Acta Orthopaedica最新文献

Background and purpose:  Limited population-based data is available concerning traumatic joint dislocations in children and adolescents. We aimed to determine the incidence, typical locations, and demographic patterns of joint dislocations in a pediatric population.

Methods:  This retrospective, population-based study analyzed pediatric joint dislocations in the Helsinki University Hospital catchment area from 2009 to 2021. Data was retrieved from electronic health records using ICD-10 codes and radiological keywords. Primary radiographs were reviewed to confirm diagnoses. Incidences were calculated using population data, and trends were analyzed by age, sex, and dislocation site. 2,741 traumatic dislocations were included.

Results:  The overall annual incidence of joint dislocations was 69 per 100,000 children, with a higher incidence in boys than in girls (72 vs 66 per 100,000, odds ratio 1.1, 95% confidence interval 1.02-1.2). The peak incidence occurred at 16 years of age for boys and 15 years of age for girls. Patellar (49%), elbow (19%), finger (12%), and glenohumeral (10%) dislocations accounted for 90% of cases with respective mean incidence; 35, 13, 8.4 and 7.1 per 100,000.

Conclusion:  The annual incidence averaged 69 per 100,000 children. Joint dislocations in children predominantly affect the patellar, elbow, finger, and glenohumeral joints, with adolescence being the most vulnerable period.

Background and purpose:  Reliable assessment of fracture healing remains a clinical challenge as radiographs and clinical examination provide only indirect information. Inducible fracture micromotion, defined as fragment displacement under load, may offer a more direct surrogate for healing. Radiostereometric analysis (RSA) can measure micromotion with high precision, but its clinical use for fracture assessment remains limited and heterogeneous. This scoping review aimed to map the existing literature on RSA for inducible fracture micromotion and summarize methodological approaches to guide future research.

Methods:  We systematically searched Medline, Embase, and Scopus. Clinical studies applying RSA to assess inducible fracture micromotion were eligible. 2 reviewers independently screened and extracted data on study design, patient population, fracture location, loading protocols, thresholds for motion, and outcomes.

Results:  7 clinical studies were included, comprising feasibility studies, prospective cohorts, and 1 imaging study. Sample sizes ranged from 6 to 16 patients, with fractures of the distal radius, femur, proximal tibia, and pelvis. All studies required intraoperative implantation of tantalum markers. Most applied differentially loaded RSA, typically comparing unloaded and loaded conditions using weightbearing platforms, force plates, or voluntary grip dynamometry. Despite varied protocols and small, single-center designs, RSA consistently detected small-scale inducible motion and, in some studies, distinguished union from non-union.

Conclusion:  This scoping review identified 7 clinical studies using RSA to assess inducible fracture micromotion, with heterogeneous methods across fracture types. These findings may guide the development of standardized approaches and support future research on RSA in fracture healing.

Background and purpose:  Contemporary data on the risk of chronic pain after total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is limited. Therefore, we aimed to investigate the incidence of chronic pain, pain characteristics, patterns of analgesic use, patient satisfaction, and willingness to undergo the same surgery again, 1 year after primary TKA and UKA for osteoarthritis.

Methods:  We conducted a nationwide online survey among unselected patients who underwent primary TKA or medial UKA for primary osteoarthritis in Denmark. At 1 year postoperatively, we assessed the incidence of moderate to severe pain (≥ 4 on the 0-10 numerical rating scale), frequency of pain, pain interference with everyday life, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain domain, the Douleur Neuropathique 4 interview (DN4i), use of analgesics, satisfaction, and willingness to undergo the same surgery again.

Results:  We sent survey invitations to 2,580 TKA patients and 1,007 UKA patients who underwent surgery in 2022. Of the 70% TKA respondents, 25% had moderate to severe chronic pain, 82% were satisfied/very satisfied with the result of surgery, and 86% indicated that they would choose to undergo surgery again. Of the 75% UKA respondents, 23% had moderate to severe chronic pain, 86% were satisfied/very satisfied, and 88% would undergo the same surgery again.

Conclusion: In Denmark, 25% of TKA patients and 23% of medial UKA patients experienced moderate to severe knee pain after 1 year. These numbers were higher than most previous estimates. Most patients were satisfied with the result of surgery and would undergo the same surgery again.

Background and purpose: Cemented fixation is widely recommended during arthroplasty for hip fractures, yet it has not been universally adopted by all surgeons and hospitals. We aimed to identify which factors were associated with a higher likelihood of cemented fixation.

Methods: We identified patients ≥ 55 years old with hip fractures treated with primary arthroplasty in Canada between 2012 and 2022. We determined fixation method along with several surgeon and hospital characteristics from the Canadian Joint Replacement Registry and other Canadian databases. We used logistic regression to estimate the odds ratios (ORs) of the association between these covariates and cemented fixation.

Results: We identified 65,823 patients who underwent arthroplasty for hip fractures. The proportion of cases with cemented fixation for hemiarthroplasty increased by 30 percentage points over the study period; the proportion for total hip arthroplasty (THA) remained relatively stable. High-volume hospitals (≥ 500 annual hip arthroplasties with ≥ 25% of these for fractures) were least likely to cement, OR = 0.30; 95% confidence interval (CI) 0.27-0.34 vs low-volume hospitals (< 500 cases/< 25% for fractures). High volume surgeons (≥ 50 hips/year, ≥ 16/year for fractures) had an OR of 0.80 (CI 0.75-0.84) compared with < 50 hips/year surgeons. Teaching hospitals were more likely to cement, OR = 1.16 (CI 1.10-1.22). The OR of cemented fixation for hemiarthroplasty (vs THA) rose from 1.13 (CI 0.99-1.29) at the start of the study period to 2.17 (CI 2.02-2.33) at the end.

Conclusion: The use of cemented fixation in hip fracture arthroplasty has increased across Canada over the last decade. However, surgeons and hospitals that treat more hip fracture patients are less likely to cement. The proportion of cemented fixation increases with patient age. Cement use is more common in hemiarthroplasty than in THA.

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.