Orthopaedics & Traumatology-Surgery & Research最新文献

Introduction: The study aims to explore whether asymmetrical bone healing occurs after bone grafting for segmental bone defects using the Masquelet technique, and to analyze the underlying causes and potential prevention strategies. The hypothesis was that bone healing after bone grafting for tibial segmental bone defects is asymmetrical.

Methods: A retrospective analysis was conducted on 67 patients with tibial segmental bone defects treated using the Masquelet technique. After all the bone defects healed, the healing time difference and incidence of local cortical bone loss of the four sides of the bone graft were analyzed, along with the associated causes. The correlation and regression analysis between the patient-specific and surgery-related factors and the difference in anterior versus posterior healing times was performed.

Results: Mean healing times (months) differed significantly (P < 0.05): posterior (7.2 ± 0.6), lateral (8.4 ± 0.8), medial (9.0 ± 1.0), and anterior (9.6 ± 1.1). The incidence of anterior cortical bone loss (7.46%) was significantly higher than that of posterior and lateral losses (0; P < 0.05). Bivariate correlation and multiple linear regression analyses identified four significant risk factors for differences in healing time (P < 0.05): defect length (β = 0.215), bone graft quantity (β = 0.450), induced membrane (IM) integrity (β = 0.637), and early-stage activity levels (β = 0.597). The regression equation was: Y = -1.954 + 0.637×IM integrity + 0.450×early-stage activity levels + 0.597×bone graft quantity + 0.215×defect length.

Conclusion: Bone healing after bone grafting for tibial segmental bone defects exhibits asymmetry, with fastest posterior healing, slowest anterior healing and even anterior cortical bone loss. Objective factors (biomechanical environment, graft settling) and subjective factors (defect length, graft stability and quantity, early-stage activity levels) both contribute. These findings inform optimized grafting protocols and rehabilitation strategies to improve clinical outcomes through more balanced healing promotion.

Level of evidence: IV; retrospective study without a control group.

Post-traumatic forearm nonunion in adults is a rare but formidable complication. Therapeutic objectives must combine bone union with restoration of radial anatomy and pronator curvature, in order to regain pronosupination function and ideal hand positioning. The rate of nonunion in forearm diaphyseal fractures, with or without infection, is in the range of 2-10%. Failed healing of these fractures is often due to an inadequate surgical technique. The objectives of the clinical and diagnostic assessment are to characterize the trauma and its initial management, the nonunion and the patient. AP, lateral and three-quarter radiographs of the forearm, including the wrist and elbow joints, are essential. CT scans of the forearm with MPR and 3D reconstructions provide the details needed to characterize the nonunion and the surrounding bone tissue. If infection is suspected, blood tests should be performed to check for inflammatory syndrome. The extent of segmental bone loss and whether or not the nonunion is infected dictate the treatment options available. The reference internal fixation is a plate. LEVEL OF EVIDENCE: >V; expert opinion.

Spinal endoscopy is a major advance in spinal surgery, offering a minimally invasive alternative to traditional techniques. Since the first attempts at indirect visualization of the spinal canal in the 20th century, numerous technological advances have extended the applications of endoscopy, from treating herniated discs to lumbar fusion. Two main techniques are used: uniportal, with a single incision for instruments and endoscope, and biportal, inspired by arthroscopy, using two separate incisions. Uniportal techniques are precise and allow minimal approaches, ideal for simple procedures, while biportal techniques offer better maneuverability for more complex procedures. Spinal endoscopy has proven effective in treating compressive lumbar pathologies: herniated discs, canal or foraminal stenosis, and medullary compression in cervical and thoracic pathologies. It considerably reduces postoperative morbidity and ensures rapid recovery, less pain and fewer infectious complications. However, the learning curve for these techniques is a significant challenge, requiring experience and specialized training. Among other limitations, there is an increased risk of hematoma, transient dysesthesia and accidental durotomy. The high cost of specialized equipment is also a barrier to widespread adoption, although savings are achieved via shorter hospital stay. Despite these challenges, spinal endoscopy is becoming increasingly well-established, with future prospects linked to technological improvements and surgeon training. LEVEL OF EVIDENCE: 4.

Introduction: The management of the long head of the biceps tendon (LHBT) is well established in case of massive, irreparable rotator cuff tears (RCTs). However, its treatment in the context of small RCTs, especially those involving the supraspinatus tendon remain controversial, with ongoing debate over whether tenotomy, tenodesis, or simple preservation is the most appropriate approach. This study hypothesized that a non-conservative treatment (either isolated tenotomy or tenodesis) would yield equivalent functional outcomes, regardless of the macroscopic intraoperative appearance of the biceps tendon.

Materials and methods: In this prospective multicenter study, 210 patients underwent rotator cuff repair for a tear primarily affecting the supraspinatus tendon. A tenotomy or a tenodesis of the LHBT was systematically performed, regardless of its intraoperative appearance (normal or pathologic). Functional outcomes at two years (VAS, Constant score, SSV, ASES score) were collected and compared according to the macroscopic aspect of the tendon. To account for potential confounding factors, a 1:1 propensity score matching was performed. Outcomes were also compared between tenotomy and tenodesis groups. Cuff healing was assessed by ultrasound at the last follow-up.

Results: At the two-year follow-up, after propensity-score matching, no statistically significant differences were found between groups in any of the tested score (Constant score, p = 0.96; VAS, p = 0.33; ASES score, p = 0.50). Before matching, functional scores were significantly better in patients who underwent tenotomy or tenodesis in combination with cuff repair when the LHBT appeared macroscopically normal during surgery: Constant score (87 ± 8 vs. 83 ± 11, p = 0.003), ASES score (91 ± 19 vs. 85 ± 22, p = 0.002), and SSV (95 ± 9 vs. 79 ± 31, p < 0.001). No statistically significant difference was found in Constant score improvement. Tenodesis was associated with better flexion strength, but no statistical differences were observed for other outcomes, including the Popeye deformity. At two years, cuff healing rates were similar between the two groups.

Conclusion: After controlling for confounding factors, the macroscopic appearance of the LHBT did not significantly influence clinical outcomes at two years after rotator cuff repair and tenotomy or tenodesis.

Level of evidence: III; Prospective non-randomized study.

Background: Clinical effectiveness of platelet-rich plasma (PRP) for knee osteoarthritis (OA) continues to be debated, largely due to inconsistencies in PRP preparation methods and the variability in platelet concentrations. The optimal therapeutic range for platelet concentration remains unclear, leading to inconsistent treatment protocols and outcomes across studies. This systematic review and meta-analysis aimed to evaluate whether platelet count in PRP influences clinical outcomes in patients with knee OA.

Materials and methods: A systematic search was conducted in MEDLINE, Scopus, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials through February 2024. Randomized controlled trials evaluating PRP injections in knee OA were included. Studies reporting platelet counts in whole blood and PRP, as well as baseline and follow-up pain and functional scores, were analyzed. Standardized mean differences (SMD) were computed, and subgroup analyses were conducted based on platelet fold increase in PRP preparation.

Results: Forty studies met the inclusion criteria. PRP improved both pain and function across all platelet concentration categories. However, lower platelet fold increases (0-2× and >2-4×) demonstrated greater clinical benefits (SMD 1.84, 95% CI [1.05, 2.04], p = 0.0004 and SMD 1.36, 95% CI [0.94, 1.79], p < 0.0001, respectively) compared to higher concentrations (>4-6× and >6-9×). Effect sizes for lower concentrations exceeded established minimal clinically important differences.

Discussion: Moderate platelet count increases (2-4×) in PRP appear optimal for knee OA treatment. Higher platelet concentrations may not provide additional benefit and could attenuate therapeutic effects. These findings highlight the importance of standardizing PRP formulations to optimize efficacy while minimizing variability.

Level of evidence: I.

Background: Biopsy and curettage are frequently used in orthopaedic oncology surgeries. However, these procedures reduce bone strength and result in pathological fractures. Therefore, meticulous planning of the size and shape of the cortical window is paramount to preserve bone strength. However, few studies have examined the shape and size of the windows created for biopsy and curettage procedures. The purpose of this study was to evaluate the effect of cortical window shape (rectangular versus elliptical) on bone strength and to evaluate the effect of ellipses with different dimensions on bone strength.

Hypothesis: The hypothesis of this study was that an elliptical cortical window would have a lesser impact on bone strength than a rectangular window, particularly in cases where the length of the ellipse increases while its width decreases.

Materials and methods: Sixty-four synthetic femur models were divided into four groups (n = 8) for compression and torsional tests. Four equal-area cortical windows were created. G1 (rectangular), G2 (elliptical, 1/1.5 ratio), G3 (elliptical, 1/3 ratio), and G4 (elliptical, 1/6 ratio). Compression tests (10 mm/min) were used to assess the maximum load, stiffness, yield load, and fracture energy. Torsion tests (50º/min) were used to measure the maximum torque, stiffness, and work done. Biomechanical performance was compared using load-displacement and torque-angular displacement data.

Results: All bone models were fractured along the cortical window. G3 (elliptical, 511.09 ± 55.07 N) had higher maximum load than G1 (rectangular, 389.18 ± 88.46 N, p = 0.003). The elliptical groups (G2:71.21 N/mm, G3:71.04 N/mm, G4:84.10 N/mm) showed greater compression stiffness than G1 (52.60 N/mm, p ≤ 0.05). G3 had higher yield load (458.72 ± 43.42 N) and work done (2.6 J) than G1 (352.43 ± 91.24 N, 1.78 J, p ≤ 0.05). No significant difference in torsion test results was observed between G3 and G1 (p > 0.05). G2 exhibited lower maximum load, yield load, and work than G3 and G4 (p ≤ 0.003). G4 exhibited higher torque (17.08 Nm) than G2 (11.73 Nm, p = 0.02) and G3 (12.62 Nm, p = 0.018). The torsional stiffness was similar across the elliptical groups.

Discussion: This biomechanical study demonstrated that elliptical cortical windows, especially those with higher length-to-width ratios, outperform rectangular windows in terms of strength under compression and torsional loads. These findings suggest that elliptical cortical windows may provide biomechanical advantages in terms of preserving bone strength and reducing fracture risk. However, as these results are based on an experimental model, further in vivo studies are needed to confirm their clinical applicability.

Level of evidence: V; Comparative laboratory study.

Background: Megaprostheses, initially developed for oncological indications, have increasingly found application in traumatology and hip and knee revision surgery. However, their frequent complications highlight the importance of learning the procedure. This study aims to provide original data on the impact of a surgeon's learning curve on key perioperative outcomes of these surgeries.

Question/purpose: The experience of surgeons performing massive arthroplasties influences key perioperative outcomes.

Patients and methods: We conducted a monocentric retrospective study between January 2005 and August 2022, involving 93 megaprostheses surgeries performed for non-oncological indications. Learning curves were constructed using the LOESS (Locally Estimated Scatterplot Smoothing) method, based on intraoperative data such as total blood loss (TBL) and blood volume transfused (BVT). These curves were used to categorize surgeons into the learning phase (SLP) and mastery phase (SMP). We also compared the cumulative incidence of reinterventions for complications between the two groups.

Results: Linear regression analysis revealed a learning effect for the TBL with thresholds of five procedures (R² = 0.139; p = 0.008), and five procedures for BVT (R² = 0.079; p = 0.002). Based on these findings, we defined the threshold for the learning phase as up to four procedures, and the mastery phase from the fifth procedure onwards. Multivariate analysis showed a slightly higher cumulative incidence of re-interventions for complications in the SLP group (33%; n = 14) compared to the SMP group (22%; n = 11), with a Hazard Ratio of 2.07 (CI 95% [0.94-4.59]; p = 0.071) without reaching statistical significance.

Conclusion: This study describes a learning curve for performing proximal and distal femur replacement with megaprostheses in non-oncological indications. Despite it is well established that all surgical procedures benefit from supervision during the early learning phase, we did not find a learning effect on the risk of reoperation for complications. Nevertheless, there is an improvement on variables such as bleeding along the learning curve, leading to suggest that these interventions should be performed by experienced surgeons or under supervision.

Level of evidence: IV.

Background: The medial patellofemoral ligament (MPFL) reconstruction is commonly conducted using gracilis, semitendinosus, quadriceps or tensor fascia lata tendon autografts or allografts. This approach, however, can sometimes lead to complications or morbidity at the site from which the graft is harvested. This study reports the clinical outcomes of non-elite competitive athletes who undergone MPFL reconstruction using an ultrahigh-strength 2-mm-wide tape.

Patients and methods: This retrospective cohort study included 67 non-elite athletes with acute or recurrent lateral patellar instability who underwent surgical treatment between December 2015 and December 2020. Athletes who underwent tibial tubercle osteotomy due to severe patellofemoral arthritis or severe osteochondral damage (kissing lesions or >2.5cm²) (1), trochlear dysplasia (Dejour type D dysplasia) (5), open physis (19) and revison MPFL reconstruction (8), were excluded. The remaining 34 athletes were followed postoperatively for a minimum of 48 months.

Results: During the follow-up period, there was only one case and which was revised by adding Fulkerson Osteotomy. Two patients had limited range of motion and joint mobilization was performed under general anesthesia at the end of the second month. The International Knee documentation Committee (IKDC), Kujala, and visual analog scale (VAS) scores showed improvement postoperatively (p < 0.001). Moreover, the mean improvements in IKDC (≈+41), Kujala (≈+33), and VAS (≈-3.8) scores exceeded the established minimal clinically important difference (MCID) thresholds, indicating that the outcomes were not only statistically significant but also clinically meaningful for patients. When comparing the pre- and postoperative radiological measurements, the mean tilt angle and mean congruence angle showed a significant decrease (p < 0.001) CONCLUSION: Suture tape may be a good alternative to autograft, as it does not cause donor site morbidity. However, its most important disadvantage is its higher cost.

Level of evidence: IV; Retrospective case series.

Background: Literature exploring impacts and quality of life limitations of pelvic ring and acetabular fracture is limited. The aim of the study is to evaluate the impact of pelvic ring and acetabular fracture on the return to work (RTW) and sports (RTS) and identify factors associated with difficulties to resume their previous activities.

Hypothesis: Patients with pelvic ring and acetabular fractures will experience difficulties to return to their previous occupation and physical activities.

Patients and methods: This is a retrospective cohort study reviewing the medical and radiological charts under IRB approbation. The patients were contacted for a final questionnaire assessing the RTW and the RTS at a minimum of two years follow-up. All patients admitted for a surgically treated pelvic ring and/or acetabulum fracture between 2009 and 2022 at a level 1 trauma center were included. For RTW, collected information covered an overview of the patients' employment situation and classifying it by level of occupational activity. Global physical activity level was assessed with the UCLA Hip Activity Scale. Other variables of interest included: concomitant injury, trauma type, pelvic ring fracture type, delay for final fracture stabilization, and complications. Initial analysis was carried out based on the ability to resume activities at the level before the trauma (success or failure). Uni- and multivariate analyzes were conducted to identify factors associated with a failed return to their activities.

Results: One hundred and thirteen patients completed the final questionnaire (73% men, average age 51 ± 16.7 years). Among 88 patients still employed at the time of the trauma, 57 patients had a difficult RTW (65%). Forty-eight patients had a difficult RTS (43%). Thirty-four patients (39%) never returned to work and 30 patients (27%) did not return to sports. The presence of other fractures within the initial trauma (OR 3.17; 95%CI 1.24-8.10; p = 0.014) and a concomitant traumatic brain injury (OR 3.78; 95%CI 1.27-11.27; p = 0.013) are significantly associated with a difficult RTW. The presence of marginal impaction on the acetabulum (OR = 7.3; p = 0.014, CI95% 1.44-37.16) is associated with a difficult RTS.

Discussion: Most patients with a surgically treated pelvic and acetabular fracture have a difficult RTW and RTS. Among the factors identified, few are modifiable. The study does not show influence of quality reduction on RTW and RTS.

Level of evidence: III; Retrospective cohort study.

Background: Intertrochanteric fractures in the elderly present challenges due to poor bone healing and high complication rates. Platelet-rich plasma (PRP) may promote early bone regeneration, but clinical evidence, especially for osteoporotic fractures, is limited. Unlike extramedullary injections, intramedullary PRP specifically targets the vascular marrow at the fracture site. This randomized controlled trial aimed to evaluate the effect of intramedullary PRP application on fracture healing and clinical outcomes in elderly patients undergoing surgical fixation for intertrochanteric fractures.

Hypothesis: We hypothesized that intramedullary PRP would accelerate early bone healing and improve postoperative functional recovery compared to placebo.

Patients and methods: This single-center, double-blind, parallel-group trial was conducted from November 2020 to December 2024. Patients aged ≥60 years with isolated low-energy intertrochanteric femoral fractures were randomized to receive either 5 mL of autologous PRP or 5 mL of normal saline intraoperatively. All patients underwent fixation with a short cephalomedullary nail. Follow-up assessments were performed at 2 weeks, 6 weeks, 3 months, and 6 months postoperatively.

Results: Eighty-four patients were randomized (40 to the PRP group, 44 to the control group), with no significant differences in baseline characteristics. At 2 weeks, the PRP group showed a significantly higher Radiographic Union Score for Hip (RUSH) than the control group (12.0 vs. 10.5; P < 0.001); however, no significant differences were observed at 6 weeks, 3 months, or 6 months. Postoperative bone turnover markers (P1NP, osteocalcin, ALP, Beta-Crosslaps, and bone-specific ALP) were comparable between groups. Functional outcomes, assessed by the Harris Hip Score, Barthel Index, and De Morton Mobility Index at 6 weeks and 6 months, did not differ significantly.

Discussion: Intramedullary PRP did not improve mid- to long-term fracture healing or functional outcomes in elderly patients with intertrochanteric fractures. Although early radiographic healing was enhanced at 2 weeks, this benefit was not sustained over time. Functional recovery also showed no significant difference. PRP may offer limited clinical benefit in this population, and further research is needed to assess its role in selected subgroups or with modified protocols.

Level of evidence: I.