Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

Social determinants of health (SDOH) are nonmedical factors that influence patient outcomes. This study aimed to determine the prevalence of randomized controlled trials (RCTs) reporting SDOH factors in their patient cohorts within several of the highest-impact spinal surgery journals. We hypothesize that SDOH factors will be infrequently reported and often miss variables such as socioeconomic status, employment status, insurance, and education level.

Methods

From 2020 to 2024, the PubMed database was queried to analyze spine RCTs reporting SDOHs from four high-impact journals. For each study, we determined the age, sex, and/or gender, body mass index (BMI), the year the article was published, the country of origin of the senior author, and self-reported SDOH factors.

Results

Of the 147 included RCTs, age (95.9%), sex/gender (94.6%), and BMI (72.8%) were reported by the majority of studies. There were a total of 33 countries represented by the RCTs reporting spine outcomes, where 25 (17.0%) RCTs were conducted in the United States, 22 (15.0%) RCTs conducted in China, 11 (7.5%) RCTs in the Netherlands, 9 (6.1%) RCTs in Japan and 9 (6.1%) RCTs in Turkey.

Conclusion

This paper provides valuable insights into the landscape of spine research and emphasizes the necessity of consistently reporting all SDOH factors. Future research can better inform clinical practice and policy decisions by addressing these considerations, ultimately improving healthcare outcomes for spine patients worldwide.

Background

Childhood obesity is a pressing global health issue with potential implications for musculoskeletal injury risk and recovery. Although the influence of obesity on bone metabolism is acknowledged, its specific connection to the incidence, patterns, and treatment results of long bone fractures in the pediatric demographic requires further clarification.

Purpose

This systematic review aims to evaluate the existing literature on the relationship between obesity and long bone fractures in children and adolescents, with a focus on fracture risk, anatomical distribution, management approaches, and clinical outcomes.

Methods

We conducted a systematic literature search of PubMed, MEDLINE, Cochrane Library, and Google Scholar for studies published from January 2000 to March 2025. Search terms included “childhood obesity”, “bone health”, and “long bone fractures”. We included English-language original research that analyzed the relationship between pediatric obesity (BMI ≥ 95th percentile) and long bone fractures. Data on study characteristics, fracture patterns, treatments, and outcomes were extracted.

Results

Out of 2,152 articles screened, 14 met the inclusion criteria. Children who were overweight or obese had higher odds of lower extremity fractures, particularly of the tibia and femur (odds ratios 1.5–3.3). Obesity was linked to more complex fracture patterns, including physical involvement and displacement, and a higher failure rate of nonsurgical management, especially for forearm and supracondylar fractures. Operative complications, such as varus deformity and pin-related issues, were more frequent in obese patients. However, no consistent differences were observed between obese and non-obese groups regarding mortality and long-term functional outcomes.

Conclusions

Pediatric obesity significantly elevates the risk and complexity of long bone fractures and complicates both nonoperative and surgical management. Acknowledging these challenges is crucial for optimizing treatment and preventing adverse outcomes. Further multicenter prospective studies are needed to clarify the underlying biomechanical and metabolic mechanisms and to guide the development of individualized management protocols.

Level of evidence

Systematic Review, Level III.

Introduction

Tenosynovial giant cell tumor (TGCT), also known as pigmented villonodular synovitis (PVNS), involving the shoulder is extremely rare and can present with a challenging clinical course. Due to the complex anatomy of the shoulder, both diagnosis and treatment are demanding. This study aims to evaluate the diagnostic and therapeutic management of shoulder TGCT based on a case series and a review of the literature.

Materials and methods

Between 2005 and 2021, four patients (2 females, 2 males) with shoulder TGCT (1 localized, 3 diffuse) underwent surgical treatment at our institution. The minimum follow-up was 39 months (range: 39–233 months). Functional outcomes were assessed using the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), the Oxford Shoulder Score (OSS), and the Short Form 36 Health Survey (SF-36). Additionally, a literature review of 65 studies comprising 108 patients was performed.

Results

Treatments consisted of arthroscopic and open resections, tendon repair, adjuvant radiosynoviorthesis, and radiotherapy, as appropriate. All patients were recurrence-free at the last follow-up, except for one with stable residual disease after radiotherapy. The mean interval from symptom onset to diagnosis was 23.6 ± 28.1 months. In the literature cohort, the mean patient age was 50.3 ± 19.7 years, with a nearly equal gender distribution. Diffuse TGCT was more common (66.1%) than nodular TGCT (33.8%). Treatment was primarily surgery, arthroscopic (53.2%) or open (42.9%), with adjuvant therapies applied in 9.3% of cases. After a mean follow-up of 37.6 ± 36.2 months in 67 cases, diffuse in 44.8%, nodular in 19.4% (no data regarding TGCT-type in 35.8%) the reported recurrence rate was 10.6% and 4.5% remained with residual disease.

Conclusions

TGCT of the shoulder remains a rare and complex condition requiring individualized treatment strategies. Arthroscopic and open resections are the mainstays of therapy, while the role of adjuvant treatments should be carefully considered. Given the risk of recurrence, follow-up is essential. Further studies are needed to establish standardized treatment protocols and evaluate long-term outcomes.

Level of evidence

Level IV (Case series with no comparison group).

Introduction

Total knee arthroplasty (TKA) in obese patients poses multiple challenges and there is a lack of consensus on various aspects of TKA in this patient population. This study is a modified Delphi consensus study of international experts to provide recommendations on TKA in obese patients.

Materials and methods

The consensus statements were generated using an anonymized two-round modified Delphi questionnaire, sent to an international panel of 53 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics, with median as the measure of central tendency. Anonymized feedback was provided to all panellists based on responses from previous rounds to help generate the consensus.

Results

9 statements reached a consensus: WHO classification (87%), BMI cut-off for single-stage bilateral TKA (92%), use of tibial stem (84%), medial parapatellar approach (92%), same surgical approach as non-obese TKA (92%), inherent malnutrition (82%), higher risk of aseptic loosening in BMI class 3 (81%), need for time interval between bilateral TKA (88%), and consensus against leaving the knee in slight flexion (82%). The panel was unable to reach a consensus on 17 statements.

Conclusion

This indicates lack of consensus on a majority of issues among experts and further research is required in this field to address evidence gaps, so we can improve our management of this increasing cohort of patients undergoing TKA. The statements reaching consensus form an important set of recommendation to improve patient selection and outcomes.

Level of evidence Level V

Background

The impact of liver cirrhosis on surgical outcomes is well-known. This study aimed to compare postoperative outcomes of total hip arthroplasty (THA) in patients with versus without cirrhosis.

Methods

A retrospective review was conducted of all patients who received a THA between 2012 and 2021 with a minimum of two years of clinical follow-up at a single, urban tertiary health center with lab results available to calculate Model for End-stage Liver Disease (MELD) scores. Using demographic variables, patients with and without cirrhosis underwent a 10:1 propensity score match. Short-term clinical outcomes were compared between cohorts. Cirrhotic patients were stratified based on their MELD score as mild (MELD < 10, n = 39) or moderate-to-severe (MELD ≥ 10, n = 10).

Results

Of the 539 patients included in this study, 49 patients were in the cirrhotic group and 490 patients were in the non-cirrhotic group. Compared to non-cirrhotic and mild cirrhotic, moderate-to-severe cirrhotic THA patients had significantly higher incidence of 30-day (2.9% vs. 2.6% vs. 30.0%, p = 0.011) and 90-day readmissions (5.9% vs. 2.6% vs. 30.0%, p = 0.038) due to periprosthetic joint infection (PJI), and higher incidence of 90-day (3.1% vs. 2.6% vs. 20.0%, p = 0.024) and all-time revisions (1.4% vs. 5.1% vs. 20.0%, p = 0.016) due to PJI. There were no differences in overall 90-day reoperation (p = 0.115) and revision risk (p = 0.202) between non-cirrhotic, mild cirrhotic, and moderate-to-severe cirrhotic THA patients. Freedom from all-cause reoperations/revisions did not differ significantly (p = 0.479) between non-cirrhotic and cirrhotic THA patients at 120 months of follow-up.

Conclusions

Cirrhotic patients, particularly those categorized as moderate-to-severe, undergoing THA may have higher risk of having a readmission or revision for PJI. However, overall 90-day readmission and revision risk were similar between non-cirrhotic and cirrhotic patients. Future research with larger sample sizes and databases is needed to further risk stratify, optimize and counsel cirrhosis patients surrounding THA.

Purpose

Proximal femur fractures primarily affect the elderly, with significant morbidity, mortality, and socioeconomic impact. The main complication of short trochanteric intramedullary nailing is the cut-out of the cervicocapital screw through the femoral head. The objective of this study was to analyze the influence of technical errors in short trochanteric intramedullary nailing for the treatment of trochanteric femur fractures on the mechanical failure of osteosynthesis.

Methods

A total of 540 patients who underwent surgery for a trochanteric femur fracture using short trochanteric intramedullary nailing were included in a single-center, retrospective study conducted between February 2012 and July 2018.

Results

Thirty patients (5.6%) experienced mechanical failure of the osteosynthesis at the 3-month follow-up. An anterior position of the cervicocapital screw, accumulation of technical errors, a tip-apex distance > 25 mm, and an intra-focal entry point were significantly associated with cervicocapital screw cut-out.

Conclusion

The mechanical failure rate is 5.6%. Short trochanteric intramedullary nailing requires precise execution to reduce the risk of cervicocapital screw cut-out, which is a source of osteosynthesis failure.

Introduction

Despite the availability of various osteotomies for varus knee osteoarthritis, including proximal tibial, distal femoral, and fibular osteotomies, HTO is the most prevalent in clinical practice. The primary focus of this study is to investigate how distal femoral morphology influences the outcomes of HTO.

Methods

Demographic characteristics, radiographic parameters, and functional scores were collected preoperatively and at 2-year follow-up from patients undergoing HTO at our institution between January 2022 and July 2022. Patients were categorized into two cohorts based on the lateral distal femoral angle (LDFA): Group I (LDFA ≤ 89°) and Group II (LDFA > 89°). Each cohort was further stratified into three subgroups according to postoperative hip-knee-ankle angle (post-HKA): Subgroup A (HKA = 180° ± 0.5°), Subgroup B (HKA = 181° ± 0.5°), and Subgroup C (HKA = 182° ± 0.5°). Radiographic and functional outcomes were compared.

Results

The study included 191 patients distributed across six subgroups (IA: 33, IB:29, IC:29, IIA:37, IIB:30 and IIC:33). Significant inter-subgroup differences were observed in the change in joint line convergence angle (ΔJLCA) for both Group I (F = 11.876, P = 0.048) and Group II (F = 9.826, P = 0.042). ΔJLCA exhibited a positive correlation with the change in hip-knee-ankle angle (ΔHKA) in both groups (Group I: r = 0.323, P = 0.011; Group II: r = 0.522, P < 0.001). In Group I, postoperative joint line orientation angle (Post-JLOA) showed no significant differences. At 2-year follow-up, subgroup C demonstrated superiority in the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) and Oxford Knee Scores (OKS) compared to subgroup A(WOMAC:P = 0.006; OKS: P = 0.007). Changes in WOMAC and OKS (ΔWOMAC and ΔOKS) correlated positively with ΔHKA and ΔJLCA but showed no correlation with Post-JLOA. In Group II, Post-JLOA differed among the subgroups (F = 9.205, P = 0.035). At 2-year follow-up, Functional outcomes were comparable across subgroups. Both ΔWOMAC and ΔOKS positively correlated with ΔHKA and ΔJLCA but negatively with Post-JLOA.

Conclusion

A mechanical axis of 182° optimizes clinical outcomes in patients with normal femoral anatomy, while 180° is preferable for cases with distal femoral varus to minimize joint line obliquity.

Introduction

For cementless implantation of hip stems, it is very important that the original stem fits exactly into the femoral prosthesis bed previously shaped using a stem rasp. If the geometry of the stem rasp does not match the prosthesis geometry, this can result in either overstuffing or post-sintering of the original stem in relation to trial reduction with the stem rasp. Overstuffing results in leg lengthening, while subsidence of the stem results in shortening with the risk of dislocation and impingement. Trial reduction with the original stem and trial head can prevent this, but is associated with additional soft tissue trauma and a longer operating time.

Materials and methods

Three groups were prospectively randomized. Group 0 was treated with the Fitmore B stem and the conventional rasp system, Group 1 with the Optimys stem and Group 2 with the Fitmore B stem with a new, optimized rasp system via a minimally invasive posterolateral approach. Intraoperatively, the differences in leg length and offset between trial reduction with the stem rasp and the original stem were recorded using a hip navigation system.

Results

The conventional rasp system led to significant overstuffing (1.2 ± 0.5 mm, p = 0.024) with the Fitmore B stem, compared with the instruments of the Optimys stem. In contrast, the optimized rasp system with the Fitmore B stem resulted in an equally precise fit of the endoprosthesis to that achieved with Optimys.

Conclusion

There are relevant differences in the fit of rasp and original stem between different manufacturers and system evolutions. In order to ensure reproducible comparability of the fit of the original stem to the trial rasp, it is imperative that trial rasps are optimally adapted to the stems. This is an important way to avoid trial reduction after implantation of the original stem.

Trial registration

This study was registered in the German Clinical Trials Register (Deutsches Register Klinischer Studien) with the registration number DRKS00026749.

Introduction

Septic arthritis is a rare but devastating complication of intra-articular corticosteroid injection (CSI), associated with significant medical morbidity and poor clinical outcomes. Although previous studies have examined risks associated with CSI, few have tracked patients long-term. This study evaluates the incidence, timing, and patient characteristics related to iatrogenic septic arthritis within 6 months of receiving a large joint CSI, offering new insights to inform clinical practice.

Materials and methods

A retrospective, descriptive cohort study was conducted using SlicerDicer, a software stratification system within Epic, to identify patients diagnosed with septic arthritis within six months of receiving an intra-articular CSI of the hip, knee, or shoulder. Data were collected from a single institution over a 10-year period (July 1, 2010 to July 1, 2020). Individual chart review was used to obtain patient demographics, clinical characteristics, and procedural details for identified cases.

Results

Of 15,021 intra-articular corticosteroid injections performed, 14 cases of septic arthritis were identified within 6 months of the procedure, resulting in an incidence rate of 0.093%. Of the affected patients, 21% had underlying inflammatory arthritis, and 21% had underlying comorbidities resulting in immunosuppression. The median time to diagnosis was 3.5 (range 1–16) weeks post-injection, with a bimodal distribution of infections occurring primarily between 1 and 3 and 7–10 weeks post-injection. Staphylococcus aureus (42%) and coagulase-negative Staphylococcus species (36%) were the most commonly isolated organisms.

Conclusions

Large joint intra-articular CSI presents a low risk (< 0.1%) for developing septic arthritis, but can present up to 16 weeks post-injection. The preliminary observation of bimodal timing and delayed presentation of septic arthritis suggests that a standard two-week surveillance window may not be long enough to fully capture all infections, particularly those involving lower-virulence organisms. These findings highlight the need for informed risk stratification and prolonged vigilance well beyond the immediate post-injection period to identify infectious complications after large joint CSI.