Acta Orthopaedica最新文献

Background and purpose:  Previous studies show no clear difference in functional outcomes between locking nails and plates for proximal humerus fractures (PHFs). Economic evaluations provide valuable insights into cost-effectiveness to guide healthcare decisions. We aimed to conduct a cost-effectiveness analysis based on a semidouble-blinded randomized controlled trial comparing nailing and plating for displaced 3- and 4-part PHFs with 2-year follow-up.

Methods:  79 patients with displaced 3- or 4-part PHFs were randomized to undergo open reduction and internal fixation using either a nail or a plate. Patients were followed for 2 years, with costs tracked for the index surgery, hospital stay, additional healthcare services, and secondary procedures. Quality-adjusted life years (QALYs) were calculated using EQ-5D, and incremental cost-effectiveness ratios (ICERs) were used to compare treatments.

Results:  38 patients in each group were eligible for analysis. Mean total costs were €21,654 (standard deviation [SD] 10,448) for nails and €16,374 (SD 3,886) for plates, with a mean difference of €5,296 (95% confidence interval [CI] 1,989-8,603). Extra costs for reoperations and other non-regular follow-ups were €3,746 (SD 10,448) for nails and €265, (SD 1,217) for plates, resulting in a mean difference of €3,480 (CI -868 to 7,829) extra costs for nails. The mean QALY showed no statistical difference between groups of 0.09 (CI -0.003 to 0.17) (1.65 in the nail group and 1.74 in the plate group).

Conclusion:  Plates were more cost-effective compared with nails but did not result in a statistically significant difference in QALY.

Background and purpose:  There is limited data on the functional outcome after hallux valgus (HV) surgery. Our study aims to assess 1-year postoperative patient-reported outcomes (PROMs) after a chevron osteotomy (CO) for 3 severity levels, the number of additional surgical interventions during the index procedure, and the association between the presence or absence of internal fixation and PROMs.

Methods:  This is a prospective cohort from the Swedish register for foot and ankle surgery (Swefoot), including patients treated with primary CO between 2014 and 2021. HV deformities were classified into 3 severity grades. Preoperative demographic data, additional surgical procedures, and PROMs (Self-reported Foot and Ankle Score [SEFAS] and the EuroQol 5-dimensional 3-level scale [EQ-5D-3L]) were collected both pre- and 1 year post-surgery.

Results:  The study included 2,259 HV feet (2,123 patients, mean age 55 (range 15-90) years, 83% women) The mean SEFAS score increased by 11 (95% confidence interval [CI] 9.8-11.8) points from the pre-surgery assessment to the 1-year post-surgery follow-up for the mild HV group, by 9 (CI 9.0-10.0) for the moderate, and by 9 (CI 7.5-9.8) for the severe group. EQ-5D-3L also improved in all 3 groups. For all 3 HV grades, patients treated with fixation demonstrated no statistically significant improvements in SEFAS scores compared with those without fixation.

Conclusion:  Distal chevron osteotomy improved 1-year patient-reported outcomes across all grades of hallux valgus. Improvements were observed both with and without internal fixation. In more severe cases, additional procedures such as Akin osteotomy and distal soft tissue release were more commonly performed.

The goal of this Acta Orthopaedica educational article is to provide an update on how to evaluate lateral malleolar ankle fractures at the level of the syndesmosis and to guide clinicians in selecting the most appropriate treatment method. We aim to clarify the indications for non-surgical treatment and to provide clinicians with an evidence-based approach to decision-making in these frequently encountered injuries. The authors introduce the concept of "congruent on weightbearing" in contrast to the historical thinking of ankle fractures as stable or unstable. We further elaborate on how this thinking should be the basis in the decision-making regarding treatment method to safely differentiate fractures that will heal uneventfully without surgical intervention from those that need internal reduction and stabilization. As long as crucial parts of the deltoid ligament are intact, lateral malleolar ankle fractures at the level of the syndesmosis maintain, or regain, joint congruency under weightbearing. Ankle fractures that stay congruent under weightbearing often heal uneventfully and can be safely treated without surgery. Furthermore, research has shown that early weightbearing and short immobilization periods are beneficial for patient recovery without an increase in complication rates.

Background and purpose:  Increased use of weightbearing radiographs to assess ankle mortise stability have suggested that most lateral malleolar fractures with a congruent mortise on initial radiographs can successfully be treated nonoperatively. We aimed to evaluate trends in the surgical management of isolated lateral malleolus fractures across Austria, England, Finland, Germany, Sweden, and Switzerland from 2013 to 2022 Methods: We performed a multi-register study to document the annual incidence of operative treatment for isolated lateral malleolus fractures through procedure codes across 6 European countries between 2013 and 2022. The annual incidence of operative treatment was calculated by dividing the total number of procedures per year by the year- and age-matched population based on publicly available demographics data.

Results:  Across the 6 studied European countries, the incidence of surgery for lateral malleolar fracture varied 6-fold between the country with highest (Germany) and lowest (England) incidences; Germany: 37 (95% confidence interval [CI] 37-38) per 105; Switzerland: 34 (CI 32-35) per 105, Austria: 27 (CI 26-28) per 105, Finland: 17 (CI 16-18) per 105, Sweden: 8 (CI 7-9) per 105, and England: 6 (CI 6-7) per 105 in 2021. Over the 10-year study period, the incidence of surgery for lateral malleolar fractures declined notably in Sweden (-29%), Finland (-26%), England (-20%), and Switzerland (-14%), but remained stable in Germany and Austria.

Conclusion:  The incidence of surgery for lateral malleolar fracture varied 6-fold across 6 studied European countries. Reductions of approximately 20-30% were observed in England, Sweden, and Finland (countries with the lowest baseline rates), while in Germany and Austria (countries with higher baseline rates), the incidence of surgery remained stable over the 10-year observation period.

Background and purpose: Concurrent benzodiazepine-opioid use is discouraged. We aimed to examine trajectories of benzodiazepine, opioid, and concurrent use following hip and knee arthroplasties for osteoarthritis (HA-OA, KA) and hip arthroplasty for fracture (HA-fracture).

Methods: In this nationwide cohort study, the Dutch Arthroplasty Register (LROI) was linked to the Dutch Foundation for Pharmaceutical Statistics (SFK). We evaluated the proportion of patients with ≥ 1 medication dispensation in the year pre- and post-procedure and the prescribing physicians. Concurrent use was defined as ≥ 7 days overlap of benzodiazepine and opioid exposure.

Results: We included 109,238 HA-OA, 17,464 HA fracture, and 113,306 KA. Between 2013 and 2021, the risk difference of postoperative benzodiazepine use was -7.2% (95% confidence interval [CI] -8.1 to -6.2%), while postoperative opioid use increased by 29.7% (CI 28.5-30.8%). Among HA-OA, from 2013 (4,391 arthroplasties) to 2021 (12,905 arthroplasties), the percentage of preoperative benzodiazepine users went from 18% to 13%, and postoperative from 23% to 14%. In contrast, preoperative opioid use changed from 25% to 33% and postoperative from 36% to 69%, In 2021, 6% of HA-OA, 11% of HA fracture, and 9% of KA received a concurrent dispensation in the first post-procedure year, predominantly in the first quarter. Orthopedic surgeons prescribed 29% (~18,732 prescriptions) of initial concurrent dispensations; subsequent prescriptions were mainly from general practitioners.

Conclusion: From 2013-2022 in the Netherlands, benzodiazepine use decreased while opioid use increased among arthroplasty patients. Concurrent use remained frequent, despite safety recommendations against co-prescribing.

Background and purpose:  There is a controversy as to whether operating rooms with laminar airflow (LAF) ventilation are less associated with prosthetic joint infection (PJI) following total hip arthroplasty (THA) than turbulent airflow (TAF) ventilation. We aimed to assess the association of LAF and TAF ventilation with PJI following primary THA.

Methods:  This prospective cohort study, based on Danish administrative databases, included patients from all Danish hospitals. Patients with a primary THA with at least 365 days of follow-up between 2010 and 2020 were included from the Danish Hip Arthroplasty Register (DHR). The patients were then linked to the Danish microbiology register. The primary outcome was revision due to PJI within 365 days after primary surgery, analyzed with multivariable Cox models and Gray's test comparing LAF with TAF. PJI was defined by either a PJI diagnosis registered in the DHR after revision or 2 or more positive cultures with identical bacteria in the perioperative biopsies taken during revision.

Results:  Of the 92,152 THAs (78,181 patients) included, 2,328 (2.5%) had revision surgery within 365 days. Of these, 843 (0.91%) were due to PJI (0.92% in LAF, 0.89% in TAF). After adjusting for patient- and surgery-related risk factors, and year of surgery, we found no difference in the PJI hazard between LAF and TAF (HR 0.99; 95% confidence interval 0.78-1.26).

Conclusion:  Our data indicate that there is no difference in the risk of PJI comparing LAF with TAF ventilation in primary THA in Denmark.

Background and purpose:  Continued opioid use persists in up to one-third of patients 12 months after total hip arthroplasty (THA). Psychological factors, including stress, may influence pain and therefore opioid consumption, yet the effect of stress history on opioid use after THA remains unclear. We aimed to examine the association between perceived stress and the risk of continued opioid use following THA in patients with osteoarthritis.

Methods:  Based on data from the Danish National Health Surveys in 2013 and 2017, a total of 1,727 individuals completed the Perceived Stress Scale and later underwent THA, tracked through the Danish Hip Arthroplasty Registry. All were over the age of 35. Patients were classified by stress level (high vs low stress). Continued opioid use was defined as ≥ 2 opioid prescriptions 1-12 months post-surgery, recorded in the Danish National Prescription Database. Adjusted prevalence differences and adjusted prevalence ratios were calculated using log-binomial regression, controlling for sex, age, comorbidities, and education.

Results:  Of 258 patients with high stress level, 68 (26%) had continued opioid use, compared with 224 (15%) of the 1,469 patients with a low level. We showed higher ratios in high stress patients (adjusted prevalence difference 9.2; 95% confidence interval [CI] 3.6-14.8, adjusted prevalence ratio 1.5 [CI 1.2-1.9]). Median morphine milligram equivalents (MME) were higher for high stress with a median difference of 1,230 (interquartile range 1,025-3,745).

Conclusion:  High levels of perceived stress before THA are associated with a higher risk of continued opioid use and greater opioid consumption in the first postoperative year. These findings suggest the potential for preoperative stress screening and targeted interventions to reduce postoperative opioid use.

Background and purpose:  Patients treated with shoulder arthroplasty may risk serious adverse events (SAEs), readmission, and death; however, the literature is inconsistent. Therefore, we aimed to compare the incidence rates of SAEs, readmissions, and mortality at 30 and 90 days following shoulder replacement with those of a matched cohort.

Methods:  Danish databases were used to include patients treated with a primary shoulder replacement due to fracture, osteoarthritis, cuff tear arthropathy, and other (2006-2021). The shoulder patients were compared (1:10) to a matched cohort from the general population. Incidence rates (IR) and incidence rate ratios (IRR) were calculated and adjusted for age, sex, and comorbidity.

Results:  The 30-day IR of SAEs was 73.5 for shoulder patients and 14.8 for the matched cohort. The IRR of SAEs was higher for all patient groups compared with the matched cohort and varied between indications for surgery (IRR 3.1-5.9) and remained higher at 90 days (IRR 1.6-3.5). The IR of readmission was 234 per 100,000 person-days at 30 days. The 30-day IR of mortality was 20.2 per 100,000 person-days for shoulder patients and 9.4 per 100,000 person-days for the matched cohort. Compared with the matched cohort the 30-day IRR of mortality was 2.0, with fracture patients having the highest risk of mortality (IRR of 3.5).

Conclusion:  At 30 and 90 days after surgery, shoulder patients, regardless of surgical indications, had higher rates of SAEs than the matched cohort. The mortality rate was higher for shoulder patients and highest for fracture patients. This information should be included in the shared decision-making process before undergoing shoulder replacement.

Background and purpose:  Over the last 2 decades, the treatment of Achilles tendon rupture (ATR) has shifted from surgery to non-surgical methods. We aimed to analyze whether this change in treatment methods has had an impact on the number of compensated patient injuries in Finland and the grounds for compensation. We also aimed to investigate where injuries occur along the treatment pathway.

Methods:  We conducted a retrospective analysis of the Finnish Patient Insurance Centre's insurance charts of compensated patient injuries in the treatment of ATR. Records of all compensated patient injury claims involving ATR from 2 periods in Finland: 2000-2006 (when 65% were treated surgically) and 2013-2019 (when 15% were treated surgically) were reviewed. Data included medical records, expert evaluations, and compensation decisions. Injuries were classified by when they occurred, and key contributing incidents were identified.

Results:  From 2000-2006 (period 1) and 2013-2019 (period 2), there were 315 patient injury claims related to ATR treatment in Finland. Of these, 126 (40%) were compensated. In both periods, delay in diagnosis was the most common reason for compensation. The number of claims remained the same between the 2 periods, and the ratio of compensated injuries to total cases declined (0.70% to 0.62%, not significant). Between the periods, infection-related claims decreased, while those related to incorrect treatment pathways and surgical errors increased (P = 0.02).

Conclusion:  The number of patient injuries has not risen in the past decade, while the number of infection injuries has decreased. Most patient injuries were related to a delay in diagnosis.

Background and purpose:  Robotic-assisted total knee arthroplasty (RATKA) can enhance surgical precision. In middle-income countries (MICs), constrained fiscal space and the double burden of rising demand for high-cost technologies and competing public-health priorities-unlike high-income countries with broader fiscal headroom and low-income countries with limited adoption of expensive innovations-make adoption decisions for RATKA particularly challenging. We aimed to evaluate the cost-effectiveness analysis (using a cost-utility framework) of RATKA vs conventional TKA (COTKA) from a societal perspective in Thailand as a MIC.

Methods:  A discrete event simulation model was employed to compare the cost-effectiveness of unilateral RATKA with COTKA over 4.5 years from a societal perspective, using patient-level data from January 2018 to June 2022 from an arthroplasty center in Thailand. Patients were propensity matched to balance comorbidities. Base case analysis assumed 1 robot performs 434 TKA cases per year with an anticipated lifespan of 12.5 years. We considered direct medical, non-medical, and indirect costs, alongside quality-adjusted life years (QALYs) gained from a societal perspective. We calculated incremental net monetary benefits (INMB) and cost-effectiveness ratios (ICERs) as the main outcome measures. Sensitivity analyses and 10 scenario analyses were performed exploring various possible settings. Threshold analyses determined combinations where RATKA could be cost-effective with positive INMB under the Thai cost-effectiveness threshold of US$4,888 per QALY gained.

Results:  The base case analysis involved 157 COTKA and 1570 RATKA matched cases with a mean age of 69 (standard deviation 8 years). The lifetime average outcomes per patient were: COTKA-US$5,031.9 and 9.07 QALYs; RATKA-US$5,666.9 and 9.16 QALYs. The incremental (RATKA-COTKA) differences were +US$633.6 (95% credible intervals [CrI] ~592-675) and +0.085 QALYs (CrI ~0.04-0.13), yielding an ICER of US$7,436.6/QALY. RATKA was not cost-effective compared with COTKA, with an INMB of -216.9 US$/patient. The probability of RATKA being cost-effective at the Thai cost-effectiveness threshold was 44.3%. For RATKA to be economically attractive, 1 robot must operate on at least 640 TKA cases/year over 12.5 years. 3 scenarios found RATKA to be cost-effective: (i) maximal robot utilization (850 cases/year); (ii) lowest capital costs (611,060 US$/robot) with high efficacy for RATKA (hazard ratio [HR] 0.6); and (iii) extreme efficacy of RATKA in reducing complications (HR 0.024).

Conclusion:  In the context of MIC, a broad adoption of RATKA is not economically attractive as treatment of end-stage knee osteoarthritis patients compared with COTKA.