Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

Two-stage revision for chronic periprosthetic joint infections (PJI) of knee megaprostheses is complex and often results in significant bone loss. DAIR-Plus and other partial exchange procedures, involving debridement with partial prosthesis removal but retaining stems, are typically used for acute PJI but may benefit select chronic cases. This study aimed to: (i) assess DAIR-Plus and partial two-stage exchange outcomes in chronic megaprosthesis infections; and (ii) identify prognostic factors to guide their use versus full component removal.

Materials and methods

Twenty-three patients underwent DAIR-Plus or partial two-stage exchange (PTSE) procedures for chronic knee megaprosthetic PJI between 2000 and 2022. Nineteen patients, were included. Targeted antibiotics were administered based on Infectious Disease Specialist recommendations. Infection eradication was evaluated using clinical and serologic parameters.

Results

Nineteen patients (mean age 53.4 years) underwent 13 DAIR-Plus and 7 PTSE. PJI-free survival was 57.9% at 1 year, 47.4% at 2 and 5 years, and 42% beyond 5 years. Among failures, 6 had persistent infection and 5 relapsed (mean time to relapse: 13.75 months). Four additional patients achieved infection control after further two-stage revisions; 7 remained uncontrolled, leading to 6 amputations and 1 chronic suppressive treatment. Outcomes did not differ significantly by age, gender, host status, oncological history, radiotherapy, or surgical approach. Staphylococcus spp. caused 63% of infections and were associated with significantly lower PJI-free survival at final follow-up (25% vs. 62% for other organisms, p = 0.048).

Conclusions

DAIR-Plus provided lasting infection control in selected chronic PJI cases, with nearly half remaining infection-free long term with notable advantages such as bone stock preservation and faster recovery. Partial two-stage exchange does not appear to offer additional advantages over DAIR-Plus. Outcomes were not influenced by clinical factors, but Staphylococcus spp. infections showed significantly lower success.

Introduction

The design of TKA implants is defined by manufacturers according to a specific alignment philosophy; however, in-vivo performance strongly depends on the surgeon’s decisions regarding component position, orientation, and soft tissue management. Mechanical Alignment (MA) and Kinematic Alignment (KA) are the most widely used strategies. Several studies have compared their clinical outcomes, but no definitive conclusions exist, and long-term multicentric follow-ups are lacking. Surgeons sometimes select the surgical alignment independently of the implant’s design rationale, meaning components designed for MA may be implanted following KA, potentially affecting outcomes and complicating interpretation. The aim of this study is therefore to compare different alignment philosophies in various TKA designs using a validated finite element model.

Materials and methods

Four implanted knee configurations were obtained by modifying accordingly a TKA starting design: standard MA with symmetric polyethylene (MA-Std, obtaining an orthogonal joint line), MA with asymmetric polyethylene (MA-Asymm, obtaining a physiological joint line), KA with tibial stem orthogonal to the tibial cut, and KA with tibial stem aligned to the tibial axis. Each model underwent a 2500 N vertical load simulating peak walking force. Polyethylene and bone stresses were extracted and compared in multiple regions of interest.

Results

Tibio-femoral interaction showed distinct contact area and pressure patterns for each configuration. Differences were minor, but KA configurations exhibited larger contact areas medially and laterally than MA configurations. The MA-Std configuration showed a medial-to-lateral force ratio close to physiological (> 50%), while MA-Asymm and KA-Std exhibited slightly higher lateral forces. Bone-implant interaction differences were minimal, primarily localized in the proximal region, reflecting variations in medio-lateral load distribution.

Conclusions

Each combination of alignment approach and prosthesis design produces a specific stress distribution at both tibio-femoral and prosthesis-bone interfaces. Surgeons should consider these biomechanical effects when selecting an implant and determining the alignment strategy to adopt.

Introduction

Cardiac etiologies are one of the main causes for out of hospital cardiopulmonary arrest (OHCA). Other etiologies might be easily overlooked, leading to delayed causal treatment. One such representative is neurogenic shock following upper cervical spine fractures after minor impact trauma in the elderly with little data on prevalence and risk factors, a drawback that we address in the present study.

Material and Methods

Between 01/2013 and 12/2023, all patients ≥ 65 years with a fracture of the first and/or second vertebra after minor impact trauma were retrospectively reviewed to evaluate the incidence and character of OHCA. Resuscitated and non-resuscitated patients were compared regarding risk factors such as age, BMI, fracture classification and displacement, cardiac illness, laboratory parameters and bone mineral density.

Results

Final data included 141 patients, 82.5 ± 7.6 years; 73 female and 68 male. The OHCA incidence was 9.9%. Pulseless electrical activity (PEA) (71,4%) and asystole (28.6%) were the only initial cardiac rhythms in these resuscitated patients. Patients were resuscitated for 14.4 ± 9.5 min before the return of spontaneous circulation (ROSC). The in-hospital survival rate was 21.4% (n = 3). Younger patient age (OR0.992 per year), a Anderson type II odontoid fracture (OR 1.145), as well as trauma during nighttime (6 pm–7am) significantly predicted OHCA (p < 0.05). Sex, BMI, bone density, fracture displacement and laboratory parameters (serum electrolytes (Sodium and Potassium), Lactate, pH, Hemoglobin, and Creatinine) revealed no direct impact on the likelihood to suffer from OHCA.

Conclusions

With an occurrence of almost 10%, OHCA resulting from an upper cervical spine injury following low impact trauma is frequent in the elderly patient, and appears to be associated with non-shockable primary rhythms (PEA or asystole). If cardiac output is successfully restored, clinicians should always exclude an upper cervical spine fracture (especially an odontoid fracture). We therefore recommend an interdisciplinary primary assessment and cervical spine immobilization.

Background

Planovalgus foot is the most frequent foot deformity in children with cerebral palsy (CP), often impairing gait and functional mobility. Radiographic angular measurements are essential tools for assessing deformity severity and monitoring postoperative outcomes, yet their dynamic behavior after correction remains poorly characterized.

Objective

To analyze pre- and postoperative variations of radiographic angles in spastic planovalgus feet surgically treated using Mosca’s calcaneal lengthening technique within a retrospective cohort, and to provide an educational reference for orthopedic residents regarding angular behavior and measurement interpretation.

Methods

A retrospective, longitudinal, descriptive study was performed on 132 (128 patients; 4 bilateral cases) feet of children with CP (GMFCS I–V) undergoing calcaneal lengthening, with or without adjunctive procedures (reefing or arthrodesis). Standardized weight-bearing anteroposterior and lateral radiographs were analyzed at five time points (preoperative, immediate postoperative, 6 months, 1 year, and 2 years). The evaluated angles included: AP talocalcaneal (Kite’s), AP talo–first metatarsal, talonavicular coverage, calcaneus–fifth metatarsal (C5M), Costa–Bartani, Meary’s, lateral talocalcaneal, and calcaneal inclination. Descriptive statistics were applied to assess temporal evolution.

Results

All radiographic parameters showed immediate postoperative improvement, confirming effective deformity correction. The AP talocalcaneal angle decreased from 31.6° preoperatively to 24.0° postoperatively, while the calcaneal pitch increased from 7.1° to 19.1°. Mild regression was observed in several angles particularly C5M and Meary’s at two years, likely reflecting growth-related and neuromuscular factors.

Conclusion

Calcaneal lengthening provides measurable and durable radiographic correction in CP-related planovalgus foot, although partial regression of some parameters over time highlights the dynamic nature of the deformity. Radiographic angles remain reliable for postoperative monitoring and educational training, supporting their use as a standardized multi-angle assessment tool in the medium-term management of these patients.

Background

Reverse total shoulder arthroplasty (RTSA) is an effective solution for various shoulder pathologies, but traditional correction of glenoid inclination through eccentric reaming can compromise bone stock and implant stability. Augmented baseplates offer a bone-preserving alternative, yet their role in patients without significant glenoid bone loss remains underexplored. This study evaluates augmented baseplates in patients with A1 glenoid without bone loss, where evidence is currently lacking. The primary rationale is to achieve controlled inferior tilt and lateralisation without excessive reaming or medialisation.

Methods

A retrospective review was conducted on 24 patients with Walch type A1 glenoid who underwent primary RTSA between December 2018 and December 2021. Preoperative CT-based planning guided the use of half-wedge augmented baseplates. Primary outcomes included range of motion (ROM), strength, pain (VAS), function (VAS), QuickDASH, SANE, and ASES scores. Radiographic assessments evaluated component fixation and scapular notching. Data were analysed using paired t-tests with a significance set at p < 0.05.

Results

At a mean follow-up of 25.2 ± 10.0 months, all patients demonstrated significant improvements in forward flexion (90° to 150°; p < 0.001) and abduction (80° to 145°; p < 0.001). Pain scores decreased significantly (6.3 to 2.1; p < 0.001), and both ASES (38.6 to 71.2; p < 0.001) and QuickDASH scores (58.8 to 34.7; p < 0.001) improved markedly. No complications, scapular notching, or implant loosening were observed.

Conclusion

The use of augmented baseplates in primary RTSA, even in patients without glenoid bone loss, is a reliable, bone-preserving technique that results in excellent mid-term clinical and radiographic outcomes.

Background

The Coronal Plane Alignment of the Knee (CPAK) classification method describes knee phenotypes. The rise in robotic-assisted total knee arthroplasties (RA-TKA) has enabled surgeons to fine-tune bony cuts, minimizing soft tissue release while prioritizing balanced gaps rather than predetermined alignment targets, a technique known as functional alignment (FA). As a patient’s preoperative CPAK changes when using FA, our aim was to assess which preoperative CPAK phenotypes are maintained post-TKA and further define this change with a simplified classification.

Methods

We retrospectively reviewed 1,028 primary RA-TKA cases performed using functional alignment (FA) technique from 2023 to 2024. Arithmetic hip-knee-ankle (aHKA) and joint line obliquity (JLO) angles were obtained using robotic software, with boundaries in accordance with CPAK. Demographics, CPAK phenotypes, and planned resections were collected and analyzed.

Results

Most cases were in CPAK 1 (34.1%), 2 (30.5%), or 3 (19.5%) preoperatively and 4 (30.2%) or 5 (51.2%) postoperatively. Postoperatively, 63.5 and 27.1% of cases retained their preoperative aHKA and JLO alignments, respectively. Of 427 cases that changed CPAK, most varus and neutral cases retained preoperative aHKA alignment, otherwise becoming neutral and varus respectively, while most valgus became neutral. Preoperative varus and valgus cases that retained aHKA had larger native deformities compared to those that became neutral. Most preoperative neutral JLO cases remained neutral, while a majority of apex distal cases became neutral. Cases that changed CPAK, compared to retained CPAK cases, were more neutral (aHKA) and apex distal preoperatively (P < 0.001). Based on results, we classified preoperative alignment according to final functional coronal alignment that would reflect tibia and aHKA angles and propose a new, simplified Functional Coronal Alignment (FCA) classification composing of four categories.

Conclusion

This study highlighted the clinical usefulness of robotics for FA and described the FCA classification system to guide surgeons in optimizing kinematics using robotic assistance for FA.

Introduction

The Pavlik harness is the standard first-line treatment for developmental dysplasia of the hip (DDH) in infants younger than six months. However, the optimal strategy for discontinuation after successful hip reduction remains debated. This study aimed to compare clinical and radiological outcomes between immediate discontinuation and gradual weaning using the Frejka pillow following successful Pavlik harness treatment.

Methods

We retrospectively analyzed data from 144 infants (166 hips) with DDH treated with the Pavlik harness between 2012 and 2023. Patients were categorized into two groups: Group A underwent immediate cessation, while Group B was gradually weaned using a Frejka pillow. Radiological follow-up included acetabular index (AI), lateral center-edge angle (LCEA), and assessment of AVN based on the Kalamchi-MacEwen classification, up to five years of age.

Results

The two groups were demographically similar. There were no statistically significant differences in recurrence rates (Group A: 9%, Group B: 5%; p = 0.53) or AVN incidence (Group A: 6.25%, Group B: 10%; p = 0.55). Group B showed a non-significant trend toward higher LCEA values at five years (p = 0.08), potentially indicating better acetabular development. However, the slightly increased AVN rate in this group raises concerns regarding prolonged abduction.

Conclusion

Both immediate discontinuation and gradual weaning protocols yield comparable outcomes in terms of recurrence and AVN. While gradual weaning may offer marginal benefit in acetabular development, the potential vascular risks warrant further investigation. Larger prospective studies are needed to establish standardized discontinuation guidelines in DDH management.

Level of evidence

III, retrospective comparative study.

Background

Mastectomy and its associated treatments may alter shoulder biomechanics and soft-tissue integrity, yet their impact on total shoulder arthroplasty (TSA) outcomes remains unclear. This study evaluated short- and long-term complications following TSA in patients with a history of mastectomy.

Methods

A retrospective cohort analysis was performed using the TriNetX Research Network, including patients who underwent primary TSA. Individuals with a history of mastectomy were identified using procedural and diagnostic coding, and those with contralateral mastectomy and TSA were excluded. Propensity score matching 1:1 was performed to balance demographics and comorbidities. Ninety-day and two-year outcomes were compared between matched cohorts.

Results

After matching, 1,865 patients with prior mastectomy were compared with 1,865 controls. Patients with a history of mastectomy had a significantly higher incidence of postoperative lymphedema (3.48% vs. 0.67%; RR 5.15; P < .0001). They also demonstrated increased risk of venous thromboembolism (4.56% vs. 3.11%; RR 1.47; P = .018). Overall postoperative infection rates were higher in the mastectomy cohort (3.96% vs. 2.70%; RR 1.47; P = .0378), including higher rates of cellulitis (2.81% vs. 1.72%; RR 1.63; P = .031). No significant differences were observed for 2-year outcomes.

Conclusion

Patients with a history of mastectomy undergoing TSA are at increased risk of perioperative postoperative lymphedema, thromboembolic events, and cellulitis. These findings highlight the importance of heightened perioperative surveillance.

Introduction

Isolated patellofemoral osteoarthritis (PFOA) remains a therapeutic challenge, with patellofemoral arthroplasty (PFA) and total knee arthroplasty (TKA) representing the main surgical options for end-stage disease. This systematic review applies the GRADE framework to evaluate comparative outcomes of PFA and TKA, providing evidence-based recommendations.

Materials and methods

A PRISMA systematic search of Pubmed, Cochrane Library, and Google Scholar was conducted (2010–2025). RCTs, comparative cohort studies, and registry analyses reporting on PFA versus TKA for isolated PFOA were included. Primary outcomes were validated PROMs and implant survival at 2, 5, and 10 years. Secondary outcomes were complications, patient satisfaction, return to sport, and cost-effectiveness. Risk of bias was assessed with RoB 2 and ROBINS-I, and certainty of evidence using GRADE.

Results

Ten studies were included (4 RCTs, 6 cohort studies; approximately 10,000 PFAs comprising registries). Moderate-certainty evidence indicated that PFA provides superior early PROMs, and short-term cost-effectiveness compared with TKA. PROMs converged between groups at mid- to long-term follow-up. Long-term data demonstrated a consistently higher revision risk for PFA with moderate certainty, with registry-based 10-year survival of 85% for PFA vs. 95% for TKA, continuing to worsen for PFA after 10 years. Complication rates were similar or lower after PFA, particularly for systemic medical events. Patient satisfaction and return to sport favored PFA short term but became comparable to TKA at mid-term.

Conclusion

In carefully selected patients with isolated PFOA, modern onlay PFA yields faster recovery, superior early function, and short-term cost-effectiveness, supported by moderate-certainty evidence. These advantages are offset by a higher long-term revision risk compared with TKA, highlighting the need to inform patients of this trade-off. TKA remains the reference standard for patients with tibiofemoral disease or instability, supported by high-certainty evidence, and offers durable, predictable long-term outcomes in more heterogeneous patient populations.

Level of evidence, II

Systematic GRADE (Grading of Recommendations, Assessment, Development and Evaluation) review of RCTs and observational studies.