Archives of Orthopaedic and Trauma Surgery最新文献

Purpose

The aim of this study is to analyse the effect of an additional radial buttress plate for palmar plate osteosynthesis in an AO/OTA 2R3 C2.1 fracture model.

Methods

Nine pairs of freshly frozen radii were analysed for pathology and bone mineral density and divided into two matched groups. One group was treated with a variable-angle palmar locking plate alone, while the second group received an additional radial buttress plate for radiopalmar double plating. An AO/OTA 2R3 C2.1 fracture was created in all specimens. The biomechanical tests were performed according to previously published protocols. Stiffness, axial displacement of the construct, as well as fragment-specific movements and rotations were assessed.

Results

No implant failure was observed. In the total cohort, stiffness increased (p < 0.01) and axial construct displacement decreased (p < 0.05). The mobility of the ulnar fragment to the shaft during cyclic testing was lower with double plating, both at baseline and endpoint (all p < 0.01). Fragment movements increased over the course of testing and were significant for the radial articular fragment relative to the shaft in the total cohort (p < 0.01). Baseline rotation of the ulnar fragment and endpoint rotation of the radial fragment in relation to the shaft were lower with double plating (all p < 0.05). In both constructs, the rotation of the ulnar fragment relative to the shaft was lower than that of the radial fragment at both timepoints (all p < 0.05).

Conclusion

Biomechanically, the addition of a radial buttress plate to a standard palmar locking plate did not alter global construct stiffness, but demonstrated advantages in fragment-specific stability in comminuted distal radius fractures.

Background

As the global prevalence of dementia rises, an increasing number of patients with cognitive impairment require Total Joint Arthroplasty (TJA). However, the specific impact of dementia on postoperative outcomes remains underreported. This systematic review evaluates the complications, mortality, and healthcare utilization associated with dementia in patients undergoing Total Hip (THA) and Total Knee Arthroplasty (TKA).

Methods

A systematic search of PubMed, Scopus, Web of Science, Embase, and the Cochrane Library was conducted following PRISMA guidelines. Eligible studies included comparative cohorts of patients with and without a diagnosis of dementia undergoing primary TJA. Methodological quality was appraised using the Newcastle-Ottawa Scale (NOS). Data were synthesized regarding mortality, readmissions, implant-related complications, and discharge disposition.

Results

Seven retrospective cohort studies comprising 13,816 patients with dementia and 869,061 controls were included. The mean NOS score was 8.4/9, indicating high methodological quality. Patients with dementia exhibited significantly worse outcomes across both procedures, including higher rates of postoperative delirium (OR: 4.25–6.40), mortality (HR: 1.43–3.05), and discharge to skilled nursing facilities (OR: 1.87). Stratification by procedure revealed distinct risk profiles: while both cohorts faced high readmission rates, THA patients demonstrated specific vulnerability to mechanical complications, including increased risks of dislocation, periprosthetic fracture (OR: 2.07), and revision surgery. These mechanical failures were frequently driven by falls and poor compliance with postoperative precautions rather than infection alone.

Conclusion

Dementia is a robust independent predictor of adverse outcomes after TJA. While both THA and TKA carry elevated systemic risks, THA poses unique mechanical challenges that may warrant the use of high-stability implants (e.g., dual-mobility cups) to mitigate dislocation risks. Perioperative strategies should prioritize caregiver-led surveillance and strict fall prevention protocols to improve safety in this vulnerable population.

Purpose

Distinguishing physiological meniscus mobility from pathological extrusion remains a clinical challenge, particularly regarding the prevention of osteoarthritis. While cadaveric studies suggest that meniscectomy increases contact stress, the in vivo dynamics of the healthy meniscus under load—specifically the role of the meniscotibial (coronary) ligament—remain poorly defined. This study aimed to establish a physiological reference standard for load transmission and contact area kinematics in the healthy knee.

Methods

In a biomechanical MRI study, nine healthy male subjects underwent high-resolution 3T MRI with prospective motion correction. Knee joints were scanned in an unloaded state and under a physiological axial load of 400 N. We performed 3D segmentation to quantify changes in cartilage-to-cartilage and cartilage-to-meniscus contact areas, differentiating between femoral and tibial interfaces.

Results

Axial loading significantly increased the direct cartilage-to-cartilage contact area, with a predominant increase in the medial compartment (+ 15.0%) compared to the lateral compartment (+ 6.7%), reflecting the physiological adduction moment. Conversely, the overall meniscus-to-cartilage contact area decreased. A detailed compartmental analysis revealed a distinct kinematic pattern: while the femoral-meniscal contact area significantly decreased due to relative motion, the tibial-meniscal contact area remained stable.

Conclusion

This study defines the in vivo healthy baseline of knee contact mechanics. The results demonstrate that under physiological load, the healthy meniscus undergoes controlled radial displacement to facilitate direct cartilage contact. Crucially, the stability of the tibial contact area supports the hypothesis that the meniscotibial (coronary) ligament acts as a primary anchor, preventing excessive extrusion at the tibial interface. These data serve as a vital benchmark for evaluating meniscus repair techniques and differentiating physiological mobility from pathological failure.

Background

Conversion total hip arthroplasty (cTHA) after prior proximal femoral fracture fixation can be performed using different femoral stems. This study aimed to (1) determine if initial fracture fixation or pattern associated with stem design in cTHA, (2) evaluate whether stem type was associated with survivorship and outcomes, and (3) propose a radiographic measurement to guide femoral stem selection.

Methods

We retrospectively reviewed 51 patients who underwent cTHA from 2016 to 2020, including 44 patients with previous cephalomedullary nail (CMN; 86.3%) and 9 patients with previous sliding hip screw (SHS; 13.7%). Stems included 32 uncemented diaphyseal-engaging (62.7%), 10 uncemented metaphyseal-engaging (19.6%), and 9 cemented (17.6%). Outcomes assessed were fracture pattern, fixation construct, stem type, survivorship, post-operative complications, and patient-reported outcome measures. Preoperative radiographs were evaluated for diaphyseal width (D), distance from greater trochanter to most distal pre-isthmic screw (GS), and ratio of GS/D (GSD). These measures were used to construct an algorithm for stem selection at the time of cTHA. Mean follow-up was 69 months. Survivorship free from stem-related and all-cause failure was calculated using Kaplan-Meier analysis.

Results

Diaphyseal-engaging uncemented stems were used more often after CMN fixation, while metaphyseal-engaging uncemented stems predominated after SHS fixation. Diaphyseal-engaging stems predominated in previous intertrochanteric, subtrochanteric, or complex fractures, while metaphyseal-engaging uncemented stems were more common in femoral neck fractures. Survivorship free from stem-related failure was 100% and from all-cause reoperation was 89%. Patients who received cemented stems were older, more likely to require transfusion or prolonged use of an assistive walking device. No significant differences were observed in complications, clinical outcomes or PROMs between stem groups. Higher GSD ratios correlated with diaphyseal-engaging stem use in SHS and long-CMN cases.

Conclusion

Femoral stem fixation type in cTHA correlated with prior fracture pattern and fixation construct. Survivorship free from stem-related failure requiring stem revision was 100% and survivorship free from all-cause failure was 89%. We propose a novel algorithm that may assist surgeons in selecting femoral stem at the time of cTHA using different patient-specific and radiographic factors.

Purpose

To investigate impact of hip involvement on lower extremity compensations in ankylosing spondylitis (AS) patients with thoracolumbar kyphosis before and after pedicle subtraction osteotomy (PSO) and to explore a spinopelvic parameter for evaluating the extent of lower extremity compensations in AS patients.

Materials and methods

A retrospective study was conducted among AS patients with thoracolumbar kyphosis underwent PSO from April 2017 to November 2019. Radiographic parameters including global kyphosis (GK), sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), sacrofemoral angle (SFA), knee angle (KA), ankle angle (AA), and femoral obliquity angle (FOA) were measured on EOS images. Based on Bath Ankylosing Spondylitis Radiology Hip Index (BASRI-h), all patients were divided into mild hip involvement (MHI) group (BASRI-h:0–2) and severe hip involvement (SHI) group (BASRI-h:3–4). Moreover, patients were divided into 5 subgroups depended on the BASRI-h degree.

Results

Fifty-seven patients were recruited in current study. Except for SFA, larger KA, AA, and FOA were observed in group SHI pre- and postoperatively (all P < 0.05). FOA in both groups were associated with KA before and after PSO (all P < 0.001). In subgroup analysis, a linear trend between KA, AA, FOA and the severity of hip involvement could be observed pre- or postoperatively.

Conclusions

Lower extremity compensations play a critical role in maintaining sagittal balance in AS patients with severe hip involvement. Residual lower extremity compensations were observed in patients with higher degree hip involvement postoperative. FOA could be served as a reliable value for evaluating lower extremity compensations in AS patients with hip involvement.

Background

Precontoured clavicular locking compression plates (LCP) aim to minimize implant-related complications by providing a close fit to the clavicle’s complex morphology. Nevertheless, the inherent anatomical variation observed across patients can lead to discrepancies between implant and bone, potentially contributing to suboptimal fit and an increased risk of complications requiring reoperation.

Objective

This study analyzed the anatomical compatibility of precontoured clavicular LCPs, detailing their fit characteristics and exploring the correlation between these findings and clinical outcomes.

Method

Fifty-six 3D, patient-specific clavicular models were reproduced from patients undergoing clavicular fixation (2018–2024). These models were created using 3D printing based on individual 3D-CT reconstructions. Two commercially available clavicular LCP designs were virtually assessed for anatomical compatibility using Computer-Aided Design (CAD) technology. Additionally, a retrospective evaluation of patient outcomes following fracture fixation with the LCPs was conducted. Correlation analysis was used to investigate the relationship between plate compatibility and implant-related complications, as well as reoperation rates.

Result

Our findings revealed a significant inverse relationship between plate length and compatibility, with longer plates demonstrating reduced overlap, increased overhang, and lower bicortical screw purchase rates. Clinically, 19.64% of patients required hardware removal due to symptomatic hardware, while 33.93% experienced implant prominence. Importantly, our analysis revealed a significant negative correlation between plate compatibility and both implant-related complications and the need for reoperation.

Conclusion

The currently available precontoured clavicular LCPs exhibit suboptimal fit, particularly in the lateral region of the clavicle. These findings highlight the importance of selecting the appropriate plate and improving plate designs to enhance anatomical conformity and potentially reduce the incidence of implant-related complications.

Level of evidence

Level III (Translational Study).

Background

Psychiatric comorbidities are increasingly prevalent among patients undergoing total hip arthroplasty (THA), yet their impact on clinically meaningful outcomes remains underexplored. This study evaluates the association between preoperative psychiatric diagnoses and patient-reported outcomes (PROMs), satisfaction, and healthcare utilization following THA.

Methods

A retrospective cohort of 11,766 patients undergoing primary elective unilateral THA between 2016 and 2022 across a multisite academic center was analyzed. Psychiatric diagnoses were identified via ICD-9/10 codes within 2 years preoperatively. PROMs were collected at baseline and 1 year postoperatively, including HOOS Pain, HOOS Physical Function Shortform (PS), HOOS Joint Replacement (JR), and VR-12 Mental Component Score (MCS). Outcomes included failure to achieve minimal clinically important difference (MCID), failure to reach patient acceptable symptom state (PASS), dissatisfaction, non-home discharge, prolonged length of stay (LOS ≥ 2 days), and 90-day readmission. Multivariable logistic regression adjusted for demographic and clinical covariates.

Results

Psychiatric diagnoses were present in 26.1% of patients. Psychiatric illness was associated with failure to achieve MCID in HOOS Pain (OR 1.43), HOOS PS (OR 1.31), and HOOS JR (OR 1.54), as well as failure to reach PASS thresholds (all p < 0.001). Patients with psychiatric diagnoses had increased odds of dissatisfaction (OR 1.34), non-home discharge (OR 1.36), prolonged LOS (OR 1.24), and readmission (OR 1.54). Subgroup analysis demonstrated a dose-dependent relationship, with multiple psychiatric diagnoses conferring the highest risk of poor outcomes.

Conclusion

Preoperative psychiatric illness is an independent predictor of suboptimal functional outcomes, lower satisfaction, and increased healthcare utilization after THA. These findings highlight the need for psychiatric screening and optimization during the preoperative period to improve outcomes in this high-risk population.

Background

Bariatric surgery has been associated with increased risks of revision surgery following total knee arthroplasty (TKA), raising concerns about its safety for weight management in this population. Semaglutide, a glucagon-like peptide-1 receptor agonist, has emerged as a promising pharmacologic alternative, though its impact on TKA outcomes remains underexplored. This study compares TKA outcomes between patients who have a history of bariatric surgery and semaglutide use.

Methods

A retrospective analysis of 19,135 TKA patients from 2012 to 2023 identified three cohorts: patients who used semaglutide (SU, n = 402), had bariatric surgery (BS, n = 418), and a BMI > 35 control group (C, n = 6,650). Demographics, BMI trends, 90-day complications, and revision rates were compared using statistical analyses, including Kaplan-Meier survivorship and multivariate logistic regression.

Results

Bariatric surgery patients experienced significantly more 90-day emergency department (ED) visits (7.9 [BS] vs. 5.7 [SU] vs. 4.0% [C], P < 0.001) and lower 10-year implant survival (90.3 [BS] vs. 94.5% [C], P = 0.039). Multivariate analysis demonstrated that a history of BS independently predicted increased odds of ED visits (OR 1.79, P = 0.005) and revision (OR 1.71, P = 0.028), while SU was not a significant predictor of adverse outcomes. The BS group achieved the largest preoperative BMI reduction (–1.8 kg/m²) vs. SU (–0.7 kg/m²) and controls (+ 2.1 kg/m²). Notably, the SU cohort regained 1.7 kg/m² within three years post-TKA.

Conclusion

While semaglutide use before TKA was associated with only modest weight loss, it appeared safe and yielded favorable short-term outcomes. Bariatric surgery, though more effective for weight reduction, carried higher complication rates and inferior long-term implant survivorship. Further research is needed to clarify semaglutide’s long-term role in TKA patients with obesity.

Level of evidence

III.

Introduction

The effect that a tourniquet has on muscle paralytic, specifically rocuronium, and thus muscle paralysis is unknown. The aim of this study was to examine the effect of tourniquet use on the duration of paralytic effect during fracture fixation of the lower extremity and that tourniquet use would prolong the paralytics effect on the muscle distal to it.

Methods

Patients undergoing open reduction and internal fixation of ankle, tibial plafond, or calcaneus fractures were prospectively evaluated at a single academic level 1 trauma center. After induction of general anesthesia with a short acting paralytic, two twitch monitors were placed, with leads along the facial nerve and leads along the common peroneal. Surgical and anesthesia team ensured that 4/4 twitches were present on the facial nerve and distal to the tourniquet along the common peroneal nerve. Then, the full dose of rocuronium was administered until 0/4 twitches were present prior to tourniquet inflation. ToF (train of four) twitches were monitored at 15 min intervals.

Results

A total of 17 ankle fractures, 1 calcaneus, and 7 pilon fractures were included in the study. Mean age was 38.8 years (22–72) and average BMI was 29.9 (22.5–38.5). Average time to regain twitches in the facial nerve was 34.5 min. 19 patients (76%) recovered 3 + twitches in the facial nerve before any twitches in the operative extremity. 19 patients (76%) had 2 or fewer twitches at the extremity for the duration of tourniquet inflation.

Conclusion

Recovery of neuromuscular function in the facial nerve was fully restored prior to the operative extremity in 76% of patients. This confirms the hypothesis that the effect of paralysis in the extremity is extended when dosed prior to tourniquet inflation. This study will help the surgeon and the anesthesia team understand the value of correct paralytic timing. This can prevent unnecessary re-dosing by anesthesia in response to facial twitches, and can aid in ensuring the desired level of paralysis in the operative extremity.