Orthopaedics & Traumatology-Surgery & Research最新文献

Background: Decreased estimated glomerular filtration rate (eGFR) is associated with acute kidney injury (AKI) following hip fracture surgery. Delaying surgery for preoperative treatment of comorbidities is controversial in this patient population. The purpose of this study was 1) to assess differences in demographics and comorbidities between AKI and non-AKI groups, 2) to analyze equations used in calculating eGFR, and 3) to identify the equation which best predicts the development of AKI following hip fracture surgery. We hypothesize that one of the equations used to calculate eGFR will be superior to the others.

Patients and methods: 124,002 cases of hip fracture surgery were performed from 2012 to 2019, based upon a query of the National Surgical Quality Improvement Program (NSQIP). Preoperative eGFR was calculated using the following: Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and Cockcroft-Gault equations. Independent associations between preoperative eGFR and postoperative renal failure were evaluated using multivariate regression analysis. The predictive ability of each equation was determined using the Akaike information criterion (AIC).

Results: AKI was diagnosed in 584 (0.71%) out of the 82,326 patients following hip fracture surgery. The AKI and no AKI cohorts differed significantly by patient sex (p = <0.001), race (p = <0.001), BMI (p = < 0.001), preoperative hematocrit (p = <0.001), preoperative albumin (p = <0.001), diabetes mellitus (p = <0.001), hypertension (p = <0.001), and congestive heart failure (p = <0.001). The Mayo equation (84.0 ± 23.7) was the equation with the highest calculated mean eGFR, followed by the CKD-EPI equation (83.6 ± 20.0), MDRD II equation (83.0 ± 38.9), CG equation (74.7 ± 35.5), and finally the re-expressed MDRD II equation (68.5 ± 36.0) which had the lowest calculated mean eGFR.. All five equations detected that a decrease in preoperative eGFR was associated with an increased risk of postoperative AKI. Lower preoperative eGFR, as calculated by each of the five equations, was significantly associated with an increased risk of AKI following surgical fixation of hip fracture. The AIC was the lowest in the Mayo equation, demonstrating the best fit of the equations to predict postoperative AKI CONCLUSIONS: We propose that using the equation that best identifies those at risk of developing postoperative AKI may help with perioperative decision making and treatment to improve outcomes, which we found to be the Mayo equation. The risk of postoperative AKI was independently associated with decreased preoperative eGFR. The results of this study may warrant further investigation utilizing prospective studies.

Level of evidence: III; retrospective cohort study.

Introduction: Total knee arthroplasty (TKA) carries a significant hemorrhagic risk, with a non-negligible rate of postoperative transfusions. The blood-sparing strategy has evolved to reduce blood loss after TKA by identifying the patient's risk factors preoperatively. In practice, a blood count is often performed postoperatively but rarely altering the patient's subsequent management. This study aimed to identify the preoperative variables associated with hemorrhagic risk, enabling the creation of a machine-learning model predictive of transfusion risk after total knee arthroplasty and the need for a complete blood count.

Hypothesis: Based on preoperative data, a powerful machine learning predictive model can be constructed to estimate the risk of transfusion after total knee arthroplasty.

Material and methods: This retrospective single-centre study included 774 total knee arthroplasties (TKA) operated between January 2020 and March 2023. Twenty-five preoperative variables were integrated into the machine learning model and filtered by a recursive feature elimination algorithm. The most predictive variables were selected and used to construct a gradient-boosting machine algorithm to define the overall postoperative transfusion risk model. Two groups were formed of patients transfused and not transfused after TKA. Odds ratios were determined, and the area under the curve evaluated the model's performance.

Results: Of the 774 TKA surgery patients, 100 were transfused postoperatively (12.9%). The machine learning predictive model included five variables: age, body mass index, tranexamic acid administration, preoperative hemoglobin level, and platelet count. The overall performance was good with an area under the curve of 0.97 [95% CI 0.921 - 1], sensitivity of 94.4% [95% CI 91.2 - 97.6], and specificity of 85.4% [95% CI 80.6 - 90.2]. The tool developed to assess the risk of blood transfusion after TKA is available at https://arthrorisk.com.

Conclusion: The risk of postoperative transfusion after total knee arthroplasty can be predicted by a model that identifies patients at low, moderate, or high risk based on five preoperative variables. This machine learning tool is available on a web platform that is accessible to all, easy to use, and has a high prediction performance. The model aims to limit the need for routine check-ups, depending on the risk presented by the patient.

Level of evidence: II; diagnostic study.

Background: Infection is one of the main complications of hip and knee arthroplasties. Topical application vancomycin to prevent postoperative infections is efficient in spine surgery, and is spreading in prosthetic surgery. However, its clinical relevance and safety are still under debate. Thus, we conducted the present study to (1) assess whether topical vancomycin reduces peri-prosthetic infection rate, and (2) investigate its influence on surgical wound complications.

Hypothesis: Our hypothesis was that topical administration of diluted vancomycin during arthroplasty would reduce infection rate within the first postoperative year.

Material and methods: In total, 1900 hip and knee arthroplasties were performed between 2014 and 2021 in a single hospital. From July 2018 and December 2021, 910 prostheses were implanted with intra-articular instillation of vancomycin and tranexamic acid. From November 2014 to June 2018, 990 prostheses were set up without vancomycin. During a follow-up of minimum 12 months, we reported periprosthetic infections occurring during the first postoperative year, as well as vancomycin-induced general or cutaneous complications.

Results: We observed periprosthetic infections in 9/990 cases (0.91%) of the control group and 10/910 cases (1.1%) of the vancomycin group (p = 0.82). In parallel, we observed wound complications (erythema, seroma, hematoma, dehiscence and delay in wound healing) in 19/990 (1.9%) and 10/910 cases (1.1%) of the control and vancomycin group, respectively (p = 0.19). There were no general complications resulting from the application of vancomycin.

Discussion: Topical diluted vancomycin does not reduce periprosthetic infection risk, and has no effect on the occurrence of surgery wound complications. Considering the present findings, the use of vancomycin cannot be recommended in current practice to prevent infections following hip and knee arthroplasties. Finally, its use does not induce any specific complications, whether local (cicatrisation) or general (related to ototoxicity or nephrotoxicity).

Level of evidence: III; case control study.

Introduction: The threshold of a Leg Length Discrepancy (LLD) by clinical examination on a sheet or centimeter paper (CP) is not known precisely whether or not it concerns limbs equipped with a hip prosthesis. We therefore conducted a prospective in silico study in order to: (1) determine the reproducibility and sensitivity of the clinical measurement of the LLD in different ideal and "degraded" clinical situations, (2) determine the threshold from which the human eye is capable of detecting a length inequality in clinic, (3) to determine whether the use of a graduated support (centimeter paper) improves the clinical measurement threshold.

Hypothesis: Our hypothesis was that clinical measurement on a centimeter support would improve clinical measurement accuracy.

Material and methods: This was an in silico study, the experiment was conducted on a mannequin. Different inequalities were created on a mannequin and photographed with a total of 30 inequalities from -22 to +22 mm on sheet or centimeter paper (CP). This was a multicenter study, with 40 different readers. We asked the readers to make a second measurement one month later. We evaluated the inter- and intra-observer reproducibility. The error rate at the threshold of 3 mm and 5 mm were calculated versus the gold standard. Finally, we determined at which thresholds respectively 75% and 95% of the measurements were correct.

Results: A total of 4140 measurements were performed and compared to the gold standard. With a threshold of 75% accurate measurement, the LLD detection threshold was 2.8 mm on centimeter paper and 4.5 mm on sheet. With a threshold of 95% accurate measurement, the LLD detection threshold was 3.4 mm on centimeter paper and 5.2 mm on sheet. Interobserver agreement (assessed overall on the 40 observers by Krippendorff's generalized Kappa) was 0.86 (95% confidence interval (CI95%) = 0.79 to 0.92) on CP and 0.71 (CI95% = 0.63 to 0.79) on sheet. Intra-observer agreement assessed by the intraclass correlation coefficient among observers who made 2 measurements had a median value (IQR) of 0.96 (0.94 to 0.99) on CP and 0.90 (0.83 to 0.94) on sheet.

Discussion: The clinical detection threshold on sheet at the patient's bed appears close to 5 mm. A more precise measurement is possible with graduated centimeter paper. A study in daily practice on patients in real situations would confirm our results.

Level of evidence: III; prospective diagnostic comparative in Silico study.

Background: Cubital tunnel syndrome (CuTS) is a prevalent compressive neuropathy addressed through various treatments, including the anterior interosseous nerve (AIN) supercharge end-to-side (SETS) transfer for advanced CuTS. Decision to add AIN-SETS is based on various indicators and protocols, but deciding on the appropriate method for borderline cases can be challenging. Therefore, this study aims to non-invasively examine the cubital tunnel anatomy of patients using CT scans and compare the findings with existing indicators and measurements, to determine if they can serve as supplementary indicators to aid in treatment decisions.

Hypothesis: The bony cubital tunnel volume is correlated to other traditional indicators and can be used as an additional indication for deciding whether to perform AIN-SETS in treating advanced CuTS.

Patients and methods: This is a single-center retrospective cohort study from South Korea, including 91 patients aged 20-70 years with CuTS. Participants were classified into Group A (n = 43), who underwent both cubital tunnel release (CuTR) and AIN-SETS, and Group B (n = 48), who underwent only CuTR. Preoperative elbow CT data were analyzed for cubital tunnel morphology analysis, with follow-up assessments such as grip strength and electromyography/ nerve conduction velocity (EMG/NCV) tests at 3,6, and 12 months postoperatively.

Results: Group A and B showed no significant differences in demographic parameters, except for a longer disease duration in Group A (p = 0.032). Group A had a smaller cubital tunnel volume (CTV) compared to Group B (1150.6 ± 52.8 mm³ vs. 1173.5 ± 56.2 mm³, p = 0.014) and a smaller cross-sectional area (40.9 ± 10.2 mm² vs. 45.1 ± 11.7 mm², p = 0.033). Pearson correlation analysis revealed statistically significant positive correlations between CTV measurements and pre-operative grip strength, as well as EMG results, a key indicator for AIN-SETS (R² = 0.48, 0.23, p = 0.01).

Discussion: Measuring the cubital tunnel anatomy using CT can aid in determining the treatment approach for advanced CuTS patients and assist in deciding whether to perform AIN-SETS surgery, serving as a supplementary indicator for cases at the borderline limits of other indicators. Future research may be necessary to establish control groups without symptoms and determine appropriate cut-off values.

Level of evidence: IV.

Introduction: The reduction of the distal tibiofibular syndesmosis (SyTFd) is a crucial factor in the functional prognosis following a suprasyndesmotic ankle fracture. Few studies have compared, using computed tomography (CT), the quality of SyTFd reduction in Weber C ankle fractures (WebC) and Equivalent Weber C (EqWebC) fractures, where there is a medial ligament injury instead of a bony malleolar lesion. This CT-based study aimed to answer the following questions: (1) Do Weber C fractures allow for better reduction of the distal tibiofibular syndesmosis compared to Equivalent Weber C fractures? (2) Are the functional outcomes one year postoperatively better for Weber C fractures compared to Equivalent Weber C fractures?

Hypothesis: The hypothesis was that WebC fractures would present better reduction of the SyTFd than EqWebC fractures due to the restoration of bone anatomy, considering the bony nature of the medial ligament involvement.

Materials and methods: Since December 2021, all patients presenting with an ankle fracture were included in a database. Suprasyndesmotic fractures were extracted, and between December 2021 and February 2022, 60 patients underwent surgery for a suprasyndesmotic fracture (28 WebC - 32 EqWebC). All patients were operated on using the same technique and underwent a postoperative bilateral CT scan in axial slices with both ankles in a neutral position (foot at 90 ° to the leg). An analysis of 8 measurements was performed under the same conditions. Each fractured ankle was compared to the healthy contralateral ankle, and a delta was obtained for each measurement. The follow-up was standardized. At one year, an AOFAS Score and a Maryland Foot Score (MFS) were recorded. Statistical differences between the two groups were measured using the Student's t-test and Chi-square test.

Results: There was a significant difference between the WebC and EqWebC groups for clinical scores at one year postoperatively: AOFAS: 92.0 ± 6.3 [78-100] vs. 80.1 ± 5.4 [62-100], p < 0.05; MFS: 90.9 ± 6.4 [78-100] vs. 81.6 ± 5.2 [64-100], p < 0.05. CT scan analysis of the SyTFd reduction found significantly better reduction in the WebC group.

Discussion: WebC fractures showed better clinical scores associated with better SyTFd reduction on postoperative CT scans. The anatomical reduction related to the bone reduction criteria during surgery could explain our findings.

Level of evidence: III; Case-Control Comparative Study.

Background: Anterior closing wedge osteotomy (ACWO) for tibial slope correction is a validated procedure in revision anterior cruciate ligament reconstruction (ACLR). This study aims to determine how different starting points of the osteotomy affect the amount of bone resection in ACWO.

Hypothesis: We hypothesized that the lower osteotomy starting points in ACWO imply larger bone resection.

Patients and methods: A total 52 patients who underwent ACWO using infra-tuberosity technique in our institution were included in this study. Each of patients was simulated using additional two separate methods (based on osteotomy level: supra- and trans-tuberosity) based on lateral calibrated pre-operative X-rays of the whole tibia according to the post-operative correction angle. The resection height of the closing wedge, which corresponded to the base of the osteotomy, was measured and compared among the three groups.

Results: The mean actual pre-operative proximal posterior tibial angle (PPTA) was 75.8 ± 2.0°. Post-operatively, PPTA was 84.0 ± 0.6°, and correction angle was 8.2 ± 2.2°. The mean resection height in the supra-tuberosity group was 7.5 ± 0.2 mm, 8.0 ± 2.1 mm in the trans-tuberosity group, and 9.2 ± 2.1 mm in the infra-tuberosity group. There were significant differences between each approach (p ≦ 0.0001). Resection height was moderate positively correlated with the starting point of osteotomy (r = 0.33, 95%CI: 0.18-0.46, p < 0.0001).

Conclusion: This study suggests that selecting a distal starting point for the osteotomy in ACWO is directly proportional to the observed increase in bone resection, providing valuable insights for pre-operative planning. These findings are clinically relevant and will aid in preoperatively deciding approach in ACWO.

Level of evidence: IV; retrospective case-control study.