Acta Orthopaedica最新文献

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.

Background and purpose:  Pediatric proximal femoral fractures are rare and frequently complicated fractures with avascular necrosis (AVN), nonunion, deformity, leg-length discrepancy (LLD), and premature physeal closure (PPC). Our aim was to describe the incidence, complications and functional outcomes.

Methods:  In this register-based study from a 10-year period (2014-2023) we identified 51 non-pathological proximal femoral fractures from the KIDS Fracture Tool database. Statistical yearbooks of Helsinki were utilized to estimate annual incidence. We used interviews and Oxford Hip Scores (OHS) for functional outcome assessment. If any symptom or functional deficit was described, or if Oxford Hip Score (OHS) was < 41, patients were also invited for clinical examination and radiography.

Results:  51 patients with a proximal femoral fracture (31 boys) were identified representing 0.2% (51/21,121) of all child fractures with a population-based annual incidence of 1.7/100,000 children. We interviewed 46/51 of the patients or their guardians via telephone. 6/46 were invited for clinical examination and radiography. Median follow-up of contacted patients was 4 (range 1-9.5) years. Complications occurred in 9/20 patients with collum and trochanteric fractures (pain from osteosynthesis 4, AVN 3, nonunion 1, coxa vara 1, LLD 1, PPC 0) and in 7/31 with subtrochanteric fractures (pain from osteosynthesis 5, misplaced pins 2, angular deformity 1, peri-implant fracture 1). All underwent reoperation. The median OHS was 48 (interquartile range 47-48) at last follow-up. Functional outcomes were impaired in 3 patients. All 3 had AVN.

Conclusion:  The incidence of non-pathological pediatric proximal femoral fractures is low. Despite frequent complications, impaired functional outcomes concerned only patients with AVN at median 4-year follow-up.

Background and purpose:  We examined the association between preoperative self-rated health (SRH) and opioid use 12 months after total hip arthroplasty (THA) for osteoarthritis.

Methods:  We identified 381,323 people who answered a question on SRH in the Danish National Health Surveys 2010, 2013, or 2017. Among these, 4,174 people age > 35 years subsequently underwent THA for osteoarthritis. SRH was categorized as poor ("poor" or "fair" health) or good ("good," "very good," or "excellent" health). Opioid use was defined as ≥ 2 prescriptions 1-12 months after THA. We calculated prevalences and prevalence ratios (PR) with 95% confidence intervals (CI) through log-binomial regression, overall and by preoperative opioid use status adjusting for potential confounders. The total morphine milligram equivalent (MME) dose after THA with interquartile range (IQR) was further calculated.

Results:  876 (21%) patients rated their health as poor and 3,292 (79%) as good. The prevalence of opioid use among patients with poor SRH was higher than among those with good SRH (PR 2.33, CI 2.05-2.65) (315 [36%] vs 132 [14%]). Similarly, among preoperative non-users, the prevalence was 62 (15%) for patients with poor SRH and 140 (6%) for patients with good SRH (PR 2.20, CI 1.65-2.93), and among preoperative users, the prevalence was 252 (54%) for patients with poor SRH and 299 (31%) for patients with good SRH (PR 1.64, CI 1.44-1.86). The overall median MME dose was higher among patients with poor SRH (2,940, IQR 800-9,610) than among those with good SRH (1,000, IQR 400-3,175) with a median difference of 1,940 (IQR 1,227-2,653).

Conclusion:  Compared with good preoperative SRH, poor preoperative SRH was associated with higher opioid use 12 months after THA for osteoarthritis.

Background and purpose:  Limited data exist on venous thromboembolism (VTE) and mortality risk in patients undergoing primary total hip (THA) or knee arthroplasty (TKA) following recent COVID-19 infection. We aimed to evaluate whether the timing of COVID-19 infection affects postoperative VTE and mortality risk after THA or TKA.

Methods:  Adult Kaiser Permanente Northern California members undergoing elective THA or TKA from 2020-2022 were identified using internal procedure codes. 33,520 patients with or without SARS-CoV-2 within 6 months preoperatively were compared. Multivariate Poisson regression was used to calculate incidence rate ratios (RRs) adjusted for demographics, comorbidities, and Covid vaccination status. The primary outcome was 90-day VTE (deep venous thrombosis or pulmonary embolism). The secondary outcome was 90-day mortality.

Results:  Among patients with recent COVID-19, the 90-day VTE rate was 0.3%, and the mortality rate was 2.5%. Recent COVID-19 within 6 to 12 weeks preoperatively did not significantly increase 90-day VTE risk (RR 1.0, 95% confidence interval [CI] 0.38-2.8) but was associated with increased 90-day mortality risk (RR 3.1, CI 1.7-5.4).

Conclusion:  Recent COVID-19 infection did not significantly impact VTE risk after THA or TKA. However, infection within 6 to 12 weeks preoperatively was associated with increased 90-day mortality.

Background and purpose:  There is ongoing debate over whether results from randomized trials assigning patients to surgery or first-line treatment can be generalized to clinical practice. Therefore, we aimed to compare patients with hip osteoarthritis accepting enrollment in the Progressive Resistance Training versus Total Hip Arthroplasty (PROHIP) trial in Denmark with those declining (enrolled in an observational cohort [non-PROHIP]).

Methods:  We used a cross-sectional study design to compare demographics and patient-reported outcomes among patients eligible for enrollment in the PROHIP trial. We used the standardized difference (StdDiff), the absolute difference with 95% confidence interval (CI), and the propensity (odds ratio [OR]) of accepting participation in the PROHIP trial to assess imbalances between groups. We pre-specified that StdDiff values < 0.2 indicated a negligible difference, whereas values ≥ 0.8 indicated incomparability.

Results: 402 patients were included, with 109 in the PROHIP trial and 293 in the non-PROHIP cohort. Patients enrolled in the PROHIP trial had a mean (standard deviation [SD]) Oxford Hip Score at baseline of 25.1 (SD 5.9) compared with 22.6 (SD 6.9) in the non-PROHIP cohort (between-group difference, 2.5 points [CI 1.1-4.0], StdDiff 0.4, OR 1.06 [CI 1.02-1.10]). This pattern was consistent across almost all secondary patient-reported outcomes applied in the PROHIP trial. For most demographic variables, there were negligible between-group differences at baseline.

Conclusion:  We found minimal imbalances in some baseline demographic variables and most patient-reported outcomes, with those who accepted enrollment in the PROHIP trial having more favorable outcomes at recruitment than those who declined. However, most differences were not clinically important.

Background and purpose:  Traditional surgery for arthritis of the distal radioulnar joint (DRUJ), which typically involves resecting the ulnar head, is being increasingly challenged by newer techniques, such as prosthetic ulnar head replacement. The aim of our prospective cohort study was to investigate the clinical and patient-reported functional results, up to 2 years postoperatively, among patients with DRUJ arthritis treated with ulnar head replacement or resection.

Methods:  40 patients were included and underwent either ulnar head replacement (n = 22) or ulnar head resections (n = 18), due to DRUJ pathology between 2015 and 2020. Patients were followed up at 3, 6, 12, and 24 months postoperatively by the means of Patient-Rated Wrist Evaluation (PRWE) (primary outcome), and Disability of the Arm, Shoulder and Hand (DASH) questionnaires, pain, range of forearm rotation, and grip strength (secondary outcomes). Postoperative complications were recorded. 19 and 16 patients, respectively, responded at the 24-months follow-up. Female sex and inflammatory arthritis were more common in the resection group. General linear regression analyses adjusting for diagnosis and baseline PRWE score were performed for our primary outcome.

Results:  The median and interquartile range (IQR) improvement in PRWE from baseline to 24 months was 69 (IQR 49-87) to 27 (IQR 6-48) in the replacement group and 60 (IQR 50-86) to 23 (IQR 5-44) in the resection group, indicating that both groups improved from baseline. There were no differences in unadjusted estimates at any time point. The adjusted means in PRWE at 24 months were 35 and 26 points in the replacement and resection groups, respectively, corresponding to a statistically insignificant mean difference of 8.6 (95% confidence interval -11.7 to 28.2). We found no statistically significant group differences in any of the secondary outcomes at any time point. Postoperative complications affected 6 patients with ulnar head replacement, whereas none were reported for patients with ulnar head resection.

Conclusion:  We found that the outcome after ulnar head replacement is not superior to ulnar head resection in the short term.

Background and purpose:  The Oral Versus Intravenous Antibiotics (OVIVA) trial demonstrated that oral antibiotic therapy was noninferior to intravenous antibiotic therapy when used during the initial 6 weeks in the treatment of bone and joint infections (BJIs). We aimed to evaluate clinical outcomes, antibiotic treatment details, and complication rates following the implementation of the OVIVA protocol.

Methods:  All patients treated for BJIs between September 2019 and September 2020 at the specialized orthopedic infection unit of Herlev Hospital were eligible for inclusion. This study included data on patient demographics, antibiotic regimens, type of infection, microbiology, length of stay, adverse drug reactions, and definite treatment failure at 1 year.

Results:  A cohort of 129 patients was included. After a median of 7 days of intravenous therapy, 127 patients underwent an early switch to oral antibiotics. The most frequently used class of oral antibiotics was penicillins (68%). Adverse drug reactions, mostly gastrointestinal, occurred in 36% of all patients. Definite treatment failure at 1 year was 13% with oral antibiotics.

Conclusion:  We found a comparably low failure rate of 13% among patients who were able to transition to oral antibiotics when applying the treatment protocol from the OVIVA study.