Archives of Orthopaedic and Trauma Surgery最新文献

Background

Cephalomedullary nail (CMN) fixation is commonly used to treat extracapsular femoral fractures but is associated with mechanical complications, including implant cut-out, cut-in, and material failure. Identifying clinical and radiographic predictors of these complications is critical for improving patient outcomes.

Methods

This retrospective cohort study analyzed 401 patients treated with CMN for per-, sub-, or intertrochanteric fractures between 2019 and 2024. Clinical, laboratory, and radiographic parameters were evaluated using logistic regression analyses to identify predictors of mechanical complications.

Results

Mechanical complications occurred in 7% (n = 28) of patients. The most common complications were cut-out (n = 16, 57%) and cut-in (n = 7, 25%). Significant predictors included increased tip-apex distance (TAD), younger patient age, and the requirement for postoperative blood transfusions. A TAD greater than 37.2 mm substantially elevated the risk of complications.

Conclusion

Mechanical complications after CMN implantation can be significantly reduced by precise implant placement to minimize TAD and careful perioperative management of hemoglobin levels. Implementing these findings into clinical practice can potentially improve surgical outcomes and reduce patient morbidity.

Objective

This study aims to investigate the functional and radiographic outcomes after internal fixation of proximal femoral fractures in children using a 3.5 mm T-plate.

Methods

From December 2015 to September 2022, all cases presenting with recent proximal femoral fractures were treated with internal fixation using a 3.5 mm T-plate. All patients were followed up for 24 months. Union time, neck shaft angle, neck length, quality of reduction, and functional outcomes were assessed.

Results

The study included 37 patients; the mean age was 8.6+/- 1.6 (6–11) years. Delbet type IV was the most frequent fracture type (13 cases, 35.1%), followed by type V (10 cases, 27%), and type III (9 cases, 24.3%), with type II accounting for 5 cases. All fractures achieved union with a mean time of 8,7 weeks (range 6–12 weeks), As regards radiographic parameters, the mean neck shaft angle difference was 4.9 (SD 3.7) degrees (range 0–16 degrees) less than the contralateral side, the mean neck resorption ratio was 93.8 +/- 4 (range 85–100), The quality of reduction was anatomical in 24 cases (64.9%), acceptable in 10 cases (37%), and considered unacceptable in 3 cases (8.1%), The functional outcome was good in 24 cases (64.9%), fair in 11 patients (29.7%) and poor in two patients (5.4%).

Conclusion

The use of a contoured 3.5 mm conventional T-plate in the fixation of recent pediatric femoral fractures (types II–V) yields good results regarding union rates, functional outcome, and maintaining the mechanics of the hip.

The Vancouver B3 type periprosthetic fracture is a rare but difficult-to-treat complication of hip arthroplasty. Various options for the treatment of Vancouver B3 periprosthetic fractures are described in the medical literature. The problem with many studies is the small number of cases, the fact that the results of Vancouver B2 and B3 fractures are only presented together, the lack of a clear definition of B3 fractures and the resulting subjective categorisation of fractures into the two groups (Vancouver B2 and B3). Therefore, the evidence in the literature for the recommendation of treatment strategies for Vancouver B3 fractures can be classified as poor. This review aims to analyse the various therapeutic options with regard to the current state of knowledge based on reports of case series.

Introduction

Osteochondroma or exostosis is the most common benign bone tumor and is typically diagnosed based on its characteristic radiographic features. While it is generally familiar to orthopaedic surgeons, the level of diagnostic familiarity among primary physicians remains unclear.

Materials and methods

This retrospective study reviewed 195 patients diagnosed with osteochondroma/exostosis who were referred to a tertiary orthopaedic oncology center. Inclusion criteria included radiological confirmation of osteochondroma/exostosis and the availability of referral documents. Diagnostic accuracy was assessed by classifying initial impressions as “osteochondroma/exostosis” or “other diagnoses.” Primary physicians were categorized by institutional affiliation (hospital or clinic) and specialty (orthopaedic or non-orthopaedic). A temporal analysis divided the study period into Period 1 (2005–2014) and Period 2 (2015–2024) to evaluate potential changes over time.

Results

Of the 195 cases, 118 (60.5%) were accurately described as osteochondroma or exostosis. Familiarity varied by anatomical location, with higher familiarity in long bones and lower familiarity in less typical sites such as toes, fingers, and ribs. Physicians affiliated with hospitals demonstrated significantly higher accuracy than those in clinics (p < 0.05), and orthopaedic surgeons outperformed non-orthopaedic physicians (p < 0.01). Temporal analysis showed no significant improvement over time: 50.0% in Period 1 and 62.4% in Period 2 (p = 0.22).

Conclusions

Diagnostic familiarity with osteochondroma/exostosis among primary physicians was moderate but varied by anatomical site and physician background. Improved musculoskeletal education, particularly regarding atypical presentations, may enhance diagnostic accuracy and referral quality.

Introduction

Periprosthetic joint infection (PJI) remains a severe complication in arthroplasty. Unicompartmental knee arthroplasty (UKA) may have lower PJI rates than total knee arthroplasty (TKA) because of smaller implants and less extensive surgical exposure. However, PJI treatment after UKA is challenging due to restricted debridement and limited options for local antibiotic delivery. This study compared the revision rate for PJI and the failure rate of implant-retaining revision for PJI between UKA and TKA in the Swiss national joint registry (SIRIS).

Methods

A retrospective analysis was conducted using SIRIS data from 2012 to 2024, examining the first revision after primary UKA or TKA and the re-revision rate after debridement with isolated inlay exchange for PJI. Both analyses assessed revisions for any cause and specifically for PJI. Kaplan-Meier survival curves and hazard ratios (HR) were calculated.

Results

Among 35’286 primary UKA and 188’952 primary TKA, 149 and 1’546 were revised for PJI, respectively. Revision rates for any cause were higher for UKA than TKA (HR 1.29, p < 0.001), whereas PJI-related revisions were about half as frequent (HR 0.53, p < 0.001). Following implant-retaining revision for PJI, repeat revision rates increased more rapidly for UKA than TKA, reaching 34.8% and 32.1%, respectively (HR 1.56, p = 0.099). The statistical precision for UKA was limited by small numbers.

Conclusions

In SIRIS, the revision rate for PJI after primary UKA was about half that after primary TKA, while the revision rate for any cause was higher. These findings support the hypothesis that smaller implants and less extensive surgery may be associated with lower infection risk. Despite limited debridement options, implant-retaining revision for PJI after UKA was as successful as after TKA. Nonetheless, failure rates for such procedures remain high in Switzerland, at roughly one-third.

Introduction

Although previous studies have examined total joint arthroplasties (TJA), research on the association between the Area Deprivation Index (ADI) and outcomes following unicompartmental knee arthroplasty (UKA) remains limited. This study evaluates outcomes following UKA and whether patients with higher ADIs (indicating greater socioeconomic disadvantage) are at increased risk for implant-related complications.

Methods

A retrospective analysis was performed using a nationwide claims database from 2010 to 2022. The ADI was used to categorize patients into high and low ADI groups. A total of 26,058 primary UKA patients for osteoarthritis were 1:1 propensity-score matched by age, gender, and Elixhauser Comorbidity Index (ECI). Primary endpoints included 2-year implant-related complications and costs. Multivariable logistic regression models computed the odds ratios (OR) for the association between ADI and 2-year implant complications. P values < 0.001 were significant.

Results

Patients undergoing UKA with higher ADIs experienced no difference in the incidence and odds of implant-related complications within 2 years compared to those with lower ADIs. Periprosthetic fractures were less common in the high ADI group (0.21% versus 0.40%; OR: 0.53, P = 0.008). Periprosthetic joint infections (PJIs) (1.27% versus 1.33%; OR: 0.95, P = 0.701), aseptic loosening (1.14% versus 1.05%; OR: 1.08, P = 0.512), manipulations under anesthesia (MUA) (1.10% versus 0.92%; OR: 1.20, P = 0.153), or all-cause revisions (3.04% versus 2.86%; OR: 1.07, P = 0.378) were similar between groups. Patients in the higher ADI cohort had significantly higher day of surgery ($5,336 vs. $4,118;P < 0.0001) and 90-day costs ($7,462 vs. $6,431; P < 0.0001) after propensity-matching and adjustment for measured comorbidities.

Conclusion

Patients undergoing UKA of higher ADIs did not experience significant differences in implant-related complications compared to those of lower ADIs. Socioeconomic disadvantage alone is not a major determinant of early implant-related outcomes following UKA. These findings support equitable patient selection and treatment decisions based on clinical indications rather than socioeconomic proxies of patient complexity.

Level of evidence

III.

Introduction

Intra-articular steroid injections (IASI) and knee arthroscopies are occasionally performed after total knee arthroplasty (TKA) in patients with persistent pain, inflammation, or mechanical symptoms. Prior studies have raised concern regarding a potential increased risk of periprosthetic joint infection (PJI) following such procedures. Comparative data on infection rates across these post-TKA interventions remain limited. This study evaluates and compares the incidence of PJI in patients who underwent IASI, knee arthroscopy, or both following primary TKA.

Materials and methods

A retrospective cohort study was conducted using patients who received primary TKA between January 2017 and January 2023. PJI was defined according to the 2018 Musculoskeletal Infection Society (MSIS) criteria. Infection rates were compared using Fisher’s exact test. The control group was propensity score matched on a 5:1 ratio independently for IASI and knee arthroscopy based on age, sex, ASA score, Charlson comorbidity index, and surgical date.

Results

362 patients (372 knees) met inclusion criteria for the treatment groups: 173 received steroid injection only (group 1), 142 underwent arthroscopy only (group 2), and 57 received both (group 3). When comparing all treatment groups (1.34%) to the matched control group of 1850 patients (0.97%), there was no significant difference between infection rates (p = 0.5708) at a minimum 2 year follow up. The infection rate in group 1 was 1.73%, in group 2 was 0.70%, and in group 3 was 1.75%. Two of the 3 infections in group 1 occurred within 30 days of IASI. The 6 month PJI rate in the 230 knees receiving IASI (group 1 and 3) was 0.87%.

Conclusions

The fact that two infections occurred within 30 days of IASI suggests a slightly increased risk of infection after IASI. However, reported PJI rates within 6 months of IASI and Arthroscopy are very low and both are considered reasonable treatment options in selected patients.

Objective

The pararectus approach (PRA) offers good visualization of the entry point for posterior column screw insertion with an adequate screw length. However, conventional practice typically employs the lateral window (LW) of the pelvic approach. This study aimed to compare the radiographic trajectory of posterior column screws inserted via the PRA with that of screws inserted via the LW approach.

Methods

We retrospectively analyzed 68 cases of posterior column screw placement during acetabular fracture surgery, beginning in March 2020, when metal-reformatted images could be generated from postoperative pelvic computed tomography (CT) scans. Group 1, consisting of 32 cases where screws were inserted through the second window of the PRA, was compared with Group 2, which included 36 cases using the LW in combination with various pelvic approaches. Demographic data (including body mass index [BMI] and presence of sacral dysplasia), the coronal angle of the posterior column screw in three-dimensional (3D) images, Sagittal Angle to Linea Terminalis (SALT), Sagittal Angle to Ischial Line (SAIL), and screw length (measured from 3D-CT metal-reformatted images) were analyzed.

Results

Demographic data, including BMI and the presence of sacral dysplasia, were not significantly different between the two groups. The average coronal angle of the posterior column screw was 4.6° in Group 1 and 12.2° in Group 2, indicating a significant difference between both groups. For sagittal angles, SALT was 75.8° in Group 1 and 34.6° in Group 2, while SAIL was − 24.5° and − 4.1° in Groups 1 and 2, respectively, with both differences being statistically significant. The average screw length, measured by 3D-CT, was 73.2 mm and 93.7 mm in Groups 1 and 2, respectively, also demonstrating a significant difference between both groups.

Conclusion

Although the PRA allows good visualization of the posterior column screw entry point, it presents limitations in achieving optimal sagittal and coronal insertion angles due to the anatomical constraints of the abdomen and surrounding structures. In contrast, the LW approach demonstrated a screw trajectory that more closely aligns with the ideal anatomical corridor.

Background

Primary vascular bone tumors are rare, spanning from benign to highly malignant lesions. Pelvic and extremity involvement is uncommon, and differentiation between benign and malignant tumors remains challenging due to overlapping radiological and pathological features. This study aimed to identify imaging predictors of malignancy and evaluate clinical outcomes in vascular bone tumors of the pelvis and extremities.

Methods

We retrospectively analyzed 18 patients diagnosed with vascular bone tumors between 2013 and 2024. Tumors were classified as benign (hemangioma, epithelioid hemangioma; n = 11) or malignant (angiosarcoma, epithelioid hemangioendothelioma; n = 7). Demographic, radiological (plain radiographs, MRI, CT), and clinical data were collected. Cortical expansion/destruction, pathological fractures, soft tissue components, and tumor size were assessed. Statistical analysis included Fisher’s exact test, Mann–Whitney U test, Spearman correlation, and ROC analysis to identify predictors of malignancy.

Results

Median age was 41.0 years for benign and 53.0 years for malignant tumors. Soft tissue components were significantly more frequent in malignant tumors (57% vs. 9%, p = 0.025), and tumor size was larger (mean 9.0 cm vs. 3.7 cm, p = 0.001). Cortical expansion, destruction, and pathological fractures did not differ significantly. ROC analysis suggested that larger tumor size (≥ 5.5 cm in this cohort) was associated with malignancy with 85.7% sensitivity and 90.9% specificity (AUC = 0.929, p = 0.003) and should be interpreted as an exploratory finding. All benign tumors underwent intralesional curettage, with no recurrences or complications observed. In contrast, malignant tumors exhibited high rates of relapse and mortality, with only one patient with epithelioid hemangioendothelioma surviving with stable disease at 112 months.

Conclusion

In vascular bone tumors of the pelvis and extremities, the presence of a soft tissue component and tumor size ≥ 5.5 cm are among the most useful radiological features associated with malignancy. While benign lesions generally have excellent outcomes with curettage, malignant tumors are associated with a poor prognosis. Histopathological confirmation remains essential, and larger series are needed to refine diagnostic and prognostic criteria.