Acta Orthopaedica最新文献

Background and purpose:  Arthroplasty registries report revision risk, but patient-reported outcomes may also measure implant performance. We aimed to evaluate (i) change in patient-reported outcome measures (PROMs) across multiple total knee arthroplasty (TKA) designs in a regional registry, (ii) the association of patellar resurfacing on the change in PROMs, and (iii) the variation in PROMs change within implants with or without patellar resurfacing.

Methods:  This is a cohort of primary TKAs from Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) performed between January 1, 2017 and September 30, 2021. The dependent measure was change in KOOS JR. Independent variables were implant name and patellar resurfacing. Multivariate modeling adjusted for patient-level factors. A previous report suggests a change of 23 points in KOOS JR as clinically relevant in achieving acceptable pain/function levels. A clinically relevance ratio (CRR) of those achieving the threshold of 23 points to the overall group was calculated for each implant.

Results:  18 implant designs met the inclusion criteria. There were 51,606 cases with complete preoperative and postoperative KOOS JR matched pairs. There was variation in improvement from preoperative to postoperative unadjusted KOOS JR scores across implant designs (P < 0.001), ranging from 18.7 (95% confidence interval [CI] 16.8-20.6) to 27.0 (CI 24.9-29.2). Patellar resurfacing resulted in greater KOOS JR improvement 1.0 (CI 0.5-1.5, P < 0.001). Of the cases with resurfaced patellae, the CRR was 50.2% (CI 49.7-50.7). For cases without resurfaced patellae, the CRR was 47.2% (CI 45.9-48.5). The association of implant design persisted whether the patella was resurfaced or not, evident in the adjusted mean change in KOOS JR (P < 0.001), ranging from 20.1 (CI 17.6-22.6) to 25.5 (CI 24.3-26.7) for resurfaced and from 17.0 (CI 13.9-20.1) to 23.3 (CI 20.3-26.2) for not resurfaced, and the CRR difference (P < 0.001), ranging from 45.8% (CI 42.5-48.6) to 55.8% (CI 50.4-60.8) for resurfaced and from 37.9% (CI 27.4-44.7) to 51.4% (CI 43.9-56.6) for not resurfaced.

Conclusion:  Implant design and patellar resurfacing both show an association with KOOS JR improvement. Variations in implant design persist whether the patella is resurfaced or not. Implant selection and patellar resurfacing may be associated with patient outcomes.

Background and purpose:  Ankle arthroscopy is being increasingly utilized, but its potential benefits and harms remain unclear. This umbrella review aimed to assess the quality of systematic reviews and meta-analyses comparing ankle arthroscopy with equivalent open procedures or nonoperative options.

Methods:  A comprehensive search of MEDLINE, Embase, and CENTRAL was conducted on March 22, 2025. 2 reviewers independently screened abstracts and full texts, with conflicts resolved by a third reviewer. Systematic reviews assessing ankle arthroscopy versus any surgery or nonoperative treatment were included. The methodological quality of the reviews was evaluated using AMSTAR 2 criteria, along with an evaluation of whether the GRADE tool was appropriately applied.

Results: The literature search identified 430 studies, of which 29 systematic reviews were included after the screening process. These reviews covered various conditions, including lateral ankle instability, osteoarthritis, fractures, and osteochondral defects. None of the systematic reviews included RCTs comparing arthroscopic procedures with nonoperative treatment. A methodological assessment using AMSTAR 2 criteria identified multiple critical flaws across all reviews, leading to an overall confidence rating of "critically low" for each. 1 study adequately applied the GRADE approach to assess the certainty of the evidence.

Conclusion:  The efficacy of ankle arthroscopic procedures remains based solely on observational evidence. Given the critically low methodological quality of existing reviews, conclusions suggesting benefits of ankle arthroscopy, particularly over open procedures, are unreliable and insufficient to inform clinical recommendations. RCTs comparing ankle arthroscopy with nonoperative treatments or sham surgery are urgently needed.

Background and purpose:  Tourniquet use in total knee arthroplasty (TKA) provides a bloodless surgical field, which may lead to a better cementation but reduced function and increased pain. We aimed to investigate the effect of a tourniquet during TKA on implant survival, implant loosening, infection, and mortality.

Methods:  Data from 24,249 TKAs, collected by the Norwegian Arthroplasty Register between 2019 and 2023, was included. Among these, 14,926 were operated on with tourniquet and 9,323 without tourniquet. Cumulative revision rates (CRRs) were estimated using 1 minus Kaplan-Meier estimates for all revision causes and Cumulative Incidence Function (CIF) for specific revision causes at 3 years of follow-up. Cox regression analyses estimated hazard rate ratios (HRRs) for all revisions and Fine and Gray analyses estimated sub-hazard ratios (SHRs) for specific revision causes. Both were adjusted for age, sex, diagnosis, ASA score, fixation, implant type, and tranexamic acid use.

Results:  At 3 years of follow-up CRR was lower for the tourniquet group at 2.49% (95% confidence interval [CI] 2.21-2.81) vs 3.59% (CI 3.14-4.10) for the non-tourniquet group. We found an increased risk of revision in the non-tourniquet group (HRR 1.81, CI 1.46-2.46) after 3 months. CIF demonstrated a lower CRR for aseptic tibial loosening for the tourniquet group (0.08%, CI 0.04-0.15) compared with the non-tourniquet group (0.39%, CI 0.25-0.58). There was a higher risk of aseptic tibial loosening for non-tourniquet TKAs (SHR 6.06, CI 3.06-12.00), but no association with aseptic femoral loosening. There was no difference in infection or mortality.

Conclusion:  Tourniquet use during TKA was associated with reduced risk of tibial loosening after 3 years but without increased risk of infection, femoral loosening, or mortality.

Antimicrobial resistance (AMR) is rising globally and is a threat and challenge for orthopedic surgery, particularly in managing prosthetic joint infections (PJIs). This review first explores several AMR mechanisms from a microbiological point of view, including selective pressure, horizontal gene transfer, and further dissemination. Second, the variation in the rise of AMR across countries is highlighted, including its impact on PJI. While countries with the highest AMR rates are expected to experience the most significant burden, no country will be immune to the increasing prevalence of PJI. Third, this review stresses that multidimensional strategies are needed to combat AMR's challenges in orthopedic surgery. These include raising awareness across all sectors, including healthcare professionals, the public, healthcare policymakers, and even politicians; advancing diagnostic technologies for early infection detection and classification of resistant or susceptible strains; promoting antibiotic stewardship; and developing new material technologies to prevent or cure PJI. This review highlights the urgent need for a coordinated response from clinicians, researchers, and policymakers to avoid AMR-related complications in PJI cases.

Background and purpose:  The effects of axial instability in the rod-screw interface resulting in axial slippage between screws and rods are largely unknown. We aimed to assess the incidence of axial slip and loss of correction by comparing tulip screw versus dual locking cup in spinal instrumentations of patients treated with posterior spinal fusion for adolescent idiopathic scoliosis (AIS). We also aimed to assess whether axial slip would affect health-related quality of life.

Methods:  This study consists of 194 patients who underwent posterior spinal fusion for AIS during 2012-2022. All patients had a minimum of 2 years' follow-up. There were 98 patients treated with segmental tulip pedicle screw instrumentation and 96 patients with segmental dual locking cup constructs. Axial slip was defined as ≥ 2 mm and was assessed by measuring the rod exceeding the last pedicle screw and the distance between the 2 lowest screws on the same rod. Loss of correction was assessed by comparing postoperative and 2-year radiographic measurements. Health-related quality of life was assessed using the SRS-24 questionnaire.

Results:  Axial slip occurred only between the lowest instrumented vertebra and the vertebra above it on the convex side of the deformity. At 2 years of follow-up, axial slippage of 2 mm or more was observed more often in the dual locking group, which was observed in 24 (25%) patients in the dual locking cup group and 11 (11%) patients in the tulip group (risk ratio [RR] 2.2, 95% confidence interval [CI] 1.2-4.4). Minimum of 10° loss of major curve correction was found in 1 (1%) patient in the tulip group and 9 (9%) patients in the dual locking group (RR 9.1, CI 1.2-100).

Conclusion:  Axial slip was significantly less frequent in the tulip group than in the dual locking cup group. This suggests that tulip screw instrumentation may offer superior mechanical stability in posterior spinal fusion for AIS. Axial slip was not associated with health-related quality of life outcomes.

Background and purpose: With more knee arthroplasties (KAs) performed in working-age patients, interest in return to work (RTW) increases. We aimed to investigate the association between body mass index (BMI) and RTW after primary KA and whether the association varies by sex, age, comorbidity, and socioeconomic position.

Methods: From Danish national registries, we included 6,128 patients aged 18 to 60 years undergoing KA from 2008-2018. Exposure was BMI in categories < 25.0, 25.0-29.9, 30.0-34.9, 35.0-39.9, and ≥ 40.0. Outcome was RTW after KA. We estimated cumulative incidence proportions (CIP) of RTW. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CI).

Results: Median time to RTW was 70 days. Overall CIP for RTW was 63% (CI 62-65) at 3 months. With BMI < 25 as reference, CIP was 65% (n = 1,401) for BMI 25.0-29.9, 64% (n = 1,130) for BMI 30.0-34.9, 60% (n = 528) for BMI 35.0-39.9, and 60% (n = 260) for BMI ≥ 40.0, corresponding to an adjusted HR of 1.06 (CI 0.98-1.15), 1.02 (CI 0.94-1.11), 0.97 (CI 0.88-1.06), and 0.96 (CI 0.85-1.08). Men with BMI 35.0-39.9 and ≥ 40 had an adjusted HR of 0.89 (CI 0.76-1.05) and 0.87 (CI 0.70-1.10). None of the associations were statistically significant. Age, comorbidity, and socioeconomic position did not modify the association between BMI and RTW.

Conclusion: More than 60% of patients RTW within 3 months but we found no association between BMI and RTW after primary KA.

Background and purpose:  The number of cancer survivors has increased. Although spine surgery rates have multiplied in the general population, they are understudied in cancer populations. We aimed to determine the incidence rates of spinal surgery for degenerative and traumatic pathologies in patients with prior cancer. Our secondary aim was to define the underlying primary cancer diagnoses and survival rates after spinal procedures.

Methods:  Data was combined from 3 nationwide registers: the Finnish Cancer Register, Finnish Care Register for Health Care, and Finnish Cause of Death Register. Spine surgeries were identified using diagnosis and procedural codes, and tumor surgeries were excluded. Incidence rates were calculated per 100,000 inhabitants and adjusted for age and sex. Kaplan-Meier survival estimates (with 95% confidence intervals [CI]) were calculated per the first spine surgery.

Results:  10,280 patients underwent 12,425 surgeries, with a mean age of 70 years; 53% were women. Degenerative pathologies accounted for 74% of the surgeries, followed by disc pathologies (20%) and trauma (6%). The incidence of spine surgeries increased from 3.7 to 15.1 per 100,000 person-years (300%) between 1997 and 2019. The increase mostly occurred in degenerative spine procedures (420%), whereas disc and trauma surgeries were temporally stable. The most common previously diagnosed cancers were breast (24%) and prostate (22%) cancers. All-cause survival after spine surgery was 94% (CI 94-95) at 1 year, and cancer-specific survival was 90% (CI 0.89-0.91) at 15 years.

Conclusion:  We showed a 300% increase in spine surgeries unrelated to cancer in patients with a history of cancer between 1997 and 2020. Survival rates remained favorable (94% [CI 0.89-0.91] at 1 year).