Archives of Orthopaedic and Trauma Surgery最新文献

Background

Trochanteric femoral fractures are associated with high morbidity and mortality with a substantial proportion of patients presenting with ongoing antithrombotic therapy (ATT). Evidence regarding the impact of ATT on surgical outcomes and complication rates in this population remains limited. The purpose of this study was to evaluate revision rates, infection risk, surgical timing, and mortality in patients with trochanteric fractures receiving ATT.

Methods

We retrospectively analyzed 656 patients who underwent cephalomedullary nailing for trochanteric femoral fractures between January 2021 and December 2024. Patients were stratified by pre-injury ATT status. The primary outcome was revision surgery; secondary outcomes included infection requiring revision, surgical timing, and mortality at predefined intervals.

Results

Of 656 patients, 319 (48.6%) presented with pre-injury ATT. Revision surgery was required in 33 patients (5.0%) and did not differ significantly between ATT and non-ATT groups (6.0% vs. 4.2%, p = 0.291). Infections occurred in 1.2% of patients, with no excess risk in ATT patients. Patients with pre-injury ATT had significantly higher mortality rates (p = 0.005), although the one-year mortality did not differ significantly (23.8% vs. 23.1%, p = 0.989) between the two groups. Competing risk analyses revealed a significant impact of pre-injury ATT on the mortality (p = 0.004) but not on the revision rates (p = 0.311).

Conclusions

In this large cohort, nearly half of all patients with trochanteric fractures were on ATT at admission. ATT was not associated with increased revision or infection risk. While overall mortality was higher in patients receiving ATT, one-year mortality was comparable between groups, indicating that early excess risk is more likely related to age and comorbidity. These findings suggest that ATT itself does not predispose to adverse surgical outcomes.

Introduction

Achieving personalized alignment in total knee arthroplasty (TKA) with conventional instrumentation remains challenging. This study validates a novel trigonometric formula that calculates the exact lateralization needed for the tibial extramedullary guide based on preoperative weight-bearing X-rays.

Methods

We retrospectively analysed 196 patients who underwent TKA between November 2018 and June 2023. Inclusion criteria: patients with preoperative weight-bearing AP lower limb X-rays aged 18 or older. Exclusion criteria: previous total hip arthroplasty, those without consent. The formula LAT = LENG(S) × sin α angle calculated tibial guide lateralization, where LAT was the lateralization distance, LENG(S) was the tibial length from radiographs, and α angle was the tibial coronal correction angle. The true radiographic lateralization was measured to validate the formula’s accuracy and defined a “safety zone” representing acceptable surgical margins to validate the formula’s accuracy and defined a “safety zone” representing acceptable surgical margins. The Intraclass Correlation Coefficient (ICC) was used to test for the measurement consistency among observers. 95% Clopper-Pearson Confidence Interval was calculated for the frequency of lateralization falling within a “safety zone”. A T-test compared LAT measurements with true radiographic lateralization.

Results

ICC showed that 97.2% of lateralization measurements fell within the defined “safety cone” (95% CI 93.9–98.9%). Inter-observer reliability was high (ICC 0.91). No differences were found between the formula-derived measurements and the true radiographic lateralization. The 95% Clopper-Pearson Confidence Interval was 93.9–98.9%. LAT was found to fall outside the safety cone with a total mean of 2.3° (range 1–5) in 2.8% of the cases, with a mean error in the degree of proximal tibial cut of -0.67° (range − 1 - +1). No association between CPAK and cases within or outside the safety cone was found (χ²= 5.014, p = 0.658).

Conclusions

This validated trigonometric formula enables surgeons to accurately calculate tibial guide lateralization for personalized alignment using only conventional instrumentation and standard radiographs. The method’s 97.2% accuracy within safe surgical margins supports its use as a reliable preoperative planning tool for personalized TKA alignment without requiring specialized software or robotic assistance.

Introduction

Compare 10-year survival of the cemented highly crosslinked polyethylene Exeter^® Rimfit™ (Rimfit) Cup and its predecessor, the ultra-high molecular weight polyethylene Exeter^® Contemporary Flanged Cup™ (ECF), both with an Exeter^® V40™ stem, in primary total hip arthroplasty (THA) for osteoarthritis in the Bay of Plenty region of NZ.

Method

We extracted national registry data for THA surgeries in the region between 1 January 2003 and 30 June 2023 and report the 10-year survival and reasons for revision of the two fully cemented implants (n = 495). We compared standard Kaplan-Meier estimates using the log-rank test. Cox proportional hazard models investigated the potential influence of six patient variables on the survival of each implant: sex, age, body mass index (BMI), ethnicity, American Society of Anesthesiologists (ASA) rating, and funding source (public/private).

Results

No statistically significant difference in 10-year survival rate between the implants (p = 0.334) (ECF 95.6% [93.4, 97.9], Rimfit 97.0% [95.9, 98.2]) or statistically significant difference in revision reasons between the implants (p = 0.09) was noted. Cox regression revealed no statistically significant influence of any of the six patient variables on the 10-year survival of the ECF (p = 0.584) or Rimfit (p = 0.611).

Conclusion

Both implants exceeded 95% survival at 10-years, which is favourable compared to the corresponding 94.8% national survivorship of cemented implants in NZ. There is no statistically significant difference in the 10-year survival rate or reasons for revision of the two cemented implants compared in this region. The Rimfit appears a suitable alternative to the ECF, from a survival and revision perspective.

Plate fixation for Vancouver type C periprosthetic femoral fractures presents a surgical challenge, and nonunion is a serious complication. The relationship between specific fixation constructs and fracture healing remains poorly understood. This study aimed to describe the radiographic characteristics of patients with nonunion following plate fixation for these fractures, with a focus on proximal fixation strategies.

This multicenter retrospective study included 18 patients who underwent plate osteosynthesis for Vancouver type C fractures between 2014 and 2022. Patients were divided into union and nonunion groups based on fracture healing at 12 months postoperatively. We analyzed postoperative radiographs to compare patient demographics and the number and type of fixation devices (screws and wires) used for the proximal fragment between the two groups.

Nonunion occurred in 5 of 18 patients (27.8%). There were no significant differences in patient baseline characteristics between the groups, except for BMI. Radiographically, the nonunion group had a significantly greater total number of proximal screws (median, 6 vs. 3; p = 0.035) and proximal monocortical screws (median, 6 vs. 2; p = 0.049) than the union group. The total number of proximal fixation devices (screws plus wires) was also significantly greater in the nonunion group (median, 8 vs. 6; p = 0.029). Receiver operating curve analysis revealed a cutoff value of 5 total number of proximal screws for predicting nonunion (area under the curve [AUC], 0.831).

A greater number of proximal fixation devices, particularly monocortical screws, is a distinct radiographic parameter associated with nonunion in Vancouver type C fractures treated with plating. This finding may not be a causative factor but rather an indicator of initial technical difficulty and fixation instability. When extensive proximal fixation is required, surgeons should consider adjunctive stabilization techniques to improve outcomes.

Introduction

The Coronal Plane Alignment of the Knee (CPAK) is a classification that evaluates the joint line obliquity (JLO) and hip-knee-ankle angle (HKA) in osteoarthritis of the knee. The primary aim of this study was to evaluate whether changes in CPAK classification between pre- and postoperative states in patients who underwent robotic-assisted (RA) bi-cruciate stabilized (BCS) total knee arthroplasty (TKA) with a 3-degree varus inclination affected patient reported outcome measurements (PROMs).

Materials and methods

This retrospective study involved 149 patients treated with bi-cruciate stabilized (BCS) TKA between 2019 and 2023 following a physiological alignment strategy and using image-free robotic-assisted (RA) technique. Pre- and postoperative CPAK classifications were compared, along with changes in arithmetic HKA (aHKA), JLO, and PROMs including the 2011 Knee Society Score, Western Ontario and McMaster Universities Arthritis Index score, Forgotten Joint Score 12, and Patella score were collected at a mean 1.95 years (range:1–5) postoperatively.

Results

CPAK classification matched pre and postoperatively in 59.1% of cases. Regardless of CPAK classification matching, there were no significant differences in any of these PROMs. aHKA matching was observed in 71.8% of cases, and JLO matching in 81.2%. Comparisons of changes in aHKA and JLO also revealed no significant differences in PROMs.

Conclusions

Robotic-assisted “Physiological alignment” BCS TKA with 3-degree varus inclination does not affect PROMs, regardless of pre-arthritic CPAK classification matching. The pre- and postoperative CPAK classifications do not always correspond accurately.

Background

Tibial plateau fractures are associated with a high incidence of posttraumatic osteoarthritis. This study aims to compare the rates of medical and surgical complications, as well as the rate of conversion to total knee arthroplasty (TKA), among patients undergoing operative fixation of tibial plateau fractures.

Methods

The TriNetX database was queried to identify patients aged 18 and older who underwent operative fixation of unicondylar (CPT 27535) and bicondylar (CPT 27536) tibial plateau fractures between January 2005 and January 2020. Patients with bilateral fractures, and those with a prior history of TKA were excluded. Medical and surgical complications were analyzed during the immediate (7d, 14d, and 30d), intermediate (90d, 180d, 1y, and 2y), and long-term (5y and 10y) postoperative periods. A multivariate model, adjusted for age, sex, and comorbidities, was used to further evaluate the risk of conversion to TKA.

Results

A total of 15,634 patients met all inclusion criteria and were included in this study (8,680 unicondylar and 6,954 bicondylar). Bivariate analysis revealed a higher risk of medical complications including DVT, PE, pneumonia, and death in the bicondylar group. The risk of surgical complications including superficial skin infection, deep infection, rehospitalization, arthrofibrosis, malunion, and nonunion were also higher in the bicondylar group. No differences were found in the rates of MI, stroke, cardiac arrest, pneumonia, ARDS, ED visits, or UTIs between groups at any time point. After multivariate analysis, the risk of conversion TKA was greater in the bicondylar fracture group at 5y (HR [95% CI] 1.43 [1.14, 1.79], p = 0.002) and 10y (HR [95% CI] 1.40 [1.14, 1.72], p = 0.001) follow-up.

Conclusions

Patients undergoing operative fixation of bicondylar tibial plateau fractures experience higher rates of medical and surgical complications, as well as an increased incidence of conversion to TKA, compared to those with unicondylar fractures.

Level of evidece

Prognostic Level III.

Introduction

Hexapod systems are accurate devices to perform deformity correction. Crucial to achieving the desirable result is the precise determination of the mounting and deformity parameters. Smith + Nephew (London, UK) developed a calibration device for their hexapod system TSF (Taylor Spatial Frame) called Beacon, which is directly mounted to the reference ring. The software indicates the Beacon in X-rays and calculates the whole hexapod construct. However, we still can find inaccuracies after completing the correction plan by the software. Since the software calibrates the construct with the bone in the center of the ring, the question arises as to whether different positions of the bone within the construct influence the calculated parameters.

Materials and methods

A tibial artificial bone (Sawbones, Vashon Island, USA) was mounted with the TSF. Iron beads were attached to define reference distances. The test setup included five different positions of the bone. X-rays and CTs (computed tomography) were performed and the distances were measured. The accuracy of the measurements of the X-rays and the CT were compared when having the bone in different positions.

Results

Measurements were dependent on the position of the bone in relation to the center of the ring. If the bone is closer to the detector than the center of the ring, the measured distance is shorter and vice versa. Resultingly, the measured total length of the bone in X-rays varied from the true length between ± 26 mm (7%). In contrast, measurements by CT showed much less variability.

Conclusion

When using X-ray planning, care must be taken if the bone is not centered in the reference ring. Measurement inaccuracies of up to 7–10% may occur. CTs give more accurate measurements regardless of the bone position. These findings should be taken into account if the limb cannot be centered in the reference ring of the hexapod system.

Purpose

Patient positioning in orthopedic and trauma surgery requires maximum stability while preserving passive mobility of the operated limb. When traction tables or positioning aids are used, the legs are secured in traction boots. This study evaluated sub-bandage pressure in the lower extremity of a supine-positioned specimen during hip arthroplasty, comparing single- and double-layer bandage systems.

Methods

A flexible multilayer and a more rigid single-layer bandage system were compared in mechanical traction tests on a cadaveric specimen. Subbandage pressure was recorded through repetitive measurements at various traction forces, ranging from 80 to 200 N.

Results

Due to its rigidity, iFix generated higher pressure near the ankle, providing better stability even at 200 N. In contrast, CO showed higher pressure at the proximal tibia and heel lift at maximum force due to its elasticity. The study found that patient fixation using the tested systems is only justifiable if the tensile force remains below 80 N throughout surgery.

Conclusion

Fixation with the tested systems is only advisable if the tensile force remains below 80 N throughout surgery. Short-term increases (e.g., for hip dislocation) are acceptable but should be brief and followed by adequate relief to allow tissue reperfusion. Additional padding is strongly recommended to distribute subbandage pressure at high traction forces.