Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

The aim of this study was to establish an international consensus statement on the indications for the addition of a patellofemoral joint arthroplasty (PFJA) in patients with a unicondylar knee arthroplasty (UKA) and symptomatic progression of patellofemoral compartment osteoarthritis.

Materials and methods

A systematic review of the literature was conducted, and the results used to inform the development of a statement by an expert working group. This was then evaluated and modified, using a Delphi process, by members of the European Knee Society (EKS).

Results

Forty-nine (round one) and forty-two (round two) EKS members took part in the Delphi process, with 83% agreement on the resulting consensus statement that the indications for this procedure are: (1) a well-functioning UKA in a satisfied patient with secondary osteoarthritis progression in the patellofemoral compartment (2), symptomatic patellofemoral compartment osteoarthritis with full thickness cartilage loss affecting the lateral facet of the patellofemoral joint (3), functional ligaments, including the anterior cruciate ligament (ACL) (4), a lateral tibiofemoral compartment with no cartilage damage greater than Ahlback Grade 1 (5), knee flexion ≥ 100° and extension loss ≤ 5° and (6) older patients with increased medical co-morbidities.

Conclusions

The simple addition of a PFJA to patients with an existing UKA and progression of patellofemoral compartment osteoarthritis is an attractive option. This EKS Delphi-derived consensus statement, which reached a strong consensus, can be used by clinicians to identify patients suitable for this procedure.

Introduction

The optimal management strategy for unstable distal clavicular fractures remains controversial. Recent studies on plate techniques have reported good-to-excellent outcomes with no serious complications. The questions are that: (1) Does the use of wire augmentation with locking plate in distal part (distal wire augmentation) reduce radiographic loss of reduction (RLOR) and get earlier bony union in distal clavicular fractures? (2) Which fixation methods are associated with a higher incidence of acromioclavicular (AC) joints arthritis or subluxation? We collected and analyzed clinical studies on different plate fixation methods for unstable fractures to identify the best surgical modality.

Methods

This retrospective case-control study included 101 patients with Neer types IIB and V unstable distal clavicle fractures treated using plate techniques. The patients were divided into four groups according to the surgical procedure: hook plate (HP group) (n = 13), lateral locking plate alone (LP group) (n = 41), locking plate with coracoclavicular (CC) ligament suture repair (LPC group) (n = 26), and locking plate with distal wire augmentation (LPA group) without CC repair (n = 21). The clinical outcomes of shoulder function were the mean Constant score and the University of California-Los Angeles (UCLA) shoulder scale. The bony union time, loss of CC distance reduction, and AC joint condition were used to evaluate the radiographic results. One-way ANOVA, Kruskal–Wallis test, and chi-square test were performed to compare differences between groups. Multiple p-value comparison corrections were calculated using the Bonferroni method.

Results

There were no significant differences in the mean Constant and UCLA scores among the groups after 1 year of follow-up. All fractures healed. The LPA and HP groups achieved earlier bone union (LPA 8.4 weeks, HP 8.9 weeks, LP 12.6 weeks, and LPC 13.4 weeks, P = 0.000); however, the HP group had the highest complication rate and required bone removal (LPA 4.0%, HP 23.1%, LP 0.0%, LPC 0.0%, P = 0.003). A low rate of RLOR was observed in the LPA group (LPA 9.5%, HP 23.1%, LP 22.0%, LPC 30.8%, P = 0.362). The incidence of AC joint subluxation was higher in the Neer type V group and was unrelated to surgical methods.

Conclusions

Hook plate and locking plate with distal wire augmentation in distal clavicle fractures result in an earlier time to bone union when compared with CC suture repair or non-CC suture repair techniques. However, HP may have the higher complication rate and require subsequent implant removal. The incorporation of distal wire augmentation appears to be beneficial in maintaining fracture reduction. In the future, larger prospective studies are needed to confirm these findings.

Level of Evidence

Level III, therapeutic study.

Introduction

Stair ascent and descent are physically demanding tasks requiring higher functional ability of the lower extremity muscles and joint range of motion than level walking, and are associated with patient satisfaction after total knee arthroplasty (TKA). This study aimed to investigate stair ascent and descent ability after cruciate-retaining (CR)-TKA using the patient-reported outcomes, and to examine the role of knee sagittal stability and handgrip strength in postoperative stair ascent and descent ability.

Materials and methods

This study included 84 female patients who underwent primary unilateral CR-TKA for knee osteoarthritis at our institute between April 2015 and February 2019. Patients were classified according to ascending and descending stair difficulty using the New Knee Society Score into those with (group D) and those without difficulty ascending and descending stairs (group A). The two groups were compared for age, height, weight, body mass index, postoperative grip strength, pre-operative and postoperative knee range of motion, anterior and posterior tibial drawer on stress radiography, and the New Knee Society Score (KSS).

Result

Group D and A consisted of 48 and 36 patients, respectively. The mean follow-up period was 2.9 years (range 1–5 years). Group D was significantly older (74.1 vs. 70.0 years old, p = 0.01) and shorter (148.6 vs. 153.3 cm, p = 0.017) than group A. The two groups demonstrated no significant differences in the range of motion preoperatively and postoperatively and in the amount of anterior tibial drawer at 20°, anterior and posterior drawer at 90°, and total anterior–posterior movement at 90°. Postoperative handgrip strength (19.6 vs. 24.1, p < 0.01) and New KSS score (107 vs. 137, p < 0.01) were lower in group D than in group A.

Conclusions

Handgrip strength was associated with stair ascent and descent ability and postoperative activity in the patient-reported outcomes, rather than CR-TKA knee sagittal stability.

Introduction

The outcomes of total hip arthroplasty (THA) are highly dependent upon the restoration of native hip biomechanics and optimal component positioning. Robotic technologies for THA have rapidly improved the accuracy of component positioning and maintaining the planned center of rotation. While robotic-assisted THA (RA-THA) has primarily been employed in surgically intricate cases, its potential benefits in scenarios of diminished surgical complexity remain less explored. Therefore, the purpose of this study was to assess the odds of developing systemic and joint complications following RA-THA in cases of reduced surgical complexity.

Methods

A retrospective cohort study was conducted using the TriNetX national database to identify patients who underwent primary THA (Current Procedural Terminology code 27,130) and more specifically RA-THA identified by ICD-10-PCS code 8E0Y0CZ and Healthcare Common Procedure Coding System code S2900 from 2013 to 2022. One-to-one propensity score matching was conducted to generate 2 cohorts: (1) RA-THA and (2) conventional THA (C-THA). Systemic and joint complications were assessed at the 30-day, 90-day, 1-year, and 5-year postoperative periods.

Results

Patients undergoing RA-THA had a lower risk of needing a revision THA at the 90-day, 1-year, and 5-year time points. RA-THA was associated with a lower risk of prosthetic dislocation at 90 days and 1 year and prosthetic pain at 1 year and 5 years. Dislocation of the hip or fracture of the femur was significantly lower in the RA-THA cohort at all four-time points. Patients undergoing RA-THA had a lower risk of developing deep vein thrombosis at 5 years.

Conclusion

These findings suggest that RA-THA has comparable systemic and less joint complication risks at 30-day to 5-year timepoints between RA-THA and C-THA. Future studies with large sample sizes and long-term follow-up are needed to understand the patient-reported outcomes and functional outcomes of RA-THA for cases with reduced surgical complexity.

Background

Unstable diametaphyseal radius fractures (DMRFs) can be prone to complications, and treatment strategies are heterogeneous. Studies are difficult to interpret as definitions of the diametaphyseal junction zone (DMJZ) are impractical for clinical use, imprecise, or prone to error.

Methods

We introduce the forearm fracture index (FFI) to define DMRFs in radiographs and ultrasound. The FFI is calculated by the ratio of the fracture’s distance to the distal radius growth plate over the width of the radius growth plate. The higher the FFI, the more proximal the fracture is. We define DMRFs to have an FFI between 1 and 2. All DMRFs treated at our institution between 2010 and 2020 were identified, and demographic data, fracture characteristics, and therapeutic strategies were assessed retrospectively. Comparative sub-analysis was performed between DMRFs(−) as defined in previous publications (Lieber in Unfallchirurg 114:292–299, 2011) and DMRFs( +) that were more proximal but still met our criteria.

Results

516 DMRFs were identified, representing 13.0% of all screened radius fractures. Excluding buckle fractures and patients lost to follow-up, 366 DMRFs were eligible for further analysis. Conservatively managed DMRFs were more distal than those managed operatively, represented by a lower FFI (1.28 vs. 1.34, p = 0.0051). 21 (5.7%) of all DMRFs were identified as DMRFs( +). These were significantly more dislocated and necessitated surgery more often than DMRFs(−) (52.4 vs. 24.6%, p = 0.009).

Conclusions

The FFI may be a good tool to identify and describe DMRFs. It can help guiding treatment decisions and make future studies on this entity more comparable.

Level of evidence

Study of Diagnostic Test, Level II.

Introduction

A separate tibial tubercle fragment (TF) is found in up to half of all bicondylar tibial plateau (BTP) fractures. Adequate healing of the TF is required to reconstitute the extensor mechanism of the knee. The purpose of this study was to compare outcomes after surgical fixation of BTP fractures with and without a TF.

Materials and methods

Retrospective comparative study of adult patients undergoing open reduction internal fixation (ORIF) of a Schatzker V/VI BTP fracture at two Level 1 trauma centers. Primary outcomes were patient-reported outcomes as assessed by the PROMIS Physical Function (PF) score and EQ-5D-3L. Secondary outcomes included rates of infection, reoperation, and nonunion. Patient demographics, fracture characteristics, and outcomes were compared for patients with and without a TF.

Results

189 patients (mean follow-up 8.1 yrs) were included. 55 patients (29%) had a separate TF. There was no significant difference in PROMIS PF (48.1 vs 47.5, p = 0.45) or EQ-5D-3L scores (0.82 vs 0.83, p = 0.32) between patients with and without a separate tubercle fragment.Patients with a TF had more open fractures (16% vs 5%, p = 0.02) and high energy injuries (66% vs 49%, p = 0.03).There was no significant difference in the rates of deep infection (15% vs 8%, p = 0.19) or unplanned reoperation (23% vs 13%, p = 0.09). There were more nonunions in the TF group (11% vs 2%, p = 0.02) but only two involved the tubercle fragment.

Conclusion

In this comparative study, the presence of a TF did not portend a worse functional outcome for patients with a healed fracture. Rates of open fracture and high energy mechanism of injury were significantly higher in the TF group.. Surgeons should be aware that a separate TF may indicate a more severe injury. More studies are needed to determine whether the presence of a TF is associated with higher complication rates.

Purpose

To describe and evaluate the modified suture technique using PDS II for capsule closure in Total knee arthroplasty.

Methods

One hundred-five patients with end-stage osteoarthritis of the knee received Total knee arthroplasty (TKA) in our department. The arthrotomy wounds were closed randomly utilizing either modified suture (the MS group, 53 patients) or traditional suture (the TS group, 52 patients) techniques. The time of suturing, rupture of the suture, water tightness, wound seepage and the days of hospitalization were recorded and compared between the two groups. Complications such as infection and rejection of the wound were also assessed.

Results

Records indicated significantly shorter time of suturing for the capsule in the MS group (4.6 ± 0.6 min) than in the TS group (16.8 ± 1.1 min, P < 0.001). The mean time of hospitalization was also significantly shorter in the MS group (7.8 + 1.8d) than in the TS group (13.1 + 2.7d, P < 0.001).There were 51 cases in MS group and 42 cases in TS group showed good tightness, the rate of tightness in the MS group (51/53) was significantly higher than in the TS group (42/52, P = 0.015).The rate of postoperative wound seepage in the MS group (3/53) was significantly lower than in the TS group (11/52, P = 0.023). The rate of rupture of the suture in the MS group (0/53) showed no significantly difference compared with the TS group (3/52, P = 0.118). There were no complications such as infection and rejection occurred in both groups.

Conclusion

The modified suture technique using PDS II appears to be a promising option for the capsule closure in TKA because it was associated with shorter surgical time, better water tightness, fewer wound see-page, shorter of hospitalization and relatively fewer complications.

Adequate intraoperative visualization is mandatory for implant application in pelvic ring injuries. Several fluoroscopic X-ray views are in practical use. The gold standard primary X-ray is the anteroposterior view of the pelvis. In addition to this view, oblique views for pelvic ring instabilities and acetabular fractures are well defined. Combinations of these views allow better identification of osseous corridors for screw applications. These corridors are based on the 3-ring concept of the hemipelvis. For pelvic ring stabilization the main osseous corridors include the retrograde and antegrade superior ramus/anterior column corridor, the supraacetabular corridor and the gluteus medius pillar corridor. The radiographic anatomy of these corridors is described in detail for screw applications with definition of image intensifier angulations, risk zones and corridor parameters. This allows for intraoperative safe implant application.

Background

Hand injuries are a leading cause of emergency department visits. Recent trends in hand trauma management reflect a shift toward outpatient care, driven by factors such as a shortage of skilled personnel or increasing cost pressures. This study analyzed these trends to propose updated management strategies for hand injuries.

Materials and methods

This retrospective cohort study included 14,414 patients treated at a certified major hand surgical trauma center between 2007 and 2022. Patients were divided into two groups: the earlier cohort (EC, 2007–2014) and the current cohort (CC, 2015–2022). Trends in inpatient and outpatient care, as well as hospitalization durations, were analyzed.

Results

During the study period, approximately one-third of all patients required inpatient treatment, with one-third of hospitalized patients staying at least one week, one-fifth staying two weeks, and one-tenth staying three or more weeks. Inpatient treatment rates decreased annually by 7%, while outpatient care increased by 5.3% annually. A significant shift toward outpatient management was noted for various injuries, including fractures, burns, lacerations, dislocations, complex injuries, and infections. Despite declining hospitalization rates, patients in the CC group had significantly longer hospital stays, reflecting the increasing complexity and severity of cases requiring admission (p < 0.001).

Conclusions

This study reveals a growing trend toward outpatient care for hand injuries, reflecting improved efficiency without compromising quality. Although fewer patients are hospitalized, those admitted require more intensive care, highlighting a shift toward ambulatory management for moderately severe cases. These findings emphasize the importance of initial injury management and underscore the need for expanding outpatient hand surgical care to meet growing demand in a rapidly changing healthcare landscape.

Level of evidence

III.

Background

Kirner deformity is a rare anomaly of the little finger in adolescents, characterized by a deformity of the distal phalanx and a radiologically L-shaped epiphysis, along with palmar and radial angulation of the distal phalanx. Due to the rarity of these pathological findings, there are no systematic literature reviews available. This work serves as an overview of the clinical presentation, frequency and age distributions, as well as possible conservative and surgical treatment options.

Methods

We present five cases of patients with Kirner’s deformity of the little finger who underwent surgical treatment. A partial tenotomy of the flexor digitorum profundus tendon from the metaphyseal/diaphyseal distal phalanx was performed. In one case, a dorsal epiphysiodesis was also carried out. Additionally, a systematic review of the literature on Kirner’s deformity was conducted, summarizing the prevalence, previously used surgical treatment options, and epidemiological data.

Results

In the presented cases, the detachment of the FDP tendon and dorsal epiphysiodesis resulted in a good functional and aesthetic outcome. Regarding the epidemiological distribution of Kirner deformity, it is noted that significantly more females are affected than males (63% vs. 36%). The average age at presentation in the respective clinic was 9.36 years (± 2.5). In more than half of all reported cases, the deformity was bilateral. Surgical intervention was performed in only 7.4% of cases, which included FDP detachment or corrective osteotomies. More than 90% of patients were treated conservatively.

Conclusion

Kirner’s deformity is a rare condition affecting adolescents. In cases where functional limitations or pain symptoms are present, we recommend surgical intervention via detachment of the FDP tendon. If the deformity is an incidental finding without functional or aesthetic limitations, conservative therapy with a corrective splint can be initiated. From our perspective, early surgical treatment before the age of 12 improves both the long-term functional and aesthetic outcomes.