Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

Kienböck’s disease is a progressive avascular necrosis of the lunate that causes wrist pain and functional impairment. Surgical intervention is often needed for advanced stage IIIB disease to relieve symptoms and preserve the carpal structure. Scaphocapitate (SC) arthrodesis is an established technique, but the value of lunate excision versus preservation remains debated. This study prospectively compared the outcomes of SC arthrodesis performed with and without lunate excision.

Materials and methods

This prospective comparative study included 38 patients with stage IIIB Kienböck’s disease, who were allocated to receive SC arthrodesis with lunate preservation (n = 19) or lunate excision (n = 19). The follow-up time was 84 months. The primary outcome measure was pain intensity, which was assessed via the visual analogue scale (VAS) for pain. The secondary outcomes included wrist function evaluated by the modified Mayo wrist score (MMWS) and patient-rated wrist evaluation (PRWE), grip strength, wrist range of motion (ROM), and radiographic parameters such as ulnar variance, the carpal height ratio (CHR), the carpal ulnar distance (CUD), and the radioscaphoid (RS) angle. The union rate, time to union, time to return to work, and incidence of postoperative complications were also recorded.

Results

Both groups demonstrated significant postoperative improvement in pain (VAS pain score, p = 0.001). At 84 months, the preservation group achieved superior pain control, with a lower mean VAS score (5 versus 12, p = 0.001). The preservation group also maintained a greater CUD (30 mm versus 23 mm, p = 0.001) and exhibited later onset of degenerative changes. MMWS improved from 49 to 73 in the preservation group and from 48 to 72 in the excision group. The PRWE scores decreased from 69 to 21 in the preservation group and from 67 to 24 in the excision group. The final grip strength reached 88% of that of the contralateral side in the preservation group and 84% in the excision group, with no significant difference in ROM. The union rates were 93% for preservation and 91% for excision. The excision group presented higher rates of degenerative changes (16 versus 8 cases) and nonunion (2 versus 1). No major differences were found in the infection rate, sympathetic reflex dystrophy, or return to work.

Conclusions

SC arthrodesis provides reliable long-term pain relief in patients with stage IIIB Kienböck’s disease. Lunate preservation provides superior pain control and carpal alignment, reduces degenerative sequelae, and is recommended where feasible.

Background

Dislocation of a total hip arthroplasty (THA) is a highly disabling complication following the implantation of primary and revision hip arthroplasties, as well as a prevalent reason for subsequent revisions. This study is designed to evaluate the survival rate, functional outcomes, and the reasons for further revision due to implant failure of Constrained Acetabular Liners (CALs).

Methods

56 patients underwent hip revision surgery using a Constrained Acetabular Liner between June 2018 and December 2022 were retrospectively evaluated. Inclusion criteria consisted of age > 18 years, follow-up of at least 12 months, prior total hip arthroplasty or bipolar hemiarthroplasty, a history of recurrent implant dislocation, or, alternatively, the presence of a high risk of implant instability in hip revisions due to mechanical conditions.

Results

The average age at the time of surgery was 72.4 years (SD 12.4). 55.6% of implants were performed for recurrent dislocation of THA, 8.9% for recurrent dislocation of bipolar hemiarthroplasty, 13.3% for aseptic loosening revisions, 4.4% for adverse reactions to metal debris revision procedures, and 17.8% for two-stage revision for periprosthetic joint infection. The average follow-up at the final evaluation was 32 months (SD 12.3). The survivorship of the implant was 88.9% at final follow-up. At the final follow-up: average HHS 77.4 ± 13.2; average WOMAC 31.4 ± 13.4; average OHS 32.1 ± 6.9; and average FJS-12 69.5 ± 19.6., and 65% showed excellent or good outcomes (HHS > 80).

Conclusions

The CALs assessed in this study have shown satisfactory functional outcomes, even when compared with other anti-dislocation systems available on the market. Both cemented and uncemented solutions have shown a good survival rate in the mid-term. However, their use should be reserved for selected cases.

Introduction

The use of a 36-mm femoral head in primary total hip replacement (THR) increases the jump distance and offers a wider impingement-free range of motion, theoretically reducing the risk of post-operative dislocation. However, concerns exist regarding its potentially greater impact on polyethylene wear and associated risks of liner fracture, aseptic loosening, and head-neck taper corrosion, compared to 32-mm femoral heads. This meta-analysis aims to compare the risk of revision for dislocation and all-causes when using 36-mm versus 32-mm metal or ceramic femoral heads with polyethylene liners for primary THR.

Methods

Medline, Embase, Web of Science, and the Cochrane Library were searched for relevant studies, while annual reports of arthroplasty registries were searched for relevant data. Random effects meta-analysis was performed. Sensitivity analysis was conducted, limiting to THR performed for osteoarthritis and using cross-linked polyethylene liners, or statistically adjusting for this factor. The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO ID CRD42024557895).

Results

Four observational studies and two registry reports were identified. Median follow-up ranged from 2.1 to 4.7 years (inter-quartile range values spanned from 0.9 to 7.7 years). The main analyses demonstrated that 36-mm heads were associated with a marginal reduction in the risk of revision for dislocation (HR 0.85, 95%CI 0.72–1.01, p = 0.058; n = 241,136) without an increased risk of all-cause revision (HR 1.06, 95%CI 0.95–1.18, p = 0.287; n = 942,617). Similar results were observed in the sensitivity analyses.

Discussion

At early to midterm follow-up, the use of 36-mm heads were not associated with an increased risk of revision for all-causes, compared to 32-mm heads. However, they may offer a protective reduction against revision for dislocation, as a marginal statistically significant reduction was observed, indicating a possible benefit. Further studies investigating these outcomes at longer-term follow up are needed to understand whether these revision risk profiles are maintained.

Medial unicompartmental knee arthroplasty (UKA) has been introduced in the fifties to treat patients with medial tibio-femoral osteoarthritis. Initial reports, showed encouraging functional outcomes, tempered by high loosening rates. With advances in the materials and prosthetic designs UKA has become common, representing more than 11% of all knee replacement surgeries and growing at a rate of 32.5% per year. This fast increase is the consequence of the new radiographic, clinical and patient-related indications. In the past, indications were strict although not universally accepted with several grey zones. More recently, indications have expanded, but there is consensus on the different aspects. The present fist-part comprehensive review focuses on the indications for medial UKA analyzing practical aspects such as patient activity and age, BMI, coronal alignment ligament competency, patella-femoral osteoarthritis, other compartments involvement with a comparison between historical approach and modern evidence. Hot topics and future directions will be discussed in the second-part of the review.

Lateral unicompartmental knee arthroplasty (UKA) is an effective surgical option for isolated lateral compartment osteoarthritis, though it remains less common than medial UKA. The lateral compartment differs substantially from the medial compartment in osseous morphology, meniscal mobility, and reliance on soft tissue stabilizers, resulting in unique kinematics that require distinct implant designs and surgical strategies. While earlier guidelines delineated narrow indications, contemporary evidence supports expanded indications, with good outcomes even in younger patients, those with higher body mass index, or mild patellofemoral joint disease. Technical considerations include surgical approach, alignment goals, and implant choice, with fixed-bearing implants preferred due to lower dislocation risk and robotic-assisted techniques showing promise for optimizing implant positioning. Modern series demonstrate survivorship exceeding 90% at 10–15 years, with functional outcomes comparable to medial UKA and superior to total knee arthroplasty in some areas such as recovery, patient satisfaction, and wound infection and other complication rates. This review summarizes the anatomy and biomechanics of the lateral compartment of the knee, indications, surgical technique, implant options, and clinical outcomes of lateral UKA.

Introduction

Scapular glenoid fractures are rare, accounting for approximately 0.1% of all fractures. Because of their morphological diversity and complex anatomy, selecting an optimal surgical approach remains challenging. This study aimed to evaluate the outcomes of a “fragment-specific management” strategy, in which the surgical approach was selected according to the fragment location and morphology of scapular glenoid fractures.

Patients and methods

A retrospective analysis was conducted on 15 patients who underwent open reduction and internal fixation for scapular glenoid fractures between 2013 and 2024. The surgical indication was defined as an articular step-off or gap ≥ 4 mm on 3D-CT. The deltopectoral, Brodsky, superior, and Judet approaches were selected individually or in combination according to fragment specificity. Radiological outcomes (articular gap and step-off), complications, and functional outcomes including shoulder range of motion and numerical rating scale (NRS) pain scores were evaluated.

Results

The mean age was 52.2 years (range, 31–73), with three female and twelve male patients. The injury mechanisms included falls from standing (n = 3), falls from height (n = 7), bicycle accidents (n = 2), and motorcycle accidents (n = 3). According to the Ideberg classification, there were six type I, two type II, three type III, two type IV, and two type V fractures. The deltopectoral approach was used in nine patients, the Brodsky approach in two, and combined approaches in four (deltopectoral–Brodsky, deltopectoral–superior, deltopectoral–Judet, and triple approach). The mean preoperative step-off and gap were 5.2 mm and 8.5 mm, improving to 0.1 mm and 0.6 mm postoperatively. No infections or nonunions occurred. At the final follow-up, the mean forward flexion, abduction, and external rotation were 144°, 147°, and 46°, respectively, with a mean NRS score of 0.8. All cases achieved bone union and satisfactory function.

Conclusions

Fragment-specific management provided excellent reduction, stable fixation, and favorable functional outcomes without major complications. This approach may be a safe and effective treatment strategy for scapular glenoid fractures.

Purpose

The Latarjet procedure effectively restores glenohumeral stability, particularly in patients with anterior shoulder instability and glenoid bone loss. However, existing outcome data are primarily derived from single-center studies. Therefore, the purpose of this study was to evaluate the short- and long-term outcomes of the Latarjet procedure in a nationwide population.

Methods

TriNetX, a global federated research network, was retrospectively queried to identify patients undergoing primary Latarjet. Patients that underwent prior capsulorrhaphy were excluded. The patient cohorts were evaluated for demographic factors, including age, sex, race, and ethnicity. Postoperative outcomes were assessed in the 30, 90, 180 days, and two years. Subgroup analysis was performed to evaluate the impact of sex on complication rates and healthcare utilization.

Results

A total of 2,258 patients met the inclusion criteria. The cohort was predominately male (81%), with a mean age of 34 ± 12 years and a mean BMI of 26 ± 6 kg/m². Over the short and mid-term follow-up periods, complications such as SSI, DVT, sepsis, hematoma, and myocardial infarction remained uncommon (less than 2%). By two years, the rate of emergency department (ED) visits nearly doubled to 14%, yet serious adverse events and revision surgeries (3.6%) remained rare. Men and women exhibited similar overall complication profiles, with no significant sex-based differences in most outcomes. However, women were more likely than men to utilize the ED (23% vs. 15%; OR, 0.56; 95% CI, 0.454–0.869; p = 0.0043).

Conclusion

The Latarjet procedure demonstrated low rats of both short- and long-term complications. While ED visits and complications such as shoulder dislocation increased over time, overall postoperative risk remained low. Complications were similar between men and women at two-year follow-up, with both groups experiencing low rates of serious adverse events. However, women’s higher rates of emergency department visits warrant further investigation. These findings support the long-term safety and efficacy of the Latarjet procedure in a large, nationally representative cohort.

Level of evidence

Level III.

Introduction

Given the inconclusive evidence regarding the effects of foot orthoses in flatfoot management, this study aimed to assess the impact of two distinct types of foot orthoses on three-dimensional bone alignment of the foot using advanced imaging techniques.

Materials and methods

Sixteen fresh-frozen cadaveric feet showing radiological signs of progressive collapsing foot deformity were collected. Two different types of foot orthoses, type I with medial support and lateral counter-support and type II with an additional metatarsal pad, were custom-made. The feet were loaded using a testing machine and scanned by weight-bearing computed tomography. Semi-automatic 3D models of bone dimensions and axes were generated to compute the foot alignment. This study was designed according to the QUACS scale.

Results

The sagittal talus-first metatarsal angle was corrected by an average of 2.0±3.0 degrees with type I orthoses (p = 0.019), and 2.6±3.7 degrees with type II orthoses (p = 0.018). The axial talocalcaneal angle was corrected by an average 1.8±2.8 degrees with type I orthoses (p = 0.021), and 2.0±3.1 degrees with type II orthoses (p = 0.02). The axial talus-first metatarsal angle was corrected by an average 1.3±2.0 degrees with type I orthoses (p = 0.024), while type II orthoses caused no significant effect (p = 0.297). No significant differences were found between type I and type II orthoses (all p > 0.05).

Conclusions

In this cadaveric study, foot orthoses with medial support, with or without a metatarsal pad, improved all angles tested, but the effect appeared to be small. It remains to be determined whether these subtle changes are responsible for the positive clinical effects described in other studies, or whether orthoses have a positive effect even without reaching the intended alignment correction.

Introduction

Distal femoral replacement (DFR) revision surgery represents significant cost to the healthcare systems as well as significant patient morbidity/mortality. A retrospective review of revision knee surgery with DFR would elucidate a treatment algorithm for patients with complex reconstructive issues. In this study, we review patients’ health metrics to better understand indications and potential complications for DFR revision. The data can then provide insight to specific patient factors that may put patients at higher risk for revision surgery.

Methods

Seventy-one patients who underwent distal femoral replacement were gathered retrospectively using ICD-9/ICD-10 codes. Patient population was grouped based on periprosthetic fracture (PPF), aseptic loosening (ASL), and periprosthetic infection (PJI). Significant descriptors and metrics were gathered for each of these patient groups. Post-operative complications, revisions, and reoperations were then gathered for the three groups.

Results

PJI group had the highest percentage of complications at 54%. PPF had the lowest percentage of complications at 25%. The variables that contributed to the largest percentage of complications in all three groups were prosthetic joint infection and aseptic loosening. The PJI group had the largest number of reoperations at 54% and revisions at 31%. The average number of reoperations in the PPF was 1.25, while the average number of reoperations in the PJI and ASL group was three.

Conclusions

In summary, high rates of complications, particularly in the PJI group are concerning; the stabilization of survivorship beyond three years offers a degree of reassurance for both surgeons and patients. The ASL indication group presented the slowest onset time for both complications and revisions. The PJI Indication group was the quickest to onset for both complications and revisions making these patients a high-risk treatment group. Finally, this study showed that revisions with DFR serves as a viable surgical option for patients, especially patients suffering from periprosthetic fractures.

Introduction

Carpal coalitions are rare congenital anomalies, with an estimated prevalence of 0.1% in Europeans. Scapholunate (SL) coalitions are particularly uncommon (~ 2% of coalitions). Altered carpal kinematics in this context are thought to predispose to fracture and nonunion. To date, no case of scaphoid pseudarthrosis in association with an SL coalition has been reported.

Materials and methods

We describe a 25-year-old man presenting with chronic wrist pain and limited extension following multiple skeletal injuries. Examination revealed tenderness in the anatomical snuffbox. Imaging demonstrated a scaphoid waist pseudarthrosis associated with an incomplete osseous SL coalition (Minnaar type 2), combined with a complete capitotrapezoid and a fibrous capitate–hamate coalition. The contralateral wrist showed a trapezoid–capitate coalition. Reconstruction was performed with a non-vascularized corticocancellous iliac crest graft and fixation using a cannulated headless compression screw.

Results

Union was confirmed by CT after 10 weeks of immobilization. At 6 months, the patient was nearly pain-free and exhibited good wrist motion (extension/flexion 60–0–70°, ulnar/radial deviation 30–0–20°, pronation/supination 85–0–80°). Grip strength was symmetric (32 kg bilaterally). Histology of resected fragments revealed non-physiological microarchitecture consistent with pseudarthrosis.

Conclusion

This is the first reported case of scaphoid pseudarthrosis associated with an SL coalition. The case highlights therapeutic dilemmas in coalition-related fractures: distal scaphoid resection risks midcarpal instability, whereas reconstruction faces an increased risk of nonunion due to altered biomechanics. Successful consolidation demonstrates that standard reconstructive techniques remain feasible and underscores the importance of recognizing coalitions as risk factors for nonunion in surgical planning.

Level of evidence

IV.