Acta Orthopaedica最新文献

Background and purpose: Dislocation is a severe complication following total hip arthroplasty (THA). Hip precautions have been recommended in the initial postoperative period but evidence supporting this practice is limited. We therefore conducted a population-based study to evaluate the association between discontinuing recommending postoperative hip precautions and the risk of early dislocation.

Methods: This is a cohort study with data from the Danish Hip Arthroplasty Register and the Danish National Patient Register. We included patients who underwent primary THA for osteoarthritis in 2004-2019 in public hospitals in the Capital Region of Denmark. The cohort was divided into the hip precautions group, comprising patients operated on between 2004 and 2009, and the no-precautions group operated on between 2014 and 2019. The primary outcome was the difference in the absolute risk of dislocation within 3 months post-surgery. The secondary outcome assessed the same risk within 2 years. We evaluated the difference in absolute risk using absolute risk regression (ARR).

Results: The cumulative incidence of dislocation within 3 months was 2.9% (confidence interval [CI] 2.5-3.3) in the hip precautions group and 3.5% (CI 3.1-3.9) in the no-precautions group. The risk of dislocation was higher in the no-precautions group but failed to reach statistical significance in the crude (ARR 1.2, CI 0.9-1.6) and multivariate model (ARR 1.4, CI 0.9-2.2).

Conclusion: We found a higher but statistically insignificant increase in the risk of early dislocation in the no-precautions group. The lack of significance in the association may be explained by the increased use of 36-mm femoral heads after the guideline revision.

Background and purpose: The primary aim of this systematic review and meta-analysis was to evaluate the success rate of 3 different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy (LLD) in the pediatric population. The secondary aim was to address effectiveness (final LLD) and the reported complications of staples, tension-band plates (TBP), and percutaneous epiphysiodesis screws (PETS).

Methods: In this systematic review we searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre-/postoperatively, successful/unsuccessful) and complications that were graded on severity.

Results: 44 studies (2,184 patients) were included. 455 underwent epiphysiodesis with PETS, 578 patients with TBP, and 1,048 with staples. Successful epiphysiodesis was reported in 76% (95% confidence interval [CI] 61-89) with PETS (9 studies), 67% (CI 54-79) with TBP (10 studies), and 51% (CI 28-65) with Blount staples (8 studies). From pooled analysis, the severe complications rate was 7% for PETS, 17% for TBP, and 16% for Blount staples. Angular deformity was reported in 4% after PETS, 10% after TBP, and 17% after Blount staples.

Conclusion: Our results showed that epiphysiodesis with PETS implants was the most successful technique. PETS had a higher success rate, fewer severe complications, and a lower proportion with angular deformity.

Background and purpose: The aim of our study was to investigate change in modifiable risk factors following preoperative optimization and whether risk of superficial surgical site infection (SSI) after total joint arthroplasty (TJA) could be reduced.

Methods: This is a prospective study of implementation of a preoperative optimization pathway for patients waiting for primary TJA. Information regarding the intervention arm was collected from January 2019 to January 2021, first at decision for operation and then at preoperative assessment 1 week prior to operation. The control arm was included between August 2018 and September 2020 after receiving conventional preoperative preparation and information gathered at preoperative assessment. Follow up occurred 6 weeks postoperatively for both groups. The primary outcome was postoperative superficial SSI.

Results: The optimization effort resulted in improvement of weight, anemia, HbA1c, vitamin D, and patient engagement. At preoperative assessment the baseline characteristics of the 2 groups were similar except that the intervention group had substantially more comorbidities. Regarding superficial SSI, association was found with BMI ≥ 30 and HbA1c ≥ 42 mmol/mol in the control group but not in the intervention group. When corrected for differences in ASA classification (reflecting comorbidities), age, and sex, being in the intervention group was associated with lower odds of occurrence of superficial SSI compared with the control group (OR 0.64, 95% confidence interval 0.42-0.97).

Conclusion: We showed that preoperative optimization in a structured cooperation between hospital and primary care was associated with a reduced risk of superficial SSI.

Background and purpose: The aim of our study was to assess the regional variations in Achilles tendon rupture incidence and treatment methods in Finland during the period 1997-2019.

Methods: The Finnish National Hospital Discharge Register (NHDR) and the Finnish Register of Primary Health Care Visits (PHCR) were searched to identify all adult patients diagnosed with Achilles tendon rupture during our study period. The population-based annual incidence and incidences of surgically and non-surgically treated Achilles tendon ruptures were calculated for each hospital district.

Results: Achilles tendon rupture incidence increased from 17.3 per 105 person-years in 1997 to 32.3 per 105 in 2019. The mean incidence of Achilles tendon ruptures ranged from 26.4 per 105 (North Savo) to 37.2 per 105 (Central Ostrobothnia). The incidence of Achilles tendon ruptures increased in all areas. The proportion of non-surgical treatment of Achilles tendon ruptures ranged in 1997 from 7% (Vaasa) to 67% (Åland) and in 2019 from 73% (Southwest Finland) to 100% (East Savo, Kainuu, Länsi-Pohja, Åland). During the study period, a shift towards non-surgical treatment was evident in all hospital districts.

Conclusion: Regional variations in Achilles tendon rupture incidence exist in Finland; however, the incidence increased in all areas during the follow-up period. More Achilles tendon rupture patients are currently being treated non-surgically throughout the country.

Background and purpose: Dislocations continue to be a serious complication after primary total hip arthroplasty (THA). Our primary aim was to report the "true" incidence of dislocations in Denmark and secondarily to validate a previously developed algorithm designed to identify THA dislocations in the updated version of the Danish National Patient Register (DNPR), based on data from the Danish Hip Arthroplasty Register (DHR).

Methods: We included 5,415 primary THAs from the DHR performed from July 1 to December 31, 2019. Version 3 of the DNPR was launched in February 2019, and a combination of data from the DNPR and a comprehensive national review of 1,762 hospital contacts enabled us to identify every dislocation occurring during the 1st year after THA to determine the "true" 1-year incidence of dislocation. The results were presented as proportions with 95% confidence intervals (CI), and validation was performed by calculating sensitivity and predictive values.

Results: The "true" 1-year incidence of dislocation was 2.8% (CI 2.4-3.3). Of these, 37% suffered recurrent dislocations during the follow-up period. Between-hospital variation ranged from 0.0% to 9.6%. The algorithm demonstrated a sensitivity close to 95%, while maintaining a positive predictive value of above 94%.

Conclusion: The "true" 1-year incidence of dislocation of 2.8% is comparable to earlier findings, and large variation among hospitals continues to be evident. We have proven the algorithm to be valid in the latest DNPR (version 3), enabling it to be employed as a new quality indicator in future annual DHR reports.

Background and purpose: There is controversy regarding the results of stemmed and stemless total shoulder arthroplasty (TSA) used for osteoarthritis. Therefore, we aimed to compare revision rates of stemmed and stemless TSA and to examine the impact of metal-backed glenoid components.

Methods: We included all patients reported to the Danish Shoulder Arthroplasty Register from January 1, 2012 to December 31, 2022 with an anatomical TSA used for osteoarthritis. Primary outcome was revision (removal or exchange of components) for any reason.

Results: 3,338 arthroplasties were included. The hazard ratio for revision of stemless TSA adjusted for age and sex was 1.83 (95% confidence interval [CI] 1.21-2.78) with stemmed TSA as reference. When excluding all arthroplasties with a metal-backed glenoid component, the adjusted hazard ratio for revision of stemless TSA was 1.37 (CI 0.85-2.20). For the Eclipse stemless TSA system, the adjusted hazard ratio for revision of a metal-backed glenoid component was 8.75 (CI 2.40-31.9) with stemless Eclipse with an all-polyethylene glenoid component as reference.

Conclusion: We showed that the risk of revision of stemless TSAs was increased and that it was related to their combination with metal-backed glenoid components.

Background and purpose: Magnetically controlled motorized intramedullary lengthening nails (ILNs) can be employed for simultaneous correction of angular deformities of the distal femur and leg length discrepancy. This spares typical complications of external fixators but requires precise preoperative planning and exact intraoperative execution. To date, its results are insufficiently reported. We aimed to elucidate the following questions: (i) Is acute angular deformity correction and gradual femoral lengthening via a retrograde ILN a reliable and precise treatment option? (ii) What are the most common complications of treatment?

Methods: Acute angular deformity correction and subsequent gradual lengthening of the distal femur with retrograde ILN was retrospectively analyzed in 45 patients (median patient age: 15 years, interquartile range [IQR] 13-19 and median follow-up: 40 months, IQR 31-50). Outcome parameters were accuracy, precision, reliability, bone healing, and complications of treatment.

Results: The median distraction was 46 mm (IQR 29-49), median distraction and consolidation index 0.9 mm/day (IQR 0.7-1.0) and 29 days/cm (IQR 24-43), respectively. The median preoperative mechanical axis deviation (MAD) was 30 mm (IQR 23-39) in the varus cohort and -25 mm (IQR -29 to -15) in the valgus cohort and reduced to a mean of 8 mm (standard deviation [SD] 8) and -3 (SD 10), respectively. Accuracy, precision, and reliability of lengthening were 94%, 95% and 96%, respectively. Accuracy and precision of deformity correction were 92% and 89%, respectively. In total, 40/45 of patients achieved distraction with a difference of less than 1 cm from the initial plan and a postoperative MAD ranging from -10 mm to +15 mm. In 13/45 patients unplanned additional surgeries were conducted to achieve treatment goal with nonunion being the most frequent (4/45) and knee subluxation (3/45) the most severe complication.

Conclusion: Acute deformity correction and subsequent lengthening of the distal femur with retrograde ILN is a reliable and accurate treatment achieving treatment goal in 89% but unplanned additional surgeries in 29% of patients should be anticipated.

Background and purpose: First-line treatment (education, exercise) for patients with hip and knee osteoarthritis (OA) aims to reduce pain and improve function. We aimed to compare progression to joint replacement within 5 years between responders and non-responders to first-line treatment for hip and knee OA, respectively.

Methods: This observational study included data for 30,524 knee OA and 13,787 hip OA patients from the Swedish Osteoarthritis Register, linked with the Swedish Arthroplasty Register, Statistics Sweden, and the Swedish Prescribed Drug Register. The primary prognostic factor was change in pain between baseline and 3-month follow-up, measured on a numeric rating scale (0-10, best to worst) where an improvement of ≥ 2 was classified as responder and ≤ 1 as non-responder. The main outcome was progression to joint replacement surgery within 5 years, assessed using baseline adjusted multivariable Cox regression analyses.

Results: At 5 years, in hip OA, 35% (95% confidence interval [CI] 32.2-37.2) of the responders and 48% (CI 45.9-49.5) of the non-responders and in knee OA 14% (CI 13.0-15.3) of the responders and 20% (CI 18.8-20.8) of the non-responders had progressed to joint replacement. Being a responder to the treatment was associated with having a lower probability of progression to surgery for both hip OA (hazard ratio [HR] 0.4, CI 0.4-0.5) and knee OA (HR 0.6, CI 0.5-0.6).

Conclusion: Patients with hip or knee OA who experienced pain relief after a first-line OA treatment program were less likely to progress to joint replacement surgery.

Background and purpose: Mortality after major lower extremity amputations is high and may depend on amputation level. We aimed to examine the mortality risk in the first year after major lower extremity amputation divided into transtibial and transfemoral amputations.

Methods: This observational cohort study used data from the Danish Nationwide Health registers. 11,205 first-time major lower extremity amputations were included from January 1, 2010, to December 31, 2021, comprising 3,921 transtibial amputations and 7,284 transfemoral amputations.

Results: The 30-day mortality after transtibial amputation was overall 11%, 95% confidence interval (CI) 10-12 (440/3,921) during the study period, but declined from 10%, CI 7-13 (37/381) in 2010 to 7%, CI 4-11 (15/220) in 2021. The 1-year mortality was 29% overall, CI 28-30 (1,140 /3,921), with a decline from 31%, CI 21-36 (117/381) to 20%, CI 15-26 (45/220) during the study period. For initial transfemoral amputation, the 30-day mortality was overall 23%, CI 22-23 (1,673/7,284) and declined from 27%, CI 23-31 (138/509) to 22%, CI 19-25 (148/683) during the study period. The 1-year mortality was 48% overall, CI 46-49 (3,466/7,284) and declined from 55%, CI 50-59 (279/509) to 46%, CI 42-50 (315/638).

Conclusion: The mortality after major lower extremity amputation declined in the 12-year study period; however, the 1-year mortality remained high after both transtibial and transfemoral amputations (20% and 46% in 2021). Hence, major lower extremity amputation patients constitute one of the most fragile orthopedic patient groups, emphasizing an increased need for attention in the pre-, peri-, and postoperative setting.

Background and purpose: Artificial intelligence (AI) has the potential to aid in the accurate diagnosis of hip fractures and reduce the workload of clinicians. We primarily aimed to develop and validate a convolutional neural network (CNN) for the automated classification of hip fractures based on the 2018 AO-OTA classification system. The secondary aim was to incorporate the model's assessment of additional radiographic findings that often accompany such injuries.

Methods: 6,361 plain radiographs of the hip taken between 2002 and 2016 at Danderyd University Hospital were used to train the CNN. A separate set of 343 radiographs representing 324 unique patients was used to test the performance of the network. Performance was evaluated using area under the curve (AUC), sensitivity, specificity, and Youden's index.

Results: The CNN demonstrated high performance in identifying and classifying hip fracture, with AUCs ranging from 0.76 to 0.99 for different fracture categories. The AUC for hip fractures ranged from 0.86 to 0.99, for distal femur fractures from 0.76 to 0.99, and for pelvic fractures from 0.91 to 0.94. For 29 of 39 fracture categories, the AUC was ≥ 0.95.

Conclusion: We found that AI has the potential for accurate and automated classification of hip fractures based on the AO-OTA classification system. Further training and modification of the CNN may enable its use in clinical settings.