Acta Orthopaedica最新文献

Background and purpose: International variation exists in the types of shoulder replacement used for treatment of specific diseases. Implant choice continues to evolve without high-quality evidence. Our aim was to evaluate trends in incidence rates of shoulder replacement and assess any recent changes in practice between countries by using registry data.

Methods: Patient characteristics, indication and year of surgery, type of replacement, and collection methods of patient-reported outcomes (PROMs) was extracted from 11 public joint registries. Meta-analyses examined use of reverse total shoulder replacement (RTSR) for osteoarthritis, cuff tear arthropathy, and acute fracture; use of anatomical total shoulder replacement (TSR) for osteoarthritis; and use of humeral hemiarthroplasty for fracture.

Results: The annual growth rate of shoulder replacements performed is 6-15% (2011-2019). The use of RTSR has almost doubled (93%). RTSR is now universally performed for cuff tear arthropathy (97.3%, 95% confidence interval [CI] 96.0-98.1). Its use for avascular necrosis, trauma, and inflammatory arthropathy is increasing. The use of RTSR was similar (43.1%, CI 30.0-57.2) versus TSR (44.7%, CI 31.1-59.1) for osteoarthritis. The types of PROMs used, collection time points, and response rates lack standardization. COVID-19 had a varying inter-registry impact on incidence rates.

Conclusion: The incidence of shoulder replacements has grown. Use of RTSR has increased for all disease indications despite limited high-quality evidence driving this change in indications outside of cuff arthropathy. Consequently, less variation is observed in international practice. Existing differences now relate to use of newer implant types and methodology of PROMs collection, which prevents international comparison and outcome analysis.

Background and purpose: Current follow-up protocols for adolescent idiopathic scoliosis (AIS) are based on consensus and consist of regular full-spine radiographs to monitor curve progression and surgical complications. Consensus exists to avoid inappropriate use of radiographs in children. It is unknown whether a standard radiologic follow-up (S-FU) approach is necessary or if a patient-empowered follow-up (PE-FU) approach can reduce the number of radiographs without treatment consequences.

Methods and analyses: A nationwide multicenter pragmatic randomized preference trial was designed for 3 follow-up subgroups (pre-treatment, post-brace, post-surgery) to compare PE-FU and S-FU. 812 patients with AIS (age 10-18 years) will be included in the randomized trial or preference cohorts. Primary outcome is the proportion of radiographs with a treatment consequence for each subgroup. Secondary outcomes consist of the proportion of patients with delayed initiation of treatment due to non-routine radiographic follow-up, radiation exposure, societal costs, positive predictive value, and interrelation of clinical assessment, quality of life, and parameters for initiation of treatment during follow-up. Outcomes will be analyzed using linear mixed-effects models, adjusted for relevant baseline covariates, and are based on intention-to-treat principle. Study summary: (i) a national, multicenter pragmatic randomized trial addressing the optimal frequency of radiographic follow-up in patients with AIS; (ii) first study that includes patient-empowered follow-up; (iii) an inclusive study with 3 follow-up subgroups and few exclusion criteria representative for clinical reality; (iv) preference cohorts alongside to amplify generalizability; (v) first study conducting an economic evaluation comparing both follow-up approaches.

Background and purpose: Knowledge concerning the use AI models for the classification of glenohumeral osteoarthritis (GHOA) and avascular necrosis (AVN) of the humeral head is lacking. We aimed to analyze how a deep learning (DL) model trained to identify and grade GHOA on plain radiographs performs. Our secondary aim was to train a DL model to identify and grade AVN on plain radiographs.

Patients and methods: A modified ResNet-type network was trained on a dataset of radiographic shoulder examinations from a large tertiary hospital. A total of 7,139 radiographs were included. The dataset included various projections of the shoulder, and the network was trained using stochastic gradient descent. Performance evaluation metrics, area under the receiver operating characteristic curve (AUC), sensitivity, and specificity were used to assess the network's performance for each outcome.

Results: The network demonstrated AUC values ranging from 0.73 to 0.93 for GHOA classification and > 0.90 for all AVN classification classes. The network exhibited lower AUC for mild cases compared with definitive cases of GHOA. When none and mild grades were combined, the AUC increased, suggesting difficulties in distinguishing between these 2 grades.

Conclusion: We found that a DL model can be trained to identify and grade GHOA on plain radiographs. Furthermore, we show that a DL model can identify and grade AVN on plain radiographs. The network performed well, particularly for definitive cases of GHOA and any level of AVN. However, challenges remain in distinguishing between none and mild GHOA grades.

Background and purpose: This study aims to assess time trends in case-mix and to evaluate the risk of revision and causes following primary THA, TKA, and UKA in private and public hospitals in the Netherlands.

Methods: We retrospectively analyzed 476,312 primary arthroplasties (public: n = 413,560 and private n = 62,752) implanted between 2014 and 2023 using Dutch Arthroplasty Register data. We explored patient demographics, procedure details, trends over time, and revisions per hospital type. Adjusted revision risk was calculated for comparable subgroups (ASA I/II, age ≤ 75, BMI ≤ 30, osteoarthritis diagnosis, and moderate-high socioeconomic status (SES).

Results: The volume of THAs and TKAs in private hospitals increased from 4% and 9% in 2014, to 18% and 21% in 2022. Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES compared with public hospital patients. In private hospitals, age and ASA II proportion increased over time. Multivariable Cox regression demonstrated a lower revision risk for primary THA (HR 0.7, CI 0.7-0.8), TKA (HR 0.8, CI 0.7-0.9), and UKA (HR 0.8, CI 0.7-0.9) in private hospitals. After initial arthroplasty in private hospitals, 49% of THA and 37% of TKA revisions were performed in public hospitals.

Conclusion: Patients in private hospitals were younger, had lower ASA classification, lower BMI, and higher SES com-pared with public hospital patients. The number of arthroplasties increased in private hospitals, with a lower revision risk compared with public hospitals.

Background and purpose: Recommendations regarding fragment-size-dependent screw fixation trajectory for coronal plane fractures of the posterior femoral condyles (Hoffa fractures) are lacking. The aim of this study was to compare the biomechanical properties of anteroposterior (AP) and crossed posteroanterior (PA) screw fixations across differently sized Hoffa fractures on human cadaveric femora.

Patients and methods: 4 different sizes of lateral Hoffa fractures (n = 12 x 4) were created in 48 distal human femora according to the Letenneur classification: (i) type I, (ii) type IIa, (ii) type IIb, and (iv) type IIc. Based on bone mineral density (BMD), specimens were assigned to the 4 fracture clusters and each cluster was further assigned to fixation with either AP (n = 6) or crossed PA screws (n = 6) to ensure homogeneity of BMD values and comparability between the different test conditions. All specimens were biomechanically tested under progressively increasing cyclic loading until failure, capturing the interfragmentary movements via motion tracking.

Results: For Letenneur type I fractures, kilocycles to failure (mean difference [∆] 2.1, 95% confidence interval [CI] -1.3 to 5.5), failure load (∆ 105 N, CI -83 to 293), axial displacement (∆ 0.3 mm, CI -0.8 to 1.3), and fragment rotation (∆ 0.5°, CI -3.2 to 2.1) over 5.0 kilocycles did not differ significantly between the 2 screw trajectories. For each separate subtype of Letenneur type II fractures, fixation with crossed PA screws resulted in significantly higher kilocycles to failure (∆ 6.7, CI 3.3-10.1 to ∆ 8.9, CI 5.5-12.3) and failure load (∆ 275 N, CI 87-463 to ∆ 438, CI 250-626), as well as, less axial displacement from 3.0 kilocycles onwards (∆ 0.4°, CI 0.03-0.7 to ∆ 0.5°, CI 0.01-0.9) compared with AP screw fixation.

Conclusion: Irrespective of the size of Letenneur type II fractures, crossed PA screw fixation provided greater biomechanical stability than AP-configured screws, whereas both screw fixation techniques demonstrated comparable biomechanical competence for Letenneur type I fractures. Fragment-size-dependent treatment strategies might be helpful to determine not only the screw configuration but also the surgical approach.

Background and purpose: There is conflicting evidence regarding treatment outcomes after minimally invasive sacroiliac joint fusion for long-lasting severe sacroiliac joint pain. The primary aim of our cohort study was to investigate change in patient-reported outcome measures (PROMs) after minimally invasive sacroiliac joint surgery in daily practice in the Swedish Spine Registry. Secondary aims were to explore the proportion of patients reaching a patient acceptable symptom score (PASS) and the minimal clinically important difference (MCID) for pain scores, physical function, and health-related quality of life outcomes; furthermore, to evaluate self-reported satisfaction, walking distance, and changes in proportions of patients on full sick leave/disability leave and report complications and reoperations.

Methods: Data from the Swedish Spine Registry was collected for patients with first-time sacroiliac joint fusion, aged 21 to 70 years, with PROMs available preoperatively, at 1 or 2 years after last surgery. PROMs included Oswestry Disability Index (ODI), Numeric Rating Scale (NRS) for low back pain (LBP) and leg pain, and EQ-VAS, in addition to demographic variables. We calculated mean change from pre- to postoperative and the proportion of patients achieving MCID and PASS.

Results: 68 patients had available pre- and postoperative data, with a mean age of 45 years (range 25-70) and 59 (87%) were female. At follow-up the mean reduction was 2.3 NRS points (95% confidence interval [CI] 1.6-2.9; P < 0.001) for LBP and 14.8 points (CI 10.6-18.9; P < 0.001) for ODI. EQ-VAS improved by 22 points (CI 15.4-30.3, P < 0.001) at follow-up. Approximately half of the patients achieved MCID and PASS for pain (MCID NRS LBP: 38/65 [59%] and PASS NRS LBP: 32/66 [49%]) and physical function (MCID ODI: 27/67 [40%] and PASS ODI: 24/67 [36%]). The odds for increasing the patient's walking distance to over 1 km at follow-up were 3.5 (CI 1.8-7.0; P < 0.0001), and of getting off full sick leave or full disability leave was 0.57 (CI 0.4-0.8; P = 0.001). In the first 3 months after surgery 3 complications were reported, and in the follow-up period 2 reoperations.

Conclusion: We found moderate treatment outcomes after minimally invasive sacroiliac joint fusion when applied in daily practice with moderate pain relief and small improvements in physical function.

Background and purpose: Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with haptic feedback has been unavailable. We explored a novel simulator, with the aim of gathering validity evidence for an embedded test and setting a credible pass/fail standard allowing trainees to practice to proficiency.

Patients and methods: The research, conducted from May to September 2020 across 3 Danish simulation centers, utilized the Swemac TraumaVision simulator for short antegrade femoral nail osteosynthesis. The validation process adhered to Messick's framework, covering all 5 sources of validity evidence. Participants included novice groups, categorized by training to plateau (n = 14) or to mastery (n = 10), and experts (n = 9), focusing on their performance metrics and training duration.

Results: The novices in the plateau group and experts had hands-on training for 77 (95% confidence interval [CI] 59-95) and 52 (CI 36-69) minutes while the plateau test score, defined as the average of the last 4 scores, was 75% (CI 65-86) and 96% (CI 94-98) respectively. The pass/fail standard was established at the average expert plateau test score of 96%. All novices in the mastery group could meet this standard and interestingly without increased hands-on training time (65 [CI 46-84] minutes).

Conclusion: Our study provides supporting validity evidence from all sources of Messick's framework for a simulation-based test in short antegrade nail osteosynthesis of intertrochanteric hip fracture and establishes a defensible pass/fail standard for mastery learning of SBT. Novices who practiced using mastery learning were able to reach the pre-defined pass/fail standard and outperformed novices without a set goal for external motivation.

Background and purpose: Few studies report on long-term levels of physical activity after THA compared with a control population. This case-control study aimed to find the long-term habitual level of leisure-time physical activity after THA and compare it with a large control group.

Patients and methods: A randomized sample of 856 patients, treated with primary THA, were identified from the Norwegian Arthroplasty Register. 429 (50%) responded to a questionnaire with a mean follow-up time of 9.6 years. We compared them with a control group of 29,272 (64%) from a population-based health study. Physical activity was measured with a questionnaire and categorized into groups according to the general recommendations for physical activity.

Results: 245 (63%) of the THA cases reported a level of leisure-time physical activity meeting the general recommendations, compared with 10,803 (39%) in the control group. The difference persisted at all ages (50-90 years). In sex, age, and BMI-adjusted regression models the chance of meeting the physical activity recommendations was higher in the THA group than in the control group (OR 2.9, 95% confidence interval 2.4-3.6).

Conclusion: The majority of the patients with THA reported a level of leisure-time physical activity meeting the general recommendations for physical activity. THA patients were more physically active in their leisure time than a control group representing a normal population.