Acta Orthopaedica最新文献

Background and purpose:  Internal fixation is the preferred treatment in the non-elderly with femoral neck fractures, regardless of fracture displacement. High complication rates are reported, in particular for displaced fractures. We aimed to compare cancellous screws with angle-stable sliding compression implants for internal fixation of femoral neck fractures in the non-elderly.

Methods:  A systematic search was carried out in Medline, Embase, Scopus, and Cochrane. The search results were screened by 2 reviewers using Covidence and assessed for risk of bias. All comparative studies were included. The studies reported at least 1 of the following outcomes: avascular necrosis, fixation failure/cut-out, non-union, any complication, reoperation, femoral neck shortening, or Harris Hip Score (HHS). Dichotomous outcomes are reported as risk ratio (RR) and continuous outcomes as mean difference (MD). All effect measures use a random effects model.

Results: The search yielded 23 studies eligible for inclusion: 4 randomized controlled trials (RCTs) and 19 retrospective cohort trials, including 1,844 fractures. Only 1 study had low risk of bias. The results demonstrated no difference in RCTs alone. Analysis of all studies showed superior outcomes in favor of angle-stable sliding compression implants for fixation failure/cut-out (RR 0.54, 95% confidence interval [CI] 0.31-0.94), any complication (RR 0.49, CI 0.28-0.87), shortening > 5 mm (RR 0.54, CI 0.37-0.80), and HHS 6-24 months (MD 3.1, CI 1.8-4.4).

Conclusion:  RCTs alone showed no significant differences between implant types. When including retrospective studies, angle-stable sliding compression implants demonstrated some advantages. The strength of evidence is limited by the predominance of retrospective cohort studies and high risk of bias in the included studies.

Background and purpose:  Data on effectiveness of nighttime bracing compared with full-time bracing in adolescent idiopathic scoliosis is scarce. We aimed to investigate risk of curve progression and surgery with nighttime bracing vs full-time bracing for patients with moderate-grade adolescent idiopathic scoliosis.

Methods:  Skeletally immature individuals with idiopathic scoliosis (25°-40°) treated with a nighttime brace as part of a parallel-group randomized controlled trial (RCT) were compared with non-participants treated with a full-time brace. In the case of curve progression of more than 6° in the nighttime brace group individuals were offered transition to a full-time brace. Surgery was offered if curve sizes were 45° or larger.

Results: Median age at treatment start was 12.8 years (nighttime brace n = 45, full-time brace n = 44). Female sex (odds ratio [OR] 6.5, 95% confidence interval [CI] 1.1-37.4), lower Risser grade (OR 1.6, CI 1.01-2.7), and larger curve size at the beginning of brace treatment (OR 1.4, CI 1.2-1.5) increased the risk of curve progression to ≥ 45°. Major curves in the groups were similar at median 33 months' follow-up (P = 0.7). After 94 months of follow-up, 11 patients in the nighttime brace group and 6 in the full-time brace group had undergone surgery (OR 2.0, CI 0.7-6.1).

Conclusion:  Nighttime bracing, including a possibility to transition to full-time brace in the case of progression, demonstrated comparable effectiveness in preventing curve progression, but a tendency to a higher risk of surgical treatment.

Background and purpose:  Sonication fluid cultures have been proposed as a complementary diagnostic method to intraoperative tissue culture sampling for the diagnosis of periprosthetic joint infection (PJI). We evaluated whether sonication provides additional clinically relevant information in the diagnosis of PJI in hip revision.

Methods:  Episodes of hip revision performed between January 2007 and December 2016 were assigned retrospectively to the European Bone and Joint Infection Society (EBJIS) definition of periprosthetic joint infection: infection unlikely, infection likely, and infection confirmed. The inclusion criteria were a minimum of 2 perioperative tissue cultures collected at the index procedure and sonication performed on a removed implant. The results of the tissue cultures were compared with the results of the implant sonication fluid cultures (SFCs).

Results:  288 hip revision episodes in 250 patients fulfilled the inclusion criteria and were analyzed. The "infection unlikely" group included 203 episodes (178 patients), the "infection likely" group included 5 episodes (5 patients), and the "infection confirmed" group included 80 episodes (67 patients). SFC delivered additional clinical information in 15/288: 6 of 203 episodes in the "infection unlikely" group, 2 of 5 episodes in the "infection likely" group, and 7 of 80 in the "infection confirmed" group. Coagulase-negative staphylococci and Staphylococcus aureus were the dominant bacterial species in both the SFC and tissue cultures.

Conclusion:  In addition to tissue cultures, sonication fluid cultures optimized the microbiological yield in 15 out of 288 hip revision episodes.

Background and purpose:  Atypical femur fractures (AFF) are associated with bisphosphonate (BP) treatment, although 10-50% of AFF patients have never used BPs. We aimed to compare the medical history, radiographs, and bone biopsies from the fracture site of patients with AFF with (BP group) and without BP exposure (non-BP group).

Methods: Between 2008 and 2021, we included 19 patients aged ≥ 50 years with incomplete AFF. During prophylactic nailing for thigh pain, a biopsy was taken that included the visible fracture line. Medical charts and radiographs were reviewed, and biopsies were analyzed histologically.

Results:  In the non-BP group (n = 9; mean age 70 years) patients had diseases affecting bone tissue properties (n = 3), pathological structural variations of the femur geometry or a fatigue-type mechanism (n = 3), or no identified causative patho-mechanism (n = 3). In the BP group (n = 10; mean age, 77 years) 2 patients had pathological variations of femur geometry and all used BPs. In the non-BP group, the fracture line was surrounded by bone resorption (n = 6) and cortical irregularities (n = 3), while the fracture line was restricted to a well-defined line in all patients in the BP group. The bone volume fraction (BV/TV) was on average 18% lower (95% confidence interval -35 to -1.2) in the non-BP group.

Conclusion:  AFF in the non-BP group are associated with bone metabolic diseases or deviations in whole-bone geometry and have a specific radiographic appearance at the fracture site whereas antiresorptive treatment appears to be the predominant etiological factor in the BP group.

Background and purpose:  Periacetabular osteotomy (PAO) for hip dysplasia is associated with intensive pain and high opioid consumption. High doses of dexamethasone may reduce this. We aimed to compare the effect of 1 or 2 doses of dexamethasone 24 mg, relative to placebo, on postoperative morphine consumption after PAO.

Methods:  A 3-group, randomized, double-blind, placebo-controlled trial was undertaken on patients ≥ 18 years, undergoing PAO (ClinicalTrials.gov: NCT03874936). Randomization Group A received 1 preoperative dose of dexamethasone 24 mg and placebo 24 hours later; Group B received 1 dose of intravenous dexamethasone 24 mg preoperatively and a repeated dose 24 hours postoperatively; and Group C received placebo at both time points. The primary endpoint was the difference in least squares mean cumulative postoperative morphine consumption between the combined dexamethasone groups and placebo within 48 hours from baseline. Key secondary outcomes included postoperative pain intensity, nausea and vomiting, antiemetic consumption and Timed Up and Go at 24 and 48 hours postoperatively, and cumulative morphine consumption from 48 hours to day 14 post-operation.

Results:  90 patients were randomized to dexamethasone groups (n = 60) and placebo (n = 30); 58 and 28, respectively, completed the trial. Mean age was 31 years and 71 (79%) were females. In the combined dexamethasone group the mean cumulated postoperative morphine consumption within 48 hours was 92 mg vs 95 mg in the placebo group, corresponding to a between-group difference of -3 mg (95% confidence interval -27 to 21; P = 0.8). There were no differences observed between groups for any of the secondary outcomes.

Conclusion:  High-dose dexamethasone did not reduce postoperative morphine use or improve any of the secondary outcomes after PAO.

Background and purpose:  The prevalence of metastatic bone disease as well as the accompanying societal costs are expected to increase due to advances in cancer treatment. While the literature suggests that there is economic value in prophylactic stabilization compared with the fixation of completed pathological fractures in long bone metastases, studies are limited by their small sample sizes and insufficient correction for potential confounders. We aimed to evaluate whether prophylactic treatment of an impending femur fracture was associated with lower healthcare costs compared with completed pathologic fractures. We further aimed to compare prophylactic surgical treatment with completed pathological fractures in terms of postoperative complications, discharge disposition, and postoperative length of stay.

Methods:  This is a retrospective cohort study with propensity score matching (PSM). We included clinical and financial data for 265 patients who received surgery for impending (n = 161) or completed (n = 104) femoral fractures of metastatic lesions, from 2 affiliated urban tertiary care centers between 2016 and 2020 in the United States. After PSM on 13 variables, including demographics and clinical characteristics, 100 impending fractures were matched with 100 completed fractures. The primary outcome was healthcare costs per episode of care, defined as the total cost from admission to 30 days after discharge.

Results:  We found no difference in total cost of care between patients undergoing prophylactic surgical treatment and patients who underwent surgical treatment for a completed pathological fracture (median difference 44 cost-units [CU], 95% confidence interval [CI] -294 to 262). No differences were seen when dividing total cost into cost during hospital admission (median difference -25 CUs, CI -152 to 159) and 30 days following discharge (median difference 31 CUs, CI -74 to 88). Patients with completed pathologic fractures were more often discharged to rehabilitation facilities (57/100, vs 30/100, P < 0.01).

Conclusion:  In contrast to earlier findings, we showed no difference in treatment costs between surgical management of impending and completed pathological fractures of femur metastases after adjusting for confounding factors. However, patients with completed pathological fractures were significantly more likely to require discharge to rehabilitation facilities, highlighting potential out-of-hospital costs related to extended rehabilitation, reduced mobility, and loss of independence.

Background and purpose:  Operating theatres are significant contributors to hospital waste and carbon emissions. In total knee arthroplasty (TKA), the number of surgical trays - and thus the carbon footprint - may be reduced by accurately estimating the prosthesis size preoperatively. We aimed to develop a predictive model to improve preoperative estimation of femoral prosthesis size and reduce the number of trays used in primary TKA.

Methods:  We retrospectively reviewed all primary TKA procedures performed between January 2012 and November 2022 at a single teaching hospital in the Netherlands. Using repeated hold-out cross-validation, we developed a prediction model based on routinely available demographic and anthropometric data to predict femoral component size. Rather than minimizing instruments per tray, our strategy focused on reducing the total number of trays. We used the created prediction model in combination with frequency data from our implanted TKAs to tailor surgical trays accordingly. We performed a post-hoc analysis to estimate the carbon emission cut and cost reduction.

Results:  The best-performing models utilized overlapping tray size ranges, with a practical limit of 3 sizes per tray. The final model predicted the appropriate size range with 97.4% accuracy. This enabled the elimination of 1 tray from the standard surgical setup, reducing total tray use by 11%.

Conclusion:  Accurate preoperative prediction of femoral prosthesis size facilitates surgical tray reconfiguration. We were able to reach an 11% reduction in total trays used with an estimated 1.03 kgCO2eq and a €29.6 cost reduction per reduced tray.

Background and purpose: Musculoskeletal deformities in cerebral palsy (CP) may be surgically treated, but population-based studies of postoperative complications after these surgeries are rare. The aim of our study was to assess the risk of complications following elective orthopedic surgery in children and young adults with CP.

Methods: We performed a register-based cohort study of 1,514 individuals born between 1990 and 2019 who underwent 2,983 orthopedic surgical events between January 1, 1997, and December 31, 2019. Data was obtained from the CP surveillance program CPUP, the Swedish National Patient Register, and the National Cause of Death Register. We used logistic regression to calculate odds ratios (OR) with 95% confidence intervals (CI) for postoperative complications within 90 days, in relation to the Gross Motor Function Classification System (GMFCS) level, anatomic level, and type of surgery (i.e., skeletal vs. soft tissue).

Results: 13% of all surgical events had at least 1 postoperative complication (6% in soft tissue surgeries, 17% in skeletal surgeries), and 51% of these were related to infection. The complication rate was higher in individuals with GMFCS levels IV and V than in the pooled GMFCS levels I-III. The highest ORs were found in GMFCS level V (7.0, CI 3.7-13.5) vs. GMFCS I and spinal surgery (7.9, CI 3.7-13.5) vs. foot/ankle surgery. The OR for skeletal surgery was 1.6 (CI 1.2-2.1) compared with soft tissue surgery.

Conclusion: 13% of all surgical events had at least 1 postoperative complication. The risk of complications after elective orthopedic surgery was higher in children with higher GMFCS levels and in skeletal surgery compared with soft tissue surgery.

Background and purpose:  Standardized reporting on methodology and results in clinical RSA research papers facilitates evaluation of quality and interpretation of results. We aimed to assess the extent to which radiostereometric analysis (RSA) and computed tomography-based RSA (CT-RSA) studies adhered to the items of the new RSA reporting guideline from 2024.

Methods:  A systematic literature search was performed to identify all clinical RSA studies published between January 2012 and February 2024. Studies were eligible for inclusion if prosthesis migration over time was assessed. The adherence of studies to each applicable guideline item (full, partial, or no) was assessed.

Results:  285 studies were included, most of which assessed prosthesis migration in the hip (n = 161) or knee (n = 99). No study reported on all guideline items. The mean (full or partial) adherence of studies to all (applicable) items was 61% (standard deviation [SD] 11). Large variation between the reporting of items was found, ranging from being reported in 1% of the studies to 100%. The least reported items in studies were the mean number and SD of days between surgery and baseline RSA examination (8% of studies), mean number and SD of days between surgery and primary endpoint RSA examination (1%), and consistent- or all-marker method for RSA analysis (3%).

Conclusion:  Current studies on average reported only 61% of the items from the updated RSA guidelines. Adherence to the guidelines in clinical RSA studies on prosthesis migration should be improved, in order to improve the quality of studies and the interpretation of outcomes on implant migration.

To our unpleasant surprise, we discovered that we have mistakenly included incorrect values in Table 2 (Reported accuracy of CT-RSA) for the paper by De Laat et al. (2024). The paper by De Laat (2024) is from our group as well. In the draft version of the systematic review manuscript, we included data from a draft manuscript of the paper by De Laat. Before publication of De Laat (2024) we updated the values for the RMS error for accuracy in translations and rotations based on an increased number of observations. However, we have overlooked to use the updated values for Table 2 of the systematic review. We are sincerely sorry for this mistake. We believe it is important to be transparent and to ensure a correct link between the systematic review and the paper by De Laat. These requested changes do not alter our conclusions of the systematic review. On behalf of all authors Bart Kaptein.