Orthopaedics & Traumatology-Surgery & Research最新文献

Background: With the emergence of new alignment techniques such as kinematic alignment (KA) and functional alignment (FA), personalized joint line restoration has gained attention, yet its theoretical underpinnings remain underdeveloped. This study aims to investigate the impact of different joint line orientation angles (JLOAs) on knee compartment loads during total knee arthroplasty (TKA), thereby establishing a biomechanical tolerance range for JLOA and providing theoretical guidance for new alignment techniques.

Methods: We collected computed tomography (CT) data from three patients with severe knee osteoarthritis (KOA) and established standard mechanical alignment (MA) finite element models for each case. Keeping hip-knee-ankle angle (HKA) neutral, we constructed a series of JLOA models from -9 ° to +9 ° (Positive numbers represent varus, negative numbers represent valgus). Subsequently, the maximum stress on the polyethylene liner surface was calculated with ANSYS in three positions: two-legged stance, one-legged stance, and squat. Finally, a mathematical model of maximum stress trend was established through statistical analyses.

Results: In the three patients' models, during both the two-legged and one-legged standing positions, the maximum stress fluctuated smoothly from -3 ° to +4 °, while the maximum stress increased markedly when JLOA reached -4 ° and +5 °. In the squatting position, the stress increased markedly when it exceeded the -3 ° to +6 ° range. Quadratic regression analysis confirmed that all patient positions exhibited U-shaped curves (p < 0.05). T-tests comparing the three position tolerance ranges (-3°to +4 °) revealed that the two-legged standing position exhibited the highest stress increase ratio (46.01%, Cohen's d = 2.50) in the non-tolerance range. A three-way ANOVA confirmed that the tolerance range effect remained consistent across patients (p = 0.839), while stress levels varied significantly between patients (p < 0.001).

Conclusions: This in silico study demonstrated that the polyethylene liners maintain relative biomechanical homeostasis within the JLOA range of -3 ° to +4 °. It is recommended that the JLOA for personalized reconstruction can be controlled within this range, serving as biomechanical theoretical guidance for new alignment techniques.

Level of evidence: IV; biomechanical computational study.

Introduction: Total hip arthroplasty (THA) in obese patients (BMI ≥ 30 kg/m²) is technically more demanding and associated with a higher risk of postoperative morbidity. Its realization seems more complex by the direct anterior approach. The hypothesis was that muscular mass would have a stronger impact than BMI on intraoperative difficulty during anterior THA. The study objectives were; 1. To assess the influence of body composition and BMI on intraoperative difficulty, 2. To determine the influence of body composition on early complications (< 3 months) and short-term functional outcomes.

Methods: A total of 162 anterior approach THAs without traction table were included. Body composition (muscle and fat mass) was assessed preoperatively by bioelectrical impedance analysis of the operated limb and trunk. Subgroup analyses were performed according to BMI (< 30, 30-35, or ≥ 35) and muscle mass (threshold set at 67%). Intraoperative difficulty was evaluated based on operative time in minutes and total blood loss in mL, calculated using the OSTHEO formula. Perioperative complications, early complications (< 3 months), and 3-month functional outcomes (Oxford Hip Score and Forgotten Joint Score) were assessed.

Results: In univariate analysis, operative time (+19 min) and total blood loss (+615 mL) were significantly higher in patients with BMI ≥ 35 compared to those with BMI < 30 (p <  0.001). Operative time was also longer (+6 min) in muscular patients (≥ 67%) (p =  0.009), with no significant difference in total blood loss. No significant differences were observed in perioperative or early postoperative complications, nor in 3-month functional outcomes between obese/non-obese or muscular/non-muscular groups. In multivariate analysis, BMI and total muscle mass were independently associated with intraoperative difficulty: Operative time (min) = 22.2 + 0.25 × total muscle mass (kg) + 1.1 × BMI (R² = 0.24, p <  0.001) Total blood loss (mL) = -692.6 + 13.3 × total muscle mass (kg) + 31.1 × BMI (R² = 0.29, p <  0.001) CONCLUSION: BMI and total muscle mass are two preoperative factors associated with greater intraoperative difficulty, as reflected by increased operative time and total blood loss in anterior approach THA. These factors can be anticipated through a more detailed assessment of body composition. Despite the increased surgical complexity, they do not appear to be associated with a higher risk of early postoperative complications. In this cohort, muscle mass did not demonstrate a stronger impact than BMI on operative difficulty, contrary to the initial hypothesis.

Level of evidence: II; Prospective comparative study.

Background: Autologous osteochondral transfer (AOT) surgery yields favorable outcomes with appropriate patient selection. Although several factors influencing surgical outcomes have been identified, the effect of meniscal volume and quality on AOT outcomes remains unclear.

Hypothesis: Better meniscal status would be associated with reduced deterioration of cartilage repair over time following AOT.

Materials and methods: Patients who underwent AOT between March 2002 and March 2021 were retrospectively reviewed. Inclusion criteria were: (1) magnetic resonance imaging (MRI) at 1-2 years postoperatively for evaluation of meniscal status, and (2) follow-up MRI after at least 2 years. Meniscal lesions were addressed during surgery, and postoperative residual meniscal status was graded using a 6-point scale (0-3 for volume, 0-3 for quality). Patients were divided into better meniscus (BM) and poorer meniscus (PM) groups using a cutoff score of 2.5, derived from a time-dependent receiver operating characteristic (ROC) curve that maximized early deterioration in the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score after AOT. Follow-up intervals were categorized into early (1-2 years), short-term (2-5 years), mid-term (5-10 years), and long-term (>10 years). Structural outcomes including MOCART scores, joint space width (JSW), and cartilage T2 relaxation times, and patient-reported outcome measurements (PROMs) including Lysholm score, IKDC subjective score, Tegner activity scale, and visual analog scale (VAS) for pain were compared.

Results: A total of 35 patients were finally included in the study, with a mean follow-up of 6.8 ± 5.2 years. Among them, 22 were classified into the BM group and 13 into the PM group. Significant group-by-time interaction effects were observed for MOCART scores (p = .048) and JSW (p = .03); the BM group demonstrated higher MOCART scores from the short-term follow-up (p = .005) and less JSW narrowing from the mid-term follow-up (p = .009). In contrast, no significant group differences were found in T2 relaxation times. Clinically, IKDC (53.5 ± 16.4 to 76.3 ± 11.0; p = .03), Lysholm (66.1 ± 18.3 to 91.7 ± 7.4; p = .02), and VAS pain scores (5.1 ± 2.3 to 1.8 ± 1.8; p = .01) significantly improved from preoperative to early postoperative follow-up and were maintained thereafter. However, no significant group differences were found.

Conclusion: Meniscal lesions should be properly addressed during AOT, as residual meniscal status was associated with cartilage degeneration. However, structural improvements on MRI did not translate into better clinical outcomes, as T2 relaxation times and PROMs were not correlated.

Level of evidence: IV.

Objective: Severe osteoarthritis of the first metatarsophalangeal joint (MTPJ-1) is commonly treated through arthrodesis. Our aim was to evaluate whether percutaneous approaches to perform MTPJ-1 arthrodesis reduce the nonunion and complication (including reoperation) rate as compared to the standard open technique.

Methods: This systematic review was designed as per PRISMA checklist; Pubmed, Cochrane, Scopus and Web of Science databases were analyzed; all studies focused on patients diagnosed with MTPJ-1 osteoarthritis and treated through arthrodesis using exclusively crossed screws. Data related to the cohort (size, age, sex, type of osteoarthritis), the study design (level of evidence and type of study), the technique adopted (the number of screws, open/percutaneous approach, technique of preparation of the joint) and the final outcome (nonunion and complication and reoperation rate) were recorded. The quality of studies included was evaluated through the MINORS score (methodological index for nonrandomized studies). The nonunion, complication and reoperation rates of the percutaneous (PERC) vs the open (OPEN) technique were compared through a proportional meta-analysis.

Results: Overall, nine studies (including 225 arthrodeses in 211 patients) were analyzed (130 cases in the PERC group vs 95 cases in the OPEN group). In the two groups, the mean (± standard deviation) sample size (PERC: 26.6 ± 5.1 cases; OPEN: 23.7 ± 10.2 cases; p = 0.33), sex distribution (PERC: 81% ± 0.6; OPEN: 57% ± 0.2 females; p = 0.17) and length of follow-up (PERC: 20.8 ± 11.6 months; OPEN: 29.5 ± 16.8 months; p = 0.19), mean age (PERC: 62 ± 5.4 years; OPEN: 59.5 ± 5.4 years; p = 0.26), were not significantly different. The pooled nonunion rate (9% vs 5% in PERC vs OPEN; p = 0.57), complication rate (15% vs 23%; p = 0.46) and reoperation rate (3% vs 5%; p = 0.74) were not significantly different. The quality of studies was moderate and comparable in the two groups (mean MINORS at 8.4 ± 1.5 points vs 11.7 ± 4.3 in PERC vs OPEN; p = 0.08).

Conclusions: The nonunion and complication (including reoperation) rate after percutaneous vs open first metatarsophalangeal joint arthrodesis (fixed using screws) are comparable at 2 years of follow-up. Only moderate-quality evidence is available so far in this area. Further comparative and prospective studies with a robust design are needed to clarify which strategy allows to obtain the best outcome after MTPJ-1 arthrodesis.

Level of evidence: IV.

Backgound: Some studies have explored the influence of theatre staff familiarity on surgical performance, but none have focused specifically on orthopedic surgery. Therefore, we performed a retrospective study aiming to: 1) compare complication rates following total hip arthroplasty (THA) performed at a surgeon's familiar site versus an unfamiliar one, 2) to compare patient-reported outcomes at one year and procedure-related outcomes as well as evaluating other surgical-related factors such as length of stay, operative time.

Hypothesis: Our hypothesis is that performing THA in a familiar versus an unfamiliar environment does not affect the occurrence of early complications.

Methods: Of the 182 cases eligible before propensity score matching, 138 elective THAs performed through the direct anterior approach were retained after matching (69 per group). In the unfamiliar group, the same experienced surgeons performed THAs at a different orthopedic center during the COVID-19 period. The mean age was 70.9 ± 12.8 years, 54.3% (75/138) were women, and the mean BMI was 26.4 ± 4.9 kg/m². Surgical complications were assessed using the CUSUM test.

Results: A total of 12 surgical complications occurred (8.7%,12/138) and no significant difference (familiar group:11.6%, (8/69) versus unfamiliar group: 5.8% (4/69) (p = 0.37)) was observed between groups. Applying the CUSUM test, for peroperative complications, surgical performance remained stable in both groups. For postoperative surgical complications only in the familiar group, the limit has been reached at the 15th procedure and remained stable thereafter. At one year postoperatively, the University of California and Los Angles activity score was significantly higher in the unfamiliar group compared to the familiar group (5.8 vs. 4.8 (p =  0.03)). No statistically significant differences were observed for other patient reported outcomes at one year and for improvement in patient reported outcomes: VAS pain (1.1 vs. 1.1 (p = 0.61)), SF-12 Mental (49.9 vs. 50.3 (p = 0.61)) and Physical (42.8 vs. 46.4 (p = 0.13)), Oxford Hip Score (39.8 vs. 43.0 (p = 0.10)), WOMAC pain (86.6 vs. 89.3 (p = 0.27)) and function (81.9 vs. 88.9 (p = 0.11)). The length of stay (4.8 vs. 6.6 days (p < 0.01)) and operative time (71.1 vs. 79.2 min (p < 0.01)) were significantly lower in the unfamiliar group.

Conclusion: Changing the orthopedic surgeon's environment has no effect on surgical performance when performing elective THA by experienced arthroplasty surgeons.

Level of evidence: III; Case-control study.

Introduction: Femoral neck fractures in the elderly require immediate postoperative weight bearing to preserve autonomy. Cementless stems rely on primary stability with close cortical contact. However, perioperative fracture may occur, and secondary subsidence remains a concern. The primary objective of this study was to assess early subsidence of a cementless femoral stem. Secondary objectives were to identify predictive factors for subsidence, dislocation, and perioperative fracture.

Material and methods: We conducted a retrospective study in patients over 65 years of age who underwent systematic implantation of an uncemented Avenir-Müller® stem. Epidemiological and radiological data were collected at 6 weeks and 3 months postoperatively. Subsidence was measured relative to the greater trochanter and expressed both as an absolute value and as a categorical variable (<2 mm or ≥2 mm). Morphological risk factors included the Canal Flare Index (CFI), Metaphyseal-Diaphyseal Index (MDI), Cortical Thickness Index (CTI), and Cortical Bone Ratio (CBR10).

Results: A total of 117 patients were evaluated, including 94 women, with a mean age of 83.1 years (range 65-103). Mean subsidence at 6 weeks was 1.1 ± 1.5 mm (median 0.6, range 0-9.1), and at 3 months 1.4 ± 1.6 mm (median 0.9, range 0-9.2). At 3 months, 22 patients (18.8%) had subsidence ≥ 2 mm. Dislocation occurred in 9 patients, with no association with subsidence ≥ 2 mm (p = 0.33). Five perioperative fractures were observed, with no identifiable predictive factor. No correlation was found between subsidence and preoperative autonomy (Rho = -0.2, p = 0.37) or surgeon experience (p = 0.66). A CTI ≤ 0.40 was predictive of subsidence (absolute value, p = 0.046; group ≥ 2 mm, p = 0.002).

Conclusion: Early subsidence of cementless stems in patients over 65 years of age undergoing hip arthroplasty for fracture is minimal. Severe osteoporosis, indicated by a CTI ≤ 0.40 on preoperative imaging, should prompt consideration of a cemented stem.

Level of evidence: IV; retrospective study.

Background: In cases of chronic anterior shoulder instability, surgical indications are guided by clinical and morphological parameters that are largely integrated into the ISIS score. The glenoid bone defect is a central decision factor. Arthro-CT represents for many the frequently used examination, but is this superiority proven for the evaluation of glenoid lesions and is its systematic use justified?

Purpose: Our aim was to compare the Bernageau view versus arthro-CT for the assessment of glenoid bone defects in anterior glenohumeral instability, and to integrate our results into the diagnostic approach.

Patients and methods: We report a retrospective study of 95 patients with chronic anterior shoulder instability, mean age 28.7 ± 11.6 years. A sample of 23 patients was selected who underwent arthro-CT of the pathological shoulder and bilateral Bernageau views. The bone defect on the Bernageau view is expressed as a percentage of the width of the healthy glenoid; on the arthro-CT it was assessed using the Sugaya method. Associated lesions (Bankart, notches, SLAP, HAGL and rotator cuff tear) were collected on the various examinations. The measurement method on the two images was validated by two examiners with high inter- and intra-observer reproducibility (ICC between 0.84 and 1). Statistical evaluation was based on non-parametric tests.

Results: The glenoid defect calculated on the Bernageau view was 5.90% (±7.56) compared with 5.93% (±6.59) for arthro-CT, the mean difference between the two measurements was 1.92 (±1.86). There were no statistically significant differences based on the Wilcoxon test (p = 0.85, CI95% [0.577; 0.911]). The Spearmann correlation coefficient between the two methods was 0.8 (CI 95% [0.577; 0.911], p < 0.001). Associated lesions included: 44% glenoid fracture, 81% Bankart lesion, 8.3% HAGL, 73% Hill-Sachs lesions, 5% SLAP and 2.1% rotator cuff tears.

Discussion: Our study supports the finding that bilateral Bernageau views provide accuracy comparable to arthro-CT in quantifying glenoid defects. Arthro-CT, which is more invasive, requires more radiation and is a potential source of infectious complications, provides additional information that is only relevant in the case of SLAP and rotator cuff tears. We therefore recommend reserving arthro-CT for the pre-therapeutic assessment of instability in specific cases: Bankart indication, patients ≥ 40 years old, or symptomatic patients of any age (functional deficits, muscle weakness, or pain during rotator cuff testing).

Level of evidence: IV.

Background: Acetabular fractures with a transverse component tend to result in poorer outcomes than other types. However, few studies have focused specifically on this fracture type. The aim of this study was to investigate predictive factors associated with outcomes after surgical treatment of such fractures.

Hypothesis: We hypothesize that the reduction was achieved in more than 50% of the cases.

Material and methods: We retrospectively collected data on patients with displaced transverse fractures who underwent surgery at our institution between 2007 and 2020. The mean follow-up was 18.5 months. The quality of reduction was assessed by the Saint-Joseph Acetabular Score (SJAS) on postoperative CT scan. Functional outcomes were assessed at final follow-up using the Harris Hip Score (HHS). Prognostic factors for SJAS and HHS such as demographics, fracture modifiers and characteristics of treatment were analyzed through multivariate analysis. Sixty-three patients, including 51 men (80.9%) and 12 women (19.1%), with a mean age of 36.7 years, were included.

Results: Twenty-one fractures achieved satisfactory reduction (33.3%). Reduction quality was significantly affected by initial displacement (p = 0.0143) and time to surgery (p = 0.0118). The functional results were excellent or good in 71.7% (45 patients) of cases according to the HHS. The functional score was significantly influenced by initial maximum step (p = 0.0186), reduction quality (p < 0.0001), and late complications (p < 0.0001). Late complications included 11 cases (17%) of hip osteoarthritis and 3 of avascular necrosis (5%).

Conclusion: Transverse fractures are challenging to treat and are associated with a poor prognosis. The quality of surgical reduction appears to be one of the most important factors in determining functional outcome, which is itself affected by initial displacement and time to surgery. Recognizing these predictive factors may help refine prognostic assessments and could inform early modifications to the surgical strategy, potentially improving long-term outcomes.

Level of evidence: IV; Retrospective study.

Background - introduction: Cuff repairs are associated with a relatively high risk of retear for which reverse total shoulder arthroplasty (rTSA) represents a treatment option. The objective of this study was to evaluate the mid-term results of rTSA after failed rotator cuff repair and to analyze the factors that may influence these results.

Materials and methods: We conducted a retrospective multi-center analysis of 117 rTSA after failed cuff repair with 2 years minimum follow-up. Clinical scores (Constant, SSV and EVA pain scores) and active range of motion were pre- and postoperatively assessed.

Results: A total of 117 shoulders with a mean follow-up of 60 months (range 24-144) were identified with a mean age of 70 years (range 49-86). Preoperatively, according to Collin classification, the supraspinatus tear with posterior extend (type D: 34%) and with antero-posterior extend (type C: 33%) were the most frequent feature. Preoperatively, according to Hamada classification, there was no osteoarthritis in 32% of cases and proven glenohumeral osteoarthritis in 46% of cases. Postoperatively, the mean Active Anterior Elevation improved from 89° ± 41° to 136° ± 33° (p < 0.001). Postoperatively, the mean Constant's score improved from 29 ± 12 to 61 ± 18 (p < 0.001) and the mean SSV score improved from 26 ± 15 to 71 ± 21 (p < 0.001). A greater Constant score was associated with an isolated Supraspinatus tear and a lower Constant score was associated with tears involving the supraspinatus and the Infraspinatus (type D) with also a negative influence on active external rotation. In absence of glenohumeral osteoarthritis, the mean Constant score was significatively lower. We also found a significantly lower mean Constant score and mean activity sub-score in younger patients. A total of 14 complications (12%) and 8 revision surgeries (7%) were reported.

Discussion/conclusion: Our results are consistent with recent series in the literature on similar indication of rTSA after failed cuff repair, and lower than those of primary rTSA. Association of an infraspinatus tear, absence of glenohumeral arthritis and a younger age were identified as predictive preoperative factors responsible for a lower result. These observations further encourage caution in the indication of a rTSA in the younger patients and in absence of glenohumeral osteoarthritis.

Level of evidence: IV; Case series with no comparison group.