Acta Orthopaedica最新文献

Background and purpose: Developmental dysplasia of the hip (DDH) affects around 1.5% of newborns in Sweden with few late detected cases (0.12 per 10,000). The most common treatment for DDH in Sweden is with the von Rosen splint, with radiographs at 3 and 12 months of age. Little is known about the remodeling of acetabular dysplasia following treatment initiated in the neonatal period. We aimed to examine the correlation between the acetabular index (AI) at 3 and 12 months.

Methods:  We included 228 patients with early detected DDH with dislocatable hips (Barlow) and dislocated hips (Ortolani), treated with the von Rosen splint at Skåne University Hospital 2003-2019. The treatment length was 6 weeks for 96 children and 12 weeks for 132 children. We calculated the correlation between AI at 3 and 12 months using Pearson correlation (r) and the mean difference, both with 95% confidence intervals (CI).

Results:  The correlation between AI at 3 and 12 months was moderate, r = 0.43 (95% confidence interval [CI] 0.35-0.50), with changes in AI that differed widely. The mean AI was 23.9° (CI 23.5-24.3) at 3 months and 24.9° (CI 24.6-25.3) at 12 months with a difference of 1.0° (CI 0.6-1.3).

Conclusion:  The correlation between AI at 3 and 12 months was moderate, with non-clinical difference for both 6 and 12 weeks of treatment. The small increase in mean AI was most likely explained by a low AI at 3 months after 12 weeks of treatment.

Background and purpose:  In patients with knee osteoarthritis (OA), psychological factors (anxiety, depression, and pain-related catastrophizing) are associated with more pain and worse physical function. Low knee awareness and high knee-related quality of life (QoL) are key indicators of a well-functioning knee. The objective of our study was to evaluate associations between psychological factors and knee awareness and knee-related QoL in patients with knee OA.

Methods:  In this Norwegian cross-sectional study of 653 patients with knee OA, 4 psychological factors were assessed: anxiety, depression, pain-related catastrophizing, and fear avoidance of physical activity. Associations between these factors and knee awareness and knee-related QoL were examined in unadjusted and adjusted regression models, controlling for age, sex, BMI, pain, and whether patients accepted or declined inclusion in a randomized controlled trial (ClinicalTrials.gov: NCT03771430). Regression coefficients with values below zero indicate negative associations between the independent and dependent factors and values above zero indicate positive associations.

Results:  Worse scores on all 4 psychological measures were associated with higher knee awareness and poorer knee-related QoL in unadjusted analyses. Standardized estimates (βs) ranged from -0.38 (95% confidence intervals [CI] -0.45 to -0.31) to -0.16 (CI -0.23 to -0.08). In adjusted analyses, pain catastrophizing (β -0.07, CI -0.14 to -0.01) and fear-avoidance (β -0.11, CI -0.18 to -0.05) remained associated with higher knee awareness, whereas poorer knee-related QoL remained associated with more anxiety (β -0.10, CI -0.16 to -0.03) and depression (β -0.14, CI -0.20 to -0.08), as well as more pain catastrophizing (β -0.19, CI -0.26 to -0.12) and fear-avoidance (β -0.19, CI -0.25 to -0.13).

Conclusion:  Higher fear avoidance of physical activity and more pain catastrophizing had the strongest associations with higher knee awareness and poorer knee-related QoL.

Background and purpose:  The 2 most common surgical approaches in hemiarthroplasty for hip fracture treatment are the posterolateral and the direct lateral approach. We aimed to estimate the relative cost-effectiveness of these approaches.

Methods:  We conducted an economic evaluation alongside a randomized controlled superiority trial for 6 months. The trial included 555 patients over 18 years of age with an acute femoral neck fracture. The effectiveness outcome used was quality-adjusted life years (QALYs), assessed using the EQ-5D-5L. Costs were measured through self-reported questionnaires administered at baseline, after 3 months, and after 6 months. We dealt with missing data through multiple imputation and analyzed the imputed datasets by comparing group means in costs and QALYs. A secondary analysis included adjustment for baseline imbalances through linear regression.

Results:  The estimated average treatment effect on the QALYs was 0.02 (95% confidence interval [CI] -0.006 to 0.046). From the healthcare and societal perspective, we found a non-significant average treatment effect on costs of 1,508 (CI -1,744 to 4,760) and 1,583 (CI -1,972 to 5,137), respectively. The probability of cost-effectiveness was 10% at a willingness-to-pay of zero, and then slowly increased to around 50% for higher willingness-to-pay values.

Conclusion:  We found no conclusive evidence of any differences between the surgical approaches with respect to costs, QALYs, and cost-effectiveness. We therefore suggest that, from an economic viewpoint, the 2 surgical approaches should be treated as interchangeable.

Background and purpose:  Both cemented and uncemented stem fixation is used in 2-stage hip revision arthroplasty addressing periprosthetic joint infection (PJI). We aimed to compare the risk of infection relapse and the risk of reoperation for any reason between uncemented and cemented stem fixation.

Methods:  Patients who underwent 2-stage hip revision arthroplasty for PJI between 2005 and 2020 were included. Data on baseline demographics, implant type, and microbiological and antibiotic treatment data was obtained from a local registry and medical records. Kaplan-Meier analysis compared relapse-free survival and reoperation-free survival between uncemented (n = 60) and cemented (n = 34) stems. Cox regression models were fitted to assess adjusted hazard ratios (aHR) for the risk of relapse or reoperation with 95% confidence intervals (CIs).

Results:  94 patients underwent 2-stage revision hip arthroplasty for PJI. Unadjusted 2-year relapse-free survival rates were 95% (CI 89-100) for patients with uncemented stem fixation and 97% (CI 90-100) for those with cemented fixation. Reoperation-free survival at 10 years was 82% (CI 70-95) for patients with uncemented fixation and 61% (CI 43-85) for those with cemented fixation. Using cemented fixation as the reference, the aHR for infection relapse was 2.0 (CI 0.2-20.1, P = 0.6) for uncemented fixation, whereas the aHR for reoperation was 0.3 (CI 0.1-0.9, P = 0.03).

Conclusion:  We showed no statistical difference in the risk of infection relapse, but uncemented stem fixation in 2-stage revision arthroplasty for PJI was associated with a reduced risk of reoperation for any reason. Uncemented stems may thus be a suitable choice in 2-stage revisions for PJI when this concept is believed to provide better fixation.

Background and purpose:  Computed tomography (CT) has become a valuable tool for preoperative planning and perioperative, real-time navigation during total hip arthroplasty (THA). CT can also quantify postoperative implant migration without the need for implanted bone markers, making it a promising alternative to the current gold standard radiostereometric analysis (RSA). Our aim was to evaluate the accuracy of preoperative planning and postoperative implant migration of both cup and stem employing AI-based software using 3D CT-images (CT-RSA) compared with conventional RSA.

Methods:  26 patients with primary THA were preoperatively 3D-planned and perioperatively navigated. They were followed and analyzed with AI-based CT-RSA within 2 days postoperatively and at 3, 12, and 24 months. 10 of the patients had implanted tantalum markers at surgery and were also followed up with conventional model-based RSA (MBRSA). The results were compared with CT-RSA. Prosthetic CAD models were used for both conventional RSA and AI-based CT-RSA analysis. Double CT and MBRSA scans were taken to evaluate precision. The preoperative plan was compared with actual perioperatively chosen implants.

Results:  AI-based CT-RSA showed consistent migration patterns, with most migration in the first 3 months, which then levelled out. Bland-Altman plots indicated good agreement between MBRSA and AI-based CT-RSA. Overall, there was high correspondence between MBRSA and AI-based CT-RSA in translations, but more divergent rotation results. AI-based CT-RSA precision was consistently slightly better than MBRSA precision. The agreement between planned and actual size of cup was 25 out of 26, and 23 out of 26 for stems.

Conclusion:  AI-based CT-RSA demonstrated accuracy comparable to MBRSA, with slightly improved precision and reduced user-dependence. The same system also provided an accurate and predictable preoperative implant plan.

Background and purpose:  It is unclear whether total shoulder arthroplasty (TSA) results in better outcomes in patients with degenerative shoulder diseases compared with hemiarthroplasty (HA). This randomized controlled trial (NCT01288066) is an international, multicenter study with the primary aim to assess pain and shoulder joint function at 5-year follow-up in adults surgically treated with TSA or HA.

Methods:  The inclusion criteria were patients aged 18 and older with primary or secondary osteoarthritis, with a functionally intact rotator cuff and glenoid morphology of Walch type A1, A2, or B1. Randomization to either TSA or HA occurred intraoperatively after full surgical preparation for glenoid prosthetic implantation in all patients. The primary outcome measure was the Constant-Murley scores (CMS) at 5-year follow-up. Secondary outcomes were patient-reported outcomes (Shoulder Pain and Disability Index [SPADI], EQ-5D, and EQ VAS), adverse events, and implant survivorship at 5-year follow-up.

Results:  There were 79 patients eligible, of whom 40 and 39 patients were randomized to receive TSA or HA, respectively. The dropout rate at 5 years was 34% due to 27 of 79 patients withdrawing consent or being lost to follow-up. The mean CMS improved from preoperative to 5 years' follow-up for both TSA and HA treatment groups. At 5 years, the TSA group had a significantly better mean CMS (77, 95% confidence interval [CI] 72-82) than the HA group (65, CI 57-73). The mean treatment difference was 12 (Cl 2.8-22; P = 0.01). The adverse event rate and relative risk of revision were not significantly different between the groups.

Conclusion:  In patients with glenohumeral osteoarthritis randomized to either TSA or HA, TSA was the favorable approach based on less pain and better joint function 5 years after surgery.

Background and purpose:  Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) aims to improve implant alignment and clinical outcomes, but its effectiveness remains uncertain. We aimed to compare whether PSI was superior to conventional instrumentation (CVI) in TKA. The primary outcome was the Oxford Knee Score (OKS) at 2 years with assessments of additional clinical outcomes up to 5 years after surgery.

Methods:  This study included 70 knees with primary osteoarthritis randomized (1:1) to undergo TKA using either PSI or CVI. Outcomes were evaluated using patient-reported outcome measures (PROMs), radiographic alignment, and radiostereometric analysis (RSA) of migration over the full follow-up period of 5 years.

Results:  68 knees underwent surgery as per protocol. At 2 years, 29 knees in the PSI group and 36 in the CVI group were assessed with the OKS, which improved significantly by 21.2 in the PSI group and 18.2 in the CVI group (mean difference [MD] 2.1; 95% confidence interval [CI] -1.5 to 5.7). PSI resulted in slightly increased tibial varus alignment (MD -1.4°; CI -2.3° to -0.4°), migrated slightly more into varus (mean difference at 2 years: -0.28 mm, CI -0.54 to -0.03 mm), and showed higher maximum total point motion (MTPM) during the period 1 to 2 years (mean difference: 0.13 mm; CI 0.01-0.25). At 5 years, 3 knees had been revised (PSI: 2; CVI: 1).

Conclusion:  PSI did not demonstrate superior outcomes compared with CVI. These findings suggest that PSI may not provide significant benefits over conventional techniques in routine TKA.

Background and purpose:  To address the limitations of radiostereometric imaging and to eliminate the need for intraoperative marker placement, CT-based radiostereometric analysis (CT-RSA) software systems have been developed. We aimed to evaluate the precision of a novel CT-RSA software system, V3MA, against an established CT-RSA software system, CTMA, while also examining the impact of CT scanner model on precision.

Methods:  7 CT scans per scanner (Siemens SOMATOM Force and GE Revolution) of a porcine cadaver with a knee implant were used for pairwise comparisons. By aligning paired CT scans, the translation (mm), rotation (°), and maximum total point motion (MTPM, mm) of the tibial implant with respect to the bone were computed. V3MA aligned the scans using the voxel gray values of the bone and implant, whereas CTMA aligned the surface points of the bone and implant. The precision of both software systems and the effect of both scanner models were investigated using paired data in a linear mixed model.

Results:  Both software systems resulted in a similar MTPM (contrast V3MA-CTMA -0.002 mm, 95% confidence interval [CI] -0.015 to 0.011; V3MA: 0.09 mm; CTMA: 0.10 mm), indicating comparable precision using a minimal important difference of 0.10 mm. Using Siemens scanner data resulted in a higher estimated MTPM than using GE scanner data (contrast Siemens-GE 0.046 mm, CI 0.024-0.067; Siemens: 0.12 mm; GE: 0.072 mm).

Conclusion:  The precision of the new CT-RSA software system, V3MA, is comparable to that of CTMA under zero-motion assumptions. Minor, clinically irrelevant, inter-scanner differences in CT-RSA precision exist for both software systems.