Orthopaedics & Traumatology-Surgery & Research最新文献

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.

Background: Hybrid fixation combining limited internal and external fixation has been proposed to improve alignment and stability in severe open tibial fractures, but its benefit in Gustilo IIIB and IIIC injuries remains unclear.

Hypothesis: (1) Does hybrid fixation combining limited internal and external fixation (HF) improve alignment correction compared to external fixation (EF) alone? (2) Are final alignment outcomes improved with HF? (3) Do union rates, time to union, and complication rates differ between the HF and EF alone? (4) Is there a threshold for initial deformity above which HF is beneficial?

Patients and methods: We retrospectively reviewed 57 patients with Gustilo type IIIB or IIIC open tibial shaft fractures treated between 2015 and 2024. The patients underwent either HF (HF group; n = 20) or EF alone (EF group; n = 37) during their first surgery.

Results: The HF group demonstrated significantly better alignment correction than the EF group (p = 0.036). At each evaluation stage - after the first surgery, after conversion, and at final follow-up - reduction quality was consistently superior in the HF group compared with the EF group (p = 0.046, 0.01, and 0.019, respectively). No malunions occurred in the HF group, whereas several malunions were observed in the EF group. Union rate, time to union, and infection-related complications were comparable between the groups. Receiver operating characteristic analysis identified an initial deformity angle of 15.2° as the threshold for predicting benefit from HF (area under the curve = 0.74).

Discussion: Hybrid fixation combining limited internal fixation with external fixation during the first-stage management of Gustilo IIIB and IIIC open tibial fractures provides better alignment control without increasing infection risk or surgical burden. This approach represents a safe and effective option for managing severe open tibial fractures.

Level of evidence: III; Retrospective comparative study.

Background: Distal radius fractures are common upper limb injuries. Open reduction and internal fixation (ORIF) using a volar plate via the Henry approach often involves myotomy of the Pronator Quadratus (PQ) muscle, which may or may not be sutured postoperatively. The value of PQ repair remains debated, particularly regarding functional outcomes and protection of the Flexor Pollicis Longus (FPL) tendon.

Objective: To compare the ultrasonographic healing of the PQ muscle with and without repair after volar plating, and to assess its potential role in FPL tendon protection. The hypothesis of our study was that the absence of PQ muscle suturing did not alter the plate-FPL distance, functional outcomes, or complications compared to sutured PQ.

Methods: We conducted a retrospective single-center study (October 2024-April 2025) including 48 patients with displaced distal radius fractures (AO A2) treated by ORIF. Twenty-three underwent PQ repair, and 25 did not. Ultrasonographic evaluations and clinical assessments were performed at final follow-up. Primary outcomes included PQ morphology and FPL-plate distance on ultrasound. Secondary outcomes comprised range of motion, grip/pinch strength, QuickDASH score, patient satisfaction, return to activity, and complications.

Results: Ultrasonography showed significantly greater distances between the radius/FPL and plate/FPL in the non-repair group. PQ was morphologically thicker in the non-repair group, although not significantly. Functional outcomes favored the non-repair group in most metrics (VAS, ROM, QuickDASH), but without statistical significance. Two complications (carpal tunnel syndrome, tenosynovitis) occurred in the repair group only.

Conclusion: Our results support the view that PQ repair after volar plating of distal radius fractures does not provide significant functional or protective advantages. The critical factor in preventing tendon complications remains correct plate placement relative to the watershed line. Future research should focus on prospective, multicenter, randomised studies with larger cohorts and longer follow-up to confirm these results.

Level of evidence: III.

Introduction: Stemless shoulder implants appeared on the market in 2003. The interest of this type of anatomic shoulder prosthesis is a better adaptation of the implant to the humeral anatomic characteristics and humeral bone preservation. These implants enabled an easier restoration of the rotation centre of the humerus, eliminating the problem of diaphyseal humeral offset, but few publications at long term are related. Therefore we did a retrospective investigation aiming to analyse signs of humeral and glenoid loosening and to assess the clinical results obtained using anatomic stemless shoulder implants of the Affinis Short™ (Mathys) type, after a minimum of 5 years.

Hypothesis: The metaphyseal fixation of the humeral implant was excellent after more than five years follow-up, with no sign of loosening.

Material and methods: It was a single-centre retrospective study conducted from 2012 to 2018, on 79 patients operated on by two surgeons. Eighty-one shoulders were clinically and radiologically reviewed in 2022 and 2023, after a minimum of 5 years post surgery. Eight patients were lost to-follow-up. The pre-surgical clinical assessment included: pain VAS (Visual Analogic Scale), functional range of movement and the Constant-Murley score. Post surgery, we also assessed the SSV (Subjective Shoulder Value), the Oxford Shoulder Score (OSS) and the Quick-DASH. The initial iconographic assessment included X-rays and a CT-scan. Post surgery, the X-ray results enabled us to analyse humeral metaphyseal anchoring and glenoid fixation.

Results: Our clinical outcomes were favourable with a significant improvement in all the clinical parameters. The mean active anterior elevation, external rotation 1 and internal rotation were 159.9 ° (±20), 40.6 ° (±2) and 7.7 pts. (±2), respectively. The mean Constant-Murley score progressed from 27.2 ± 5.5 (range, 19-47) to 70.6 ± 11.8 (range, 12-96) at 5 years of follow-yp. At final follow-up, the pain VAS was 1.0 ± 1.5, the OSS was 15.6 ± 7.4, the Quick-DASH was 14.1 ± 23.2 and the SSV was 90.2% ± 11.5%. On the X-rays, radiolucent lines were observed on the inferior level of the glenoid cavity on 6 shoulders, but none was significant, and no radiolucent lines were identified concerning the humeral implant. A secondary surgical intervention was necessary for one patient who, following a fall, presented at 70 months a subscapular tendon tear.

Conclusion: Our results are in line with the literature. After a minimum of 5 years post surgery, we can confirm the stability of the stemless humeral implant and the quality of the clinical results. Our single case of surgical revision has confirmed the interest of preserving humeral bone stock.

Level of evidence: IV; Retrospective study.