Archives of Orthopaedic and Trauma Surgery最新文献

Introduction

According to current clinical practice, a minimum of 7 knots are required to provide secure hold in high-strength sutures. A new technology featuring a suture tape with a salt-infused silicon core has been recently developed, potentially reducing the number of needed knots. Aims: to (1) assess the influence of number of knots on tape security, (2) evaluate the effect of different ambient conditions on knot security, and (3) compare the biomechanical competence of the novel versus a conventional suture tape.

Materials and methods

A conventional suture tape (ST, SutureTape^tm) was considered for knot tying together with the novel suture type (DT, Dynatape^tm). Specimens were assigned to receive different number of knots, ranging from 3 to 7, and to be exposed to different media during tying―air (dry), saline solution (wet), and fat (fatty-wet). Seven specimens were considered for each suture type, knot number and ambient condition. With knotted sutures mounted between two roller bearings, quasi-static tensile ramp tests were performed to evaluate knot slippage, ultimate force at rupture, and minimum number of knots preventing suture unraveling for each suture tape and condition.

Results

Whereas the ST ruptured without unraveling with a minimum of 6 knots in all specimens and ambient conditions, the minimum number of knots for a DT rupture without unraveling was 6 in dry, 4 in wet, and 5 in fatty-wet condition. Ultimate force at rupture with a minimum number of needed knots did not differ significantly between ST and DT (p ≥ 0.067), in contrast to knot slippage that was significantly bigger for ST versus DT in wet and fatty-wet conditions(p ≤ 0.001).

Conclusions

In fatty-wet conditions―related to open surgery―the novel Dynatape^tm suture tape requires 5 instead of 7 knots to achieve their security. In wet conditions―related to arthroscopic surgery―this number can be reduced to 4 knots. In contrast, the conventional SutureTape^tm needs 6 knots to provide security in all conditions.

Background

Debridement, antibiotics, and implant retention (DAIR) for acute periprosthetic joint infection (PJI) is under debated since the reported success rate is inconsistent. This study aimed to explore the efficacy of vacuum sealing drainage (VSD) used as an adjunct to irrigation and debridement for acute PJI.

Methods

Patients undergoing debridement, irrigation with component retention, and application of vacuum seal drainage in the deep portion surrounding the infected sites from January 2014 to February 2021 were retrospectively reviewed. The definition of failure included the requirement of prosthesis removal; persistent infection-related symptoms; suppressive antibiotics therapy due to failure of controlling the infection; infection-related death.

Results

45 patients were included in this study with a mean follow-up of 45.62 ± 13.87 months. There were 28 males and 17 females with a mean age of 63.29 ± 17.74 months. The overall success rate was 86.67% with 6 failures. Multivariate analysis revealed a significant association between Charlson comorbidity index and treatment failure (OR = 2.226, 95% CI, 1.057–4.687, p = 0.035).

Conclusions

The incorporation of VSD in the deeper region enhances the outcomes of DAIR, achieving an 86.67% success rate in managing acute PJI. This approach offers a potentially safe and effective treatment, though patients with higher Charlson comorbidity index and elevated preoperative CRP levels face increased risks of failure.

Introduction

Management of osteochondritis dissecans (OCD) lesions of the capitellum is challenging. Historically, variability exists between surgeons in the evaluation, treatment, and return to sport criteria. The purpose of this study was to define the current trends regarding evaluation, nonoperative and surgical management, and return to sport criteria for capitellar OCD lesions among surgeons.

Methods

A 21-question cross-sectional survey was administered to 24 Orthopaedic surgeons specializing in elbow OCDs. The survey included questions concerning imaging, specific non-operative treatments trialed, indications for surgery for stable and unstable lesions, preferred surgical techniques, osteochondral autograft utilization, and factors determining return to sport.

Results

Twenty-one surgeons responded (88%). The most common surgical indications for stable lesions were time (≥ 6 months, 68%) and mechanical symptoms (52%). Drilling (45%) and fragment fixation (35%) were most preferred. For unstable lesions, factors in order of importance for determining surgical procedure were lesion size, lateral wall integrity, location on capitellum, skeletal maturity, and sport. For small (< 1 cm²), centralized lesions, 81% preferred debridement with microfracture. For large (> 1 cm²), lateralized lesions, 52% preferred debridement and microfracture and 48% preferred osteochondral autograft transfer (OAT). OAT was considered for 80% of failed procedures, 47% with lateral wall involvement, and 27% > 1 cm². Return to sport after debridement was typically 2–3 months (52%), fragment fixation was 4 months (52%), and OAT was 4–6 months, while microfracture had wide variability (3–6 months). The factors in order of importance were lack of pain, time, then imaging. Two-thirds of surgeons wait longer to release overhead athletes or gymnasts.

Conclusions

There is significant variability in the management of capitellar OCD in athletes. Small, centralized lesions are likely to be treated with debridement and microfracture with faster return to sport. Treatment of large, lateral lesions remains variable. Regarding OAT procedures, perceived morbidity, reimbursement, and limited evidence dissuade use. There is no consensus on return to sport, though lack of pain and time were most important; overhead athletes and gymnasts are restricted longer from returning to sport.

Level of Evidence

Level 5, diagnostic, cross-sectional survey.

Purpose

The aim of this study was to perform a systematic review of the current literature to elucidate the optimal duration of systemic antibiotic therapy following one-stage revision TKA in the setting of PJI.

Methods

We conducted an electronic search in four databases including Medline (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials without any publication date, language or study design filter on October 1, 2022. The search strategy adhered to PRISMA guidelines and consisted of four main keywords categories which were knee arthroplasty or knee prosthesis, infection and one-stage/single-stage revision. Duration of antibiotic administration were classified to three groups: short-term IV therapy (≤ two weeks), short-term IV therapy plus oral therapy, and long-term IV therapy (minimum six weeks).

Results

We identified 963 studies, of which 21 were included in the systematic review. Coagulase-negative Staphylococcal species were the most frequently isolated pathogens. The mean eradication rate for all the studies analyzed was 88.4% (range, 62.5–100%). Short-term IV + long-term oral antibiotic therapy demonstrated significantly higher eradication rate compared to the other two regimens following one-stage revision TKA (p = 0.023) (Table 4). In the ten studies with great than five years of follow-up, this difference was no longer statistically significant. Subgroup analysis of antibiotic-loaded cement (ABLC) usage demonstrated higher eradication rates with short-term IV + long-term oral (92.8%) and long-term IV antibiotics (89.7%) compared to short-term IV antibiotics alone (p = 0.006).

Conclusion

We demonstrated that short-term IV antibiotics followed by oral antibiotics had similar eradication rates to long-term IV antibiotics in long-term studies, which were both superior to short-term IV antibiotics alone. Nevertheless, there remains a need for prospective and randomized studies to further elucidate a patient-based protocol for the type and duration of antibiotic use following one-stage PJI treatment of the knee.

Background

Uncemented total hip arthroplasty (THA) is a successful treatment for advanced hip joint diseases. More recently, short stems became increasingly popular, but stem subsidence remains a concern. This study investigates early short stem subsidence in a large patient cohort using a simple measurement approach for everyday practice.

Methods

This retrospective, single center, single implant design study included 1000 patients with primary THA. Subsidence was evaluated using standardized weight-bearing radiographs taken 3–5 days and 2–3 weeks postoperatively with full weight-bearing (FWB). A novel Subsidence Index (SID) was introduced to quantify stem subsidence in a simple and reproducible manner. The SID is calculated by averaging four distinct linear measurements between defined anatomical landmarks on the femur and the implant, captured on standard radiographs without additional software.

Results

Out of all analyzed patients 6% (60/1000) had subsidence of more than 3 mm. The mean subsidence was 1.3 mm (range, 0 to 16.25 mm).

There were 0.6% (6) who underwent stem revision for symptomatic subsidence. Men and obese patients had greater subsidence. However, patient age, BMI, stems without lateral bone contact and other demographic factors were not associated with subsidence.

Conclusion

Early subsidence is relatively frequent with this uncemented short stem, however revisions are rare. Patients with risk factors should be counseled regarding FWB and radiographic controls should be performed. The SID provides an easy, non-invasive and inexpensive tool for early subsidence assessment; however, its simplicity limits its accuracy. Further research is needed in comparison to more elaborate methods.

Introduction

This study evaluates the necessity of routine X-ray follow-ups in children with developmental dysplasia of the hip (DDH), identified through Graf hip ultrasound, a standard component of screening in Germany. The purpose of this study was to investigate the occurrence of radiological deterioration in hips that were initially diagnosed and treated according to established guidelines within a university-based risk-enriched cohort and to identify associated risk factors.

Materials and methods

Patients diagnosed with developmental DDH from 2009 to 2018 with sonographically healthy hips (alpha > 64°) post conservative therapy and at least one follow-up X-ray by the age of two were analysed. Patients with significant comorbidities, syndromes, malformations, non-compliance with treatment, or missing X-ray data were excluded. Descriptive analysis of sonography, X-ray, and patient records were followed by univariate analysis and subsequent multiple logistic regression, identifying risk factors for severe and extreme dysplasia in X-rays.

Results

Of the 450 included hips, 254 were classified as Graf Type 2a or higher, leading to treatment. Subsequent X-rays revealed severe dysplasia in 53 hips and extreme dysplasia in seven hips. Univariate analysis identified sex, initial Graf-Type, therapy type and duration as significantly associated with pathological radiographs. A regression model identified the initial Graf type as the predominant predictor with hip types 3a and 4, cast therapy and overhead extension as independent predictors.

Conclusions

The data demonstrate pathological findings even after successful conservative treatment of DDH. Worsening of X-ray findings appear less frequent in mild dysplasia. These insights support routine radiographic follow-up assessments after successful conservative therapy. However, further dedicated studies are needed to determine whether patients with initially normal radiographs require radiographic follow-up.

Purpose

The purposes of this study was to develop a novel therapy-oriented acetabular bone defects classification system based on Statistical shape models (SSMs) and evaluate the reliability and reproducibility of its application.

Methods

We retrospectively reviewed and annotated pelvic Computed tomography (CT) of patients who had undergone revision total hip arthroplasty at our institution and constructed a dataset to develop the novel method for quantitatively describing acetabular bone defects that is based on SSMs. Then, using this method, classification systems are suggestive for diagnosis and corresponding treatment suggestion. In addition, the interobserver and intraobserver reliability of this classification system was calculated.

Results

The novel classification based on SSMs was successfully applied to 106 hips, Incidences of type A, B, C, D and E were 16.04%, 27.36%, 34.91%, 14.15% and 7.55%, respectively. The novel classification system demonstrated a higher level of interobserver and intraobserver reliability (0.828 and 0.844).

Conclusion

This classification system, which has demonstrated moderate to strong interobserver and intraobserver reliability, may be particularly useful to accurately evaluate acetabular defects and suggest surgical strategies, as a complement to the traditional Paprosky classification system in revision THA.

Introduction

The presence of a Lisfranc injury alone is considered a surgical indication in most patients. Indications for primary arthrodesis (PA) versus open reduction internal fixation (ORIF), however, is a topic of debate among surgeons. Conflicting data exists as to which treatment modality leads to improved patient-reported outcome measures (PROMs), reoperations, and complications.

Methods

Databases queried included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their dates of inception to 3/21/2024. Studies were incorporated into this analysis if they had included patients with acute Lisfranc injuries and compared outcomes between PA and ORIF. PROMs, reoperations, and complications were captured. Results were reported as effect sizes (ES) and odds ratios (OR).

Results

There were eighteen studies included in this SRMA. Pooled data from 13/16 studies that reported AOFAS and VAS demonstrated better outcomes after PA compared to ORIF. AOFAS was 84.4 ± 28.5 after PA and 75.7 ± 29.0 after ORIF. VAS pain was 1.4 ± 2.7 after PA and 2.0 ± 3.3 after ORIF. There were 3 more studies that reported other PROMs and favored ORIF. Return to preinjury activity was 79.2% after PA and 65.7% after ORIF. The prevalence of midfoot post-traumatic arthritis was reported as 2.8% after PA and 17.3% after ORIF. Adjacent joint arthritis was not reported in the current literature. After PA, 77/438 (17.6%) patients underwent reoperations, and after ORIF, 514/802 (64.1%) patients underwent reoperations. After excluding planned hardware removals, relative rates of unplanned reoperations were 14.7% (n = 62/423) after PA and 38.3% (n = 181/472) after ORIF (p < 0.001). Non-operative complications occurred in 43/406 (10.6%) patients after PA and 95/753 (12.6%) patients after ORIF (p = 0.31). Meta-analyses demonstrated that AOFAS (ES: 0.41, CI 0.13, 0.68, p = 0.004) and VAS pain (ES: − 0.53, CI − 0.91, − 0.15, p = 0.006), and return to activity rates (OR: 2.71, CI 1.43, 6.39) favored PA over ORIF. Post-traumatic arthritis (OR: 0.29, CI 0.11, 0.77) and reoperations (OR: 0.16, CI 0.06, 0.44) were less prevalent after PA compared to ORIF.

Conclusion

This systematic review and meta-analysis suggested that PA provides better short- and medium-term outcomes in the setting of Lisfranc injuries when compared to ORIF with rigid fixation. Due to a lack of available clinical studies, the long-term effects of PA are largely unknown but may include increased adjacent joint arthritis, pain, and need for further surgery—especially in young and active patients. Future research demonstrating long-term outcomes would be helpful in clinical decision making.

Level of evidence

I.

Introduction

Increasing incidences for fragility fractures of the pelvis (FFP) have been reported and surgical treatment remains demanding. While conventional screw osteosynthesis is a common method, complications may arise due to altered bone morphology in the osteoporotic pelvic bone. The iFuse implant system is a novel implant, first introduced for treatment of degenerative sacroiliac joint dysfunction, which offers promising biomechanical characteristics with potential benefits for treatment of FFP. Yet data on the use for FFP is limited. The objective of this study is to compare early postoperative mobility of patients treated with screw osteosynthesis only versus patients treated with additional iFuse stabilization based on insole force sensor gait analysis. We hypothesized that additional iFuse implantation leads to superior postoperative mobility.

Materials and methods

In the prospective observational study, 37 orthogeriatric patients with FFP types II-IV were included. Postoperative mobility of patients treated with conventional screw osteosynthesis only (group 1) and patients with additional iFuse implantation (group 2) was compared. Mobility was examined using insole force sensors (Loadsol^®, Novel GmbH).

Results

Postoperative comparison of gait analysis showed no significant difference in average (APF) and maximum peak force (MPF) between group 1 (n = 19, APF 64.9% ± 13.3, MPF 76.0% ± 14.1) and group 2 (n = 18, APF 67.6% ± 9.9, MPF 78.2% ± 10.1). Gait symmetry measured by FTI (force–time integral) ratio was significantly higher in group 2 (48.5% ± 3.3) than in group 1 (44.9% ± 5.4; p = 0.023). Median Barthel Index was higher in group 2 (55) compared to group 1 (45), yet not significantly (p = 0.058). Postoperative pain levels showed no significant differences between both groups.

Conclusion

Comparison of early postoperative mobility showed similar mobility outcomes in both groups. Patients with additional iFuse implantation had a more balanced gait pattern, whereas no significance was found in peak force parameters. Additional iFuse implantation showed promising results regarding patient mobility, therefore our hypothesis was partly confirmed. In future long-term examinations with larger patient cohorts should be aimed for.

Introduction

There is a clear roadmap for the treatment of primary insertional Achilles tendinopathy (IAT), but data on the outcome of revision surgery is missing. The current study aimed to analyze the outcome following revision surgery for surgically failed IAT.

Material and methods

Included were patients with IAT revision surgery at a single reference center (01/2010–10/2016) and a follow-up of at least 12 months. Revision surgery was performed, whenever possible, through a midline incision transachillary approach (MITA) with debridement of all pathologies present. The patient-rated outcome was assessed per the FFI (preoperative, final follow-up) and VISA-A-G (final follow-up). The aim was to evaluate the patient rated outcome following revision surgery for recurrent IAT.

Results

Out of 24 eligible patients, 19 (79%) were included in the final follow-up. The mean follow-up duration was 4.6 ± 2.2 years. The FFI Overall improved from preoperatively 68 ± 19 to 14 ± 17 points (< 0.001) at the final follow-up. The final VISA-A-G was 71 ± 28 points. 39%/36% (FFI/VISA-A-G) of patients reached patient-rated outcome scores comparable to a healthy reference population. No factors could be identified to influence the outcome significantly.

Conclusion

IAT revision surgery results in an improvement of the patients’ symptoms, but only one-third of the patients recover fully.