Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

Although surgical alignment of the rear-foot might be sufficient to achieve acceptable correction of pronation-distortion deformity, concomitant correction of the medial arch might improve functional results.

Methods

We present our experience with combined hind-foot alignment and medial arch reconstruction by in-situ naviculocuneiform arthrodesis for treatment of flexible flatfoot in children. We retrospectively evaluated clinical data available from pediatric (< 18 years old) patients treated for flexible flatfoot in our department.

Results

We performed 160 surgical corrections of flat foot in 94 children over the study period. Median age was 13 (range, 12–14) years. All patients had a minimum postoperative follow-up of 24 months. Overall postoperative outcomes were optimal in 82% (n = 113/160) of cases, good in 15% (n = 24/160) of cases, and adequate in 3% (n = 3/160) of cases. At 24-month follow-up, complete surgical correction of deformity was achieved in 89% (n = 143/160) procedures. Complete consolidation of arthrodesis was achieved within 3 months form surgery in 84% (n = 134/160) of cases, between 3 and 6 months in 12% (n = 21/160) of cases. There was a significant difference in pre-operative AOFAS score among the different weight categories (p < 0.001). At post-hoc analysis, OB patients had lower AOFAS versus NW or OW patients. At 24-months follow-up, there was a significant difference in AOFAS scores among the different weight categories (p = 0.04). At post-hoc analysis, OB patients had lower AOFAS versus OW patients. There was no difference in AOFAS scores at final follow-up (p = 0.12). Postoperative pain was absent in 88% (n = 140/160) of cases.

Conclusion

At a minimum 24-month follow-up, patients who undergo flat-foot deformity correction using a surgical technique combining sinus tarsi arthroeresis and medial arch reconstruction by naviculocuneiform arthrodesis experience good short-term results.

Introduction

Unstable large sized tear-drop fractures of the cervical spine (LSTDF) are difficult fractures to operate and there is a lack of standard in treatment. This study introduces an innovative technique for direct tear-drop fragment osteosynthesis with anterior cervical discectomy and fusion (TDFO-ACDF) and retrospectively analyzes clinical and radiological outcomes in five patients.

Patients and methods

Through a standardized anterior approach, the tear-drop fragment was reduced anatomically, the lower endplate restored and stabilized with lag-screws. Additionally, in four of five cases an anterior cervical discectomy and fusion (ACDF) using iliac crest bone graft was performed in combination with a VECTRA plate (DePuy Synthes, Zuchwil, Switzerland). X-ray check-up and functional outcome (neck disability index, NDI) was assessed during regular outpatient visits for at least two years postoperative.

Results

From 2013 until 2021 we operated five patients with the above-mentioned injury. All patients were operated the day after the accident and were hospitalized for 4 to 7 days. None of them had any neurological failures and all of them showed full clinical and radiological recovery without any clinical impairments. Median NDI was 2% ranging from 0 to 4% after a median follow up of 39 months (range 29 to 119 months).

Conclusion

The presented concept for treating large-sized tear-drop fractures of the cervical spine is safe. Utilizing a standard anterior approach with fundamental fracture management principles, this method enables direct bone healing and provides excellent postoperative results.

Introduction

Total Knee Arthroplasty (TKA) is the primary definitive treatment for knee osteoarthritis (OA) and has been essential in helping patients reduce knee pain and regain mobility. There is a need to assess whether various factors such as surgical complications from primary TKA, pre and postoperative range of motion (ROM), Charlson Comorbidity Index (CCI), comorbidities other than CCI, and demographics representative of an outpatient TKA population affect patient-reported outcome measures (PROMs).

Materials and methods

Retrospective chart review was performed on 444 patients who underwent TKA at an outpatient surgical facility. Demographics, qualitative, and quantitative measurements were collected at baseline, 4–6 months, and 1-year postoperatively. Patients were stratified by CCI into low (< 2), moderate (2–4), and high (> 4) risk categories. A generalized linear model was used to assess the relationship between time, complications, risk categories, and Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR).

Results

Majority of patients were women (58.9%), non-Hispanic white (81.9%), categorized as moderate risk CCI (78.8%), with 22.5% experiencing complications post-TKA. KOOS, JR scores improved over time, with an increase of 18.1 points at 4–6 months and 26.1 points at 1-year post-TKA (p < 0.0001). Surgical complications were linked to a decrease of 3.5 points in KOOS, JR scores, whereas patients with high pre-TKA KOOS, JR scores had an increase of 6.4 points after surgery. Patients who identified as African American experienced an average of 4.7 points lower on KOOS, JR than non-Hispanic whites (p = 0.0211). High-risk patients (CCI > 4) on average, had higher KOOS, JR scores 12 months after TKA. African Americans and those with surgical complications reported Lower KOOS, JR scores.

Conclusions

TKA improved KOOS, JR scores through one year with the greatest improvement in PROM being in higher-risk patients, those without surgical complications. Patients with surgical complications and/or African American race had a lower average KOOS, JR score.

Background

Methylene blue (MB), a phenothiazine dye with antimicrobial activity, is used to stain soft tissues and guide thoroughness of debridement during revision total knee arthroplasty (rTKA) for periprosthetic joint infection (PJI). The purpose of this study was to determine if instillation of MB prior to arthrotomy impacts culture yield in TKA PJI.

Methods

We retrospectively reviewed 266 patients diagnosed with TKA PJIs according to the 2018 International Consensus Meeting (ICM) criteria from January 2018 – March 2023 at a single academic hospital. Demographics, perioperative outcomes, and preoperative and intraoperative culture positivity were compared between patients who received intraoperative MB (MB group; n = 26) and those who did not (nMB group; n = 241). A record of detected organisms was included in the analysis.

Results

There was no difference in preoperative aspiration culture positivity between groups. However, the MB group had a higher percentage of preoperative to intraoperative culture concordance (89.5 vs. 69.9%; P = 0.04). Although the overall rate of intraoperative culture positivity did not differ significantly between groups, the MB group had more intraoperative cultures obtained per patient (4.9 vs. 4.5; P = 0.02) and higher numbers of positive intraoperative cultures per patient. Concordance rates for patients in both groups with positive preoperative and negative intraoperative cultures were similar (10.5 vs. 16.5%, P = 0.50). Among patients with negative preoperative cultures, intraoperative culture positivity was more discordant in the MB group (0 vs. 18.8%; P = 0.03). There was no difference in the number of patients that received antibiotics following aspiration (68.4 vs. 49.6%; P = 0.12).

Conclusion

While MB use did not affect overall culture positivity, it could interfere with intraoperative pathogen detection in patients with negative preoperative cultures. In these cases, MB should be avoided to decrease inaccuracies in intraoperative culture yield. If preoperative cultures are positive, MB may improve surgical debridement and likelihood of infection eradication.

Introduction

The dynamic lumbopelvic interaction has gained increasing importance in hip-preserving surgery, even though the coexistence of lumbopelvic malalignment with pre-arthritic hip deformities has been poorly studied. This study aimed to examine (I) the frequency of static and functional lumbopelvic malalignment (II) and to compare the lumbopelvic alignment between symptomatic mild to severe hip dysplasia (HD) and impingement-driven acetabular retroversion (AR).

Methods

Sagittal lumbopelvic radiographs were reviewed in standing, relaxed-seated and deep-seated position for pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), and sacral slope (SS). Static lumbopelvic alignment was classified as “Flatback”, “Normal”, or “Hyperlordotic” and functional lumbopelvic alignment was categorized as “Stiff”, “Normal”, and “Hypermobile”. Static and functional (Δ between the above-mentioned positions) lumbopelvic parameters were compared among HD, borderline hip dysplasia (BHD), and AR.

Results

Ninety-eight patients undergoing hip-preserving surgery for HD (n = 47), BHD (n = 36), and AR (n = 15) were prospectively enrolled. Static lumbopelvic malalignment occurred in 44.9% of patients (44/98), with “Hyperlordotic” alignment being the most frequent (36/44). Additionally, 28.6% of patients (28/98) exhibited functional lumbopelvic malalignment. Static lumbopelvic parameters showed differences between hip instability and impingement, with lower PI (42° vs. 57.3°, p = 0.001; 42° vs. 53.7°, p = 0.01) and PT (5.6° vs. 15.8°, p < 0.001; 5.6° vs. 12.4°, p = 0.01) in AR patients compared to HD and BHD in standing position. Moreover, SS was significantly lower in AR (40.9° vs. 50.1°, p = 0.02) and BHD (43.8° vs. 50.1°, p = 0.05) compared to HD in deep-seated position. Significant differences in functional lumbopelvic parameters were observed only between HD and BHD in PT (Δ standing – deep-seated position, 7.1° vs. -1.2°, p = 0.04).

Conclusion

Static and functional lumbopelvic malalignment is prevalent in patients with pre-arthritic hip deformities. While static lumbopelvic parameters vary between instability- and impingement-driven hip deformities, functional lumbopelvic alignment is quite similar among HD, BHD, and AR.

Introduction

Modifiable patient-related factors contribute to morbidity and functional outcomes after acetabular fracture. This study will investigate the relationship between tobacco smoking and patient-reported functional outcomes after acetabular fracture.

Materials and methods

A retrospective cohort study of 770 patients with 782 acetabulum fractures was performed following operative (n = 535, 68%) or non-operative (n = 247, 32%) management. Musculoskeletal Function Assessment (MFA) scores were assessed a minimum of 12-months after injury in 37.5% of patients.

Results

Tobacco smoking was pervasive with 44% current users and 14% former users. Current tobacco smokers had higher associated MFA scores, when compared to former and never smokers (42.7 vs. 36.5 and 26, p < 0.001). On linear regression analysis, history of tobacco smoking (current or former) was a risk factor for higher, worse outcomes on the MFA (B = 9.86, p = 0.02).

Conclusions

Current or former tobacco smoking was predictive of worse patient-reported functional outcomes scores after acetabular fracture.

Level of evidence

Level III, Prognostic.

Introduction

Taper-wedged stems have a stable fit and favorable clinical results. However, detailed studies on stem-bone contact patterns and clinical outcomes specific to Japanese patients are limited. This study aimed to describe stem-bone contact patterns and assess clinical outcomes in Japanese patients undergoing primary total hip arthroplasty (THA) with taper-wedged stems designed to fit the bone morphology of the Japanese population.

Methods

We retrospectively reviewed 125 Japanese patients who underwent THA via a direct anterior approach using taper-wedged stems designed to fit the bone morphology of the Japanese population. Relationships between stem-bone contact patterns and clinical and radiographic outcomes were examined. Preoperative radiographs were evaluated to assess femoral morphology. Postoperative radiographs were evaluated to determine stem-bone contact patterns and the canal filling ratio. We divided the patients into proximal and distal fitting groups according to the stem-bone contact pattern. Osseointegration was assessed on the last follow-up radiograph using the Engh and O-SS scores.

Results

The mean follow-up period was 5.1 years. Proximal femoral stem-bone contact was achieved in 90.4% of the cases. Both groups had good clinical and radiographic outcomes. Except for differences in preoperative bone morphology, there were no differences in demographics or clinical outcomes between the groups. The distal fitting type was more common in cases with champagne flute morphology. No aseptic loosening or revision was observed, and good osseointegration was obtained in either group.

Conclusion

THA with taper-wedged stems designed to fit the bone morphology of Japanese patients achieved favorable stem-bone contact patterns and acceptable short- to mid-term clinical and radiographic outcomes. Population-specific implant designs tailored to Japanese bone morphology may improve surgical outcomes and implant longevity.

Introduction

Prolonged opioid usage has numerous side effects, contributing to poorer long-term outcomes. An unexplored area pertains to patient-specific factors that influence chronic opioid consumption in cases of multiple fractures. We aimed to assess the prevalence and identify risk factors for chronic opioid usage in orthopedic polytrauma patients.

Materials and methods

We retrospectively identified 167 patients who sustained multiple lower extremity fractures occurring at a level-one trauma between July 2017 and June 2020. Utilizing the state prescription monitoring database, we gathered opioid prescription data for 3 months before and one year following the surgical procedure.

Results

In total, 68 patients (41%) exhibited chronic opioid use after trauma. Of the 167 patients, 38 (22.7%) engaged in pre-admission opioid usage, of which 28 patients (73.7%) displayed chronic usage after discharge. Pre-admission opioid use (odds ratio 9.02, P = < 0.001) and an Injury Severity Score (ISS) greater than 15 (odds ratio 3.62, P = 0.007) increased the odds of chronic usage compared to those without these risk factors. The chronic use group had significantly more surgeries performed on average (mean 4 vs. 2.9; P = 0.015) and a higher frequency of open fractures (P = 0.017). Polytrauma patients that obtained greater amounts of Morphine Milligram Equivalents (MMEs) before, during, and after admission, were statistically more likely to become chronic opioid users.

Conclusions

Chronic opioid use is common after polytrauma. Polytrauma patients with pre-admission opioid use, a higher ISS, and escalated opioid requirements during hospitalization should be closely monitored for long-term opioid use. Sustained endeavors to mitigate opioid consumption and enhance non-opioid approaches are essential in preventing long-term challenges secondary to chronic opioid usage in polytrauma patients.

Level of evidence

Prognostic Level 2 Retrospective Cohort.