Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

Relative fibular shortening compared to the tibia and syndesmotic widening are recognized contributors to the valgus tilt of the talus. This study aimed to assess: (1) the impact of fibular shortening relative to the tibia; and (2) the influence of syndesmotic widening, in correcting a large varus talar tilt (TT) associated with advanced ankle osteoarthritis through medial opening wedge valgization supramalleolar osteotomy (SMO).

Materials and methods

We retrospectively reviewed the clinico-radiographic findings of 41 patients with a preoperative TT of 8 degrees or more who underwent SMO for varus ankle osteoarthritis, with a minimum follow-up of more than two years. We compared several clinico-radiographic parameters between the three groups based on postoperative TT changes (decreased TT by 2 degrees or more, no TT changes [TT change between − 2 and 2 degrees], and increased TT by 2 degrees or more).

Results

In total, 18, 16, and 7 patients were included in the groups with postoperative decreased TT, no TT changes, and postoperative increased TT, respectively. The postoperative talocrural angle was greater in the postoperative increased TT group than in the postoperative decreased TT group (P =.036). The postoperative tibiofibular clear space was greatest in the postoperative decreased TT group (P =.037), whereas the other two groups were not significantly different (P =.260). In the postoperative increased TT group, postoperative tibial plafond inclination was the lowest among the three groups (P =.048 and 0.023, respectively), indicating the greatest plafond valgus inclination to the ground. All postoperative clinical parameters were significantly lower in the postoperative increased TT group (P <.05).

Conclusion

When performing SMO for varus ankle osteoarthritis, TT correction might be associated with the relative length of the fibula to the tibia and the role of the syndesmosis, implying the need for fibular shortening/valgization and syndesmotic widening. Additionally, excessive correction during SMO that places the tibial plafond in a valgus position relative to the ground floor can paradoxically increase TT and exacerbate ankle osteoarthritis.

Level of evidence

Level III.

Introduction

In comparison to primary TKA, outcomes of revision TKA will always appear inferior. When trying to assess outcomes of revision TKA for PJI, a group of aseptic revisions can serve as a reliable control, as compared to primary TKA. Our primary aim was to compare functional outcomes of septic versus aseptic revisions by using 5 scoring systems.

Materials and methods

We retrospectively reviewed 45 revision knee arthroplasty cases. Of the 45 cases, 17 belonged to the septic group and 28 to the aseptic group. The scores obtained were assessed for differences between the two groups using the Mann-Whitney U test. Pearson correlation coefficient (r) was calculated to assess the correlation between the PCS and MCS of the SF-36 score vs. other scores.

Results

The mean WOMAC score in the septic group was 38.88 ± 6.35 and in the aseptic group was 44.96 ± 10.07. With regards to the SF-36 score, the RE component (role limitations due to emotional problems) showed a significant difference, being poorer in the septic group (51.06 ± 31.57) as compared to the aseptic group (69.18 ± 28.62). We found a higher incidence of rest pain and nocturnal pain in the septic group. None of the scoring systems showed correlation with the SF-36 score.

Conclusion

In our study, there was a significant difference in the outcome of revision TKA based on etiology only with regards to the WOMAC score. Moreover, our study brings to the fore the importance of not just surgical management of patients with septic failure but also the importance of paying heed to the emotional and social problems encountered by these patients which has an impact on their outcome as a whole and diminishes their perception of benefit from revision surgery in spite of equivocal knee scores as compared to their counterparts.

Introduction

The clinical benefits of high tibial osteotomy (HTO) in patients with mild varus deformity with degenerative medial meniscal tear (DMMT) remain unclear. This study aimed to compare clinical outcomes among middle-aged patients with mild varus deformity who underwent arthroscopic meniscal repair and HTO for DMMT.

Materials and methods

In this retrospective study, patients who underwent isolated arthroscopic meniscal repair via the inside-out technique and those who underwent medial opening-wedge HTO were assigned to group M and H, respectively. The inclusion criteria were: an age of 40–65 years; percentage of mechanical axis of 30–50% measured using full-length weight-bearing anteroposterior radiographs; Kellgren–Lawrence grade ≤ 2; minimum postoperative two-year follow-up; and HTO correction angle < 10°. Clinical outcomes were assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and minimal clinically important difference achievement rate for the KOOS subscales preoperatively and at the final follow-up.

Results

Group M and H included 21 and 41 patients, respectively. The median ages were 53 and 58 years in groups M and H, respectively. In group H, 24 cases underwent meniscal repair. No significant differences in all KOOS subscales were found preoperatively. However, the median KOOS symptoms subscale in group H (89.3) was significantly better than that in group M (80.4) at the final follow-up (p = 0.04).

Conclusion

The main finding of the study indicated that KOOS symptoms after HTO were superior to those after isolated arthroscopic meniscal repair for DMMT. HTO might be a potentially useful treatment for DMMT in middle-aged patients with mild varus deformity, even with a small correction angle.

Level of evidence

Retrospective comparative study, Level III.

Traumatic lumbosacral instability (TLSI) refers to a traumatic disruption of the axial skeleton at the level of the lumbosacral motion segment and/or sacrum, resulting in mechanical separation of the caudal spinal column from the posterior pelvic ring. Managing TLSI and its four underlying conditions poses unique challenges among spinal and pelvic injuries. This second part of a two-part series focuses on treatment strategies and decision making in TLSI, with an emphasis on surgical stabilization techniques. The primary objectives of this article are to: (1) elucidate factors influencing clinical decision-making, (2) synthesize current treatment options for the injury patterns underlying TLSI, and (3) briefly outline expected outcomes and complications.

Introduction

The minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) that adopts paramedian incisions and tubular retractors to perform the decompression and interbody fusion has been widely used in the surgery for lumber degenerative disease (LDD). Bilateral pedicle screw fixation (BPSF) and unilateral pedicle screw fixation (UPSF) are the primary fixing techniques in MIS-TLIF. We conducted an updated systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the efficacy and safety between UPSF and BPSF in patients undergoing MIS-TLIF surgery for LDD.

Materials and methods

We searched the PubMed, Embase, and Cochrane Library databases for potential RCTs till June 2023. The effects of the fixation methods on clinical outcomes were estimated using the odd ratio (RR), risk difference (RD), and mean difference (MD) with a 95% confidence interval (CI) and a random-effects model.

Results

We obtained six RCTs. There was no significant difference between UPSF and BPSF in fusion rate, hospitalization day, low back pain, leg pain, Oswestry Disability Index, and SF-36 for physical functioning at 3–6 months and ≥ 6 months after surgery. Neither the total complication nor the individual complications showed differences between the two methods. However, UPSF significantly decreased operation time (MD = − 39.05; 95% CI: − 53.50 to − 24.67) and estimated blood loss (MD = − 60.41; 95% CI: − 79.09 to − 41.73) compared with BPSF.

Conclusion

UPSF is better than BPSF when operation time and estimated blood loss are considered. BPSF may be considered for patients with single-level LDD without high-grade spondylolisthesis.

Introduction

The influence of patient age on the clinical outcome of surgically treated osteochondral lesions of the talus (OCT) is controversial. Aim of this study was to evaluate the 24 months follow-up data of the German Cartilage Registry (KnorpelRegister DGOU, GCR) regarding the influence of patient age on clinical outcomes after surgical OCT treatment.

Materials and methods

303 patients met the inclusion criteria and were divided into patients < 40 years (27.1 ± 5.8 years, n = 177) and patients ≥ 40 years (50.8 ± 7.4 years, n = 126). Pre- and postoperative FAOS total scores, subscores and ΔFAOS for most frequent surgical techniques (bone marrow stimulation, matrix-augmented bone marrow stimulation, matrix-augmented bone marrow stimulation with additional bone grafting) and lesion size characteristics were evaluated for both groups. ANOVA analysis with post hoc Duncan test was applied for statistical analysis.

Results

Both patients < 40 years and patients ≥ 40 years benefit from surgical treatment of OCT showing significant changes from pre- to postoperative FAOS total score (63.8 ± 20.3 to 81.5 ± 17.8 in patients < 40 years, p < 0.001; 57.3 ± 20.1 to 74.9 ± 21.6 in patients ≥ 40 years, p < 0.001) and subscores. Younger patient group tended to higher pre- and postoperative scores. ΔFAOS was not different between both groups. Older patient group had significantly higher lesion size area and volume; proportion of additional bone grafting was increased.

Conclusion

Results of surgical therapy of OCTs are independent from patient age. There is no superiority of a specific surgical technique depending on patient age.

Introduction

Previous literature lacks parametric analysis of clavicle fracture morphology. The aim of this study was to describe the features of comminuted midshaft clavicle fracture in surgically treated patients.

Methods

A total of 117 consecutive patients with an acute displaced midshaft clavicular fracture were retrospectively evaluated. All fractures underwent open reduction and internal fixation. The radiographic and surgical data of all patients were collected.

Results

There were 39 AO type B fractures and 78 type C fractures. In the overall sample, the average proximal main fragment measured 8.41 ± 1.40 cm in length, which was greater than the distal main fragment of 5.34 ± 0.94 cm on the radiograph. From the three-dimensional CT images, 104/117 patients (88.89%) had coronal plane fracture lines. During the operation, 94/117 patients (80.34%) were seen to have one or more fragments in the antero-inferior quadrant only. 102 of 117 patients (87.18%) were found to have a constant segment for anatomic reduction. For those anatomic reduction were available, 98 (96.08%) had cortical contact of main fracture fragments in the posterior-superior quadrant of the fracture region.

Conclusions

Comminuted midshaft clavicle fracture frequently had coronal plane fracture lines. Wedge-shaped or multifragmentary fragments were predominantly located anteriorly or inferiorly. In the posterior-superior portion of the clavicle, cortical contact was found to guide reduction.

Introduction

Percutaneous sacroiliac screw placement is the main surgical approach to treat unstable posterior pelvic ring injuries. Intraoperative fluoroscopic imaging is an important part of safe sacroiliac screw placement. However, how to determine the right perspective view is challenging. We developed a trigonometric algorithm to verify how preoperative pelvic computed tomography (CT) can be used to predict ideal screw path and safety angle.

Materials and methods

The normal pelvic CT data of 30 volunteers from our hospital between September 2021 and June 2023 were collected, and analyzed and reconstructed using Materialise Mimics 21.0. The angle between the cross-sectional ideal screw path and the horizontal plane (∠α), the angles of the pelvic inlet and outlet on the sagittal plane (∠1, ∠2), and the insertion angles of virtual screws at the inlet and outlet (∠a, ∠b) were measured. The ideal insertion angles (∠A, ∠B) and safety angles of the screws at the pelvic inlet and outlet were calculated using trigonometric functions.

Results

The virtual screw insertion angle ∠a of 30 pelvises measured at the inlet was 18.57 ± 4.33°, and the ideal screw angle ∠A calculated using trigonometric functions was 18.72 ± 4.71° (range, 13.84 ± 0.75°-23.36 ± 0.98°). The difference between the measurement and calculation was only 0.15 ± 0.19° and not significant. The angle ∠b of the virtual screw insertion measured at the outlet was 25.37 ± 5.13°, and the ideal screw angle ∠B calculated using trigonometric functions was 25.58 ± 4.93 ° (range, 19.02 ± 0.88°-31.31 ± 1.01°). The difference between the measurement and calculation was only 0.20 ± 0.13° and not significant. The distance e from the optimal screw insertion point to the vertical line through the anterior superior iliac spine is 32.34 ± 1.76 mm, and the distance f to the horizontal line through the posterior superior iliac spine is 28.61 ± 0.81 mm.

Conclusions

During preoperative planning, trigonometric calculations were used to determine the ideal screw placement angles and safety angle at the inlet and outlet of the screw path. Combined with intraoperative C-arm fluoroscopy, individualized screw insertion can help orthopedic surgeons quickly and accurately obtain intraoperative images and accurately determine the direction of screw insertion.

Introduction

The frequency of revisions in total knee arthroplasty (TKA) is rising. Various classifications of bone defects exist, each with its own limitations. Recently, Belt et al. have proposed a new classification for TKA revisions based on X-ray imaging. We evaluated the Belt et al. classification and verified if this new classification is reliable, and if it correlates with the implant used during revision surgery for periprosthetic joint infection.

Methods

This is a retrospective study. We reproduced the paper proposed by Belt et al. with the radiological data of all patients who underwent two stage revision for infected TKA in our institution between January 2017 and December 2022. Five different operators classified the bone defect for each patient at two time points. Subsequently, we assessed intra- and inter-operator reproducibility. We also collect the surgery data from our registry to verify if there is a correlation between augment use and epiphyseal bone defect.

Results

The classification proposed by Belt is reliable, and have a good reproducibility inter and intraoperator. There is no correlation between the bone defect. And the use of augment, and so this classification is usless in the prediction of the material needed in the operating room.

Conclusion

The Belt at al. classification is reliable, but a classification which can predict the implant neded have to be developed.