Archives of Orthopaedic and Trauma Surgery最新文献

Purpose

To determine the diagnostic performance of magnetic resonance imaging (MRI) for subscapularis (SSC) tendon tears, identify the strongest independent MRI predictors, and evaluate the accuracy of MRI in predicting tear size.

Methods

A retrospective cohort study of patients who underwent arthroscopic rotator cuff repair was conducted. From a total of 376 surgeries, 278 patients met the inclusion criteria. All patients had a preoperative 1.5-T MRI. A blinded shoulder surgeon and a musculoskeletal radiologist independently evaluated six MRI signs for SSC rupture. Arthroscopic findings served as the gold standard. Diagnostic performance metrics (accuracy and predictive value) were calculated, and a multivariate logistic regression was performed to identify independent predictors.

Results

Arthroscopy confirmed an SSC tear in 99 of 278 patients (35.6%). For the radiologist, overall accuracy was 73%; for the surgeon, it was 70%. Performance was substantially higher for complete tears than for partial tears, with a positive predictive value for partial tears of only 24%. Multivariate logistic regression identified two independent predictors of an SSC tear: tendon hyperintensity on axial images (OR 3.97, p < 0.001) and a “naked” lesser tuberosity on sagittal images (OR 4.83, p = 0.029). A simplified diagnostic model based on these two signs achieved an accuracy of 75.5%, with 74.7% sensitivity and 76.0% specificity.

Conclusion

MRI performance is poor for diagnosing partial SSC tears but good for complete tears. Tendon hyperintensity (axial) and a naked lesser tuberosity (sagittal) are the strongest independent predictors of an SSC tear. A simplified diagnostic model focusing on these two signs may offer a more efficient and accurate approach to preoperative assessment.

Introduction

Flexor tendon injuries of the hand often result in significant functional impairment. Rehabilitation protocols after surgical repair are critical for optimizing outcomes, yet the comparative effects of active versus passive rehabilitation remain debated. Shear wave elastography (SWE) offers an objective imaging method to monitor tendon stiffness, but its role in hand tendon recovery is not well established. This study aimed to compare functional outcomes between active and passive rehabilitation protocols, while exploring the potential utility of SWE in monitoring tendon healing.

Materials and methods

In this randomized controlled pilot trial, patients undergoing flexor tendon repair were assigned to either active (AR) or passive (PR) rehabilitation protocols. Functional outcomes were assessed using grip strength, pinch strength, dexterity tests, and validated questionnaires (SF-12, Duruoz Hand Index, Modified Hand Injury Severity Score). Tendon stiffness was measured longitudinally with SWE. Group comparisons and correlations between stiffness and clinical outcomes were analyzed.

Results

20 patients with 34 tendons completed 12-week follow-up. Both AR and PR groups showed significant functional improvements over time (p < 0.05). No significant intergroup differences were observed in grip strength, pinch strength, dexterity, or patient-reported outcomes. SWE measurements did not significantly differ between groups or time points. Functional recovery was achieved without parallel increases in stiffness, and correlations between SWE and clinical parameters were inconsistent.

Conclusions

Both active and passive rehabilitation protocols supported early functional recovery following flexor tendon repair. SWE provided objective monitoring of tendon healing but did not consistently correlate with functional outcomes. These findings highlight the multifactorial nature of tendon recovery and suggest that SWE may complement, but not replace, clinical assessment in postoperative rehabilitation. Larger cohorts and extended follow-up are needed.

Trial registration

ClinicalTrials.gov identifier: NCT05598918. Registered on 28 October 2022.

Introduction

Periprosthetic distal femur fractures are often considered more complex and morbid than native distal femur fractures, yet few studies directly compare them. This study aimed to compare patient characteristics, treatment strategies, and early complications between native and periprosthetic distal femur fractures using the Lewis–Rorabeck classification.

Methods

We retrospectively analyzed 152 patients treated surgically for distal femur fractures at a level I trauma center. Cases included native fractures (n = 90) and periprosthetic distal femur fractures (n = 62), further divided into Lewis–Rorabeck Type I/II (n = 49) and Type III (n = 13). Demographics, comorbidities, surgical details, and in-hospital complications were assessed. We conducted a multivariate analysis comparing native fractures with Lewis–Rorabeck Type I/II fractures, as well as comparing Type I/II with Type III fractures.

Results

Patients with periprosthetic fractures were older and had higher BMI than those with native fractures (p < 0.001). Multivariate analysis showed no significant differences in surgery duration, mortality, mobility at discharge, transfusion needs, or revision rates between native distal femur fractures (AO/OTA Type A) and Lewis–Rorabeck Type I/II. The complication rate was significantly lower in the periprosthetic group (p = 0.029). Lewis–Rorabeck Type III fractures showed significantly longer time to surgery (p = 0.015) and revision surgery was performed more frequently compared to Lewis–Rorabeck Type I/II fractures. However, no differences were observed in early postoperative complications, mobility at discharge, or length of hospital stay.

Conclusion

This study directly compares periprosthetic distal femur fractures stratified by implant stability to native distal femur fractures. The findings challenge the perception that periprosthetic fractures are universally more difficult to treat. Periprosthetic fractures achieve results comparable to native fractures. The increased complexity of Lewis–Rorabeck Type III fractures is reflected in prolonged time to surgery and an increased need for revision surgery.

Introduction

Although immersive virtual reality (VR) is used for training in various surgical procedures, its efficacy in complex multistep orthopaedic surgeries is less established. The aim of this study was to evaluate the effectiveness of immersive VR simulation training in comparison to the surgical technique guide and video for fixed-bearing total knee replacement (TKA) among junior orthopaedic surgery residents in their first and second years of postgraduate training.

Material and Methods

Twenty-two orthopaedic surgery residents were blocked randomized into two groups based on year of study: one receiving surgical training for TKA using a surgical technique guide and instructional video (control group, CG), and the other using an immersive VR training module (VR group). Group allocation was determined by drawing envelopes. Following the training, participants performed TKA on cadavers with standardized surgical instruments and implants. Subjective and objective data were collected before, during and after the procedure. Participants were assessed using a procedure-specific checklist, the global ratings scale of the Objective Structured Assessment of Technical Skills (OSATS), and the global summary score of the Procedure-Based Assessment (PBA) for TKA. Operative time was recorded, while confidence and motivation metrics were evaluated through pre- and post-assessment questionnaires.

Results

Residents from a single institution were randomized equally (n = 11) in the VR and CG groups. The VR group achieved significantly higher scores in instrument handling (VR 3.3 ± 0.5 vs. CG 2.5 ± 0.7, p = 0.005) and flow of operation (VR 3.5 ± 0.8 vs. CG 2.7 ± 0.5, p = 0.024) compared to CG group on the OSATS. The VR group performed significantly better than CG group in PBA (VR 4.3 ± 0.6 vs. CG 2.9 ± 0.8, p < 0.001). The VR group achieved significantly higher mean score for correct steps performed than CG group (VR 29.7 ± 2.9, CR 25.8 ± 5.8, p = 0.05). There was no difference in procedure time when comparing the VR group (54.8 ± 14.8 min) with the CG group (55.4 ± 10.9 min; p = 0.93). The VR group would recommend this training method to other trainees and acknowledged that it significantly increased their confidence in performing TKA.

Conclusions

Although there was no significant difference in TKA completion times between VR and control groups, the VR group demonstrated superior performance in specific skill assessments and executed a higher number of TKA procedural steps correctly. Positive trainee feedback suggests immersive VR training is well-received and has potential for enhancing surgical education in orthopaedics.

Introduction

Quality assurance in arthroplasty has become increasingly important in light of rising procedure volumes and patient expectations. In 2012, the EndoCert system was introduced in Germany as a standardized certification program addressing structural, process, and outcome quality.

Methods

This retrospective cohort study evaluated the impact of EndoCert certification on hip and knee arthroplasty outcomes in a rural hospital. A total of 847 patients undergoing 1,011 primary or revision procedures were included, covering a pre-certification period (2014/2015) and post-certification years (2016, 2018, 2020). Process indicators (preoperative planning, imaging, operative time) and outcome indicators (infections, dislocations, thromboembolic events, revisions) were analysed.

Results

Process quality improved markedly following certification. Preoperative planning compliance increased from 63% pre-certification to 96% post-certification, and standardized radiographic assessment improved from 71% to 98%. Operative times increased (from 82 min to 94 min) due to a higher proportion of complex revision procedures (rising from 6 revisions pre-certification to 19 revisions in 2020). Despite increased surgical complexity, overall complication rates remained low. Prosthetic joint infection (PJI) rates rose proportionally with revision volume (from 0/6 cases in 2014–2015 to 2/22 in 2018 and 3/19 in 2020), reflecting small absolute numbers rather than a true increase in infection risk.

Conclusion

EndoCert certification contributed to the standardization and optimization of care processes without compromising clinical outcomes. Certification programs such as EndoCert strengthen structural and process quality and serve as tools for continuous quality improvement. Future multicentre studies incorporating patient-reported outcomes are needed to comprehensively assess the long-term benefits of certification.

Purpose

the diagnosis of prosthetic joint infection (PJI) as a serious complication after total hip and knee arthroplasty is important; however, current criteria lack a universal definition and often exclude key clinical symptoms. This study evaluates the prevalence of clinical signs and symptoms of chronic hip and knee PJI to provide a descriptive map of clinical presentation.

Methods

We conducted a systematic search of Medline, Embase, Web of Science and Scopus to identify studies reporting the prevalence of clinical signs and symptoms in chronic hip or knee PJI published up to June 29, 2024. Statistical analysis was conducted in STATA 17.0 to calculate pooled prevalence and assess heterogeneity. Risk of bias was evaluated using the Joanna Briggs Institute tool. Meta-regression based on the PJI sample size was performed, and a corresponding bubble plot was generated.

Results

Of the initial 3,081 records, 2,360 were excluded during title and abstract screening, and 721 articles underwent full-text screening to minimize the exclusion of relevant studies. Ultimately, 26 cohort studies met the inclusion criteria, comprising 2,350 cases. The criteria used to define PJI varied among studies, with the Musculoskeletal Infection Society (MSIS) criteria being the most commonly used. Meta-analysis showed that 38.1% of patients had fever, 24.7% had a fistula or sinus tract, 85.5% reported pain, 62.1% showed local inflammation, and 49.3% had swelling. Subgroup analysis based on the joint and microorganisms involved reduced heterogeneity levels.

Conclusion

We concluded that pain, local inflammatory signs, along fever are the most prevalent symptoms of chronic periprosthetic joint infection in the hip and knee. High heterogeneity in several symptoms indicates the pooled prevalence should be interpreted with caution.

Introduction

Anaesthesia for hip fracture surgery is often supplemented with a peripheral nerve block (PNB) to reduce postoperative pain. Common PNBs include fascia-iliaca compartment block (FICB) and femoral nerve block (FNB). Since the introduction of the pericapsular nerve group (PENG) block, debate continues as to which technique provides superior analgesia. This review aimed to compare the postoperative analgesic efficacy of three PNBs when administered perioperatively to adult hip fracture patients.

Methods

CINAHL, Cochrane CENTRAL, Embase, Medline, Web of Science and Google Scholar were searched in April 2025. Statistical analysis was performed using a random-effects model.

Results

19 randomised trials (1059 patients) were included. Pain scores between PENG and FICB at 6, 12 and 24 h were not significantly different. Compared to FNB, PENG significantly lowered pain scores at 6 h (P = 0.004). Opioid consumption in the 24 h postoperative period was significantly lower in PENG than FICB (P = 0.02), but not in FNB. No outcome reached the minimal clinically important difference. Evidence was graded very low to moderate.

Conclusion

There is insufficient evidence to state superiority of PENG over FICB or FNB when used perioperatively in patients undergoing hip fracture repair. No included studies reported time to mobilisation, highlighting a significant evidence gap in existing primary research. Further high-quality, sufficiently powered randomised trials are still needed.

Introduction

Despite the growing use of unicompartmental knee arthroplasty (UKA), no prior systematic review has focused exclusively on stair ascent and descent biomechanics. This review addressed this gap by synthesizing spatiotemporal, kinematics, and kinetics outcomes compared to healthy individuals and between operated and contralateral limbs.

Materials and methods

Five databases, including Medline, Embase, CINAHL, Web of Science, and Ergonomics Abstracts were searched until February 2025. Studies were screened based on title and abstract, followed by a full text reading conducted by two authors following inclusion and exclusion criteria. The risk of bias was assessed using ROBINS-I tool. Main outcomes included spatiotemporal, kinematics and kinetics outcomes compared to healthy individuals or contralateral limb.

Results

A total of 7 studies were included. All the included studies evaluated stair ascent, descent or both. A total of 92 patients operated with UKA, and 58 healthy individuals were included. Medial unicompartmental knee arthroplasty does not appear to fully restore normal knee function in terms of knee flexion amplitude compared to healthy individuals during stair ascent. Moreover, UKA patients appeared to decrease stride velocity and increase contact time compared to healthy individuals during both stair ascent and descent.

Conclusions

Due to the limited quality of included studies, definitive conclusions could not be drawn. However, patients following UKA exhibit altered stair negotiation mechanics with persistent asymmetry compared to healthy controls. This highlights the need for future longitudinal research on stair negotiation following UKA, including assessment of muscle activation and a focus on mobile-bearing UKA.

Level of evidence

Level III, systematic review.

Background

Pediatric fractures are a major public health concern, noticeably impacting child morbidity. A comprehensive global analysis of incidence, disability, and socioeconomic factors has been limited.

Materials and methods

This epidemiological analysis used Global Burden of Disease (GBD) 2021 data (1990–2021) to evaluate the incidence of orthopaedic fractures and years lived with disability (YLDs) in children aged 0–19 years across 204 countries. We reported trends in absolute numbers, rates per 100,000 pediatric population, and calculated average annual percent changes (AAPCs) via linear regression. The relationships of incidence with SDI and YLD with SDI were assessed using Locally Estimated Scatterplot Smoothing (LOESS) regression. In addition, the impact of COVID-19 was assessed by comparing the periods 2017–2019 and 2019–2021.

Results

Global pediatric fracture incidence and YLD rates per 100,000 pediatric population significantly declined (1990–2021; AAPC: − 1.25% and − 1.53%; p < 0.001). During the COVID-19 pandemic (2019–2021), incidence rate decline slowed (– 0.08%) compared to the pre-pandemic period (− 1.615), with falls notably increasing (1.11%). In 2021, falls (51.66%), mechanical forces (15.80%), and road injuries (8.24%) were primary causes of fractures. Patella, tibia/fibula, or ankle fractures was the most common group of fractures, peaking in 15–19-year-olds. Incidence and YLD rates negatively correlated with SDI, peaking around 0.75.

Conclusion

Global pediatric fracture rates declined by 1.25% annually from 1990 to 2021, with falls, mechanical forces, and road injuries as main causes. The COVID-19 pandemic increased fall-related fractures, highlighting future lockdown risks. Higher fracture rates were seen in low- and mid-SDI regions, underscoring the need for targeted prevention. Clinicians should allocate resources based on injury patterns, while policymakers must focus on prevention and improving care access in high-burden areas.

Introduction

Diabetes is a known risk factor for surgical-site infection (SSI) following total joint arthroplasty (TJA), but the impact of antidiabetic medications on outcomes remains unclear. This study investigated the association between medication regimen, clinical outcomes, and glycemic control in patients with Type 2 diabetes (T2DM).

Methods

We retrospectively reviewed T2DM patients undergoing primary, elective TJA from 2011 to 2022. Patients were stratified by their antidiabetic medication regimen taken for at least one month in the year preoperatively: (1) one medication, (2) 2 + medications, and (3) insulin-containing regimen. Cohorts were matched by preoperative hemoglobin A1c (HbA1c), age, body-mass index (BMI), sex, and ASA class. Demographics, outcomes, and glycemic markers were compared.

Results

Of 2767 TJAs, 55.4%, 30.1%, and 14.5% fell into Cohorts 1, 2, and 3, respectively. After matching, each cohort included 273 procedures. Insulin-treated patients had greater blood glucose variability during hospitalization (153.7 vs. 114.8 [1] & 119.0 [2]; P < 0.001). Long-term outcomes, revision incidence, and SSIs did not differ significantly across cohorts. In regression of the pre-match population, insulin-containing regimens (OR: 2.8; P = 0.015), higher BMI (OR: 1.1; P = 0.002), and elevated preoperative HbA1c (OR: 1.3; P = 0.049) predicted SSI following THA. No significant predictors of SSI after TKA were found, and medication regimen was not associated with revision risk.

Conclusion

Patients with T2DM on insulin-containing regimens exhibited worse perioperative glycemic control and increased SSI incidence after THA, although medication regimen did not affect outcomes after TKA. Our findings are the first to suggest that insulin requirements in patients with T2DM, independent of glycemic control measured with preoperative HbA1c, may influence infection risk following THA and complicate perioperative glycemic control after TJA. We emphasize the importance of perioperative optimization and proactive management of these higher-risk patients, regardless of their preoperative HbA1c.