Orthopaedics & Traumatology-Surgery & Research最新文献

Background: Many techniques have been described for lateral ankle ligament reconstruction. Although the biomechanical properties of gracilis tendons are different from those of ligaments, the use of a gracilis tendon autograft is a popular option for anatomical reconstruction. Graft maturation and the biomechanical processes over time remain unclear. This study describes changes in graft stiffness following anterior talofibular ligament (ATFL) reconstruction and graft reaction to varus stress.

Hypothesis: The reconstruction would be stiffer than the native ATFL, but would decrease during follow-up.

Methods: Twenty patients were prospectively included after arthroscopic reconstruction of the ATFL and calcaneofibular ligament for ankle stabilization. All patients were followed up 3, 6, and 12 months after surgery to assess graft stiffness by shear wave elastography (SWE) at different angles of varus in the ankle. At one year the EFAS and AOFAS functional scores were obtained. A control group of twenty healthy subjects were included to compare graft stiffness to that of a native ATFL.

Results: The stiffness of the native ATFL in the control group was 12.8 +/- 2.4 kPa in neutral position, 18.4 +/- 4.8 kPa at 15 ° of varus, 31.9 +/- 6.6 kPa at 30 ° of varus. One year after surgery, graft stiffness was statistically higher and averaged 56 +/- 9 kPa, 70.2 +/- 11.6 kPa and 84.9 +/- 10.5 kPa, respectively. Postoperative graft stiffness at three, six, and twelve months was not correlated with any of these scores, reflecting patient satisfaction and good function at one year.

Conclusion: Graft stiffness decreases over time but remains four times stiffer than that of a native ATFL at one year in the neutral position. ATFL graft stiffness at one year during varus stress appears to be different from that of a native ATFL.

Level of evidence: III.

Background: Despite new modern surgical techniques, no short-term functional differences have been demonstrated between operative and non-operative treatment for acute acromio-clavicular (AC) dislocations Rockwood III-V. Few studies describe the long-term clinical and radiological results of these lesions. We aim to compare the one- and ten-year outcome of patients either treated non-operatively or with hook plate fixation for Rockwood III AC lesions.

Hypothesis: Non-operative treatment is not inferior to surgical treatment at short and long-term follow-up when considering patient function and radiological degenerative changes.

Patients and methods: Prospective randomized trial including 56 consecutive patients aged between 18 and 60, admitted to a level one trauma center for an acute Rockwood III AC joint dislocation. Patients were randomized to two groups: non-operative or surgical treatment with hook plate. Outcome measures were obtained by an independent examiner and included Constant score, DASH score, complications, and radiological results at one and minimum ten years (last visit delayed due to COVID-19 pandemia). Data analysis with a 5% alpha error.

Results: We observed no difference between the two groups for the Constant score at one year (non-operative 93.3 ± 7.4 vs surgical 92.7 ± 6.7, p = 0,41) and ten years (93.3 ± 10 vs 98.2 ± 5.2, p = 0,08). Similar results for all other clinical outcomes were censed. The reoperation rate was higher in the surgical group (88.5 vs 3.3%, p < 0,01), but consisted of hardware removal in most cases. Radiological degenerative changes were present in both groups at ten years (non-operative 33.3% vs surgical 50%, p = 0,24).

Discussion: This study confirmed that non-operative treatment was not inferior to surgical treatment with a hook plate for acute Rockwood III AC joint lesion at both short and long-term follow-up periods. Patients treated non-operatively achieved very high clinical scores, nearly equivalent to normal function. Further research should identify the patient-specific risk factors associated with the rare cases of failed non-operative treatment.

Level of evidence: I; randomized controlled study, therapeutic.

Introduction: With the aging population comes an increase in the number of distal radial fractures and therefore in the number of cases requiring volar locking plate (VLP) fixation. The complication rates after VLP fixation vary greatly from one study to the next. Several authors have already focused on these complications and how to lower their rate. The aim of this study was to identify risk factors for complications after VLP fixation of distal radial fractures that lead to implant removal.

Hypothesis: Implant removal (except systematic removal) after VLP fixation can be predicted by risk factors for complication.

Materials and methods: There were 2951 patients included in the study and divided into two groups: fixation without implant removal and fixation with implant removal. Then, intrinsic factors (age, sex, dominant side, tilt, type of fracture based on the AO classification (extra-articular - partial articular - complete articular - fracture); as well as one extrinsic factor (plate position according to the Soong classification compared to the watershed line) were identified. For all these factors, the relative risk (RR) was computed using univariate and multivariate models. The risk factors that reached statistical significance (p < 0.02) were used in the multivariate analysis.

Results: The univariate and multivariate analyses identified three risk factors for complications, i.e. implant removal: being under 62 years of age (RR = 1.99; CI 1.56-2.54, p < 0.0001), type 2R3C fracture according to the AO classification (RR = 1.50; CI 1.17-1.93, p = 0.0050) and Soong grade 2 plate position (RR = 1.73; 1.32-2.26, p < 0.0001).

Conclusion: Our study showed that plate position recorded as grade 2 was a risk factor for complications and therefore implant removal. This is an extrinsic factor that is implant and surgeon dependent. Moreover, intrinsic factors were also identified such as age and type of fracture. Assessing these risk factors after VLP fixation of distal radial fractures may lead to early detection of these complications and an opportunity to propose implant removal as a preventive measure.

Level of evidence: III.

Bakground: Child malignant bone tumors often develop near growth cartilage. The gold standard surgery consists in large segmental resection. This resection often requires the sacrifice of growth cartilage, leading to inequality of limb length. Prothesis are used for reconstruction when the epiphysis is resected, otherwise different strategies of osteosyntheses and grafts may be an option.

Hypothesis: The aim of the study was to analyze the foot size inequality after surgery of lower limb malignant bone tumor in patients with growth residual.

Patients and methods: A retrospective study analyzed the data of 60 patients followed in an oncology pediatric center, between January 2008 and December 2018, for surgically treated malignant bone tumor. All surgeries were realized between January 1992 and December 2013. The primary outcome was the foot size inequality at the last consultation. Categorical variables were described by frequencies and percentages, and compared with Student tests. Continuous variables were described by median and interquartile range, the linear relationship between the foot size inequality and the explanatory variables were analyzed with Pearson tests.

Results: A foot size inequality of 1.15 cm [-0.5-3] was measured, a statistically significant difference (p < 0.0001). Younger children had a greater difference, as the patients with a greater final leg inequality. The children who required several surgeries because of mechanical issues also had a higher foot length difference.

Discussion: The foot length inequality after bone tumor surgery of the lower limb in children with residual growth potential is a reality not enough described.

Level of evidence: IV.

Introduction: Total hip arthroplasty has been associated with the onset of low back pain, which can significantly impact patients' quality of life. However, a detailed evaluation of the time until the onset of long-term low back pain following total hip arthroplasty remains largely unknown. This study aimed to explore the relationship between total hip arthroplasty and the development of long-term lower back pain. Through survival analysis, we examined the time of onset of low back pain in a cohort of patients who underwent the procedure, providing a detailed temporal perspective of this postoperative complication.

Hypothesis: The onset of low back pain in patients undergoing total hip arthroplasty tends to manifest in the medium and long term.

Materials and methods: A survival study using the Kaplan-Meier method was conducted on 299 patients who underwent total hip arthroplasty between 2010 and 2020 at the Hospital Clínico Universitario Lozano Blesa in Zaragoza. The event of interest was the occurrence of low back pain during monthly follow-ups, which was subsequently stratified by sex and body mass index (BMI). Death and the end of the study follow-up were considered as censored data.

Results: The sample comprised 67.6% men and 32.4% women. Additionally, 68.2% of patients were overweight or had grade 1 obesity. During the follow-up of the entire sample, 96 patients developed low back pain, with 28 cases occurring within the first 2 years. The 50% survival of the population without low back pain was established at 39 months, with a mean follow-up of 112.25 months (95% CI 105.87-118.62). Significant differences were observed in the onset of lower back pain in men when considering different BMI grades. However, no significant differences were found between sexes or among different BMI groups when gender was not taken into account.

Discussion: The results of this study provide valuable information on the survival of patients undergoing total hip arthroplasty who experienced low back pain over an extensive follow-up period. These findings have significant implications for clinical practice, indicating that patients undergoing total hip arthroplasty should be informed of this potential risk.

Level of evidence: IV; retrospective case series study.

Introduction: The posteromedial compartment of the knee houses several important anatomical structures, including the oblique popliteal ligament (OPL), an accessory insertion tendon of the semimembranosus muscle. Popliteal cysts develop from the synovial bursa located between the medial gastrocnemius and the semimembranosus, typically secondary to intra-articular pathologies causing effusion. This study aimed to describe the normal anatomy of the postero-medial capsule of the knee and its anatomical variations, particularly in the presence of popliteal cysts.

Materials and methods: This was a prospective descriptive study conducted over four consecutive months, including 96 knees from 96 patients who underwent arthroscopy for various intra-articular pathologies. The anatomy of the oblique popliteal ligament was categorized into four types: integrated OPL (Type 1), prominent "cord-like" OPL (Type 2A), normally prominent OPL (Type 2B), and bulging OPL (Type 3). The presence of popliteal cysts was evaluated preoperatively using magnetic resonance imaging (MRI).

Results: Type 1 OPL was observed in 13 knees (13.5%), Type 2A in 22 (22.9%), Type 2B in 40 (41.7%), and Type 3 in 21 (21.9%). MRI revealed popliteal cysts in 20 knees (20.8%), of which 8 (8.3%) were symptomatic. No popliteal cysts were identified in Type 1 knees. Cysts were present in 2 of 22 Type 2A knees (9.1%), 6 of 40 Type 2B knees (15%), and 12 of 21 Type 3 knees (57.1%). A statistically significant relationship was found between the anatomical type of the postero-medial capsule and the presence of a popliteal cyst (p < 0.001).

Conclusion: Arthroscopic anatomy of the postero-medial capsule appears altered in the presence of a popliteal cyst. This alteration is characterized by a bulging OPL within the joint, creating a communication orifice at its superior margin leading to the cyst. Posteromedial synovectomies aimed at disrupting the unidirectional flow mechanism into the cyst should target a triangular area defined by the medial gastrocnemius, the semimembranosus, and the oblique popliteal ligament.

Level of evidence: IV; observational study.

Purpose: For the athlete, anterior Cruciate Ligament (ACL) rupture and its surgical management are often a turning point in their career. Success and time to return to sport are essential parameters for athletes and their support staff, so it is critical to understand the prognostic factors influencing return to sport after anterior cruciate ligament reconstruction (ACLR). The aim of this study was to determine the influence of hamstring muscle composition on muscle power following ACLR with autogenous hamstring grafts.

Methods: 24 patients with chronic torn ACL were included at a single-center over a period of 17 months. They underwent surgical repair and during this procedure grafts were harvested from the gracilis and the semitendinosus. Muscle composition was assessed on the remaining proximal part of the semitendinosus muscle, which is usually discarded, by immunostaining. Muscle power was defined by comparing the strength of the operated leg and the healthy leg on an isokinetic dynamometer at 6 months according a standardized protocol after 6 months of outpatient rehabilitation. Various other intrinsic and extrinsic factors were also studied, such as body mass index (BMI), age, sex, smoking, or sport practiced, to determine factors influencing isokinetic strength test after ACLR.

Results: No statistical relationship was identified between muscle composition and the muscle power between the operated and healthy leg. Smoking and female gender were associated with worse muscle recovery. Age and BMI had no influence on isokinetic performance at 6 months.

Conclusion: Following ACLR muscle composition is not associated with difference in strength between the two legs at 6 months. Determining muscle fiber composition of the patient does not inform the rehabilitation protocol or predict muscle strength recovery. Larger series data is required to understand the influence of gender or tobacco on muscle fiber characteristic.

Level of evidence: I; Prospective prognostic study.

Introduction: Although previous studies have shown that severe medial knee osteoarthritis (OA) (Kellgren-Lawrence grade IV) is a risk factor for patient dissatisfaction following medial open-wedge high tibial osteotomy (MOWHTO), it is uncommon to perform arthroplasty as a primary surgical option in patients 55 years of age or younger. Thus, the purpose of our study was to evaluate whether severe medial knee OA is a risk factor for dissatisfaction following MOWHTO depending on patient age based on a cutoff of 55 years.

Material and methods: We retrospectively reviewed the data of 270 consecutive patients who underwent MOWHTO with a minimum of 2 years of follow up. Patients were divided into 2 groups based on satisfaction following surgery, a Satisfied group (new Knee Society Score satisfaction subscore >20) and a Dissatisfied group (≤20). In order to assess risk factors for patient dissatisfaction depending on the age range, a subgroup analysis was conducted based on a cutoff age of 55 years. Preoperative demographics, OA grade, articular cartilage and meniscus status, severity of varus deformity, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and surgical factors were compared.

Results: At 2 years after surgery, binomial logistic regression analysis showed that severe medial knee OA was associated with patient dissatisfaction following HTO in the entire cohort (odds ratio [OR] 4.557, 95% confidence interval [CI] 2.300-9.030, p < 0.001). In subgroup analysis depending on age range, severe medial OA was not a risk factor for dissatisfaction in the age ≤55 years group. However, severe medial knee OA in the age >55 years group was a significant risk factor for dissatisfaction after MOWHTO (OR 6.78, 95% CI 2.979-15.431, p < 0.001).

Conclusion: Severe medial OA was not a risk factor for dissatisfaction in patients age 55 years or younger who underwent MOWHTO. Therefore, surgeons can take this result into account when counseling younger patients considering MOWHTO.

Level of evidence: III.