Archives of Orthopaedic and Trauma Surgery最新文献

Purpose

The implementation of prehabilitation prior to total joint arthroplasty (TJA) has been recognized to potentially decrease pain, reduce length of stay (LOS), and increase patient satisfaction. With longer wait times for surgery due to the COVID-19 pandemic contributing to deterioration of function, this study aims to assess the benefits of a physical therapy (PT) and home evaluation program to improve outcomes.

Methods

A retrospective chart review of 130 primary THA and 124 primary TKA patients undergoing a new pre-operative PT and home safety evaluation program was performed to assess outcomes. Demographic data were compared to assess baseline characteristics. Pain was evaluated with inpatient/outpatient morphine milligram equivalents (MME) and VAS scores. Mobility was assessed using multiple measures by a physical therapist. Mean postoperative range of motion (ROM), overall complications, and non-home discharge was compared.

Results

Of the 254 TJA patients, 67 (26%) patients underwent the prehabilitation program. Prehabilitation THA patients had statistically significantly higher Boston Activity Measure Post-Acute Care (AMPAC) scores on postoperative day 0, lower subjective VAS pain scores on the day of discharge, and greater 3-month postoperative ROM measurements. Prehabilitation TKA patients had statistically significantly less outpatient opioid MME pain requirements (p < 0.05). There were no significant differences in LOS, discharge destination, use of walking aids, or surgical complication rates.

Conclusion

Prehabilitation programs prior to TJA may facilitate early postoperative mobility and improved pain relief through patient education and conditioning. In older patients with chronic pain, prehabilitation prior to TJA may contribute to lower pain scores and less opioid requirements.

Introduction

Patients with Parkinson’s disease (PD) are a vulnerable subgroup facing elevated risks of complications and functional decline following knee arthroplasty. However, data on the outcomes of minimally invasive unicompartmental knee arthroplasty (UKA) in this population are limited. This study´s purpose was to assess perioperative complications, implant revision-free and reoperation-free survivorship as well as functional outcome in PD patients following UKA.

Materials and methods

In this retrospective single-center study, 42 knees in 39 patients with PD who underwent medial or lateral UKA between 2016 and 2022 were analyzed. The mean age was 70.6 ± 9.1 years, and the mean BMI was 27.9 ± 5.2 kg/m². A total of 26 medial and 16 lateral UKAs were performed, with a minimum follow-up of two years (mean 5.0 ± 2.0). All medical complications were recorded. Implant survivorship (tibia and/or femur) and reoperation-free survival were evaluated using Kaplan-Meier analysis, allowing estimation of long-term survival beyond the mean follow-up duration. Functional outcomes were assessed using the Oxford Knee Score (OKS) and the UCLA Activity Score.

Results

Of the 42 knees, 6 (14.3%) underwent reoperation, including 4 cases (9.5%) requiring implant revision. The cumulative 9-year implant survivorship was 90.5% (95% CI: 81.7–99.3), and reoperation-free survival was 85.7% (95% CI: 75.1–96.3), respectively. No perioperative cardiovascular complications occurred. OKS improved significantly from 16.2 ± 5.5 to 39.6 ± 7.1 (p = 0.027), while the UCLA Activity Score showed a trend towards improvement from 4.0 ± 2.0 to 5.0 ± 1.7 (p = 0.078).

Conclusion

In this observational study, UKA in patients with PD was associated with favorable implant survivorship and encouraging functional outcomes. Considering the very low medical complication rate observed in this study, UKA may represent a viable treatment option for isolated end-stage unicompartmental osteoarthritis in carefully selected patients.

Introduction

Both subtalar arthroereisis and osteotomies are well-recognised surgical reconstructive options for paediatric pes planus deformity. We compared the clinical and radiographic outcomes of subtalar arthroereisis versus osteotomies in the surgical management of symptomatic idiopathic flexible pes planus in paediatric patients 2–18 years old. Specifically, we evaluated changes in key radiographic parameters and validated patient-reported outcome measures, as well as complications, to determine relative efficacy and safety.

Methods

Electronic databases (PubMed, Embase, and The Cochrane Library) were searched from inception through August 23, 2024, following PRISMA guidelines. We reviewed studies involving patients aged 18 years or younger with idiopathic pes planus. The inclusion criteria encompassed all types of osteotomy procedures and subtalar arthroereisis, including both exosinotarsal (screw-type) and endosinotarsal (spacer-type) techniques. A random-effects meta-analysis was conducted to assess unweighted mean differences for radiographic angles and AOFAS scores.

Results

Sixty studies (4,555 feet) were included: 46 arthroereisis (4,089 feet), 15 osteotomy (448 feet), and 1 combined (18 feet). Osteotomy demonstrated greater radiographic improvement in AP Meary’s angle (MD − 12.7 degrees vs. − 9.8 degrees; p < .0001), calcaneal pitch (MD 11.1 degrees vs. 4.1 degrees; p < .0001), and Kite’s angle (MD − 11.7 degrees vs. − 6.8 degrees; p < .0001). Arthroereisis achieved superior correction of lateral Meary’s (MD − 11.7 degrees vs. − 10.1 degrees; p < .0001), lateral Kite’s (MD − 7.1 degrees vs. − 4.2 degrees; p < .0001), and talonavicular coverage (MD − 15.6 degrees vs. − 12.7 degrees; p < .0001). Post-operative AOFAS improvements were similar (MD 29.2 vs. 26.4). Overall complication rates were 9.2% for arthroereisis (predominantly sinus tarsi pain) and 10.5% for osteotomy (primarily infections).

Conclusion

While osteotomy yields greater correction of calcaneal inclination and hindfoot valgus, subtalar arthroereisis provides superior restoration of the lateral longitudinal arch and forefoot adduction. Despite these radiographic differences, both techniques provide equivalent functional gains. Due to its minimally invasive nature and favorable safety profile, arthroereisis is a viable first-line option, while osteotomy remains essential for correcting severe structural calcaneal pathology.

Introduction

microbiological eradication after two-stage revision is not obtained in up to 18% of cases, yet the prognostic value of positive cultures at reimplantation remains controversial. The primary aim of the study was to evaluate outcomes of patients with positive cultures at second stage, identifying failure predictors. The secondary outcome was to compare reintervention-free survival.

Materials and methods

this retrospective cohort study included patients treated using a two-stage protocol between 2016 and 2022. PJI was diagnosed using MSIS 2013 criteria, and treatment failure was defined according to a Delphi-based consensus. Cox regression analysis was employed to assess risk factors for failure, including Charlson Comorbidity Index (CCI); American Society of Anesthesiologists (ASA) score; age; time to reimplantation; joint; number of previous septic revisions; positive cultures number at reimplantation; a difficult to treat organism.

Results

83 cases were reviewed (63 hips, 20 knees). The average interval between stages was 181 days. Over 6 years follow-up (FU), elevated BMI was the only significant predictor of failure (HR 1.19; 95% CI 1.02–1.39; p = 0.03). In contrast, positive cultures at reimplantation were not associated with an increased failure risk (p = 0.95), even in cases with multiple positive cultures (p = 0.72).

Conclusions

elevated BMI at reimplantation was independently associated with subsequent failure. Clinical outcomes were not significantly associated with the presence or number of positive cultures, although smaller effects cannot be excluded given the limited sample size. These findings emphasize the importance of a patient-focused rather than culture-centered approach.

Level of evidence

III.

Introduction

Medial unicompartmental knee arthroplasty is widely used to treat anteromedial osteoarthritis, yet limited data exist on outcomes during its implementation phase. Therefore, this study aimed to evaluate the learning curve and the clinical and radiological outcomes during the early implementation of medial unicompartmental knee arthroplasty.

Materials and methods

The first 200 medial unicompartmental knee arthroplasty procedures performed by two arthroplasty surgeons were analyzed to assess the relationship between outcomes and the cumulative number of cases. The primary outcome was the learning curve for the duration of surgery, while secondary outcomes included the Oxford Knee Score, the Forgotten Joint Score, and the Activity and Participation Questionnaire, which were assessed at 3, 12, and 24 months postoperatively. Implant survival and positioning were evaluated at the final follow-up.

Results

Cumulative summation analysis showed a data-driven reduction in surgical duration after 55 cases. Median Oxford Knee Score was 41 (IQR 34–44) at 12 months and 42 (IQR 35–45) at 24 months. Implant survival at 5 years was 97.4% (95% CI: 95.1–99.7). Radiographically, 86.5% of patients had tibial implant valgus/varus within 5° of neutral, and no tibial implant overhang exceeded 2 mm.

Conclusion

Medial unicompartmental knee arthroplasty was associated with favorable clinical outcomes during early implementation. Surgical duration indicated a learning curve over 55 cases. Patient-reported outcome measures remained stable, showing reliable outcomes regardless of the learning phase. Surgical precision was maintained throughout, indicating proficient surgical outcomes even during the early phase.

Introduction

Acetabular bone defects pose significant challenges during revision total hip arthroplasty (rTHA) due to varying bone quality and quantity. Accurate preoperative evaluation and classification systems are essential to guide surgical planning and ensure stable acetabular fixation. Over the years, several classification systems have been proposed, each emphasizing different variables. The aim of this systematic review was to provide a comprehensive overview of existing classification systems for acetabular bone defects in rTHA.

Materials and methods

A systematic review of the literature was performed to identify all original acetabular bone defect classifications. Studies focusing solely on femoral defects and not-surgery oriented were excluded. The details of each classification system have been reviewed, and a comparison of their inter-observer and intra-observer reliability has been performed.

Results

A total of fifteen classification systems were recognized, published between 1986 and 2024. Variables taken into consideration differ considerably from classification to classification. These include defect location and pattern; the quality of remaining bone stock; the presence of ischial lysis; columns and walls integrity, the presence of pelvic discontinuity; cup loosening and/or migration; and the presence or absence of pain. All but one classification system requires intraoperative evaluation for accurate classification.

Conclusions

While numerous classification systems for acetabular bone defects exist, none is universally accepted. Variability in the parameters assessed and the frequent need for intraoperative evaluation hinder replicability and consistency. A universally accepted, reliable classification framework remains a significant unmet need in the management of acetabular bone defects.

Purpose

The optimal surgical treatment of displaced isolated radial head fractures remains unclear and patient-reported outcomes have not been comprehensively evaluated. In this systematic review, we aimed to compare patient-reported pain, function, and return to work outcomes following open reduction internal fixation (ORIF), radial head excision, and radial head arthroplasty (RHA) in patients with isolated radial head fractures.

Methods

Four electronic databases were searched for the period from January 2000 to August 2023 to identify studies comparing surgical management interventions for isolated radial head fractures. Standard methods were used for title, abstract and full-text screening and data extraction, applying PRISMA 2020 guidelines. Risk of bias was assessed using standardised checklists.

Results

Eleven studies were eligible for inclusion. The mean age of participants across the studies ranged from 36 to 65 years, with almost equal gender distribution across 434 participants. Ten studies showed a high risk of bias due to methodological concerns. Follow-up periods ranged from 12 to 84 months post-operatively. Across the included studies, 179 participants (41%) underwent RHA, 139 (32%) underwent ORIF and 116 (27%) underwent excision arthroplasty. Seven studies included patient-reported functional outcomes with relatively better function for ORIF and RHA than excision arthroplasty, eight studies reported patient-reported pain outcomes with similar pain scores across the groups and only one study reported a return to work outcome showing no difference between groups. Significant variation in comparator groups and outcome instruments precluded meta-analysis.

Conclusions

This review demonstrates the paucity of high-quality evidence on patient-reported outcomes after surgical management of isolated radial head fractures. There is currently no evidence to indicate any surgical treatment modality is superior with regard to patient-reported outcomes, given the limited number of studies, substantial outcome measure variation and the inherent high risk of bias in existing studies.

Purpose

Midshaft clavicle fractures are common and often associated with scapular dyskinesis (ScD), particularly in cases of shortening. While fractures with less than 2 cm shortening are often treated conservatively, emerging evidence suggests that even minor shortening can increase the risk of ScD and impair functional outcomes. This study investigates the impact of surgical versus conservative treatment on ScD and functional recovery.

Methods

A retrospective analysis of 60 patients with isolated midshaft clavicle fractures was conducted. Patients were categorized into surgical and conservative groups. Fracture shortening was assessed using radiographs, outcomes were assessed using the SICK Scapula Rating Scale, Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons Scale and Visual Analog Scale (VAS). Logistic regression and ROC analysis was applied to identify ScD predictors, and critical shortening threshold.

Results

ScD was observed in 43.3% of all patients, with 53.6% of the conservative group, and 34.4% of the surgical group; however, the difference was not statistically significant (p = 0.216). Surgical treatment was associated with significantly better SST and VAS scores at the final follow-up (p < 0.05). Logistic regression identified clavicular shortening (p < 0.001) and lower BMI (p = 0.033 - univariate) as significant predictors of ScD. ROC analysis revealed that a shortening threshold of 0.4 cm had a sensitivity of 73.08% and a specificity of 91.18% for predicting ScD (AUC = 0.874, p < 0.001).

Conclusion

Surgical treatment may reduce residual shortening and lower the prevalence of ScD, indicating a possible benefit in limiting dyskinesis even in minimally displaced fractures.

Level of evidence

Level III, retrospective comperative study.

Introduction

Comminuted patellar fractures, particularly AO/OTA 34-C2 and C3 fractures, present substantial challenges in achieving stable fixation and anatomical reconstruction. Conventional tension-band wiring may fail in such cases due to insufficient mechanical stability. This study aimed to evaluate the clinical and functional outcomes of a fracture pattern-driven plate osteosynthesis technique using multiple miniplates tailored to the intricate morphology of multifragmentary patellar fractures.

Methods

A retrospective review was conducted of 62 patients with AO/OTA 34-C2 or C3 patellar fractures treated between 2018 and 2023 at two academic trauma centers. All patients underwent fixation using a fragment-specific approach involving anterior tension-band plating and miniplates, guided by preoperative CT-based fracture mapping. The outcome measures included radiographic reduction quality, union rate, range of motion (ROM), Lysholm score, and isokinetic quadriceps strength at 6 and 12 months.

Results

Anatomical or good reduction was achieved in all cases (72.6% anatomical, 27.4% good), with a 100% union rate and low complication rate (3.2% reoperation rate). The mean final ROM was 132.9° ± 6.8°, and Lysholm scores improved from 70.3 ± 10.0 at 6 months to 89.1 ± 6.7 at 12 months. However, isokinetic peak torque deficits persisted at 12 months (mean 24.6% ± 13.0), and the body mass–normalized extension torque averaged 0.99 ± 0.40 Nm/kg, indicating residual muscle weakness despite rehabilitation.

Conclusion

The fracture-pattern-driven osteosynthesis technique using multiple miniplates offers a reliable method for managing complex patellar fractures, providing excellent reduction quality, high union rates, and satisfactory functional outcomes. This approach enables individualized fixation strategies tailored to fragment morphology. Despite good clinical recovery, persistent deficits in quadriceps strength highlight the need for prolonged rehabilitation beyond 12 months to achieve complete functional restoration.