Archives of Orthopaedic and Trauma Surgery最新文献

The number of individuals aged > 90 years (super-old) is steadily increasing, along with the incidence of femoral neck fractures. Surgical treatment in patients aged > 85 years is associated with a high risk of complications, and in super-old patients, surgical intervention is particularly challenging because of multiple comorbidities. However, data on mortality without surgery and its associated factors in this age group are lacking. This study aimed to (1) evaluate the 6-month mortality rate following femoral neck fractures in super-old patients and (2) identify factors associated with 6-month mortality following injury.

This retrospective study included patients aged > 90 years admitted to our hospital with femoral neck fractures between April 2010 and March 2021, with at least 6 months of follow-up. We collected data on demographics, fracture type, preinjury ambulatory function, treatment type (surgical or non-surgical), and admission laboratory data. Patients were grouped by survival status at 6 months after injury, and mortality rates and associated predictive factors were analyzed.

A total of 76 patients were included in the study (non-surgical group, n = 37; surgical group, n = 39). The cohort included 14 men and 62 women, with a mean age of 91.9 years (range, 90–96 years). The overall 6-month mortality rate was 21.0% (16/76), with higher mortality in the non-surgical group (40.5%) than in the surgical group (2.5%). Significant predictors of 6-month mortality were pre-injury ambulatory function and serum albumin levels at admission.

In super-old patients with femoral neck fractures, the 6-month mortality rate is approximately 20%, increasing to 40% in the absence of surgical treatment. Poor preinjury ambulatory function and low albumin levels were significant predictors of mortality. These findings highlight the importance of surgical treatment and pre-operative assessments in this population.

Cemented fixation remains the standard in total knee arthroplasty (TKA), but cementless techniques are gaining popularity, particularly in younger, more active patients. Robotic assistance may improve the accuracy of cementless implantation and promote favorable outcomes.

A retrospective review was conducted of 130 cruciate-retaining primary TKAs performed using the ROSA^® robotic-assisted system between October 2021 and September 2023 by a single high-volume surgeon. Patients received either a cementless Persona Trabecular Metal^® (n = 80) or cemented Persona^® (n = 50) prosthesis. Patient demographics, perioperative data, complications, and revisions were recorded. Patient-reported outcome measures (PROMs) WOMAC, Oxford Knee Score, Knee Society Score, and Forgotten Joint Score-12 were collected preoperatively and at minimum one-year follow-up.

Patients in the cementless group were younger (p < 0.001) and more frequently men (p = 0.003). Both groups showed significant improvement in all PROMs from baseline (p < 0.001), with no statistically significant differences in final PROMs between groups. One revision occurred in the cemented group (2.0%) due to stiffness and pain; two manipulations under anesthesia (MUA) were required in the cementless group (2.5%). No differences were observed in operative time or hospital length of stay.

At short-term follow-up, cementless and cemented robotic-assisted TKAs demonstrated equivalent improvements in PROMs and survivorship. Cementless implants may represent a viable option in appropriately selected patients, particularly younger individuals, when combined with robotic precision. Long-term data are needed to confirm durability.

Total hip arthroplasty (THA) is a widely performed procedure presenting substantial functional improvement in patients with hip joint pathology. Cementless acetabular components have well renowned popularity for their potential for long-term durability and bone preservation. Among these implants, trabecular metal technology (TMT), particularly using tantalum, has been introduced to enhance biological fixation and implant longevity.

This retrospective study analyzed 3464 primary THAs performed using tantalum TMT acetabular cups between 2012 and 2022 at a single high-volume arthroplasty center. Patients included were adults undergoing THA for osteoarthritis, hip dysplasia, post-traumatic arthritis, or avascular necrosis, with a minimum follow-up of 24 months. Clinical outcomes were evaluated using the Harris Hip Score (HHS), and implant survivorship was assessed via Kaplan–Meier analysis.

The mean follow-up was 7.03 years (± 2.58). The mean HHS improved significantly from 46.7 (± 7.2) preoperatively to 91.07 (± 7.8) at final follow-up. The implant survivorship free from any reoperation was 97.78%, while survivorship free from aseptic loosening was 99.89%. Radiographically, mean cup inclination was 41.3° (± 5.9), with signs of potential aseptic loosening in only four cases (0.11%). Complications included 46 infections managed with DAIR/DAPRI and 30 implant-related revisions, primarily due to dislocation or mechanical failure.

Tantalum acetabular components demonstrate excellent mid-term clinical and radiographic performance in a broad patient population, suggesting their utility in both high-demand and compromised bone quality cases. Continued follow-up is necessary to confirm long-term implant survivorship.

Introduction

Comparative data on fixation techniques for associated both-column (ABC) acetabular fractures are scarce. Compared with both column plating (AP + PP) via a combined anterior–posterior approach, single column plate plus other column lag screw fixation obviates the need for a second surgical approach. In this study, we (1) developed a clinically relevant ABC fracture model and (2) biomechanically compared the fixation strength of single column plate plus other column lag screw fixation and both column plating.

Materials and methods

An ABC fracture model was created using fourth-generation composite hemipelves. Three different ABC fracture fixation techniques were biomechanically compared: (1) anterior column plate plus posterior column screw fixation (AP + PCS), posterior column plate plus anterior column screw fixation (PP + ACS), and anterior column plate plus posterior column plate fixation (AP + PP). Both single-leg stance (SLS) and sit-to-stand (STS) loading protocols were applied (loads from 50 to 750 N, ramp: 100 N/s). Fracture gap motion (FGM) and relative interfragmentary rotation (RIFR) between the four main fracture fragments were analysed at 750 N using an optical 3D measurement system.

Results

Single column plate plus other column lag screw fixation techniques (AP + PCS and PP + ACS) provided comparable fixation strength to AP + PP, as evidenced by similar or even lower FGM and RIFR values. Moreover, no significant differences in FGM and RIFR were found between AP + PCS and PP + ACS. Compared to SLS loading, STS loading resulted in higher mean FGM and RIFR between the posterior iliac wing and the posterior column fragment across all fixation techniques.

Conclusions

In our ABC fracture model, both column plate fixation (AP + PP) via a combined approach did not demonstrate superior biomechanical stability compared with single column plate plus other column lag screw fixation. The latter, however, requires only one approach, thereby reducing surgical time and approach-related morbidity, and appears preferable if reduction of both columns is achievable through a single approach.

Introduction

Distal radius fractures (DRFs) are among the most frequent injuries treated by orthopaedic surgeons. Although postoperative infection is uncommon, it represents a clinically relevant complication that may affect outcomes. This systematic review aimed to evaluate the incidence, subtypes, and treatment of infections following surgical management of DRFs.

Materials and methods

A systematic search of MEDLINE/PubMed and Cochrane Library was performed from inception to June 2024, following PRISMA guidelines. English-language longitudinal studies (prospective or retrospective) reporting infection after DRF surgery were included. Case reports, meta-analyses, animal studies, and articles without relevant outcomes were excluded. Extracted data included infection incidence, classification, microbiological findings, and reported management.

Results

Fifty-five studies met inclusion criteria, encompassing 6499 patients and 6451 procedures. A total of 341 infections were reported (5.3%). Superficial surgical site infections accounted for 22.6% of cases, deep infections for 12.0%, and pin-tract infections for 61.0%. Infection rates differed by fixation method: approximately 2.0% for open reduction and internal fixation, 12.0% for Kirschner-wire fixation, and 13.9% for external fixation. Microbiological confirmation was reported only in a minority of studies; when available, Staphylococcus aureus was the most frequently isolated organism. Management strategies ranged from oral antibiotics and local wound care for superficial infections to intravenous antibiotics with debridement and hardware removal for severe cases.

Conclusions

Infections following DRF surgery are relatively rare but vary across fixation techniques, with pin-tract infections predominating in percutaneous and external constructs. The heterogeneity of infection definitions and the scarcity of microbiological reporting limit comparability between studies. Standardized SSI/FRI classification and more consistent documentation are needed to improve evidence-based prevention and treatment strategies.

Introduction

The Minimal Clinically Important Difference (MCID) is critical in assessing patient-reported outcomes following total joint arthroplasty (TJA). Although many studies consider the MCID for Improvement (MCID-I), thresholds have also been defined for the MCID for Worsening (MCID-W). However, the potential impact of the MCID-W on surgical outcomes in TJA is under-investigated. This study investigated the association between the MCID-W and revision rate.

Materials and methods

This retrospective study was performed using 2787 primary TJAs—1563 total knee arthroplasties (TKAs) and 1224 total hip arthroplasties (THAs)—with minimum five-year follow-up. Patient-Reported Outcomes Measurement Information System Physical Function Short Form 10a (PROMIS PF-10a) scores were collected preoperatively and at one-year postoperatively. Patients were classified based on experiencing MCID-I, MCID-W, or “no change” after TJA (scores between MCID-I and MCID-W). MCID-W and MCID-I values were determined by a distribution-based method. Revision-free survival was compared at 1 year, 3 years, and 5 years postoperatively.

Results

The overall revision rate for the entire TJA cohort was 1.1% at 1 year, 1.8% at 3 years, and 2.2% at 5 years postoperatively. TJA patients who experienced MCID-W had a higher revision rate than MCID-I patients at 1 year (3.6 versus 0.8%, P < 0.001), 3 years (5.3 versus 1.1%, P < 0.001), and 5 years postoperatively (5.7 versus 1.5%, P < 0.001). Similarly, stratifying into TKAs and THAs revealed an association between MCID-W and higher revision rates. Revision-free survival curves for MCID-W patients revealed lower survival at 1 year (P < 0.001), 3 years (P < 0.001), and 5 years (P < 0.001).

Conclusions

Patients experiencing the MCID-W are more likely to undergo revision surgery at 1, 3, and 5 years following both THA and TKA procedures. The MCID-W may be a useful tool to help identify postoperative THA and TKA patients at highest risk for revision surgery. Future studies utilizing MCID-W as a predictive tool are needed to determine its effectiveness in optimizing TJA patient outcomes.

The present Bayesian network meta-analysis compared reverse total shoulder arthroplasty (rTSA) to hemiarthroplasty (HA) and open reduction and internal fixation (ORIF) for displaced proximal humeral fractures (PHF) in patients above 60.

This study was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. In December 2024, PubMed, Web of Science, and Embase databases were accessed. No time constraint was set for the search. All clinical studies were accessed comparing rTSA, ORIF and HA for displaced PHF in patients older than 60. Only studies which compared at least two of the interventions of interest were eligible when they reported a minimum of 12 months of follow-up. Two-, three-, and four-part displaced fractures and fractures with a head-splitting component were considered.

Data from 878 procedures were collected. 72% (631 of 878 patients) were women. The mean length of the follow-up was 33.8 ± 14.8 months. The mean age of the patients was 73.4 ± 4.6 years. Between groups, comparability was found in the mean age, the ratio of men to women, the length of the follow-up, and the time elapsed from injury to the procedure. The rTSA demonstrated the lowest rate of complications, followed by HA and ORIF. The rTSA demonstrated the lowest rate of revision, followed by HA and ORIF. Given the limited and heterogeneous data, only complications and revision rates were analysed in the network meta-analysis; functional outcomes were discussed narratively.

In patients above 60 with displaced PHF, rTSA was associated with a lower complication and revision rate than ORIF and HA.

Level IV, systematic review and meta-analysis.

Background

Pelvic discontinuity is a rare but challenging condition in revision hip arthroplasty. Traditional reconstruction with anti-protrusio cages often lacks anterior support, providing no resistance against medial migration or implant protrusion, thereby potentially compromising long-term stability and implant longevity.

Methods

This retrospective study included 13 patients with intraoperatively confirmed pelvic discontinuity who underwent revision total hip arthroplasty between 2014 and 2023. Patients were divided into two groups: Group 1 (n = 8) received anti-protrusio cage reconstruction alone, while Group 2 (n = 5) underwent additional anterior quadrilateral surface plating prior to cage implantation. Clinical and radiological outcomes were assessed with a minimum follow-up of 2 years (mean: 6.3 years), including complications, loosening, and reoperation.

Results

Thirteen patients (mean age: 73.3 years) with intraoperatively confirmed pelvic discontinuity were included.Complication and reoperation rates were significantly higher in Group 1 (75%) compared to Group 2 (20%) (p < 0.001). Kaplan–Meier analysis demonstrated superior complication-free survival in Group 2 (80% at 11 years) versus Group 1 (37.5% at 11 years). Periprosthetic fracture rates did not differ significantly (p = 0.21).

Conclusion

Preliminary results suggest that the addition of quadrilateral surface plating may enhance construct stability and reduce complications. Further studies with larger cohorts and biomechanical validation are warranted.

Purpose

Although severe pain caused by progressive ankle osteoarthritis (OA) impairs patients’ quality of life, factors associated with severe pain in ankle OA are unknown. This study aimed to analyze the characteristics of pain and the association between pain, radiographic alignment, and computed tomography (CT) and magnetic resonance imaging (MRI) findings in patients with varus ankle OA.

Methods

Seventy-five ankles from 73 patients with varus ankle OA who underwent surgery were retrospectively reviewed. Pain was evaluated using the self-administered foot evaluation questionnaire (SAFE-Q). Ankle alignment was assessed by radiography. Subchondral bone sclerosis was assessed by CT-derived Hounsfield unit (HU) ratio, and synovitis and bone marrow edema (BME) were assessed by MRI. The relationship between pain and imaging findings was analyzed.

Results

Pain and pain-related scores in the SAFE-Q significantly correlated with the Takakura-Tanaka classification stage (r = − 0.529), osteophyte score (r = − 0.460), HU ratios (r = − 0.729), synovial thickness score (r = − 0.387), and BME area (r = − 0.475). Multivariate analysis revealed that high HU ratio, progressed OA stage, and thick synovium were significantly associated with severe pain. Notably, HU ratios showed moderate to strong correlations with pain, regardless of radiographic severity, even in the regions where joint space was radiographically preserved.

Conclusions

Subchondral bone sclerosis, OA severity, and synovitis are significantly correlated with pain in patients with varus ankle OA. The novel finding is that HU ratios of subchondral bone correlate with pain irrespective of radiographic stage, suggesting that severe pain reflects hidden mechanical stress and cartilage degeneration associated with subchondral sclerosis. Varus ankle OA with severe pain should be managed early and appropriately, regardless of radiographic severity.

Level of evidence

III.

Purpose

The purpose of this study was to assess the odds of nonunion for open and closed fractures in patients with bipolar disorder (BD) and characterize any confounding effect of medication prescription.

Materials and methods

This was a retrospective cohort study with data sourced from the TriNetX Research database. Our query was for patients that are ≥ 18 years old with extremity long bone fractures with and without prior BD diagnosis. A 1:1 propensity score matching method, matching for age; sex; nicotine use; long-term NSAID use; long-term opioid use; and prior diagnoses of obesity, osteoporosis, and the Charlson comorbidities, was used to create reference groups. The primary outcome was fracture nonunion. Odds of fracture nonunion of the observed groups were compared to the control groups using an odds ratio (OR) with 95% confidence interval (CI).

Results

A total of 1,824,610 patients with long bone fractures were analyzed, with 2.8% having BD. The nonunion rate was higher in patients with BD (3.9%) than those without BD (3.2%, P < .001). The highest nonunion rates were observed in open fractures at 5.1–16.2%, with no significant difference between patients with and without BD (OR 1.04, 95% CI 0.89–1.22). Closed fractures had nonunion rates of 1.6–5.4%, with BD patients showing 1.30 times higher odds (95% CI 1.21–1.41). In BD patients, having a medication prescription for treatment of BD increased the odds of nonunion in closed fractures by 1.68 times (95% CI 1.50–1.88) when compared to those without medication prescription. When patients prescribed medications were removed, BD patients no longer had significantly different odds of nonunion in closed fractures (OR 1.07, 95% CI 0.95–1.21).

Conclusions

Pharmacological prescriptions for BD, but not BD itself, were associated with significantly increased odds of nonunion in closed fractures, while open fractures were unaffected. Orthopaedic surgeons should consider these increased odds when treating these patients and tailor fracture treatment strategies accordingly.