. QGA was performed, measuring joint angles in the hips, knees and ankles. The same measurements were then made using the points obtained on OpenPose. The Mann-Whitney test was used to compare the two methods.

Results: There were only slight differences in angle measurements (in degrees) for the knees: right, 0.54 [-0.61; 1.71], p = 0.361; left, -1.09 [-2.16; 0.01], p = 0.051. Differences were greater for the hips (right, 9.32 [8.28; 10.35]; left, 7.54 [6.55; 8.54], p < 0.01) and ankles (right, -6.67 [-7.22; -6.12]; left, -7.07 [-7.60; -6.54], p < 0.01).

Discussion: OpenPose provided angle values close to those of QGA for the knees in the sagittal plane, independently of pathology and walking aid. In the hips and ankles, on the other hand, differences were too great to allow clinical application of OpenPose.

Level of evidence: IV.

Background: A subset of patients undergoing anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) lag behind their peers in regaining overhead range of motion (ROM) after surgery. The primary purpose of this study was to compare the rate of recovery of ROM after aTSA and rTSA performed in stiff (preoperative passive external rotation [ER] ≤0 °) versus non-stiff (preoperative passive ER >0°) shoulders with RCI-GHOA.

Hypothesis: We hypothesized that preoperatively stiff shoulders (preoperative passive ER ≤0 °) would have slower recovery in ROM postoperatively with lower postoperative motion compared to non-stiff shoulders.

Methods and materials: A retrospective review of a multi-institution shoulder arthroplasty database was performed between 2001 and 2021. We identified 1,164 aTSAs and 539 rTSAs performed for RCI-GHOA with a minimum of 2-year clinical follow-up along with follow-up between 3-6 months and a third visit at any other time point. Primarily, the rate of recovery in ROM and time to maximum ROM was evaluated. Secondarily, we assessed six outcome scores and the influence of subscapularis repair during rTSA. Recovery in each outcome was modeled using continuous two-phase segmented linear regression models with random effects. Rate of recovery was defined as the slope of the first segment. Patients were considered to have recovered after surgery at the timepoint corresponding to the inflection point between piecewise segments.

Results: Of the 1,164 aTSAs and 539 rTSAs included, 172 aTSAs (15%) and 80 rTSAs (15%) were stiff preoperatively, respectively. Compared to preoperatively stiff aTSAs, non-stiff aTSAs regained ER, abduction, internal rotation (IR), and forward elevation (FE) faster over a shorter duration. Similarly, non-stiff rTSAs regained ER, abduction, and FE faster and over a shorter duration compared to stiff rTSAs, but regained IR more slowly over a longer duration. Stiff rTSAs performed with subscapularis repair did not have any appreciable gain in ER after the immediate postoperative period. Although non-stiff and stiff rTSAs performed without subscapularis repair regained ER at a similar rate (4.4 vs. 4.2 °/month), stiff rTSAs continued to regain ER 1.9-times longer (11.9 vs. 6.4 months). When the subscapularis was repaired, non-stiff rTSAs regained abduction and IR faster over a short duration compared to stiff rTSAs.

Conclusions: Preoperative stiffness is associated with slower recovery of active ROM over a longer duration in patients undergoing shoulder arthroplasty for RCI-GHOA.

Level of evidence: III; Retrospective Cohort Comparison; Treatment Study.