Advances in Orthopedics最新文献

Purpose: Geriatric hip fractures often require allogenic blood transfusions, which increases the risk of transfusion related complications. Tranexamic acid (TXA) has been shown to have a positive effect on hip fractures, with the American Academy of Orthopedic Surgeons (AAOS) recommending its use; however, optimal dosing and timing has not been delineated in the literature. This study evaluates the effectiveness of early TXA administration in reducing transfusion rates in extracapsular geriatric hip fracture patients.

Methods: From 2021 to 2023, a retrospective chart review compared geriatric fragility hip fracture (AO/OTA 31A) patients who received TXA at admission (1-g IV at presentation and 1-g IV three hours later) with those who did not. The primary outcome evaluated was allogenic blood transfusion rates. Patient demographics, hemoglobin levels during admission, hidden blood loss, length of hospital stay, and 90-day perioperative complications were also recorded.

Results: Among 168 patients, 102 received TXA and 66 did not. There was no statistically significant difference in allogenic transfusion rates between the groups (p = 0.27). Secondary outcomes, including hemoglobin/hematocrit levels, hidden blood loss, and length of hospital stay, were also similar. Thromboembolic event rates were comparable.

Conclusion: Our findings align with recent literature that questions TXA's effectiveness in reducing transfusion rates in this population. Early TXA administration may not adequately address hidden blood loss in geriatric hip fractures, possibly due to high comorbidity burden, pre-existing anemia, and delayed surgery. Further research is necessary to explore alternative strategies for managing early blood loss and optimizing outcomes in this population.

Introduction: Distal radius fracture (DRF) is the most common fall-related fracture, with an incidence of up to 18% of the elderly population who are being examined in the emergency department. Conservative treatment in the geriatric population is the treatment of choice, and traditionally the wrist after reduction is placed in volar flexion and ulnar deviation position (Cotton position). The aim of this study is to compare two-cast position (Cotton and Functional position) for conservative treatment of geriatric DRFs, according to functional outcomes at twelve months.

Patients and methods: This randomized prospective study compared and evaluated the functional outcomes and cost of physiotherapy in the geriatric population with DRFs. Regarding functional outcomes, these were measured using the QuickDASH Score, Patient-Reported Wrist Evaluation, pain (VAS score), and health-related quality of life measurement (15D), while for the cost of physical therapy, the number of sessions performed by patients in both groups was measured.

Results: Ninety-three patients (75 female and 18 men) with an average age 79.2 ± 6 (range 67-90 years) with a DRF were included in the study. Among these patients, 9 underwent surgical intervention due to loss of reduction and were consequently excluded from our study. The study ultimately encompassed a total of 84 patients. The mean age for Group A was 79 ± 2 years, and for Group B, it was 79 ± 1 years (p = 0.61). The mean follow up for all patients was 1 year. Functional cast-position group (Group B) showed better results in terms of functional recovery: PRWE (Mdiff = 1.52, 95% CI [-7.77, 3.81]), QuickDASH Score (Mdiff = 8.00, 95% CI [2.27, 13.72]), and posttraumatic pain (Mdiff = 1.27, 95% CI [0.86, 1.69]). Cost of physiotherapy (z = 128, p < 0.001) and HRQol-15(Mdiff = 1.81, 95% CI [1.02, 2.60]) was statistically significantly greater in the Cotton position group versus Functional position group.

Conclusion: Our results indicate that functional cast-position produces better functional outcomes with a lower rate of complication than volar-flexion and ulnar-deviation cast (VFUDC) position. Despite the fact that the VFUDC group underwent a greater number of physical therapies, they presented less good functional results. In conclusion we recommend the use of functional cast in elderly low energy DRFs.

Introduction: Postoperative pain following total knee arthroplasty (TKA) can exacerbate sympathetic activity, elevate blood pressure, and potentially increase blood loss. However, the relationship between these factors remains unclear. This study evaluates the correlation between postoperative pain intensity and perioperative blood loss.

Methods: A retrospective analysis was conducted on 405 unilateral TKAs, stratified by average visual analog scale (VAS) in the first 24 h postoperatively into mild (VAS 0-3), moderate (VAS > 3-6), and severe (VAS > 6-10) pain intensity groups. The primary outcomes were the effect of pain intensity on mean calculated blood loss (CBL) and risk of blood transfusion. Secondary outcomes included length of hospital stay (LHS) and complications. Multivariable regression analysis was employed.

Results: Adjusted mean differences in CBL and LHS were not significantly different among the pain intensity groups. However, severe pain intensity was associated with a higher risk of blood transfusion (risk ratio: 1.92, p = 0.068). Preoperative hemoglobin (Hb) was the only protective factor against blood transfusion; each 1 g/dL increase in preoperative Hb reduced the blood transfusion risk by 61% (risk ratio: 0.39, p  <  0.001). Additionally, the severe pain intensity group had the highest incidence of overall complications (13.3%) observed during 180 days post-TKA (p  <  0.01).

Conclusion: Patients experiencing severe pain intensity in the first 24 h after TKA tend to have a higher risk for blood transfusion and a significantly higher risk of overall complications. Thus, optimizing pain control is important to enhance recovery for current clinical pathways of TKA.

Purpose: Residual rotational instability following anterior cruciate ligament reconstruction (ACLR) remains a clinical challenge, leading to renewed interest in adjunctive lateral extra-articular procedures (LEAP). This study aimed to compare clinical decision-making between experienced orthopaedic surgeons and an artificial intelligence (AI) model regarding indications for LEAP in ACLR, to assess concordance, and to explore the potential role of AI in surgical planning.

Methods: A cross-sectional comparative study was conducted using 40 hypothetical ACLR case profiles, reflecting a range of patient demographics, injury characteristics, and activity levels. An AI model trained on literature-based criteria and expert input generated binary recommendations ("perform LEAP" or "do not perform LEAP") for each case. Twenty-two high-volume knee surgeons independently reviewed all cases, blinded to AI recommendations, and indicated whether they would recommend a LEAP. Agreement between surgeon decisions and AI recommendations was calculated, and factors influencing concordance were analysed using chi-square tests, t-tests, and Pearson correlations (p < 0.05).

Results: Overall, surgeon agreement with AI recommendations was high but varied by clinical factors. A positive pivot shift test was the strongest predictor of concordance (93.9% ± 4.8 vs. 71.8% ± 25.7; p = 0.0004, Cohen's d = 1.23). Surgeons agreed more often when the AI recommended LEAP (92.7% ± 6.5) than when it advised against it (70.9% ± 27.0; p = 0.0006). Male patient cases yielded higher agreement (91.1% ± 7.4) compared with female cases (75.7% ± 27.0; p = 0.018). Ligamentous laxity (Beighton score) showed a moderate positive correlation with agreement (r = 0.39; p = 0.013), while age, revision status, associated lesions, and time from injury to surgery were not significant predictors.

Conclusion: Surgeons demonstrated strong alignment with AI recommendations in clear-cut scenarios, particularly when traditional clinical signs such as a positive pivot shift were present. Discordance emerged in borderline cases, notably when AI recommended against LEAP or in female patients. These findings suggest AI could support orthopaedic decision-making by standardising criteria for LEAP, enhancing consistency in ambiguous cases, and prompting the development of evidence-based scoring systems to refine indications.

Trial registration: IRB cleared, no need for trial registration as all cases hypothetical and no patient data included in the study.

Osteoporotic-related weakening of bone is a common cause of hip fractures. The standard of care for the diagnosis and management of osteoporosis is the dual-energy x-ray absorptiometry bone mineral density T-scores. Many individuals considered nonosteoporotic, however, still sustain fractures since these tools do not incorporate vital bone parameters and subject-specific characteristics. The purpose of this work was to (1) develop a simple analytical model for estimating the force exerted on the femur during a fall (i.e., impact force) based on measurable patient metrics and (2) define a quantifiable fracture risk index by comparing finite-element-derived bone strength and impact force, which could be validated in a cohort of human subjects. Aggregated regression models were derived for estimating impact force based on patient age, weight, height, and soft tissue thickness. Patients with a history of hip fractures were then compared to a matched nonfracture group via the bone strength index (BSI), defined as the ratio between bone strength and maximum impact force. The BSI was lower in the fracture group compared to the control group by 0.23 (p = 0.045). The combination of patient-specific impact force on the femur during a fall and bone strength could provide additional insights into osteoporotic hip fracture risk alongside standard risk assessments.

Socioeconomic disparities are known to affect outcomes after primary total hip and knee arthroplasty. Revision procedures may be similarly associated, though this relationship remains unclear. This study examined the association between socioeconomic status (SES), measured by the Distressed Communities Index (DCI), and short-term complication rates following revision total hip (rTHA) and knee arthroplasty (rTKA).This retrospective cohort study included 851 consecutive revision arthroplasties (502 rTKAs, 349 rTHAs) performed between January 1st, 2018, and January 1st, 2025, with at least 6 months of follow-up. Preoperative and postoperative data were collected via chart review. Multivariate regression analyses were conducted, adjusting for demographic and clinical variables. Alpha was set at 0.05. Higher Charleston Comorbidity Index (CCI) was associated with increased 90-day medical complications in both rTHA and rTKA (p < 0.001). Higher EBL was also associated with greater medical complications for rTHA patients (p = 0.048). Younger age, higher CCI, and greater operative time correlated with higher surgical complication rates in rTKA (p < 0.05). DCI was associated with increased postoperative opioid use in rTHA patients and decreased 30-day readmission in rTKA patients (p = 0.005 and 0.025, respectively). However, after adjusting for pain, DCI was not independently associated with 90-day complications. Post hoc analysis demonstrated adequate statistical power. SES, as measured by the DCI, was not independently associated with short-term postoperative complications following rTHA or rTKA.

Clinical significance: These findings suggest that DCI and similar indices used in isolation may have limited utility in risk-stratifying revision arthroplasty patients.

Purpose: To evaluate the clinical outcomes and effectiveness of the newly developed Oblique Locking Hip Screw (OLHS) compared with those of the commonly used cephalomedullary nail (CMN) in trochanteric femoral fracture treatment in older patients.

Methods: This was a single-center retrospective study of patients with trochanteric fractures. Overall, 129 patients were analyzed: 64 treated with OLHS and 65 with CMN. Patient demographic data, fracture classification, surgical parameters (e.g., operating time and intraoperative blood loss), and clinical outcomes were assessed. Postoperative outcomes were evaluated using radiographic findings and statistical analyses, including Fisher's exact test and the Mann-Whitney U test.

Results: The study included 57 patients in both the OLHS and CMN groups with 3 months of radiographic follow-up data. OLHS was more commonly used for stable AO A1 fractures, whereas CMN was preferred for unstable A2 fractures. Postoperative telescoping was greater with OLHS than with CMN (4.8 ± 4.3 vs. 3.0 ± 4.7 mm; p = 0.0028; mean difference 1.8 mm, 95% CI 0.15-3.45). Mortality, union, and adverse events were similar; two CMN patients had nonunion, with one conversion to total hip arthroplasty.

Conclusion: OLHS provides satisfactory clinical outcomes for trochanteric fractures in this exploratory study, with preliminary evidence of adequate stability. Further randomized controlled trials or matched comparative studies are warranted to confirm these findings.

Background: Orthobiologic treatments such as autologous platelet-rich plasma (A-PRP) and mesenchymal stem cells (MSCs) are widely used for knee osteoarthritis (OA). Umbilical cord-derived PRP (UCD-PRP), with its standardized composition and high growth factor content, has emerged as a promising allogeneic alternative, though comparative data are limited.

Purpose: To compare the short-term clinical outcomes of UCD-PRP versus adipose tissue-derived MSCs (ADT-MSCs) following debridement and lavage arthroscopy in patients with early-stage knee OA.

Study design: Cohort study; Level of evidence, 3.

Methods: This retrospective study included 225 patients with Kellgren-Lawrence grade I-II knee OA treated with either UCD-PRP (n = 75) or ADT-MSCs (n = 150) after arthroscopy. Outcomes assessed at baseline, 6, and 12 months included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score, and Visual Analog Scale (VAS) for pain. Multivariate analysis assessed predictors of outcome.

Results: Both groups showed significant functional and pain improvements from baseline at all follow-up points. The UCD-PRP group demonstrated superior pain reduction on VAS at 3 and 6 months compared with ADT-MSCs (ΔVAS at 3 months, p = 0.042; at 6 months, p = 0.0065). Functional scores (WOMAC, KOOS, and IKDC) showed no significant between-group differences at 12 months. Higher BMI was independently associated with poorer clinical outcomes (p < 0.001).

Conclusion: UCD-PRP provides superior short-term pain relief compared with ADT-MSCs following knee arthroscopy for early OA, with comparable functional outcomes at 12 months. Its standardized, allogeneic preparation and minimal donor-site morbidity make UCD-PRP a promising orthobiologic option for knee OA management.

Level of evidence: Level III.

The optimal fixation method for humeral shaft fractures remains a topic of debate. Intramedullary nailing (IM nailing) and plate fixation are the most common surgical options, each with distinct advantages and complications. This study aimed to compare the functional outcomes and complications associated with IM nailing and plating fixation for humeral shaft fractures at Sultan Qaboos University Hospital. This retrospective cohort study included adults who underwent humeral shaft fracture fixation from January 2012 to December 2022. Patients were treated with either IM nailing or plate fixation. Outcomes that were measured included time to union, operative time, complications rate, and the abbreviated form of the Disabilities of the Arm, Shoulder, and Hand (DASH) score. About 73 patients were included in the study, 37 of whom underwent IM nailing, and 36 patients had plate fixation. There were no statistically significant differences in any of the measured outcomes: surgical site infection (p = 0.475), operative time (p = 0.365), time to union (p = 0.055), delayed union (p = 0.325), nonunion (p = 0.491), revision procedures (p = 0.254), and postoperative radial nerve injury (p = 1.000). The Quick DASH scores were similar between the two groups (p = 0.443). In conclusion, both IM nailing and plating fixation are effective methods for treatment of humerus shaft fractures with no statistically significant differences. The Nail group showed not only a trend of slightly shorter time to union but also a higher rate of complications. The Plate group had a higher incidence of delayed union but fewer cases of postoperative complications. Surgical choice should be individualized based on patient and fracture characteristics.

Background: Fractures of the femur are one of the major complications of solid tumor metastasis to bone. Tumor resection with reconstruction using modular prostheses achieves optimal local tumor control, pain reduction, and improved patient function and quality of life. Unfortunately, the surgical treatment of femoral fractures with prostheses is associated with high blood loss, requiring the transfusion of blood products. Blood transfusion carries several risks, including immune suppression and a higher risk of postoperative infection, deterioration of functional outcomes, and prolonged hospital stays. An inexpensive and effective way to reduce blood loss and the number of transfusions is tranexamic acid (TXA).

Methodology: In our study, we analyzed 82 cases of patients treated with resectional prostheses for pathological fractures between 2017 and 2021. The operations of 42 patients were performed between 2017 and 2019 without the use of TXA. Another 38 patients were operated on in 2020-2021 with the use of TXA prophylaxis. Total blood loss (TBL), hemoglobin drop, number of transfusions, and adverse thromboembolic events were evaluated.

Results: After surgery, patients who received TXA had higher hemoglobin levels on the first day than those in the control group (0.99 g/dL p = 0.03), and the blood loss was reduced by 217 mL in the TXA group (p = 0.09). Transfusion rate was reduced from 43% to 17% (p = 0.04). No differences were seen in the number of complications.

Conclusion: TXA significantly reduced transfusion rates and hemoglobin drop, without increasing complications.

Trial registration: ClinicalTrials.gov identifier: NCT06244498.