Acta Orthopaedica最新文献

Background and purpose:  One of the most severe complications of distal radius fractures (DRF) is the development of complex regional pain syndrome (CRPS). The incidence proportion (IP) of CRPS following DRF varies widely in the literature. Our aim is to report the incidence proportion of CRPS in DRF patients, subgrouping on age, sex, and treatment choice, and secondarily to assess development over time.

Methods:  Data was extracted from the Danish National Patient Register on patients > 18 years diagnosed with a DRF (S525) in the period 1998-2017.

Results:  There were 247,128 DRF in 203,533 patients with a mean age of 61 years. 75% were females. Within 1 year, 493 DRF patients developed CRPS corresponding to a 1-year IP of 0.20% and with an incidence density of 0.57/100,000/year. Median time from DRF to diagnosis was 89 days (SD 73). The IP ranged from 0.01% to 0.39% between age groups with the 30-65-year-olds having the highest incidence proportion. The surgically treated group had an IP of 0.31% and the non-surgical group had an IP of 0.17%. CRPS was slightly more common in women than men (0.21% vs 0.16%). We found a decrease in IP after 2010 from 0.24% to 0.14%.

Conclusion:  There was a low IP of CRPS diagnosis after DRF treatment with an observed higher IP in the 30-65-year-olds and in surgically treated patients. We consider this to be a minimum IP due to possible undiagnosed cases, but the overall results may be closer to the clinical reality than previous studies.

Background and purpose:  In 2013, the first clinical practice guideline for subacromial pain syndrome (SAPS) was developed in the Netherlands to support healthcare professionals. SAPS refers to non-traumatic, non-rheumatologic shoulder complaints that are particularly painful during arm elevation. It includes conditions such as supraspinatus tendinosis, calcific tendinitis, and degenerative supraspinatus tears. Over 50,000 patients annually consult orthopedic surgeons for these issues. In response to new evidence and clinical needs, an updated guideline was developed. Part 1 addresses prevention, diagnosis, imaging, and non-surgical treatment. Using a multidisciplinary, evidence-based approach, the guideline aims to answer key clinical questions around SAPS.

Methods:  Initiated by the Dutch Orthopedic Society, the guideline committee identified knowledge gaps through group sessions. Each module was based on a PICO-formatted key question and reviewed by professionals from different fields. The AGREE and GRADE methods were applied to ensure a systematic evaluation of evidence, leading to conclusions and recommendations.

Results:  (i) Inform patients about the potential positive effects of a healthy lifestyle and encourage gradual exercise within sport and work. (ii) Perform a cluster of physical diagnostic tests to diagnose SAPS. (iii) Perform ultrasonography in patients with clinical suspicion of (partial thickness) rupture of the supraspinatus tendon. Consider MRI if ultrasound is not available or inconclusive. (iv) Consider barbotage for symptomatic calcific tendinosis, preferably with corticosteroid injection in the bursa, if a previous corticosteroid injection was ineffective. (v) Consider a subacromial corticosteroid injection (with a local anesthetic) to enable exercise therapy in patients with severe complaints that impair their ability to participate in exercise therapy. (vi) Consider suprascapular nerve block for patients with therapy-resistant SAPS when other non-surgical treatment is ineffective.

Conclusion:  The updated guideline provides multidisciplinary recommendations for physical examination, imaging, and conservative management of SAPS.

Background and purpose:  Radiostereometric analysis (RSA) of total knee arthroplasty (TKA) is used as an early safeguard during the phased evidence-based introduction of new implants. The goal of our study was to compare the long-term revision risk between RSA-tested implants and non-RSA-tested implants in the Netherlands using patient-level data.

Methods:  All primary TKAs between 2007 and 2016 from the Dutch Arthroplasty Register were included, and procedures with an RSA-tested implant were identified. Both all-cause major revision risk and revision risk because of loosening were calculated at 5 and 10 years postoperatively using Kaplan-Meier analyses. Sensitivity analyses were performed with stricter definitions of implant characteristics to classify procedures as RSA-tested, to avoid camouflage of different subdesigns within the same brand implant portfolio.

Results:  83,638 RSA-tested and 104,105 non-RSA-tested TKAs were included. Cumulative all-cause major revision percentages for the RSA-tested group at 5 and 10 years were 2.2% (95% confidence interval [CI] 2.1-2.3) and 3.6% (CI 3.4-3.7), respectively, compared with 2.5% (CI 2.4-2.6) and 3.3% (CI 3.2-3.4) for the non-RSA-tested group. RSA-tested TKAs showed higher 10-year revision risks because of loosening than non-RSA-tested procedures (1.8%, CI 1.7-1.9 vs 1.4%, CI 1.3-1.4, respectively). Comparable results were found after stratification by various patient characteristics and with stricter classification approaches.

Conclusion:  Regarding all-cause revision risk, RSA-tested TKAs had a slightly lower risk at 5 years. However, at 10 years the RSA-tested TKAs had a higher all-cause revision risk and higher revision risk because of loosening compared with the non-RSA-tested TKAs.

Background and purpose:  In 2013, the first clinical practice guideline for subacromial pain syndrome (SAPS) was developed in the Netherlands to support healthcare professionals. SAPS refers to non-traumatic, non-rheumatologic shoulder complaints that are particularly painful during arm elevation. It includes conditions such as supraspinatus tendinosis, calcific tendinitis, and degenerative supraspinatus tears. Over 50,000 patients annually consult orthopedic surgeons for these issues. In response to new evidence and clinical needs, an updated guideline was developed. Part 2 focuses on supraspinatus tears, biceps tendon pathology, and calcific tendinosis. Using a multidisciplinary, evidence-based approach, the guideline aims to answer key clinical questions around SAPS.

Methods:  Initiated by the Dutch Orthopedic Society, the guideline committee identified knowledge gaps through group sessions. Each module was based on a PICO-formatted key question and reviewed by professionals from different fields. The AGREE and GRADE methods were applied to ensure a systematic evaluation of evidence, leading to conclusions and recommendations.

Results:  (i) Start with exercise-based therapy (with corticosteroid injection) for isolated, symptomatic, non-traumatic supraspinatus tears. Consider cuff repair if no improvement after 3-6 months. (ii) Avoid biceps tenotomy/tenodesis on a healthy tendon unless at risk during cuff repair. (iii) Evaluate patient- and tear-specific factors; use MRI for detailed assessment. (iv) Consider barbotage for calcific tendinosis; repeat once if needed. Reserve surgery for persistent large calcifications. (v) Postoperative immobilization should not exceed 3 weeks.

Conclusion:  The updated guideline provides multidisciplinary recommendations for surgical management.

Background and purpose:  Traumatic fractures of the thoracolumbar spine happen in the younger, working-age population and often compromise return to work (RTW), a key factor in functional recovery and overall quality of life. Our review summarizes the current evidence on RTW following traumatic thoracolumbar fractures without spinal cord injury.

Methods:  A comprehensive literature search was conducted in Embase, Medline (OvidSP), Web of Science, CINAHL and Cochrane through July 2025. Studies were included if they met the following criteria: (i) traumatic thoracolumbar spine fracture without spinal cord injury, (ii) RTW reported as an outcome measure, (iii) prospective or retrospective cohort study or case-control design, and (iv) availability of a full-text article. Risk of bias was assessed for each included study.

Results:  31 studies met the inclusion criteria. Follow-up ranged from 3 to 226 months. Only 8 out of 31 studies were rated as low risk of bias. Reported RTW rates varied widely: 25% to 100% after surgical treatment (n = 19 studies) and 38% to 100% after non-surgical treatment (n = 19 studies). Pooled estimates showed that the mean RTW is between 76% and 84% in patients with a thoracolumbar spine fracture, irrespective of treatment modality.

Conclusion:  Estimated RTW rates range between 76% and 84%.

Background and purpose:  National joint arthroplasty registries are the gold standard for monitoring long-term acetabular implant survivorship. Sensitive radiographic surveillance (SRS) has been recommended as a complementary surveillance approach, but no study has investigated whether implants introduced with no sensitive radiographic surveillance (NSRS) are associated with higher revision rates. Therefore, we investigated whether acetabular implants with NSRS are associated with higher revision rates than those with SRS.

Methods:  Acetabular implants with SRS were defined as those with published evidence of stability measurements assessed using either radiostereometric analysis or "Ein Bild Röntgen Analyse." Evidence of SRS of acetabular implant designs was sourced from 2 literature reviews. A mixed-effects model was used to pool and compare the revision rate of acetabular implants with SRS and NSRS at 5 and 10 years from 5 arthroplasty registries.

Results:  There were 29 unique acetabular implant designs with SRS and 86 designs with NSRS that had matching 5- and 10-year revision rates. At 5 years, there was a mean difference of 0.8% (95% confidence interval [CI] 0.5-1.1) in mean all-cause revision rates favoring implants with SRS. Mean all-cause revision rates at 10 years for acetabular implants with SRS and NSRS were 5.2% (CI 4.9-5.5) and 7.4% (CI 7.0-7.9) respectively, with a mean difference of 1.8% (CI 1.2-2.3) favoring implants with SRS.

Conclusion:  Acetabular implants with NSRS were associated with 1.8% higher pooled revision rates than those with SRS at 10 years, which represents a relative increase in acetabular revision burden of approximately 36%.

Background and purpose: Tibial periprosthetic fractures (PPF), periprosthetic joint infections (PJI), and bearing dislocations (BD) are among the most common short-term complications in medial unicompartmental knee arthroplasty (mUKA). We aim to assess whether patients with these complications have patient-reported outcome measures (PROMs) that differ from patients with primary mUKA, primary total knee arthroplasty (TKA), or after revision TKA .

Methods: This observational study included 74 mUKA patients reoperated for PPF (n = 22), PJI (n = 15), or BD (n =3 7) between January 2018 and January 2023. Comparator groups included 1,940 primary mUKA, 3,485 primary TKA, and 350 reoperated TKA patients. The primary endpoint was Oxford Knee Score (OKS) at 12 months. Missing data was imputed, and multilevel Tobit regression was used to analyze differences in PROMs.

Results: At 12 months, reoperated mUKAs had lower PROM scores than primary mUKAs (OKS difference -3.3, 95% confidence interval [CI] -5.0 to -1.5) and TKAs (OKS difference -2.7, CI -4.4 to -0.9) but higher than reoperated TKAs (OKS difference: 3.0, CI 1.1 to 5.0). PPF mUKAs had 12-month scores resembling reoperated TKAs (OKS difference -0.7, CI -3.9 to 2.5). PJI mUKAs and BD mUKAs had 12-month scores resembling primary mUKAs (PJI: OKS difference -2.4, CI -6.2 to 1.5, BD: OKS difference -2.2, CI -4.7 to 0.2) and primary TKAs (PJI: OKS difference -1.7, CI -5.6 to 2.1, BD: OKS-difference -1.6, CI -4.1 to 0.8).

Conclusion: Patients reoperated for PJI and BD achieved outcomes comparable to primary mUKAs and TKAs, while PPF resulted in scores lower than primary mUKAs and TKAs, comparable to reoperated TKAs.

Background and purpose:  The use of a tourniquet in knee replacement surgery is debated. Given the conflicting evidence, we aimed to compare the risk of revision after total knee replacements (TKR) with or without the use of tourniquet.

Methods:  In this register based observational study, we included the 5 most common cemented primary TKR models due to osteoarthritis reported to the Swedish Arthroplasty Register 2010-2024 and followed them until December 31, 2024. The first revision for implant loosening was the primary outcome. We estimated the cumulative revision rate (CRR) with 95% confidence interval (CI) using the 1-Kaplan-Meier method. We examined the use of a tourniquet regarding the risk of revision using multiple Cox regression analysis to calculate the hazard ratio (HR) with CI and adjusted for potential confounding factors.

Results:  Of the 149,616 TKRs included, 65,570 (44%) were with tourniquet and 84,046 (56%) without tourniquet. The CRR was similar at all time-points for all causes and infection; however, CRR started to increase at 6-7 years for implant loosening with use of a tourniquet. In the Cox regression analysis, the use of a. tourniquet was associated with an increased risk of revision for implant loosening after 5 years (HR 1.56, CI 1.06-2.30). There was no difference in revision for all causes (HR 1.07, CI 0.99-1.15) or infection (HR 1.08, CI 0.97-1.21).

Conclusion:  The use of a tourniquet was associated with an increased risk of revision for implant loosening after 5 years, while no association was found for all-cause revision or infection. Our results do not support the use of a tourniquet in TKR as a strategy to reduce the risk of revision, either due to all causes, implant loosening, or infection.

Background and purpose:  Patellofemoral joint replacements (PFR) and total knee replacements (TKR) are surgical treatment options for patellofemoral joint osteoarthritis. We aimed to compare patient-reported outcome measures (PROMs) for these procedures, and revision thresholds for PFR.

Methods:  Data from the National Joint Registry (2009-2021) was linked with the Hospital Episodes Statistics (HES) database. Data was then merged with the PROMs dataset and adjusted using inverse proportional treatment weighting methods. Primary PROMS were Oxford Knee Score (OKS) and EQ5D-3L at the 6-18-month mark with a minimal clinically important difference of 5 for OKS. Secondary outcome measures included threshold to revision, defined as the cut-off score at which an arthroplasty was revised. Differences in patient characteristics between those classed as best and worst outcomes were compared and regression analyses examined the influence of factors such as age, provider type (public or private healthcare), and comorbidities on PROMs with results stratified by sex.

Results:  340,449 matched records were analyzed (1,085 PFR, 339,364 TKR). The median postoperative OKS was 35 (PFR) and 38 (TKR), with a difference of -2.4. Patients with the best PFR outcomes were older (62.0 vs 57.2 years, P = 0.01). The median 6-month EQ5D-3L was 0.77 (PFR) and 0.80 (TKR). PFR had a higher revision hazard ratio (3.4, 95% confidence interval 2.7-4.4, P = 0.01), indicating a lower threshold for revision.

Conclusion:  Up to 18 months, in terms of OKS and EQ5D-3L, there was no significant difference between the 2 procedures. PFR had a lower threshold for revision compared with TKR. Future research should incorporate more objective measures, such as activity level, where objective differences might be identified.

Background and purpose:  While complication rates for primary pelvic and acetabular fracture surgeries are well documented, limited data exists on complications following osteosynthesis implant removals. We aimed to evaluate the complication rates of pelvic implant removals with respect to the surgical approach, type of implant, and indication for removal.

Methods:  This retrospective, consecutive case series included all patients undergoing pelvic implant removal between January 2013 and December 2023 using Kocher-Langenbeck, modified Stoppa (AIP), or ilioinguinal approaches for the removal. Isolated minimally invasive, percutaneous implant removals were excluded.

Results:  154 implant removals in 141 patients were analyzed. Overall complication rate was 34% (n = 53). Most common complications were intraoperative bleeding requiring transfusion (n = 17; 11%), postoperative anemia requiring transfusion (n = 12; 7.8%), and vascular injuries (n = 9; 5.8%). The ilioinguinal approach showed a higher complication rate (19/37; 51%) than the Kocher-Langenbeck (21/68; 31%) or the Stoppa/AIP approach (13/49; 27%). Removal of implants from the anterior pelvic ring and acetabulum (22/45; 49%) also had a higher complication risk than from the posterior pelvic ring and acetabulum (20/67; 30%) or of symphyseal plates (11/42; 26%). Removal due to infection also showed a particularly high complication rate (25/57; 44%) compared with aseptic indications, e.g., interfering material or removal for THA.

Conclusion:  Pelvic implant removals, especially from the anterior pelvic ring or acetabulum, using the ilioinguinal approach, and in case of infection, are associated with a particularly high complication risk. These findings can support clinical decision-making and informing patients on the potential risks of hardware removals.