Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

Patients undergoing total hip arthroplasty (THA) in tertiary centres often present with complex comorbidities that increase the risk of perioperative adverse events (AE). While fast-track and outpatient protocols are expanding, reliable risk stratification tools tailored to high-risk European populations remain limited. This study aimed to (1) compare comorbidity burden in a high-risk population to national data, (2) determine incidence and risk factors for in-hospital AE and (3) develop a simple, pragmatic score to identify patients at elevated AE risk.

Materials and methods

We retrospectively analyzed 4,101 elective primary THA cases from a German tertiary care centre (2010–2019). Comorbidity burden was quantified using the Elixhauser Comorbidities (EC) and benchmarked against national registry data (EPRD). Independent predictors of in-hospital AE were identified using multivariate logistic regression. These variables were then used to develop a pragmatic preoperative clinical risk score via LASSO regression, internally validated with 10-fold cross-validation and bootstrapping.

Results

Compared to the national registry, our cohort showed significantly higher rates of major comorbidities, including cardiac valvular disease, diabetes, and fluid/electrolyte disorders. The overall in-hospital AE rate was 2.6%. Six comorbidities—including pulmonary circulation disorders (OR 10.7, 95% CI: 3.6–31.8)—were independently associated with AE. The derived LASSO model demonstrated strong discrimination (AUC 0.80; 95% CI: 0.75–0.84) and calibration (Brier score 0.07). A cutoff score ≥ 2 identified patients with an AE rate of > 7%, while scores < 2 corresponded to an NPV of 0.99, supporting its utility in identifying low-risk patients for fast-track pathways.

Conclusions

Patients treated in tertiary centres exhibit elevated comorbidity burden but maintain acceptable perioperative AE rate. A simple, validated clinical score can flag patients at substantially increased risk of in-hospital AE who may benefit from closer in-hospital surveillance and effectively identify low-risk candidates for fast-track THA pathways. Further external validation is warranted.

Introduction

Periprosthetic joint infections (PJI) pose considerable challenges in arthroplasty, with two-stage revisions involving the use of antibiotic-loaded spacers being the prevailing treatment modality for chronic low-grade PJI. Whilst the incorporation of antibiotics has been demonstrated to enhance infection management, the biomechanical impact of such agents on polymethylmethacrylate (PMMA) spacers remains to be elucidated. The present study evaluates the load-bearing capacity of spacers with varying antibiotic concentrations of vancomycin in order to determine structural failure thresholds.

Materials and methods

A total of twenty PMMA knee spacers were subjected to testing, with the samples divided into two distinct groups based on the antibiotic concentration: a low concentration group (5% vancomycin) and a high concentration group (20% vancomycin). The spacers were subjected to uniaxial loading in two configurations: a standard weight-bearing position and a dislocated position with 10° femoral angulation. The breaking forces were measured using a servo-hydraulic testing machine. Statistical analyses were performed using Mann-Whitney-U tests, with significance at p < 0.05.

Results

In the standard position, the mean breaking force for the low and high antibiotic groups was 38.7 ± 9.3 kN and 35.5 ± 5.8 kN, respectively (p = 0.421). In the dislocated position, breaking forces were significantly lower at 2.2 ± 0.7 kN and 2.0 ± 0.3 kN, respectively (p = 0.311). Spacer fractures occurred exclusively in femoral components, with a 17-fold reduction in load capacity in dislocated configurations. The antibiotic concentration of vancomycin exerted no significant effect on biomechanical integrity.

Conclusion

In the experimental ex vivo study, it was demonstrated that vancomycin concentrations of up to 20% by volume in PMMA knee spacers do not significantly affect the structural integrity. However, the positioning of the spacer has been shown to have a significant impact on biomechanical stability, with dislocation having a substantial effect on load capacity.

Purpose

(1) to establish an objective measure of postoperative physical performance following hip arthroscopy using a markerless motion-capture system to analyze the Landing Error Scoring System (LESS) and (2) to validate the postoperative LESS test by evaluating its correlation with postoperative PROs.

Methods

Data were prospectively collected and retrospectively analyzed for patients who underwent hip arthroscopy from October 2017 to December 2019. Inclusion criteria were patients having undergone hip arthroscopy with minimum 1-year follow-up, pre- and postoperative PROs, and postoperative LESS. Protocol was for LESS to be performed 6 months postoperatively. Participants successfully completed three trials of a jump-landing movement assessment. The LESS data and 3-dimensional motion analysis were collected simultaneously during the jump-landing task. The LESS score is a summation of landing technique “errors,” using a range of readily observable aspects of human movement. This LESS score was examined for possible correlation with postoperative PROs.

Results

3-month and 1-year postoperative mHHS, NAHS, VAS, and VR-P were significantly correlated with postoperative LESS scores. 3-month postoperative iHOT and 1-year postoperative SF-P were significantly correlated with postoperative LESS. No significant correlation was found between LESS scores and 3-month or 1-year postoperative HOS-SSS, 1-year postoperative iHOT or 3-month postoperative SF-P. No correlation was found between SF-M or VR-M and postoperative LESS scores at any study time points.

Conclusion

LESS, analyzed by a markerless motion capture system, may correlate with 3-month and 1-year PROs following hip arthroscopy. Pure mental questionnaires do not show significant correlation between the two assessment tools. This study suggests validation of LESS as an objective measure of postoperative physical performance.

Introduction: Computer-assisted (CA) surgery is increasingly adopted in total hip arthroplasty (THA) to enhance implant positioning accuracy. However, robust evidence regarding its impact on postoperative complications compared with manual THA (M-THA) remains limited. This study evaluated the association between CA-THA and early postoperative complications using a large Japanese database. Materials and Methods: We analyzed 336,624 THA cases recorded in the Japanese Diagnosis Procedure Combination (DPC) database between December 2011 and March 2023. Of these, 242,067 underwent M-THA and 94,557 underwent CA-THA. One-to-one propensity score matching was performed to adjust for age, sex, body mass index, comorbidities, and diagnosis. Outcomes included surgical complications, medical complications, and in-hospital mortality. Results: After matching, 93,887 patient pairs were analyzed. Compared with M-THA, CA-THA was associated with lower odds of dislocation (OR 0.667, 95% CI 0.556–0.786, p < 0.001), infection (OR 0.763, 95% CI 0.687–0.848, p < 0.001), and re-operation (OR 0.822, 95% CI 0.732–0.922, p < 0.001), but higher odds of periprosthetic fracture (OR 1.301, 95% CI 1.118–1.514, p < 0.001). No significant differences were found in medical complications or mortality. Conclusions: In this nationwide cohort, CA-THA was associated with reduced risks of dislocation, infection, and reoperation, but an increased risk of periprosthetic fracture compared with M-THA. Further research should clarify optimal indications and refine patient selection criteria for CA-THA. In this nationwide cohort, CA-THA was associated with reduced risks of dislocation, infection, and reoperation, but an increased risk of periprosthetic fracture compared with M-THA. Further research should clarify optimal indications and refine patient selection criteria for CA-THA.

Purpose

Delayed or neglected acetabular fractures present complex challenges due to comminution, osteoporotic bone, and joint incongruity. Optimal management remains controversial, and data on combined reconstruction with acute total hip arthroplasty (THA) are limited. This study aimed to evaluate the clinical, functional, and radiological outcomes of combined open reduction and internal fixation (ORIF) with acute THA in patients with delayed, unreconstructible acetabular fractures.

Patients and Methods

This prospective study was conducted at a tertiary university referral center between February 2018 and January 2022. Patients aged > 50 years with fractures diagnosed or treated > 3 weeks post-injury and deemed unreconstructible by ORIF alone (based on multidisciplinary review and intraoperative confirmation) were included. Exclusion criteria included active infection, pathological fractures, prior hip arthroplasty, or medical contraindications. ORIF was performed to restore acetabular geometry, using autologous bone grafts or trabecular metal as required, followed by THA with cemented or cementless components according to preoperative planning and intraoperative judgment. Functional outcomes were assessed using Harris Hip Score (HHS, including MCID), WOMAC, and EQ-5D. Radiographs evaluated implant stability, graft incorporation, and complications. Reliability testing was performed for fracture classification and radiographic assessment.

Results

Twenty-two patients completed a mean follow-up of 30 months (range 24–48 months). Fracture patterns included anterior column–posterior hemitransverse (n = 7), posterior wall (n = 6), both-column (n = 5), and transverse posterior wall (n = 4). Mean operative time was 185 min, with 850 mL blood loss. Complications occurred in 4 patients (18%), including infection, transient neuropraxia, and dislocation. Mean HHS improved significantly from 42.3 preoperatively to 86.1 at final follow-up (p < 0.001), with 82% achieving good-to-excellent outcomes and > 75% exceeding MCID. Patients aged ≤ 65 years demonstrated slightly higher functional recovery (HHS 88.6 vs 84.2, p = 0.05) and lower complication rates compared with those > 65 years. Early surgery (≤ 8 weeks) showed trends toward higher HHS gain, greater WOMAC and EQ-5D improvement, and lower complication rates. Functional improvement correlated positively with radiological stability (r = 0.42, p = 0.04).

Conclusion

Combined ORIF with acute THA provides substantial functional recovery, durable implant stability, and acceptable complication rates. Early intervention and careful acetabular reconstruction optimize functional and radiological outcomes, supporting this approach as an effective strategy for delayed acetabular fractures in patients.

Background

Femoral impaction bone grafting (IBG) is an established technique for managing severe bone loss during revision total hip arthroplasty (rTHA). Despite its widespread use, the extent of graft incorporation and the degree of stem subsidence remain incompletely characterized. This systematic review evaluates graft incorporation and stem subsidence outcomes in femoral IBG for rTHA.

Methods

A systematic review was conducted following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta–Analyses) guidelines. Three databases were searched from inception to December 31, 2024, for studies involving rTHA with femoral IBG and a minimum follow–up of 12 months. Meta–analyses focused on graft incorporation rates and stem subsidence. Subgroup analysis examined age, pre–operative bone loss, graft type, follow–up duration and other predictors. Heterogeneity was assessed using the I² statistic under a random–effects model.

Results

A total of 33 studies (2395 patients; 2514 hips) met inclusion criteria. The mean patient age was 66 years (range 22–95 years), with a male–to–female distribution of 48%/52%. The hips–weighted mean follow–up was 8.8 years (range of study means 1.1–17.0 years). Overall, the pooled proportion of graft incorporation was 76%; 95% confidence interval (CI) 63%–85%. The weighted average subsidence across all studies was 2.5 mm (95% CI 1.7–3.1 mm). Subgroup analyses showed no statistically significant differences in graft incorporation rates based on graft type (p = 0.399), age (p = 0.742), or follow–up duration (p = 0.560). Similarly, stem subsidence did not differ significantly by gender (p = 0.181), graft type (p = 0.460), or age (p = 0.301). Preoperative bone loss classification (Endo–Klinik, Paprosky) was not associated with notable differences in graft incorporation (p = 0.263) or subsidence (p = 0.486).

Conclusions

Femoral IBG for rTHA demonstrates variable but generally favorable graft incorporation rates, averaging 76% (95% CI 63%–85%), with a mean stem subsidence of 2.5 mm at mid–to–long–term follow–up. Neither graft type, stem design, age, nor preoperative bone loss classification significantly influenced subsidence or incorporation variability.

Purpose

To explore how to accurately perform direct anterior approach (DAA) total hip arthroplasty (THA) by identifying key anatomical landmarks to optimize surgical procedures and reduce complications.

Methods

Twenty hip joints from 10 lower limb specimens were used to simulate DAA THA. The anatomical structures and their relationships were observed from superficial to deep.

Results

The transverse fascia lata(TFL) perforating vessel is located 40.62 ± 1.16 mm distal and 41.14 ± 1.26 mm posterior to the anterior superior iliac spine (ASIS). The fascia lata is incised 19.44 ± 0.49 mm medial to this vessel to access the Hueter interval. Within this interval, the ascending branch of the lateral femoral circumflex artery (a-LFCA) is 31.17 ± 0.25 mm distal to the perforating vessel. The lateral femoral cutaneous nerve branches cross the interval at 48.02 ± 0.38 mm from the ASIS, and its main trunk is 2.64 ± 0.11 mm thick, 39.33 ± 0.43 mm from the incision projection, 21.98 ± 1.05 mm from the Hueter interval. The femoral nerve is closest to the acetabulum at 90°, 17.55 ± 0.44 mm from the anterior margin, and the uppermost branch entering the rectus femoris is 8.62 ± 0.08 mm from the ASIS. Releasing the joint capsule and external rotator muscle group increases femoral lift by 19.12 ± 0.20 mm.

Conclusion

The TFL perforating vessel can be located through the ASIS, and further, the Hueter interval and the a-LFCA can be located through the vessel. Attention should be paid to the corresponding safe and dangerous areas during operation to reduce complications. These findings allow precise surgical entry to minimize risks and shorten learning curve.

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.