Orthopaedics & Traumatology-Surgery & Research最新文献

Background: Proximal femoral nail antirotation (PFNA) fixation for intertrochanteric fractures often results in nail or blade protrusion, particularly in Asian populations, and is associated with postoperative lateral hip pain. However, not all patients with protrusion experience pain. The specific lengths and locations causing clinically significant pain remain unclear. This study aims to determine the cut-off values and locations of PFNA nail and blade protrusions that predict lateral hip pain and to evaluate their relationship with functional outcomes.

Hypothesis: Protrusion of the PFNA-II nail and blade beyond specific radiographic cut-off values is associated with increased lateral hip pain after intertrochanteric fracture fixation.

Methods: In this comparative observational study, 226 patients with intertrochanteric fractures treated with PFNA-II fixation were recruited from August 2021 to December 2023. Inclusion criteria included age ≥60 years, ≥6 months post-fixation, and radiographic fracture union. Lateral hip pain was evaluated using the Visual Analog Scale (VAS, 0-10) at two sites: the nail tip (greater trochanter) and the end of the blade. The patients were divided into four groups according to VAS scores: Group A (nail tip pain, VAS < 4), Group B (nail tip pain, VAS ≥ 4), Group C (blade end pain, VAS < 4), and Group D (blade end pain, VAS ≥ 4). Protrusion lengths (medial/lateral nail, superior/inferior blade) were measured radiographically. The Receiver Operating Characteristics (ROC) analysis determined the cut-off values, and multivariate logistic regression evaluated the risk factors. The Harris Hip Score (HHS) was used to evaluate functional outcomes.

Results: Medial nail protrusion ≥3.775 mm (sensitivity 91%, specificity 61%) and lateral nail protrusion ≥8.015 mm (sensitivity 85%, specificity 65%) predicted nail tip pain. The superior blade protrusion ≥10.95 mm (sensitivity 56%, specificity 70%) and the inferior blade protrusion ≥3.265 mm (sensitivity 60%, specificity 66%) predicted blade end pain. Medial nail protrusion increased pain risk (odds ratio 17.17, 95% CI 7.68-38.39). HHS did not show a significant correlation with protrusion, except for a weak negative correlation with inferior blade protrusion (r = -0.39, p = 0.032).

Conclusion: Distinct radiographic cut-off values of PFNA-II protrusion predict postoperative lateral hip pain. While pain is mainly associated with medial nail and superior blade protrusion, excessive inferior blade protrusion may slightly impair hip function. The refinement of the PFNA II design and surgical technique to minimize protrusion could further improve postoperative outcomes in Asian patients.

Level of evidence: II.

Background: Anterior lumbar interbody fusion (ALIF) is an alternative for treating spine pathologies. Bone substitutes are increasingly used to enhance fusion and minimize iliac graft harvest complications. Despite numerous options, no gold standard exists. After we started using anorganic bone matrix/15-amino acid peptide fragment (ABM/P-15), we observed unexpected abnormal findings on postoperative CT scan. Our study aimed to investigate this matter: is ABM/P-15 associated with a higher rate of these findings than other substitutes? Do they impact fusion or clinical outcomes?

Hypothesis: We hypothesized that the use of ABM/P-15 was associated with more unexpected findings, potentially impacting fusion or clinical outcomes.

Patients and methods: This retrospective study included patients undergoing ALIF between 2020 and 2022, divided into two groups: one having received ABM/P-15 and the other different bone substitutes (InductOS, TBF, MagnetOs, ß gel). Unexpected findings (migration or calcification) and fusion rates were evaluated on postoperative (3- and 12-month) CT scan. Clinical outcomes (Oswestry Disability Index (ODI) and pain) were also measured.

Results: Among 152 patients (76 per group), unexpected findings were more prevalent with ABM/P-15 [40 patients (53%) vs 1 (1%); p < 0.001]. Regardless, both groups were similar in fusion rates at 1 year [72 patients (95%) vs 68 (89%); p = 0.367] and clinical outcomes (ODI decrease: 17 vs 19 points, p = 0.491).

Conclusion: ABM/P-15 showed a higher incidence of unexpected findings (calcification or product migration) than other bone substitutes, with no impact in fusion success or clinical outcomes.

Level of evidence: III.

Background: Müller-Weiss disease (MWD) is a complex pathology of the foot. Accompanied by navicular sclerosis, deformity, and osseous collapse, it leads to the destruction of the talonavicular (TN) joint. This review builds on and updates previous publications on Müller-Weiss disease, and compared with earlier systematic reviews the current study provides a systematic and PRISMA-based synthesis dedicated specifically to treatment outcomes and algorithms, including all available studies up to 2024. The aim of this systematic review was to answer the following questions: (1) what is the outcome depending on the treatment technique? (2) what is the treatment of choice depending on the stage of the disease? (3) what are the limitations and challenges in the current understanding and management of Müller-Weiss disease?

Material and methods: A systematic review was conducted according to the PRISMA 2020 guidelines. Pubmed and Google Scholar were used for a comprehensive search conducted using the keywords "Müller-Weiss" or "Mueller-Weiss" within the titles and abstracts of publications up until September 2023. Studies not presented in English, French, German, Italian, Spanish, or Portuguese were excluded. In total, 25 publications met the inclusion criteria and underwent further analysis. AOFAS Score was used to assess and compare the results of studies.

Results: A variety of treatments were reported including nonoperative, joint sparing, and fusion procedures. Calcaneus osteotomy was reported in 3 studies (12%) and isolated percutaneous decompression was mentioned once as a treatment option. Arthrodesis emerged as the prevailing therapeutic approach, featuring in 80% of the studies (n = 20). The most frequent technique was a talonavicular-cuneiform arthrodesis for Maceira's stages III-V. We report a treatment algorithm adapted for the radiographic and clinical stage of the MWD.

Conclusion: MWD is a complex pathology that requires tailored management. Early diagnosis, accurate radiographic assessment and appropriate treatment are essential. Although there is no gold standard treatment, talo-navicular-cuneiform arthrodesis is emerging as one of the most effective options for deformity correction and symptom relief.

Level of evidence: IV; Systematic Review.

Background: The "ilio-Stoppa" approach is a combination of the lateral and middle windows of the ilio-inguinal approach and the anterior intra-pelvis (AIP) approach, indicated for acetabular fractures with a predominantly anterior component. The multiplication of these windows allows better access to the acetabulum, but this approach and its results remain poorly documented in the literature. The aim of this study was to answer the following questions: what were the radiological outcomes (quality of reduction according to Matta criteria and Saint Joseph score) with the ilio-Stoppa approach? What were the factors influencing these results? What were the complications associated with this approach?

Hypothesis: The ilio-Stoppa approach offers good radiological outcomes while providing an extended three-dimensional exposure of acetabular fractures with a predominantly anterior component.

Patients and methods: This was a bi-centric retrospective descriptive study with prospective data collection extended over five years about 116 patients operated on for acetabular fractures using the ilio-Stoppa approach. The mean age was 46 years and the sex-ratio were 4,3. Fracture patterns according to Judet and Letournel classification and peri-operative data were collected. The outcomes of this surgery were evaluated using Matta and Saint-Joseph scores and complications were recorded at a mean follow-up of 22 months. Factors influencing the radiological results were analysed.

Results: The predominant fracture type was both-column fracture (n = 36, 31%). The average operative time was six days. Fracture reduction was anatomical in 73% of cases according to the Matta score. The mean St-Joseph prognostic score decreased from 16.5 to 7 postoperatively. Injury to the lateral femoral cutaneous nerve was the most frequent complication (n = 17, 15%). Unfavorable radiological outcomes were significantly associated with age, body mass index (BMI), fracture type and femoral head protrusion.

Discussion: The ilio-Stoppa approach allows extended anterior exposure of the acetabulum with particularly fractures including the supra-acetabular area, the lower iliac wing and/or the quadrilateral plate. Careful preoperative planning is essential especially in elderly patients, high BMI and in fractures with a transverse component and/or femoral head protrusion. It could be an alternative to the ilio-inguinal approach and AIP approach associated with a lateral window.

Level of evidence: IV; retrospective study.

Elastic Stable Intramedullary Nailing (ESIN) is the treatment of choice for forearm fractures in children. However, fractures occurring at the distal metaphyseal-diaphyseal junction (DMDJ) of the radius are notoriously difficult to treat. This paper presents a modified ESIN method to treat these fractures. Surgical intervention was considered for fractures with angulation >10 ° in the coronal plane, 20 ° in the sagittal plane, >1 cm of bayoneting, and instability after reduction. A radial approach is used. Once the nail is at the biceps tuberosity, it is retracted by 4 cm and at bent 90 °, and reinserted so that the nail lies against the medial cortex, thereby stabilizing the fracture. Twenty-seven patients were treated, all showing <5° of coronal and sagittal tilt as well as <5 mm of coronal translation and <5° of difference in pronation-supination. This new ESIN method is an effective technique for the treatment of DMDJ fractures on the radius in children. LEVEL OF EVIDENCE: IV; Technical note and case series.

Introduction: Increased posterior tibial slope (PTS) increases the risk of anterior cruciate ligament (ACL) graft failure. Infratubercle anterior closing-wedge slope-reducing osteotomy (ACW-SRO) preserves the tibial tubercle and allows simultaneous ACL revision.

Purpose: This technical note outlines the surgical steps and short-term radiographic outcomes of combined ACW-SRO and ACL revision.

Methods: Forty-six patients (mean age 24, BMI 23) with PTS ≥12 ° underwent surgery between January 2022 and December 2023. The osteotomy was performed 2 cm below the tibial tubercle, fixed with a locking plate and screw, and ACL tunnels were drilled after fixation. Postoperative care included partial weightbearing for 3 weeks and bracing in -10 ° extension.

Results: PTS improved from 76 ° to 85 ° (p < 0.001), with a mean correction of 9 °. Coronal alignment was preserved (p = 0.12). All osteotomies healed within 4 months. One superficial infection (2%) and one screw backout (2%) occurred; no hinge fracture, nonunion, or hardware failure was observed.

Level of evidence: IV; Retrospective case series.

Objective: Transforaminal Lumbar Interbody Fusion (TLIF) aims to relieve nerve compression and fuse the affected segment in its anatomical position. Multiple approaches and interbody cages designs have been developed for this purpose. The study aimed to assess the early impact of posterior approach (open vs. minimally invasive) and interbody cage design on global and segmental lordosis, as well as disc height.

Methods: A prospective, multicenter comparative study was conducted with patients undergoing monosegmental TLIF at L4-L5 or L5-S1 using either open or minimally invasive procedures. Interbody cages utilized were either straight or banana-shaped, made from PEEK or porous titanium. Assessments included clinical evaluations (radicular and lumbar Visual Analog Scale) and radiological measurements (global lordosis, segmental lordosis, disc lordosis, and disc height) using segmental and centered profile X-rays preoperatively (PrO), immediate postoperatively (IPO), and at 3-months (3 M). The study focused on early effects of the approach and cage design on sagittal parameters.

Results: From January to December 2021, 191 patients (129 in group A - open surgery, 62 in group B - minimally invasive) were included, exhibiting similar preoperative characteristics. Both groups showed significant improvements in clinical results and sagittal alignment at IPO and 3 M. Group A displayed notably higher segmental lordosis (3 M: 21°±7 vs 18°±8), while group B exhibited greater disc height. Mixed model showed that Banana-shaped cages were associated with greater increases in segmental lordosis, while straight cages provided superior disc height restoration.

Conclusion: Surgical approach has no influence on sagittal parameters. The design of the interbody cages has an influence on early segmental lordosis and disc height, with banana-shaped cages contributing more to the restoration of segmental lordosis.

Level of evidence: IV.

Background: The exacerbation of interfacial stiffness differences can lead to localized stress concentration and an increased incidence of pedicle screw loosening. Consequently, the etiology behind the higher occurrence of screw loosening in osteoporotic patients stems not only from a reduction in bone strength but also from a progressive decline in bone elastic modulus. In this context, we hypothesize that constructing pedicle screws using materials with low elastic modulus may help mitigate stiffness discrepancies at the bone-screw interface, potentially serving as an alternative biomechanical strategy to reduce the incidence of screw loosening.

Methods: In vitro experiments were conducted to evaluate the biosafety of the novel low elastic modulus titanium alloy, Ti2448. This assessment was performed through various methods including the CCK-8 assay, flow cytometry, live and dead cell staining, and lactate dehydrogenase detection. In-vivo insertion of Ti2448 block have also been performed to assess whether it caused a local inflammatory response. Subsequently, conventional and low elastic modulus titanium alloy pedicle screws with identical shapes are machined. A comprehensive biomechanical study, comprising mechanical tests and numerical simulations, was conducted using an osteoporotic test block to evaluate the impact of reduced differences in bone-screw interfacial stiffness on local stress distribution and screw anchorage capability.

Results: The ideal biosafety of the Ti2448 has been demonstrated through both in vitro and in vivo examinations. Furthermore, when compared to traditional titanium alloy, screws with a low elastic modulus exhibit superior anchorage capabilities in mechanical testing. Correspondingly, mechanical simulations indicate that the low elastic modulus screw can reduce interfacial stiffness differences, thereby alleviating stress concentration at the bone-screw interface.

Conclusions: Low elastic modulus titanium alloy pedicle screws, characterized by their excellent biosafety, represent a viable alternative for the internal fixation of osteoporotic patients. This innovative approach aims to minimize interfacial stress concentration and mitigate the risk of screw loosening.

Level of evidence: IV; basic science and biomechanical study.