Acta Orthopaedica最新文献

Background and purpose: The amount of information publicly available from arthroplasty registries is large but could be used more effectively. This project aims to improve the knowledge concerning existing registries to facilitate access, transparency, harmonization, and reporting.

Methods: Within the International Society of Arthroplasty Registries (ISAR) we aimed at developing, testing, adopting, and making publicly available a short, standardized registry description with items considered relevant for stakeholders using a cross-sectional study survey. Items were chosen based on a literature review and expert advice, selected by 9 ISAR working group members, tested iteratively in 3 registries, and commented upon by 4 external experts. All 29 ISAR member registries as of July 2023 were invited to participate in the project.

Results: Included items covered general descriptive information regarding registries, information related to governance, outcomes, data quality, data access, and registry production. The template was adopted, completed, and made publicly available by 25 of the 29 registries. Of those, 2/3 were national registries. 23 captured both hip and knee arthroplasties and 10 captured shoulder arthroplasties. Most registries had public reporting of data quality, methods, and results. Data was accessible in all but 2 registries, mainly as aggregated data. Important items relevant to registry quality for researchers to consistently indicate in scientific papers include scope, inclusion criteria, outcomes definitions, coverage/completeness, and validation processes.

Conclusion: This ISAR initiative implemented a short, standardized description to facilitate appropriate use of orthopedic registry data worldwide relevant for a diverse group of stakeholders including researchers, industry, public health and regulatory agencies.

Background and purpose:  The introduction and development of new total knee arthroplasty (TKA) implant designs are industry driven. To date, an adequately powered randomized controlled trial (RCT) to provide evidence of the superiority of novel implant designs over conventional ones is often lacking. The aim of our RCT was to investigate the functional outcomes of a novel TKA implant design compared with 2 conventional TKA designs. Primary outcome was difference in the change in Oxford Knee Score (OKS) at 2 years. Secondary outcomes were Forgotten Joint Score, 15D quality of life questionnaire, UCLA activity score, and complications.

Methods:  We compared functional outcomes between a novel TKA implant design (Persona CR) and 2 conventional designs (NexGen CR, PFC CR). 240 patients with severe knee osteoarthritis were recruited to a pragmatic, single-center, prospective, parallel-group RCT between September 2015 and August 2018. The duration of follow-up was 2 years.

Results:  Of 240 randomized patients, 225 were included in the intention-to-treat analysis (mean age 61.8 years; 67.5% females). The OKS exceeded minimal clinical important difference (MCID) from baseline to 2 years in all 3 treatment groups (Persona CR: 18.9 points, PFC CR: 20.3 points, NexGen CR: 19.4 points). At 2 years the difference between Persona CR and PFC CR in the change score was -1.0 (95% confidence interval [CI] -3.6 to 1.7). Similarly, the difference between Persona CR and NexGen CR was -0.9 (CI -3.6 to 1.9). At the time of final follow-up evaluation, OKS was equivalent between groups, as CI excluded between-group differences larger than 4 points.

Conclusion: We showed no clinically relevant differences in functional outcomes measured with OKS, 15D, or FJS between the 2 conventional implant designs and the novel implant design at 2-year follow-up.

Background and purpose: Treatment of idiopathic scoliosis in childhood aims to prevent curve progression. It is generally accepted that curves > 50° have the highest risk of progression, but less well described is what happens with mild to moderate curves. The aim of this study was to assess long-term curve progression and health-related quality of life (HRQoL) and compare thoracic and thoracolumbar/lumbar (TL/L) curves.

Methods: We identified 177 patients diagnosed with a pediatric spinal deformity and treated at our institution from 1972 through 1983. 91 of 129 eligible patients with idiopathic scoliosis completed follow-up (71%). Patient files from treatment/observation in childhood were reviewed including detailed descriptions of radiographs. At follow-up we assessed long standing full-spine radiographs and HRQoL with the Scoliosis Research Society 22 revised questionnaire.

Results: Mean follow-up was 41 years (standard deviation [SD] 2.5 years). 21 patients underwent surgery in adolescence or early adulthood leaving 70 patients for analysis of curve progression, of whom 61 had complete radiographs. For patients with a main curve < 25° at the end of treatment in adolescence (n = 19) mean curve progression was 7° (SD 9); for 25-40° curves (n = 26) 16° (SD 13); for 40-50° curves (n =10) 22° (SD 8); and for curves > 50° (n = 6) 17° (SD 6). There was a linear association between main curve size at follow-up and SRS-22r subtotal score (P = 0.003).

Conclusion: We found substantial curve progression for patients with main curves > 25° at end of treatment, but with a considerable variation between patients. Curve progression was not associated with curve size at the end of treatment and did not differ significantly between thoracic and TL/L curves. Larger main curve size at follow-up was associated with lower HRQoL.

Background and purpose:  For medial knee osteoarthritis (OA), operative and nonoperative treatment options are available. Two widely applied unloading therapies are a valgus unloader brace and a high tibial osteotomy (HTO). We aimed to compare the effects of a valgus unloader knee brace with an HTO on knee pain after 1 year in patients with symptomatic medial knee OA.

Methods: We recruited patients from 9 Dutch hospitals between August 2014 and February 2019 for an open-labeled multi-center randomized controlled trial (Dutch Trial Register NL4200). Patients aged 18 to 65 years with symptomatic medial compartmental knee OA were randomized to either a valgus unloader brace or an HTO. The primary outcome was the pain subscale of the Knee injury and Osteoarthritis Outcome score (KOOS) after 1 year. Patients were evaluated at 3, 6, 9, 12, and 24 months.

Results:  51 patients were included in the study, of whom 23 were randomized to the unloader brace and 28 to the HTO. The HTO, compared with the unloader brace, showed a significant and clinically relevant difference at 12 months of follow-up in KOOS pain of -28 (95% confidence interval -43 to -13).

Conclusion:  We found that, on group level, an HTO is more effective in reducing knee pain than an unloader brace after 12 months.

Background and purpose:  Evidence for long-term outcomes following acetabular fractures in older adults is limited. We aimed to evaluate mortality, complications, and need for subsequent surgical procedures in operatively and nonoperatively treated older patients with acetabular fractures.

Methods: Patients aged ≥ 70 years with acetabular fractures treated at Uppsala University Hospital between 2010 and 2020 were included. Fractures were classified according to Letournel. Local medical records were analyzed and cross-referenced with the Swedish Arthroplasty Register to identify reoperations and delayed arthroplasty procedures. Follow-up time ranged from 2-12 years. Primary outcome was mortality 1 year after injury. Descriptive statistics, survival analysis using the Kaplan-Meier method, and logistic regression models were used.

Results:  247 patients (67% men) with a median age of 80 years (range 70-102) were included. Most patients were ASA class 3 (67%). 148 (60%) patients were treated operatively. The 1-year mortality was 15% (95% confidence interval [CI] 9-21) in the operatively and 29% (CI 19-37) in the nonoperatively treated group. Difference in adjusted mortality rates between treatments did not reach statistical significance. 20% of patients treated with open reduction internal fixation (ORIF) underwent some form of reoperation. In the nonoperatively treated group, 1% had a delayed THA.

Conclusion:  The 1-year mortality following acetabular fractures in older people was 21% (CI 15-26), underscoring the frailty of this patient group. ORIF alone was associated with a 20% reoperation rate while the rate of delayed surgical treatment in patients selected for nonoperative treatment was 1%.

Background and purpose:  Vascularized fibular grafting following tumor resection is an essential treatment option in limb salvage surgery. We aimed to evaluate: (I) bone healing, (II) complications and reoperations, (III) limb salvage, and (IV) survival.

Methods:  We present a retrospective evaluation of a national cohort comprising 27 patients. The indications were 13 cases of Ewing sarcoma, 12 cases of osteosarcoma, and 2 cases of giant cell tumor. The median age at surgery was 16 years (interquartile range [IQR] 10-18), and the median follow-up was 82 months (IQR 32-101). Patients were analyzed overall, as well as in subgroups based on tumor location (upper versus lower extremity) and pathology (osteosarcoma versus Ewing sarcoma).

Results:  The primary rate of graft union was 63%, and after secondary procedures the overall rate of graft union was 67%, with a median time to union of 13 months (IQR 9-17). The reoperation rate was 74%, while the limb salvage rate was 93%. The 5-year overall survival rate was 81% (95% confidence interval [CI] 61-92). Patients with upper extremity tumors were more likely to attain graft union (risk ratio [RR] 5.5, CI 1.3-31.5) and less likely to undergo multiple reoperations (RR 0.3, CI 0.8-0.9) than patients with lower extremity tumors.

Conclusion:  Vascularized fibular grafting following tumor resection was associated with a graft union rate of 67%, a high frequency of reoperations, a high limb salvage rate (93%), and a 5-year survival rate of 81%.

Background and purpose:  The optimal approach to the hip joint in patients with displaced femoral neck fractures (dFNF) receiving a total hip arthroplasty (THA) remains controversial. We compared the direct lateral approach (DLA) with the direct anterior approach (DAA) primarily on Timed Up and Go (TUG), and secondarily on the Forgotten Joint Score (FJS), the Oxford Hip Score (OHS), EQ5D-5L, and the EQ5D-VAS.

Methods:  Between 2018 and 2023, we conducted a randomized controlled trial including elderly patients with dFNFs treated with THA. The primary outcome was the difference in TUG at 6 weeks postoperatively. Key secondary outcomes were TUG at 2, 12, and at 52 weeks postoperatively, and FJS, OHS, EQ5D-5L, and EQ5D-VAS at 2, 6, 12, and at 52 weeks postoperatively.

Results:  130 patients with a mean age of 78.6 (standard deviation 1.2) were allocated to DAA (n = 64) or DLA (n = 66). There was no statistically significant difference in TUG times at 6 weeks postoperatively between the DAA and the DLA, 16.0 s (95% confidence interval [CI] 13.2-18.7) vs 17.8 s (CI 15.1-20.4), estimated mean difference -1.8 s (CI -5.7 to 2.0). However, patients who underwent DAA had a significantly higher FJS at 2, 6, and 12 weeks.

Conclusion:  Among elderly patients with dFNF we found no difference between DAA or DLA regarding crude mobility as demonstrated with the TUG test, but patients treated with DAA showed better outcomes in the FJS in the early post-fracture period though not at 52 weeks.

Background and purpose:  Disease- or procedure-specific registers offer valuable information but are costly and often inaccurate regarding outcome measures. Alternatively, automatically collected data from administrative systems could be a solution, given their high completeness. Our primary aim was to validate a method for identifying secondary surgical procedures (reoperations) in the Danish National Patient Register (DNPR) within the first year following primary fracture surgery. The secondary aim was to evaluate the accuracy of the diagnosis and procedure codes used to determine the causes of these reoperations. Finally, we developed algorithms to enhance precision in identifying the reasons for reoperations.

Methods:  In a national cohort of 11,551 patients with primary fracture surgery, reoperations were identified through subsequent surgical procedure codes in the DNPR. Each patient record was reviewed to confirm the reoperations and causes. To improve accuracy, a stepwise algorithm was developed for each cause.

Results:  We identified 2,347 possible reoperations; 2,212 were validated as true reoperations by review of patient record, i.e., a 94% positive predictive value (PPV). However, the coding for the causes of these reoperations was inaccurate. Our algorithm identified major reoperations with a sensitivity/PPV of 89/77%, minor reoperations 99%/89%, infections 77/85%, nonunion 82/56%, early re-osteosynthesis 90/75%, and secondary arthroplasties 95/87%.

Conclusion:  While the overall reported reoperations in the DNPR had a high PPV, the predefined diagnosis and procedure codes alone were not sufficient to accurately determine the causes of these reoperations. An algorithm was developed for this purpose, yielding acceptable results for all causes except nonunion.

Spondylolysis is defined as a defect or elongation in the pars interarticularis of the lumbar spine, either unilateral or bilateral. Growing children with bilateral spondylolysis may develop spondylolisthesis, i.e., forward slipping of the affected vertebra. The etiology of spondylolysis is regarded as a stress fracture due to repetitive loading associated with a genetic predisposition. Lumbar magnetic resonance imaging (MRI) shows an increased signal intensity before an actual fracture line develops. In low grade spondylolisthesis, two-thirds of children with acute pediatric spondylolysis will undergo bony union with early activity restriction. Health-related quality of life is improved in patients achieving bony union as compared with patients having non-union, of which one-fourth will additionally develop spondylolisthesis. In patients with high-grade spondylolisthesis, defined as a more than 50% forward slippage of the affected vertebra, spinal fusion is recommended to prevent further progression.

Background and purpose:  Early migration of the uncemented cruciate-sacrificing rotating platform ATTUNE and Low Contact Stress (LCS) tibial components was classified as at-risk for aseptic loosening rates exceeding 6.5% at 15 years based on recent fixation-specific migration thresholds. In this secondary report of a randomized controlled trial (RCT) we aimed to evaluate whether the 5-year migration, inducible displacement, and the clinical outcome of the ATTUNE components were comparable to those of the LCS.

Methods:  Patients from the initial 2-year radiostereometric analysis (RSA) RCT were recruited for a 5-year follow-up. At 5 years, participants underwent 2 supine and 1 loaded RSA examination, clinical assessments, and questionnaires. Migration was analyzed using maximum total point motion (MTPM), translations, and rotations, focusing on 5-year migration, continuous migration (> 0.10 mm/year), and inducible displacement. Revisions, along with clinical and functional outcomes, were also evaluated.

Results:  At 5 years, 24 ATTUNE and 24 LCS implants were analyzed. The mean MTPM was similar for tibial components (ATTUNE 1.13mm [confidence interval (CI) 0.94-1.33]; LCS 1.24 mm [CI 1.05-1.46]) but significantly lower for the ATTUNE femoral component (1.14 mm [CI 0.92-1.39]) than LCS 1.87 mm [CI 1.57-2.21]). 2-to-5-year migration rates were comparable, but 11 ATTUNE and 7 LCS exceeded 0.10 mm MTPM/year, indicating a higher risk of loosening. Inducible displacement was similar, although 1 patient with a tibial ATTUNE showed excessive displacement (3.34 mm MTPM) with focal osteolysis but no symptoms. 1 revision 10 days post-surgery was performed for an ATTUNE insert spinout, resolved with an isolated insert exchange. Clinical and functional outcomes were comparable.

Conclusion:  At the 5-year follow-up, ATTUNE tibial components showed similar migration, while the femoral component migrated significantly less than the LCS, which mainly occurred during the first 2 years. 2-to-5-year migration rates, inducible displacement, and clinical and functional outcomes were comparable. These findings suggest a comparable long-term risk of aseptic loosening between the uncemented ATTUNE and LCS knee systems.