Orthopaedics & Traumatology-Surgery & Research最新文献

Purpose: To determine in the long-term the rate of osteoarthritis of recession wedge trochleoplasty performed in patients with high-grade trochlear dysplasia and recurrent patellar dislocations. The hypothesis was that the rate of secondary osteoarthritis was low.

Methods: Fifteen consecutive patients (17 knees) undergoing a recession wedge trochleoplasty surgery for recurrent patellar dislocation were retrospectively included. Recurrence of dislocation and functional scores of Lille and Kujala were collected. A complete radiological assessment was carried out to assess secondary patella-femoral and femoro-tibial osteoarthritis.

Results: No recurrence of dislocation was observed. Mean Lille and Kujala scores were respectively 84 ± 9/100 and 78 ± 12/100 at an average follow-up of 11.2 ± 1.8 years (132 ± 22 months, range 96-165). No significant radiological changes in osteoarthritis were observed. Of the 15 knees without any radiological signs of patellofemoral osteoarthritis at time of surgery, 7 presented a bone remodeling (Iwano1) and 8 had no signs of osteoarthritis at the latest follow-up. Among the 2 knees with a preoperative Iwano stage 1, one evolved to Iwano stage 2.

Conclusion: Recession wedge trochleoplasty is an effective treatment for recurrent patellar instability in patients with a high-grade trochlear dysplasia. In the long term, the patellofemoral joint is stable, the functional scores are good, and there is no significant arthritic degeneration.

Level of evidence: IV, retrospective series.

Introduction: The treatment of early onset scoliosis (EOS) has seen significant advancements, particularly with the introduction of magnetically controlled growing rods (MCGR). However, a discrepancy between reported and actual rod lengthening during treatment has raised concerns.

Hypothesis: This retrospective study aims to investigate the disparity between reported and actual lengthening of MCGR and to identify factors contributing to the failure of the lengthening process.

Material and methods: Radiographs of the whole spine taken immediately before and after surgery were used for measurements. Documented rod lengthening read from the external remote controller (ERC) was used for analysis. The distraction procedure was classified as failed when the quotient of the measured distraction of MCGR actuators on radiographs and the declared lengthening of the rods using the ERC device was less than 0.3.

Results: Analysis of fifty patients with idiopathic and neuromuscular scoliosis revealed a diminishing discrepancy between ERC-reported lengthening and radiographic measurements after the sixth distraction (p < 0.05), with noticeable failures occurring after the eighth procedure (quotient of mm X-ray/mm ERC of less than 0.3). The bending of MCGRs played a crucial role, with a higher failure rate observed on the convex side of the spinal curve (p = 0.045). Additionally, postoperative thoracic kyphosis (TK) demonstrated a potential association with distraction failure, suggesting altered spinal alignment might affect the efficacy of MCGR treatment.

Discussion: The study emphasizes the importance of precise MCGR bending and vigilant monitoring, especially on the convex side of the spinal curve. We discovered a notable difference between expected and real rod lengthenings, especially after multiple procedures. This emphasizes the importance of closely monitoring MCGR treatments for accurate scoliosis management in young patients.

Level of evidence: IV; retrospective study.

Introduction: The main complication following scaphoid fracture is nonunion, which requires a surgical intervention to prevent the development of Scaphoid Nonunion Advanced Collapse (SNAC) wrist arthritis. In some cases, the bone eventually heals in malunion. There is a lack of published data on the clinical and radiological consequences of these malunions. The aim of our study was to determine if there was a correlation between the scaphoid's shape after bone graft treatment of a nonunion and the development of arthritis and to determine the strength of the correlation between the shape and clinical outcomes.

Hypothesis: There is no correlation between the scaphoid's shape and the development of radiocarpal arthritis nor the clinical and functional outcomes in the long-term after nonunion treatment.

Patients and methods: Fifty patients having a mean age of 27.5 ± 10.3 years (19-68) were included and followed for a mean of 92.2 ± 58.6 months (18-244). The scaphoid's shape was determined using CT data (LISA: lateral intrascaphoid angle, H/L: height/length ratio) and using radiographs (RLA: radiolunate angle). The clinical data (age, sex, dominant hand, smoking habits, occupation, work status at final follow-up), the operative data, potential complications and functional outcomes (DASH, MWS, PRWE) were collected during the final follow-up visit.

Results: The mean RLA was 7.4 ± 11.1 ° (min -21; max +46), the mean LISA was 30.5 ± 5.8 (min 22 max 47) and the mean H/L was 0.6 ± 0.2 (min 0.5 max 0.8). The mean DASH was 17.7 ± 18.9 (min 0 max 63.6). PRWE was 26.3 ± 26.3 (min 0, max 127) and MWS was 82.7 ± 19 (min 25 max 100). There was no statistically significant correlation between the scaphoid's shape and the development of arthritis (p = 0.38 for RLA, p = 0.24 for LISA, p = 0.38 for H/L), nor between the scaphoid's shape and the clinical or functional outcomes at a mean follow-up of 7.7 years.

Conclusion: In this study, the development of arthritis and the clinical outcomes were not correlated with the scaphoid's shape after nonunion treatment by bone graft, whether vascularized or not.

Level of evidence: IV; retrospective study.

Introduction: Combined anterior cruciate ligament (ACL) and meniscal tear patterns and their effect on knee stability have been widely researched, however, their evolution and repairability from time of injury have been scarcely addressed. When addressed with delay, meniscal lesions associated with ACL tears may increase in severity and irreparability. This study aims to investigate the incidence, rate and pattern of meniscus tears in the context of ACL deficient knees and to assess the meniscal condition in early versus late ACL reconstruction (ACLR). The hypothesis was that an increased time between trauma and ACLR was associated with different meniscal tear patterns.

Material and methods: Between 2012 and 2022, ACL reconstruction was performed in 1,840 cases. Out of the reviewed 1,317 ACLR's 726 exhibited concomitant meniscal lesions. The mean age was 32 years ±10. Meniscal tear status was evaluated during arthroscopy according to the ISAKOS classification. Patients were divided into 2 groups according to injury-to-surgery time: <2 months (116; 16%) and >2 months (610; 84%).

Results: Vertical meniscal lesion was the prevalent pattern regardless of the meniscus involved and the time from injury to ACLR, accounting for 50 to 76% of the patients. No significant difference was found comparing patterns rates between early and delayed treatment groups for both compartments. There was a significant difference in the distribution of circumferential areas of meniscal tears when comparing the medial with the lateral compartment. However, no significant difference in circumferential distribution of medial or lateral meniscus tears are present when performing surgery within or beyond 2 months.

Conclusion: There was no difference in meniscal tear patterns between early and delayed ACLR. The most frequent meniscal tear pattern was the vertical tear. No difference was found in circumferential distribution of meniscal tears between early and delayed ACLR. However, the circumferential distribution of meniscal tears was different comparing medial and lateral meniscus.

Level of evidence: III.

Introduction: Septic nonunion is one of the most feared complications in traumatology. Two-stage management using the induced membrane technique is a validated treatment option, but to date there is no consensus on the ideal type of osteosynthesis for the second stage of surgery. The aim of this study was to compare the results of two-stage treatment of tibial septic nonunion, depending on the type of osteosynthesis used.

Hypothesis: Our hypothesis was that internal centromedullary nailing osteosynthesis during the second stage of management of septic tibia nonunion would achieve bone union and healing of the infection, while allowing faster resumption of weight-bearing without increasing the complication rate.

Material & methods: This was a retrospective monocentric continuous comparative study including all 2-stage tibial septic nonunions treated from January 2008 to July 2018, with a minimum follow-up of 18 months. Healing and septic reactivation rates, as well as time to union and weight-bearing on the limb, were compared according to the type of osteosynthesis used. Primary success was defined as recovery from septic nonunion, and secondary success as recovery after at least one additional surgical procedure.

Results: Forty-nine patients were included, aged 39.5 +/- 14.8 years. Primary and secondary success rates were 77.6% (38/49) and 87.8% (43/49), with a mean follow-up of 29.4 +/- 11.3 months. Internal osteosynthesis did not lead to more septic reactivation than external stabilization (p = 0.49), while allowing union within the same deadlines. Osteosynthesis with a centromedullary nail allowed earlier weight-bearing (1.5 +/- 0.9 months) vs. plate (4.8 +/- 1.5) or vs. external fixator (5.3 +/- 1.8) (p < 0.001).

Conclusion: Secondary conversion to internal osteosynthesis during the second stage of nonunion cure allows consolidation in same delays, without increasing the risk of infectious recurrence. It also enables faster weight-bearing on the operated limb, particularly in the case of centromedullary nailing.

Level of evidence: III; comparative study.

Introduction: Although sagittal alignment is known to influence pelvic position, few studies accurately identify the relationship between sagittal alignment and acetabular orientation. We hypothesized that postoperative PT should be correlated with acetabular change in native hips after surgical correction of adult spinal deformity. The objective of this study was therefore to describe the correlation between the change in pelvic tilt and the change in acetabular orientation two years after surgical correction of adult spinal deformity.

Material and method: Based on a retrospective study of a prospective mono center database, 127 acetabuli out of sixty-nine patients were analyzed preoperatively and at two years postoperatively of surgical management of sagittal imbalance by posterior arthrodesis extended to the pelvis. The analysis was based on bi-planar EOS radiographs with 3D reconstructions of the pelvis and spine using SterEOS 3D software. The following specific parameters were analyzed: sacral slope, pelvic tilt, lumbar lordosis, SVA, acetabulum tilt (AT), anteversion (AA) (orientation of the acetabulum in the axial plane), abduction (AAbd) (orientation of the acetabulum in the frontal plane), inclination (AI) (orientation of the acetabulum in the sagittal plane), and anterior acetabulum coverage (ACA). A Pearson correlation was performed between the pre-and postoperative change in acetabular parameters (right and left) and pelvic parameters. Linear regressions were performed to identify the most relevant pelvic and spinal parameters. A subgroup analysis was performed to identify a difference between distal sacral and distal ilium fixations.

Results: All measured acetabular parameters were significantly different two years after surgery. Changes in AT (p = 0.03), AI (p = 0.03) and ACA (p = 0.05) were significantly greater in the ilium fixation group. Postoperative PT reduction was strongly correlated with the decrease of AT and AA ( = 0.61 and = 0.57, p < 0.001), it was also correlated with the increase of AI and ACA and the decrease of AAbd. The entire cohort linear regression analysis revealed that a 1 ° decrease in PT resulted in a 0.4 ° decrease in AA and a 0.6 ° decrease in AT (R2 = 0.45 and = 0.38).

Conclusion: Our study highlights the significant influence of the change in sagittal alignment on acetabular orientation in standing position. This correlation explains the increased risk of anterior hip impingement, the change in acetabular load distribution that might lead to early hip osteoarthritis, and the overall change in the subjects' gait pattern.

Level of evidence: IV.

Introduction: Percutaneous vertebroplasty (PVP) is a frequently employed technique for treating osteoporotic vertebral compression fracture (OVCF). However, there is still controversy regarding whether PVP with different courses affects clinical efficacy. Therefore, this study aims to investigate the impact of different courses of OVCF on early clinical and radiological outcomes after PVP.

Hypothesis: OVCF with shorter course can obtain more satisfactory clinical efficacy and radiological results after PVP.

Materials and methods: A retrospective analysis was conducted on the clinical data of 100 patients undergoing PVP for OVCF. Patients were categorized into early group (n = 37, <2 weeks), intermediate group (n = 35, 2-4 weeks), and late group (n = 28, 4-6 weeks) according to the time from the occurrence of OVCF to undergoing PVP. The visual analogue scale (VAS) and oswestry disability index (ODI) were used to evaluate the clinical effect before, 1 day, and 12 months after surgery. Anterior vertebral height ratio (AVHR) and local kyphosis angle (LKA) were measured on plain radiographs to evaluate the radiographic changes. The cement volume, cement leakage, hospitalization time, new fractures, and outdoor activity (ODA) were compared among the three groups.

Results: Compared with preoperative, VAS and ODI of the three groups were significantly improved (p < 0.05). There was no difference in VAS at 1 day and 12 months after surgery among the three groups (3.3 vs. 3.2 vs. 3.2, 1.7 vs. 2.0 vs. 2.0, respectively). ODI was significantly better in the early and intermediate groups at 1 day and 12 months after surgery (33.49% vs. 32.37% vs. 35.24%, 31.86% vs. 30.73% vs. 34.56%, all p < 0.05), and without inter-group differences. Postoperative AVHR and LKA were improved in all three groups (p < 0.05). The improvement of AVHR and LKA at 1 day and 12 months after surgery was more significant in the early and intermediate groups (AVHR: 21.00% vs. 18.52% vs. 26.31%, 21.82% vs. 20.03% vs. 27.75%, LKA: 17.82º vs. 17.61º vs. 20.49º, 19.07º vs. 19.10º vs. 20.80º, all p < 0.05), and without inter-group differences. The cement volume in the late group was less (4.3 ml vs. 4.3 ml vs. 3.2 ml, p < 0.05), but there were no differences in cement leakage and new fractures. Patients in the late group had a longer hospitalization time (5.1d vs. 5.0d vs. 6.4d, p < 0.05) and poorer ODA (5/15/17 vs. 4/17/14 vs. 11/11/6, p < 0.05).

Conclusion: OVCF with a course of less than 4 weeks can recover partial vertebral height and improve local kyphosis after PVP. The clinical and radiological outcomes are better than course of more than 4 weeks. We recommend performing PVP within 4 weeks of the occurrence of OVCF.

Level of evidence: III; retrospective comparative study.

Background: Periprosthetic femoral fractures (PFF) are a challenging complication of hip arthroplasty surgery, posing a high risk of morbidity, mortality and reoperation. The Vancouver Classification describes a B2 PFF around a loose stem with sufficient bone stock. In recent years, the number of B2 PFFs and cementation of femoral stems have increased substantially.

Hypothesis: This systematic scoping review aimed to review the options available to surgeons in managing Vancouver B2 PFFs around cemented polished taper-slip (PTS) stems and establish an algorithm of management to treat varying fracture presentations.

Patients and methods: This study reviewed articles reporting on Vancouver B2 PFFs around cemented femoral stems between 2012 and 2022. Data extracted included: patient demographics, index prosthesis, surgical intervention and decision for treatment, operation time, transfusion requirement, length of hospital stay, post-operative rehabilitation protocol, mobility outcomes, radiological outcomes, complications, reoperations, mortality rates and follow-up.

Results: In total, fourteen studies met all inclusion criteria including 552 cases. Mean patient age was 76.8 years with a male:female ratio 1:1.83 and median follow-up 49.2 months. Treatment options included open reduction and internal fixation (ORIF), revision arthroplasty using cementless modular and monoblock long-stems ± distal locking, cement-in-cement revision and cemented long-stem revision ± impaction bone grafting.

Conclusions: Management of B2 PFFs around cemented PTS stems is complex and aims to obtain stable fracture and stem fixation. Options include ORIF, cement-in-cement and cementless revision. The optimal choice depends on a combination of patient, fracture and surgeon factors. This review has proposed an algorithm to aid in decision making.

Level of evidence: III; systematic scoping review.

Introduction: Patellar instability is a multifactorial pathology requiring precise evaluation of its contributing factors, particularly patella alta. Patellotibial height measurement indexes, such as the Caton-Deschamps index, have the disadvantage of being referenced to the tibia. Patellotrochlear indexes are more appropriate but fail to account for variable knee flexion during magnetic resonance imaging (MRI).

Objective: This study aims to validate a new MRI-based patellotrochlear measurement, the extension patellar engagement (EPE) index, which is reproducible and measures patellar height relative to the trochlea independently of knee flexion during MRI.

Materials and methods: A retrospective study was conducted on 77 MRIs (37 unstable patients with a history of patellar dislocation, 40 controls with meniscal injury). The EPE index is the ratio between the patellar engagement length on the cartilaginous trochlea and the patellar cartilage length, measured on a knee virtually extended. Four measurements on multiple sagittal slices were used to calculate the EPE index.

Results: The inteobserver intraclass correlation coefficient (ICC) was excellent (0.79). The mean EPE index's value for all knees was 0.22. It was significantly higher (p = 0.034) in the instability group (0.26) compared to the control group (0.19). The average knee flexion during MRI was 11 ° (range: -8 ° to 25 °).

Discussion: The EPE index is reproducible. It is an anatomical index to classify patella alta when the patella does not reach the trochlea in knee extension (EPE index ≤0). It is also a functional index, with a mean value of 0.19 in the control group.

Conclusion: The EPE index measures the patellar engagement on the trochlea taking into account the knee flexion during MRI. It may guide surgical decision-making for patellar distalization and quantify the required correction.

Level of evidence: III; retrospective comparative study.