Orthopaedics & Traumatology-Surgery & Research最新文献

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.

Background: Distal femoral osteotomy (DFO) improves valgus limb alignment. However, it might affect lower limb length discrepancy (LLD) and influence functional scores. This study aims to evaluate functional scores and radiographic parameters associated with LLD after DFO.

Hypothesis: It was hypothesized that the presence of LLD after DFO affects functional scores and associated with femoral length.

Patients and methods: A total of 50 patients who underwent DFO, including 24 closed wedge (CW) DFO and 26 open wedge (OW) DFO, were included. Patients were divided into three groups according to the presence of LLD after DFO: LLD-Absent group, LLD-CW group and LLD-OW group. Patient demographics, functional scores (Knee injury and Osteoarthritis Outcome Score (KOOS)), and radiographic parameters were evaluated and compared between the three groups. Multivariable logistic regression analysis was used to assess the radiographic parameter associated with the presence of post-operative LLD.

Results: There were no significant differences between the three groups in demographic data, correction angles, complications including hinge fractures, time to osteotomy union, and functional scores. However, the return to sports (RTS) was significantly different between three groups. By further analysis between CWDFO and OWDFO, RTS in CWDFO was faster than those in OWDFO. There were significant differences in post-operative mLDFA and Δ femur length. Additionally, post-operative mLDFA was significantly associated with the presence of LLD (Odds ratio 0.11, 95% confidence interval 0.01 to 0.49, p = 0.03).

Conclusion: Functional scores and postoperative outcomes following DFO are not affected by the presence of LLD. RTS is independent of LLD, but rather dependent on the surgical procedure and RTS in CWDFO was faster than those in OWDFO. Postoperative mLDFA is the radiographic parameter associated with the presence of LLD. These findings are clinically relevant and should be accounted for in preoperative planning of DFO.

Level of evidence iii: Retrospective with comparative study.

Introduction: The management of antiplatelet therapy (APT) in patients undergoing spinal surgery is complex, requiring balancing the risks of thromboembolic events against those of potential perioperative bleeding. This review evaluates the effects of continuing versus discontinuing APT on the surgical outcomes of spinal surgery.

Hypothesis: The hypothesis is that continuing antiplatelet therapy (APT) in patients undergoing spinal surgery will not significantly increase intraoperative blood loss, operative time, or postoperative complications compared to discontinuing APT, but may lead to a higher need for postoperative transfusions.

Material and methods: Systematic search was done in EMBASE, Scopus, PubMed Central, Google Scholar, and ScienceDirect databases for studies comparing the continuation of APT to its discontinuation in terms of estimated blood loss, operative time, hospital stay length, postoperative transfusion units, postoperative complications, postoperative hematoma, readmission rate, cardiovascular events amongst patients undergoing spinal surgery. Risk of bias was assessed with the Newcastle Ottawa scale and synthesized the data using random-effects meta-analyses, summarizing outcome results as either standardized mean differences (SMDs) or odds ratios (ORs) as appropriate.

Results: 13 studies were included in meta-analysis. Similar estimated blood losses (SMD = 0.125; 95%CI, -0.087 to 0.337) and operative times (SMD = 0.231; 95%CI, -0.225 to 0.687) were found between the patients who continued and those who discontinued the APT. However, patients who continued APT had a slightly higher chance of requiring postoperative transfusions (SMD = 0.244; 95%CI, 0.030 to 0.458). Similar hospital stay lengths, and postoperative complication or cardiovascular event rates were found.

Discussion: Continuing APT during spinal surgery does not significantly increase the risks of intraoperative blood loss or increase the operative time, however; it may increase the need for postoperative transfusions. These findings suggest that for patients at risk of thromboembolic events, the benefits of continuing APT outweigh the risks.

Level of evidence: III; Systematic Review and Meta-analysis.