Risk factors for post-traumatic osteoarthritis and subsequent total hip arthroplasty in patients with acetabular fractures

BACKGROUND

Post-traumatic osteoarthritis (PTOA) often develops after acetabular fractures, leading to a need for total hip arthroplasty (THA). This study aimed to identify the risk factors associated with PTOA and subsequent THA among patients with acetabular fractures treated with open reduction and internal fixation (ORIF).

METHODS

The records of patients with closed acetabular fractures treated at a tertiary care medical center in Taiwan from 2002 to 2019 were retrospectively reviewed. Eligibility criteria were patients who underwent ORIF with a minimum follow-up of 2 years. The primary outcomes were occurrence of PTOA and subsequent THA. Multivariate logistic regression was employed to identify significant factors associated with PTOA and THA.

RESULTS

A total of 54 patients were included, with a mean age of 41.4 years and 76% were male (n = 41). PTOA occurred in 28 patients (52%), and 13 patients (24%) required THA. Advanced age (adjusted odds ratio [aOR] = 1.05, 95% confidence interval [CI]: 1.00-1.10, p = 0.035) and a both column fracture (aOR = 12.80, 95% CI: 2.21-74.16, p = 0.004) were significant predictors of PTOA. Time to ORIF (aOR = 1.36, 95% CI: 1.06-1.75, p = 0.018) and unsatisfactory Matta criteria (aOR = 7.62, 95% CI: 1.30-44.58, p = 0.024) were significant predictors for subsequent THA.

CONCLUSION

Age and fracture pattern are independent predictors of PTOA, while time to ORIF and Matta criteria are predictive of the need for THA. Early timing of ORIF could decrease the likelihood of subsequent THA, underscoring the importance of prompt surgical intervention in clinical decision-making to optimize patient outcomes. Further research is needed to refine preoperative risk stratification and clinical management strategies for patients with acetabular fractures.

Variability in the classification, management, and outcome reporting for avascular necrosis of the femoral head: A systematic review

Introduction

There is no universally-utilized classification system for avascular necrosis of the femoral head (AVNFH), a debilitating condition that arises due to impaired blood supply resulting in cortical collapse. AVNFH may require early intervention to prevent irreversible damage leading to total hip arthroplasty. The purpose of this study is to assess the variability in classification, management, and outcomes reported in randomized controlled trials (RCTs) related to AVNFH.

Methods

PubMed, Embase, and Medline were queried for RCTs on the treatment of AVNFH (2010-2023). The number of patients, number of femoral heads, minimum follow-up, AVNFH classification system, treatment interventions, and outcome measures were extracted. Variability in classification, management approach, and reporting of outcomes was evaluated.

Results

A total of 30 RCTs met inclusion criteria, encompassing 1891 total patients. The mean number of patients in each study was 63 (SD = 41), with a mean minimum follow-up of 30 months (SD = 17). The Association Research Circulation Osseous classification system was utilized in 63 % (n = 19) of studies, Ficat and Arlet in 20 % (n = 6) of studies, Steinberg in 10 % (n = 3), Mitchell in 3 % (n = 1), and the China-Japan Friendship Hospital classifications in 3 % (n = 1). There were 61 treatment interventions, stratified into nine categories. Radiographic imaging was most commonly used to evaluate patients at follow-up.

Conclusion

There are a variety of classification systems, treatments, and outcome measures utilized in the literature to categorize and quantify AVNFH. The utilization of a universally-accepted classification system and standardized outcome reporting may help to ensure reproducibility and accuracy given a continued lack of consensus.

Lack of validated patient-reported outcome tools persists in paediatric and adolescent hip arthroscopy-A systematic review

PURPOSE

This systematic review aimed to (1) identify commonly used patient-reported outcome (PRO) tools in paediatric hip arthroscopy and (2) assess whether the PROs used in this population have been formally validated.

METHODS

Two systematic searches of MEDLINE, Embase and CENTRAL, from inception to 31 March 2024 and 22 August 2024, respectively, followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The first search identified PRO instruments used in studies on hip arthroscopy in patients aged 19 and under. The second focused on the clinimetric properties of these tools in paediatric hip arthroscopy. PRO utilization was stratified by pathology, trends over time and publication type. Use of the Consensus-based Standards for the Selection of Health Measurement Instruments tool, and a descriptive analysis, were planned to assess the eligible clinimetric studies.

RESULTS

Fifty-seven studies were included, identifying 10 hip-specific and 5 nonspecific PROs. The second search did not identify any clinimetric studies on these tools used in paediatric patients. The most commonly reported hip-specific PRO were the modified Hip Harris Score (n = 48), the Hip Outcome Score-Sport-Specific Subscale (n = 25) and the Non-Arthritic Hip Score (n = 20). Hip arthroscopy was used to treat over seven different conditions, with femoroacetabular impingement being the most common (n = 41, 77%). Between 2005 and 2024, the variety of hip-specific PROs increased, with seven new ones introduced by 2019-2024. Additionally, this study found a relatively equal distribution of outcomes across presentation abstracts and manuscripts.

CONCLUSIONS

The key finding of this study is the ongoing lack of hip-specific PRO tools in the paediatric hip arthroscopy literature, with reliance on adult-derived instruments. The absence of clinimetric studies and heterogeneity in PRO use emphasises the need for standardized, paediatric-specific tools. Developing and validating such instruments should be prioritized to ensure accurate, age-appropriate outcome assessment and care.

LEVEL OF EVIDENCE

Level III.

Pelvis/acetabulum: management of geriatric injuries

Geriatric pelvic and acetabular fractures pose significant challenges due to patient frailty, comorbidities, and the complexity of fracture patterns. This review examines current evidence and evolving strategies for managing these injuries. Treatment approaches range from nonoperative management to surgical interventions, including percutaneous fixation, open reduction and internal fixation (ORIF), and total hip arthroplasty, either as a standalone procedure or combined with ORIF. Decision making is guided by fracture morphology, patient functionality, and physiological reserve to optimize clinical outcomes. Minimally invasive techniques, particularly for fragility fractures of the pelvis, have gained traction because of their ability to provide stable fixation while minimizing surgical morbidity. The importance of early mobilization and a multidisciplinary perioperative approach is highlighted as essential in reducing complications and improving recovery. Despite advancements, controversy remains regarding the optimal treatment of complex acetabular fractures in elderly patients. This review synthesizes the latest evidence and expert perspectives to aid clinicians in selecting the most appropriate management strategies, with the goal of restoring mobility, minimizing complications, and enhancing the quality of life in this vulnerable population.

Chronically increased osteoclastogenesis in adult celiac disease patients does not hinder improvement in bone health induced by gluten-free diet: Role of vitamin D, OPG and IL-6

The etiology of bone loss in celiac disease (CeD) remains a clinical challenge, with uncertainties present such as the extent of involvement of malabsorption and inflammation-induced osteoresorption processes in development of osteopenia/osteoporosis (OPN/OP), or reasons for failure to achieve healthy bone mass (BMD) even after long-term gluten-free diet (GFD) treatment. This observational prospective study explores the in vitro osteoclastogenic potential of peripheral blood precursors originating from adult active (newly diagnosed and untreated) celiac disease patients (aCeD) and describes the longitudinal changes in osteoclastogenesis after long-term adherence to GFD. To find connections between in vitro observations and in vivo bone metabolism changes, serum levels of 25(OH)D3, PTH, bCTX, PINP, CRP, IL-6, RANKL and OPG were measured before and after GFD and levels of these markers were correlated with the rate of osteoclastogenesis in vitro. OPG and IL-6 showed associations with BMD and/or presence of OPN/OP. Patients after GFD (CeD-GFD) exhibited improved BMD and increased serum 25(OH)D3 levels, alongside reduced bCTX and PINP levels. Compared to healthy donors, aCeD osteoclast genesis in vitro was higher and, surprisingly, remained elevated even in CeD-GFD patients. Negative correlation was found between osteoclastogenesis rate and serum OPG in aCeD, while osteoclastogenesis rate positively correlated with PTH in CeD-GFD. These results highlight OPG as marker for risk of OPN/OP in CeD and suggest that improvement of BMD after GFD is a result of uncoupling between bone metabolism and osteoresorptive action of osteoclasts after GFD.

Acromioclavicular dislocation associated with fracture of the coracoid process: a series of cases and review of the literature

PURPOSE

Complete acromioclavicular (AC) dislocation associated with fracture of the coracoid process (CP) is uncommon. The strong coracoclavicular ligaments, instead of rupture, may avulse the CP near its base, and with disruption of the AC joint may allow complete dislocation of the clavicle. We report ten cases, one of the largest series in literature, and reviewed the findings and treatment previous reported cases, to allow potential readers to establish the most appropriate treatment.

METHODS

We have prospectively collected those cases in which we had identified an association of an AC dislocation with a fracture of the CP, as well as retrospectively reviewed the records that were coded as AC dislocations and CP fracture looking for this association in the senior author institutions. A literature search was completed on PubMed, Web of Science and Scholar Google, using a sensitive search strategy.

RESULTS

We have collected a total of ten patients with the association of a CP fracture to an AC dislocation in a period of twenty-five years. A review of the cases reported in literature shows a great variability in treatment methods from conservative to more surgically in recent years.

CONCLUSIONS

When an AC dislocation is identified by clinical examination and X-rays, one should be aware of a possible fracture of the CP. It is possible this association to be more frequent than shown in literature because of the CP fracture can easily be missed out or mistaken with an unfussed epiphysis in routine anteroposterior radiography. Multiple approaches have been opted for by surgeons to deal with this combined injury and are the basis of this review.

Knowledge mapping of core decompression in osteonecrosis of the femoral head: a bibliometric analysis

Background

Osteonecrosis of the femoral head (ONFH), caused by disrupted blood supply leading to bone cell death and joint collapse, remains a critical orthopedic challenge. While core decompression has advanced significantly in ONFH treatment, no bibliometric analysis has mapped its research landscape.

Method

We analyzed 854 articles from the Web of Science Core Collection (1986-2023) using VOSviewer, CiteSpace, and bibliometrix.

Results

Publications surged from 5.4/year (1986-2001) to 52.3/year (2015-2023), reflecting intensified interest. China (253 articles, 29.6%) and the United States (232, 27.2%) dominated contributions, with Stanford University and Johns Hopkins University as top institutions. International collaborations linked China to the United States, Germany, and England. Clinical Orthopaedics and Related Research was the most cited journal (4708 citations). Keyword analysis revealed emerging hotspots: mesenchymal stem cells (19 occurrences), cell therapy, and angiogenesis. Citation bursts highlighted Mont MA's seminal work (burst strength: 19.67) on joint-preserving strategies and stem cell-enhanced core decompression.

Conclusion

This first bibliometric study delineates trends, collaborations, and frontiers in core decompression for ONFH, emphasizing the translational potential of stem cell therapies.

Reconstruction of unfixable comminuted posterior wall acetabular fractures with autologous bone graft: A systematic review

Background

Posterior wall acetabular fractures, often caused by high-energy trauma, are complex injuries that pose significant surgical challenges, especially when comminuted. Traditional fixation techniques have shown variable outcomes, with severe comminution sometimes rendering fragment fixation impossible. The aim of this study was to evaluate the clinical and radiological outcomes of autologous bone grafting for reconstructing severely comminuted unfixable posterior wall acetabular fractures.

Materials and methods

A systematic review was conducted in accordance with the PRISMA guidelines. The search for clinical studies was carried out across four databases: Embase, PubMed, Medline, and Scopus. The included studies were evaluated using the Coleman Methodology Score. The present study protocol was registered in PROSPERO.

Results

The study involved 71 patients, with an average age of 37.12 years. Autologous iliac crest grafts were predominantly used, with the Kocher-Langenbeck approach in all cases. Clinical outcomes, assessed by Merle d'Aubigne and Harris Hip Scores, showed 78.9 % of patients reporting excellent to good results. Radiological outcomes indicated 66 % with excellent results per Matta's score. The overall success rate ranged from 57 % to 100 %, with a 5 % conversion to total hip arthroplasty. Complications were reported in 7 % of cases, including nonunion and avascular necrosis.

Conclusion

Autologous bone grafts for comminuted, non-fixable posterior wall acetabular fractures may be considered as a potential salvage option in young patients, potentially delaying the need for THA.

In-Hospital mortality in Spondylodiscitis: Risk factors assessed through the National Inpatient Sample analysis

OBJECTIVE

Spondylodiscitis (SD) poses an increasing challenge to healthcare providers by its insidious onset and diverse clinical manifestations, concurrent with an aging population, immunocompromising conditions and various influencing comorbidities. Overall mortality remains relatively high, up to 7.3%, despite advancements in diagnostics and treatment. Past studies have struggled to differentiate leading causes for mortality. With this study we want to utilize the large data group available through the National Inpatient Sample (NIS) to assess the in-hospital mortality in patients with SD in different age-groups and to identify risk factors.

METHODS

Utilizing the 2020 NIS, Healthcare Utilization Project (HCUP) adults (>18 years) were screened using the primary diagnosis of SD by ICD-10 Code (M46.2x, M46.3x and M46.4x). Demographic information, admission details, clinical data, comorbidities, and surgical treatment were extracted using the Clinical Classifications Software Refined (CSSR) categories. Comorbidities include pre-existing conditions and those acquired during hospitalization. Age was categorized into 3 groups (<65 years; 65-79: ≥ 80). The primary outcome was in-hospital mortality, with multivariable logistic regression analysis used to identify independent risk factors.

RESULTS

In total 3,975 patients met our inclusion criteria resulting with an in-hospital mortality rate of 0.9 %. The mortality group was significantly older (70.86 years to 58.74 years compared to the survival group) with elective admission being more common (p=<0.001) with a similar sex distribution. Patients ages 65-79 were more common in the mortality group. Overall fourteen comorbidities differed significantly between the two groups. Chronic diseases were more common in the mortality group, whereas alcohol and substance abuse were more prevalent in the survival group. Age, especially patients < 65 years, elective admission status, paralysis and pneumonia were identified as independent risk factors for mortality.

CONCLUSION

Management of SD remains complex. Our study revealed a lower rate of in-hospital mortality and length of stay than previous studies. Elective admission status was the strongest predictor of mortality, highlighting the benefits of early diagnosis and treatment. Patients > 65 years, especially octogenarians, were identified to be particular at risk. Risk factors contributing to mortality in SD may differ from etiological risk factors, highlighting areas for potential further research.

Editorial Commentary: Meniscus Allograft Transplantation With Concomitant High Tibial Osteotomy and Cartilage Restoration Risks Reoperations and Potential Worsening Outcomes Following Subsequent Total Knee Arthroplasty

The management of the 25- to 45-year-old patient with meniscal deficiency, chondral degeneration, and pain remains challenging. With the potential of a knee replacement in the future, the question I wrestle with is, "When is enough enough?" Meniscus allograft transplantation, when combined with osteotomy and/or cartilage restoration procedures, improves functional outcomes compared to preoperative levels but has not been demonstrated to delay progression of osteoarthritis and often leads to reoperations. Moreover, concomitant procedures do not show improved survivorship of the meniscal allograft. While many undergoing these procedures return to active lifestyles, many do not return to preinjury levels. Balanced clinical-patient discussions are needed about the benefits, limitations, and expectations of meniscus allograft transplantation and associated procedures on not only the current condition of the knee but also the future implications, including reoperations and potential worsening outcomes following total knee arthroplasty. Notably, meniscal allograft transplantation and concomitant procedures lead to additional surgeries, with up to a 59% reoperation rate at an average of 43 months. In some, more surgery does not necessarily lead to improved outcomes, and caution should be exercised; only 44% return to preinjury activity level after meniscus allograft transplantation and high tibial osteotomy. Forty percent are disappointed by level and type of sports participation following meniscus allograft transplantation, but only 14% of those patients would not undergo the procedure again.

Patients Have Acceptable Patient-Reported Outcome Measures After Medial Unicompartmental Knee Arthroplasty Regardless of Age

BACKGROUND

Contemporary evidence-based indications no longer consider age regarding eligibility for medial unicompartmental knee arthroplasty (mUKA). This has led to more surgical candidates; however, whether patients still have satisfactory outcomes lacks evidence. This study examined the association between age and change in patient-reported outcome measures after mUKA as well as the achievement of patient acceptable symptom state (PASS) and minimal important change (MIC).

METHODS

We included 782 mUKAs performed between February 1, 2016, and April 26, 2023. The mean change from preoperative Oxford knee score (OKS), forgotten joint score (FJS), and activity and participation questionnaire (APQ) was assessed at 3, 12, and 24 months after surgery, respectively. The achievement of 12-month PASS (OKS ≥ 30) and MIC (changes in OKS ≥ 8; FJS ≥ 14) was also assessed. Patients were divided into the following age groups: <55, 55 to < 65, 65 to < 75 years (reference group), and ≥ 75 years. There were 432 women (55%), and patients had a mean age of 67 years (range, 29 to 93) and a mean body mass index of 30 (range, 20 to 53).

RESULTS

Median OKS, youngest to eldest, were 34, 35, 36, and 35 (3 months); 40, 39, 41, and 43 (12 months); 42, 41, 43, and 42 (24 months), respectively. We found no differences in change in OKS between groups. Patients aged 55 to < 65 years had lower changes in FJS at 24 months and APQ at 12 and 24 months. Patients ≥ 75 years had lower 24-month changes in APQ. We found no association between age and the fraction achieving either PASS or MIC (youngest to eldest, 90, 90, 94, and 95%).

CONCLUSIONS

We found good patient-reported outcome measures improvements and satisfactory outcomes after mUKA in all age groups; however, patients aged 55 to < 65 years had worse changes in FJS and APQ. Results support contemporary indications for mUKA, and applying an age cutoff is unwarranted.

Gut and Joint Microbiomes: Implications in Osteoarthritis

This review summarizes and discusses key recent findings suggesting that microbiomes can play a role in the development and progression of osteoarthritis. Evidence supporting a gut microbiome-joint connection derived from human and animal studies is enumerated and discussed, with particular attention on the microbial and molecular basis for the development of therapeutic interventions that involve targeting the gut. Additionally, clinical data supporting the concept of a living microbiome within a diarthrodial joint are summarized. A discussion of key limitations in the current data and important technical considerations for firmly establishing the existence of a synovial joint microbial community is included.

The KNEE study: A prospective multicentre observational study of 459 fractures around the knee in older patients

BACKGROUND

The KNEE Study is a prospective multicentre service evaluation examining the current UK management of fragility fractures around the knee. It aims to describe operative decision making, causes of treatment delays, weight-bearing strategies, and post-operative management.

METHODS

Data were prospectively collected across a 4-month period via a collaborative approach. All patients aged >60 with a fracture of the proximal tibia or distal femur were included. Data collected include injury classification, operative vs non-operative management, time to theatre, post-operative weight bearing, and post-operative optimisation as per BOAST guidelines for frail older patients.

RESULTS

Data were available for 459 patients across 39 centres. This included 252 distal femoral fractures, and 207 proximal tibial fractures. Distal femoral fractures were significantly older (81.5 vs 73.3), had poorer mobility (42 % mobile ≤1 stick vs 79 %), and were more comorbid (median charlson co-morbidity index 5 vs 3) than proximal tibial fractures. Operative management was undertaken in 292/459 cases (198/252 femur, 94/207 tibia). When operative management was undertaken, there was a delay >36 hours to theatre in 62.8 % of cases. The main reasons for this were theatre capacity (42.6 %) and availability of a specialist surgeon (25.1 %). Only 11.5 % of cases were delayed pending medical optimisation or anticoagulant reversal. Patients managed operatively were significantly more likely to weight-bear on the first day post treatment (69.5 % vs 55.8 %). Operatively managed patients were significantly more likely to receive post-operative standards of care including Geriatric review, physio assessment, and bone health assessment.

CONCLUSION

Early return to weight bearing and ongoing secondary prevention are core tenants in the management of fragility fractures. Management of fragility fractures around the knee continues to lag behind that of hip fractures, with lower rates of weight bearing, slower access to theatre, and poorer post-operative care.

Comparative efficacy of platelet rich plasma, hyaluronic acid, and corticosteroid injections in adhesive capsulitis management: A meta-analysis

OBJECTIVE

To compare the efficacy of platelet-rich plasma (PRP) and hyaluronic acid (HA) against corticosteroid injections in adult patients with adhesive capsulitis (AC), in impacting pain relief and range of motion (ROM).

LITERATURE SURVEY

A systematic review was conducted between January and February 2024 through PubMed and Google Scholar using the following keywords: "PRP," "Hyaluronic Acid," "Bone Marrow Aspirate," "Frozen Shoulder," "Periarthritis," "Adhesive Capsulitis," and "Corticosteroid Injections." Inclusion criteria were studies published between January 2019 and February 2024 and used corticosteroids as a comparison for orthobiologic treatment. The initial search yielded 47 studies, refined to 21 after applying eligibility criteria. Ultimately, six studies were selected.

METHODOLOGY

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, a Cochrane Risk of Bias analysis was performed, and data were independently extracted by multiple authors. A meta-analysis was conducted to compare the efficacy of PRP and HA against corticosteroids measured by visual analog scale (VAS), Shoulder Pain and Disability Index (SPADI), Disabilities of the Arm, Shoulder, and Hand (DASH), and UCLA Shoulder scores.

SYNTHESIS

Qualitatively, studies with 3 months or longer patient follow-ups demonstrated better long-term efficacy in pain reduction and ROM improvement with PRP or HA injections. A 6-month improvement in pain as measured by VAS had a significant standardized mean difference (SMD) of -1.31 (95% confidence interval [CI], -1.56 to 1.04). There were significant improvements in functional outcomes at 6 months in DASH (SMD of -1.23 [95% CI, -1.71 to -0.74]) and UCLA Shoulder scores (SMD of 0.74 [95% CI, 0.47-1.00]): No significant differences were observed in 3-month outcomes: DASH (SMD of -0.12 [95% CI, -0.54 to 0.30]) and SPADI scores (SMD of -0.34 [95% CI, -0.78 to 0.10]). Cochrane analysis identified one study with high risk of bias.

CONCLUSIONS

The review highlights orthobiologics as a promising alternative to corticosteroid injections in managing AC, with PRP providing more long-term pain relief compared to corticosteroid injections. Improvements in shoulder ROM were also seen but require further studies to determine their significance. However, substantial heterogeneity (I2 > 50) was observed, underscoring the need for future research to standardize methodologies and improve consistency.

10-year follow-up results of the initial application of 3D-printed percutaneous guides in drilled decompression of femoral head necrosis

OBJECTIVE

To explore the feasibility and clinical significance of computer-aided design 3D-printed percutaneous guides in femoral head necrosis drilling and decompression surgery, and compare it with traditional surgery under fluoroscopy. The study also reports the results of follow-up after 10 years.

METHODS

A retrospective study was conducted on patients with femoral head necrosis who had undergone drilling decompression surgery from November 2011 to November 2015. There were 15 patients in the guide group and 15 patients in the control group, and all of them were followed up for 5 to 10 years after the surgery. All patients were staged according to ARCO staging based on imaging manifestations. The guide group used 3D-printed percutaneous guides designed with computer-aided design and printed using 3D printing technology, while the control group used traditional fluoroscopy for guidance. The study compared operative time, number of fluoroscopies, and guide needle adjustments.

RESULTS

The baseline data did not differ statistically significantly. The guide group had significantly shorter operative times, fewer fluoroscopies, and fewer guide needle adjustments compared to the control group. The average operative time in the guide group was 27.8 min, with 11.2 fluoroscopies and 1.2 guide needle adjustments, while the control group had an average operative time of 44.4 min, with 34.4 fluoroscopies and 3.4 needle adjustments. There was no significant difference in preoperative Harris scores between the two groups, but both groups showed significant improvement in postoperative Harris scores. After 10 years, the guide group had fewer cases of femoral head necrosis progressing to advanced ARCO stages III or IV, and fewer cases requiring total hip arthroplasty compared to the control group.

CONCLUSION

The use of computer-aided design 3D-printed percutaneous guides in femoral head necrosis drilling and decompression surgery is feasible and clinically significant. It reduces operative time, fluoroscopy, and guide needle adjustments, and is more effective in preventing the progression of femoral head necrosis to advanced stages compared to traditional surgery under fluoroscopy.

Efficacy and safety of platelet-rich plasma combined with core decompression and enhanced bone grafting versus core decompression with enhanced bone grafting alone in treating femoral head necrosis: a systematic review and meta-analysis

BACKGROUND

The efficacy and safety of platelet-rich plasma (PRP) combined with core decompression (CD)-enhanced bone grafting for the treatment of osteonecrosis of the femoral head remains controversial. This study aimed to conduct a systematic review and meta-analysis of the efficacy and safety of PRP combined with CD-enhanced bone grafting for treating osteonecrosis of the femoral head and to compare this method with CD-combined bone grafting as a way to provide theoretical bases for future clinical treatments and research.

OBJECTIVE

This study aimed to assess the improved efficacy and safety of core decompression combined with platelet-rich plasma-enhanced bone grafting for osteonecrosis of the femoral head compared to core decompression-enhanced bone grafting.

METHOD

We systematically searched several databases for randomised controlled trials comparing bone graft and core decompression with or without PRP, including 16 studies involving 999 subjects and 1139 hip cases. This meta-analysis followed the Preferred Reporting Items (PRISMA) guidelines. The study is registered with PROSPERO under code CRD42024557968.

RESULT

16 articles involving 999 patients (1139 hips) were included in this study. Pooled analyses demonstrated that when core decompression-enhanced bone grafting was combined with PRP, the Harris hip score (mean difference [MD]: 5.26, 95% Cl:4.81-5.71; P < 0.00001), visual analog scale (MD: -0.74, 95% Cl:-0.99 - -0.49; P < 0.00001) and reduction in the need for THA: (risk ratio [RR]: 0.29; 95% Cl:0.16-0.53; P < 0.0001) were superior to core decompression-enhanced bone grafting alone. Furthermore, a pooled analysis confirmed the safety of PRP [RR:0.33; 95% Cl:0.13-0.83; P = 0.02]. All these results were statistically significant.

CONCLUSION

Compared to CD-enhanced bone grafting, the combination of PRP appears to yield superior therapeutic outcomes in restoring hip function, alleviating pain, preventing THA, and ensuring postoperative safety. Moreover, we require a higher level of randomised controlled trials to evaluate its efficacy and safety.

Nutritional status reshapes gut microbiota composition in adolescent Afghan refugees in Peshawar, Pakistan

Although the human gut microbiome, and its role in health and disease, have been extensively studied in different populations, a comprehensive assessment of gut microbiome composition has not been performed in vulnerable refugee populations. In this study, we hypothesized that overall nutritional status, as indicated by serum micronutrients concentrations, is an important driver of variations in gut microbiome composition. Therefore, gut-microbiome diversity and associated demographic, health and nutritional factors were assessed in adolescent Afghan refugees (n=206). Blood and faecal samples were collected and analysed for nutrition status markers and 16S rRNA gene amplicon-based community profiling, respectively. Bioinformatics and statistical analysis were performed using SPSS, QIIME and R. Overall, 56 distinct phyla, 117 families and 252 genera were identified in the faecal samples. Bacterial diversity (alpha and beta diversity) and the Firmicutes:Bacteroidetes (F/B) ratio were significantly higher in the 15 to 19 year old age group (cf. the 10-14 age group) but were lower in the underweight and vitamin D deficient groups. Furthermore, LEfSe analysis identified significant differences in the relative abundance of bacterial genera based on age, BMI and micronutrient (vitamins and minerals) status. These results were further scrutinised by correlation analysis which confirmed that age, BMI and micronutrient status show significant correlations with F/B ratio and the relative abundance of specific bacterial taxa. Collectively, our study provides the first indication of how the gut-microbiota profile of adolescent Afghan refugees is associated with a range of nutrition-status factors. These findings can thus provide a basis for translational microbiota research aimed at improving the health of such understudied and vulnerable populations.

Increasing incidences of acetabular, pelvic, and proximal femur fractures in The Netherlands

PURPOSE

This study aims to investigate incidence rates of acetabular, pelvic, and proximal femur fractures in The Netherlands over a 10-year period (2012-2022). With an aging population, understanding trends in these osteoporotic fractures is essential for improving patient outcomes and guiding healthcare strategies.

METHODS

A retrospective cohort study was conducted using data from two national databases, forming a 'hospitalised' and an 'all patients' cohort. The study population included patients diagnosed with acetabular, pelvic, and proximal femur fractures in The Netherlands during the study period. Incidence rates were calculated per 100,000 person-years and linear regression was used to assess temporal trends. Age-adjustments were performed using Dutch population data from the Central Bureau of Statistics (CBS). Comparative analyses between the two cohorts were conducted to identify discrepancies.

RESULTS

A total of 283,991 patients were identified (12,020 acetabular, 70,595 pelvic and 201,376 proximal femur fractures). Of these patients, 159,563 were hospitalised (7123 acetabular, 24,192 pelvic, and 128,252 proximal femur fractures). Incidence rates of acetabular fractures increased by 26 % (hospitalised) and 98 % (all patients), while pelvic fractures showed stagnation in hospitalised patients (-0.13 %) but a 44 % rise in all patients. Proximal femur fractures increased by 5 % (hospitalised) and 15 % (all patients). Significant differences between the databases were noted across all fracture types.

CONCLUSION

The incidence of acetabular, pelvic, and proximal femur fractures has significantly increased in the last decade, most notably in acetabular and pelvic fractures. Furthermore, a shift toward out-patient treatment of acetabular and pelvic fractures was found. These findings highlight the need for improved fracture prevention and out-patient management strategies, while also underscoring the need for a nationwide registration for these injuries.

Cross-cultural adaptation and validation of the Vietnamese version of the Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients with knee osteoarthritis

Background

Knee osteoarthritis (KOA) is common in Vietnam, affecting about 34 % of individuals over 40 years of age. The Knee Injury and Osteoarthritis Outcome Score (KOOS) is an internationally recognized patient-reported outcome used to assess the impact of KOA but it is not yet available in Vietnamese.

Objective

This study aimed to translate the KOOS into Vietnamese and assess the psychometric properties of the translation (KOOS-V).

Methods

The translation process involved forward/back translation, expert review and cognitive interviews for pretesting. Content validity was assessed by seven experts using the Content validity Index (CVI). A sample of 133 Vietnamese KOA patients (mean age: 63.7 years, 83 % female) completed the KOOS-V, Short Form 36 Health Survey (SF-36) and Numeric Pain Rating Scale (NPRS), and 67 of them were re-assessed after 5-8 days. Psychometric analyses included internal consistency, test-retest reliability, construct validity and cross-cultural comparison of KOOS-V subscales.

Results

KOOS-V exhibited excellent content validity (CVI = 0.86-1.00), satisfactory internal consistency (Cronbach's α = 0.70-0.98) and good to excellent test-retest reliability (ICC = 0.77-0.90). Construct validity was confirmed by moderate to strong correlations with SF-36 Physical Functioning (Spearman's ρ = 0.66 to 0.82) and moderate correlations with NPRS (ρ = -0.49 to -0.62). The cross-cultural comparison showed that the KOOS subscales in Vietnam presents the same challenge as in other cultures.

Conclusions

The KOOS-V is a reliable, valid tool for assessing the functional impact of KOA in Vietnamese patients, contributing to its broader use worldwide in clinical and research settings.

Biomechanical comparison of different double plate constructs for distal supracondylar comminuted femur fractures (AO/OTA 33-A3)

INTRODUCTION

Dual plating for distal femoral fractures, especially with a metaphyseal comminution, is biomechanically superior compared to single lateral plating, promotes fracture union and prevents complications. However, the optimal placement and length of the additional medial plate are still unknown. Thus, we aimed to biomechanically compare three different double plate constructs for distal femoral fractures.

MATERIALS AND METHODS

A distal femoral fracture with a metaphyseal comminution (AO/OTA 33-A3) was created in synthetic femora and stabilized according to the following groups of 6 specimens each: Single lateral plate (SP), double plate with anteromedial oblique locking plate (DPOB), double plate with parallel medial locking plate with 4 screws (DP4S) and double plate with parallel medial locking plate with 6 screws (DP6S). Afterwards, the femora were tested axially with a quasi-static load of 400 N as well as torsionally with 5 Nm of internal and external rotation. Interfragmentary motion and rotation were measured with an optical 3D motion analysis system.

RESULTS

Fracture gap motion and varus-valgus tilt under axial testing were significantly lower with DPOB, DP4S and DP6S than with SP (p = 0.02) without a significant difference between the double plate constructs. DP4S and DP6S showed a significant lower anteroposterior tilt under axial loading than SP (p = 0.02), whereas DPOB showed no significant difference compared to SP but had a significantly higher anteroposterior tilt than DP6S (p = 0.02). Under internal and external rotation testing, anteroposterior shift was significantly different, and axial rotation was significantly lower with DPOB, DP4S and DP6S compared to SP (p = 0.02) without a significant difference between the double plates.

CONCLUSION

Dual plating is biomechanically superior under axial and torsional loading compared to the traditional single lateral plating for distal femoral fractures with metaphyseal comminution. A parallel arrangement of double plates is biomechanically more effective in resisting anteroposterior tilt, whereas the length of parallel medial plates (with 4 or 6 screws) has no influence on the biomechanical performance.

Arthroscopy Within Three Months Prior to Unicompartmental Knee Arthroplasty Is Associated With an Increased Rate of Periprosthetic Joint Infection

BACKGROUND

Arthroscopy remains a commonly performed procedure in patients who have meniscal or other osteochondral pathology prior to ultimately being indicated for unicompartmental knee arthroplasty (UKA). The purpose of this study was to examine the timing of knee arthroscopy prior to UKA and its association with 2-year periprosthetic joint infection (PJI) rates and medical and surgical complications.

METHODS

Patients undergoing UKA who had history of ipsilateral arthroscopy within 2 years prior to the UKA were identified in a national insurance database. A control cohort of propensity matched patients who did not have a history of arthroscopy was identified. Study cohorts were established based on timing of the arthroscopic procedure: 0 to 3, 3 to 6, 6 to12, and 12 to 24 months prior to UKA. Patients were included if they had 2-year postoperative follow-up after UKA. The 90-day rates of postoperative medical and 2-year surgical complications were recorded. Multivariate analysis was conducted to account for confounding variables and covariates.

RESULTS

A final cohort of 3,471 patients met inclusion criteria. Patients undergoing UKA within three months of the arthroscopic procedure demonstrated a higher incidence of PJI when compared to the control cohort (3.30 versus 1.12%, P = 0.012). In addition, there was an increased rate of periprosthetic fracture observed in those undergoing UKA within three months of arthroscopy when compared to the control (1.10 versus 0.20%, P = 0.010).

CONCLUSIONS

Patients undergoing ipsilateral arthroscopy within three months of a UKA demonstrated a nearly 3-fold increased incidence of PJI when compared to the control. There was no increased incidence of PJI when UKA was staged greater than three months after arthroscopy. These findings provide insight for preoperative considerations for arthroplasty surgeons in this patient population.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Patellar bone defect grafting does not reduce anterior knee pain after bone-patellar tendon-bone anterior cruciate ligament reconstruction

PURPOSE

Donor site morbidity is the main drawback to using bone-patellar tendon-bone (BPTB) as a graft in anterior cruciate ligament (ACL) reconstruction. The objective of the study was to determine whether refilling the patellar bone defect after BPTB harvesting with autograft bone decreased kneeling pain to a greater degree when compared with a group in which bone defect is left unaddressed.

METHODS

This is a randomised single-blinded controlled study. Forty patients were randomised into two groups; group 1: Patellar bone defect filled with autologous bone; group 2: Bone defect left undressed. Pain was measured by means of pressure algometry (PA). Functional outcomes were measured with the Kujala and Victorian Institute of Sport Assessment-Patella (VISA-P) score. Magnetic resonance imaging (MRI) was done to measure bone buildup between groups at the 1-year follow-up.

RESULTS

No differences were observed in the different algometry measurements and the scores were assessed at 3, 6 and 12 months postoperatively. The ratio of void filled remained consistently higher (p = 0.003) in group 1 when compared to group 2.

CONCLUSIONS

Although refilling the lower pole of the patella with autologous bone from the harvested BPTB autograft loads the bone defect, it does not reduce pain at the donor site 1 year after surgery.

LEVEL OF EVIDENCE

Level 1, therapeutic study.

Complications following total knee arthroplasty in patients with prior extensor mechanism dysfunction: A retrospective review

Background

Extensor mechanism disruption following total knee arthroplasty (TKA) is a rare, yet serious complication. While previous patellar abnormalities are a theoretical risk factor for this complication, there is a scarcity of literature describing the impact of prior extensor mechanism dysfunction (EMD) on this and other complications following TKA. In this study, we describe our institutional experience with complications following TKA after EMD.

Methods

Sixty-one knees that underwent total knee arthroplasty between April 2007 and April 2023 in patients with previous EMD were identified. Extensor mechanism dysfunction types included patellar fracture, patellar tendon rupture, patellar realignment surgery, previous patellar dislocation, and a chronic laterally tracking patella impacting extensor mechanism function. Primary outcomes included extensor mechanism failure, infection, dislocation, aseptic loosening, revision surgery, and stiffness requiring manipulation under anesthesia (MUA).

Results

A total of 61 knees, comprised of 53-patients, were included. There were complications witnessed in fifteen patients, leading to a 24.6 % overall complication rate. There was one extensor mechanism disruption in the form of a partial quadriceps tendon tear requiring repair. There was one patellar dislocation requiring reoperation. There were five superficial infections successfully treated non-operatively and four deep infections requiring reoperation. A total of nine reoperations were performed, four of which were revisions. Four patients underwent MUA due to severe post-operative stiffness.

Conclusion

In this study, we found a high complication rate following TKA in patients with previous extensor mechanism dysfunction. There was one case of partial quadriceps tendon rupture requiring repair.

Temporal and regional trends of fractures in the United States: A review of the global burden of disease database

Background

Musculoskeletal diseases, including bone fractures, are a significant contributor to global disability. Understanding temporal and regional trends in bone fractures is crucial for effective healthcare planning and resource allocation. We sought to analyze recent epidemiological trends of different types of fractures in the United States and determine correlations and associations between fracture trends and potential influencing demographic factors (i.e. age, sex, regional-specific).

Methods

Data from the Global Burden of Disease Database were analyzed to examine fracture incidence, prevalence, and years lived with disability (YLDs). Statistical analyses were conducted to determine temporal trends and sex-based differences.

Results

The analysis revealed significant increases in hip fractures and decreases in pelvic fractures over time. Fractures of the patella, tibia, fibula, and ankle remain prevalent across all regions and sexes, with notable variations.

Conclusions

These findings underscore the importance of targeted interventions and resource allocation to address the burden of fractures on public health. Despite limitations, this study provides critical insights into fracture epidemiology, guiding future prevention and management strategies.

Patient-specific factors associated with conservative treatment failure in de Quervain tenosynovitis

Introduction

Most patients with de Quervain tenosynovitis are well managed with nonsurgical treatments, however, wrist pain persists or recurs in some patients, affecting activities of daily living. This study aimed to identify patient-specific factors associated with persistent or recurrent symptoms after conservative treatment of de Quervain tenosynovitis.

Methods and materials

We retrospectively collected data from patients with de Quervain tenosynovitis who had been conservatively treated. The failure group comprised 28 patients who had received surgical intervention and had persistent or recurrent symptoms for >1 year. The improvement (control) group included 84 patients who experienced pain relief and regained thumb abduction and extension function. We used multivariable logistic regression to assess patient factors including age, sex, body mass index, history of smoking, and comorbidities, namely diabetes mellitus, hyperlipidaemia, psychiatric illness, trigger finger, carpal tunnel syndrome, and osteoarthritis of the wrist.

Results

In univariate analysis, body mass index, diabetes mellitus, trigger finger, and carpal tunnel syndrome were significantly different between the failure and improvement groups. The multivariable analysis identified diabetes mellitus as an independent patient-specific factor significantly associated with the failure of conservative treatment.

Conclusions

Patients with diabetes mellitus are more likely to require surgical intervention and have persistent or recurrent symptoms following conservative treatment for de Quervain tenosynovitis.

Total Knee Arthroplasty in Pseudarthrosis of Hoffa Fracture: A Case Report

CASE

A 55-year-old woman presented with chronic left knee pain and functional disability 1 year after nonoperative treatment of Hoffa fracture of lateral femoral condyle, due to pseudarthrosis and consequent knee osteoarthritis. She underwent single-stage fracture fixation and primary total knee arthroplasty with successful outcome at her 4-year follow-up.

CONCLUSION

The combination of Hoffa fracture fixation and primary total knee arthroplasty can achieve satisfactory results in terms of pain relief, functional improvements, and avoid complications related to a 2-stage procedure. This case report highlights total knee replacement after nonunion of Hoffa fracture and reviews the literature.

The Gut Microbiome and Joint Microbiome Show Alterations in Patients With Knee Osteoarthritis Versus Controls: A Systematic Review

PURPOSE

To assess the current scientific literature on the microbiome's relation with knee osteoarthritis (OA), with specific focuses on the gut microbiome-joint axis and joint microbiome-joint axis.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines; the PubMed, Embase, and Cochrane databases were searched for relevant English-language clinical studies on the gut and/or joint microbiomes' association with knee OA in humans. Bias was evaluated using the Methodological Index for Non-randomized Studies score.

RESULTS

Thirty-five thousand bacterial species comprise the gut microbiome; approximately 90% are members of the phyla Bacteroides and Firmicutes. Symbiosis between the gut microbiome and host under normal physiological conditions positively affects host growth, development, immunity, and longevity. Gut microbiome imbalance can negatively influence various physiological processes, including immune response, inflammation, metabolism, and joint health including the development of knee OA. In addition, next-generation gene sequencing suggests the presence of microorganisms in the synovial fluid of OA knees, and distinct microbiome profiles detected are presumed to play a role in the development of OA. Regarding the gut microbiome, consistent alterations in microbial composition between OA patients and controls are noted, in addition to several associations between certain gut bacteria and OA-related knee pain, patient-reported outcome measure performance, imaging findings, and changes in metabolic and inflammatory pathways. Regarding the joint microbiome, studies have revealed that increased levels of lipopolysaccharide and lipopolysaccharide-binding protein in synovial fluid are associated with activated macrophages-and are correlated with worsened osteophyte severity, joint space narrowing, and pain scores in knee OA patients. In addition, studies have shown various microbial composition differences in OA patients compared with controls, with certain joint microbes directly associated with OA pathogenesis, inflammation, and metabolic dysregulation.

CONCLUSIONS

The gut microbiome-joint axis and joint microbiome show alterations in microbial composition between patients with OA and controls. These alterations are associated with perturbations of metabolic and inflammatory pathways, imaging findings, OA-related pain, and patient-reported outcome measure performance.

LEVEL OF EVIDENCE

Level III, systematic review of Level II and III studies.

Differential risk of autoimmune disorders in non-traumatic osteonecrosis: clue to pathogenesis

INTRODUCTION

Non-traumatic osteonecrosis is a frequent complication in patients with autoimmune disorders, though its prevalence varies markedly depending upon the type of disorder. Understanding the causes of this difference can help uncover the underlying pathophysiology of osteonecrosis and guide the development of effective preventive and therapeutic strategies.

AREAS COVERED

In this perspective study, we reviewed available databases, including PubMed, Cochrane Library, Scopus, and Web of Science, to explore why the risk of osteonecrosis varies among different autoimmune disorders. Is this variation primarily due to the disease's pathophysiology, the use of medications such as corticosteroids, or a combination of both? If both factors are involved, what is the extent of each contribution in this context?

EXPERT OPINION

Non-traumatic osteonecrosis is often induced by an interaction between disease pathophysiology and corticosteroid use. In patients with different autoimmune disorders but an identical history of corticosteroid use, the risk of osteonecrosis is influenced by how the underlying pathophysiology compromises bone health. In autoimmune disorders with multiple adverse effects on bone, such as SLE (systemic lupus erythematosus), there is a much higher risk of osteonecrosis compared to disorders with minimal impact on bone health, such as celiac disease and MS (multiple sclerosis).

Comparative Efficacy of Retrograde Pubic Ramus Intramedullary Nails and Percutaneous Cannulated Screws in Treating Anterior Pelvic Ring Fractures: A Retrospective Cohort Study

OBJECTIVE

To compare the clinical outcomes of retrograde pubic ramus intramedullary nail (RPRIN) and percutaneous cannulated screw (PCS) in the treatment of anterior pelvic ring fractures (APRFs).

METHODS

This retrospective cohort study included 45 patients with APRFs treated between February 2019 and October 2022 in our trauma center. Patients were divided into two groups based on the surgical method: 20 received RPRIN fixation, and 25 received PCS fixation. Key variables including operation time, fluoroscopic time, blood loss, and postoperative complications were analyzed. Fracture reduction quality was assessed using the Matta score system, and pelvic functional recovery was evaluated using the Majeed score system at the final follow-up. Quantitative variables were compared using the independent sample t test, while categorical variables were analyzed using Chi-square and Fisher's exact tests.

RESULTS

The RPRIN group had significantly shorter operation time (36.3 ± 5.6 min vs. 49.5 ± 6.9 min, P < 0.01), fluoroscopic time (32.0 ± 2.8 s vs. 48.4 ± 3.6 s, P < 0.01), and less blood loss (20.4 ± 7.6 mL vs. 34.0 ± 5.7 mL, P < 0.01) than the PCS group. Fracture reduction quality (Matta outcome) and pelvic functional recovery (Majeed outcome) were comparable between the two groups (P > 0.05). No significant complications were reported in either group.

CONCLUSIONS

Both RPRIN and PCS are effective for treating APRFs. However, RPRIN offers distinct advantages by reducing operation time, fluoroscopic time, and blood loss, making it a more efficient and less invasive option. Further multicenter studies and biomechanical analyses are warranted to confirm these findings.

Percutaneous C1C2 transarticular screw fixation for atlantoaxial osteoarthritis with 3D navigation: technical note and functional outcomes

PURPOSE

Atlantoaxial osteoarthritis is a debilitating condition often resistant to conservative management. In refractory cases, C1-C2 fusion becomes a surgical option. Recent advancements, particularly in 3D navigation, have allowed for more precise and minimally invasive approaches, though there are limited reports on isolated percutaneous C1-C2 arthrodesis for osteoarthritis. This study aims to evaluate the feasibility, accuracy, and clinical outcomes of percutaneous C1-C2 transarticular screw fixation using 3D navigation in patients with disabling atlantoaxial osteoarthritis.

METHODS

Ten patients (median age: 75.5 years), all female, underwent percutaneous C1-C2 screw fixation using the Magerl technique, guided by 3D navigation. Preoperative assessment included CT and contrast-enhanced imaging to ensure safe screw placement. Postoperative evaluations included pain assessment, radiographic analysis, and patient satisfaction.

RESULTS

Transarticular screws were inserted in all of patients, with no significant intraoperative complications. Median operative time was 65 min with blood loss under 100 mL. Postoperative pain improved with the median VAS decreasing from 10 preoperatively to 1 at one year. Screw backout was observed in one patient without clinical repercussions. All patients expressed satisfaction and would undergo the procedure again.

CONCLUSION

Percutaneous C1-C2 transarticular screw fixation with 3D navigation is a safe and effective treatment for severe atlantoaxial osteoarthritis. It offers significant pain relief, accurate screw placement, and reduced postoperative morbidity. Preoperative anatomical evaluation remains critical to minimize risks. Level of Evidence Level III, Retrospective Cohort.

Surgical dislocation of the hip without trochanteric osteotomy for the treatment of bone tumors around the hip

PURPOSE

Bone tumors around the hip pose significant surgical challenges. While surgical dislocation with a trochanteric flip osteotomy through a posterior approach is commonly used, it is associated with known complications. This study is the first to report outcomes using surgical hip dislocation without a trochanteric osteotomy for this purpose. We evaluated early to long-term outcomes of this approach and compared results between patients undergoing extensive curettage with adjuvants and those undergoing simple excision.

METHODS

Sixteen patients (18 hips) with benign or intermediate bone and synovial tumors were treated using surgical dislocation without a trochanteric flip osteotomy. Patients had a minimum follow-up of 12 months (median 3.6 years, range 1-11 years). Outcomes included local recurrence, complications, functionality, and quality of life (QoL) assessed with SF-12 (mental and physical components), HOOS, TESS, and MSTS scores. Comparative analysis was performed between extensive curettage with adjuvancy and simple excision. Results All procedures were completed successfully without any local recurrences or significant complications. Patients had a median hospital stay of 3 days (ranging from 1 to 4 days), and the median follow-up duration was 3.6 years (ranging from 1 to 13 years). The mean SF-12 physical and mental health scores were 51 and 42, respectively. Additionally, the scores for HOOS, MSTS, and TESS were 74, 77%, and 86%, respectively. One patient (6%) developed osteoarthritis, while three (17%) experienced lateral hip pain managed conservatively. No significant differences were found in complications, functionality, or QoL between the extensive curettage and simple excision groups.

CONCLUSION

Surgical dislocation of the hip without trochanteric osteotomy is a safe and effective alternative for excising tumors around the hip. It provides excellent exposure and achieves successful oncologic and functional outcomes. Patients requiring extensive curettage with adjuvants achieve comparable results to those treated with simple excision, offering a viable and novel surgical option for challenging cases.

Lateral unicompartmental knee arthroplasty is an effective procedure for lateral post-meniscectomy knee osteoarthritis: a case-control study at a mean 7-year follow-up

BACKGROUND

Meniscectomy is a common knee surgery for meniscal tear, and is associated with progressive osteoarthritis (OA). There are few literatures focus on the use of lateral unicompartmental knee arthroplasty (UKA) for lateral post-meniscectomy knee osteoarthritis (PMKO). Therefore, the purpose of this study is to compare the outcomes of lateral UKA performed for lateral PMKO and primary lateral compartment knee osteoarthritis (LCKO).

METHODS

A total of 38 consecutive patients (38 knees) who received lateral UKAs for isolated lateral PMKO between September 2013 and September 2019 were retrospectively analyzed. Other thirty-eight patients (38 knees) with primary LCKO were allocated into control group by 1:1 matching according to age, gender, and body mass index. The clinical outcomes were evaluated using the American Knee Society Score, range of motion, Forgotten Joint Score, and EuroQol-5D (EQ-5D) Score. The radiographic assessments included hip-knee-ankle (HKA) angle, mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and posterior tibial slope angle (PTSA).

RESULTS

With a mean 7 years follow-up, there was no significant difference in functional and radiographic outcomes between groups. However, the PMKO group showed severe lateral OA (p = 0.02) preoperatively and less OA progression in the medial compartment postoperatively (p = 0.046). The preoperative mLDFA was significantly more valgus in the LCKO group (p < 0.001). No case of revision occurred in either group.

CONCLUSION

Lateral UKA is a valid procedure for lateral PMKO. The clinical and radiographic results are similar in patients underwent lateral UKA for lateral PMKO and for LCKO. Patients with lateral PMKO exhibited severe lateral OA preoperatively and less OA progression in the medial compartment compared to those with LCKO. It is crucial to prevent ascension of the lateral femoral joint-line and maintain proper valgus alignment during lateral UKA.

Results of surgical treatment of Hoffa fractures in pediatric population: 8-case series

Objectives

Hoffa's fractures are extremely rare in children. Very few cases have been published in connection with this condition. The present study highlights the healing outcomes of surgical treatment in pediatric Hoffa's fractures without direct comparison to conservative treatment.

Methods

During this interval, on average, eight children with Hoffa fractures were treated in our department for 10.1 years. Seven had unicondylar fractures (4 lateral and 3 medial), and one had a bicondylar fracture. Unicondylar cases were operated upon with the lateral parapatellar approach, and a combination of direct lateral and medial access with PPA was applied for the bicondylar fracture. A Cannulated Compression Screw was used for fixation. The postoperative care included restricted weight-bearing for 10 weeks and removal of the fixation at 6 months. Follow-up was conducted on knee function and pain, and Letenneur scores were evaluated.

Results

The bone union was obtained between 12 and 18 weeks. In the unicondylar cases, knee function was satisfactory, and most outcome measures showed supporting results. There was limited mobility in the bicondylar case and some mild varus; the Letenneur score was fair. Unicondylar fractures with bedding and early functional exercises did well in the long term, while the results of bicondylar fractures were poor.

Conclusion

This study presents a surgical treatment approach for pediatric Hoffa fractures and monitors the results. However, it does not provide a comparison with conservative measures. The findings also offer insight into the surgical protocols needed for better long-term outcomes in children with Hoffa fractures.

Patients with Robotic Arm-Assisted Medial Unicompartmental Knee Arthroplasty (mUKA) Regain Their Preoperative Activity Level Two Weeks Earlier Compared to Robotic Arm-Assisted Kinematically Aligned Total Knee Arthroplasty (rKA-TKA)

BACKGROUND

This study compared the early rehabilitation progress of patients undergoing robotic-assisted medial unicompartmental knee arthroplasty (mUKA) and robotic-assisted kinematically aligned total knee arthroplasty (rKA-TKA), focusing on daily activity by step-count measurements.

METHODS

A retrospective analysis of prospectively collected data from 88 patients (53 rKA-TKA and 35 mUKA) was conducted. Patients wore Garmin Vivofit® 4 activity trackers pre and postoperatively. Daily step counts were analyzed, and clinical outcomes were assessed using various scores, including the Knee Society Score (KSS) and Forgotten Joint Score (FJS).

RESULTS

Preoperative median daily step counts were comparable between groups (rKA-TKA: 3988 and mUKA: 4315; p = 0.128). At 6 and 7 weeks post-surgery, the mUKA group showed significantly higher median step counts (3741 and 4730) compared to the rKA-TKA group (2370 and 2910), with p-values of 0.015 and 0.048, respectively. The mUKA group reached 86.7% of their preoperative step count at week 6 and 100% at week 7, while the rKA-TKA group achieved 59.4% and 73%, respectively. Both groups surpassed their preoperative activity levels by week 9. Clinical outcomes at 2 months and 1 year post-surgery showed no significant differences between groups.

CONCLUSIONS

While both the mUKA and rKA-TKA patients achieved their preoperative daily activity levels within nine weeks post-surgery, the mUKA patients reached this milestone approximately two weeks earlier. This study demonstrates a clinical benefit of mUKA in terms of faster postoperative remobilization, even when compared to kinematically aligned robotic-assisted TKA.

Relationship between anterior or posterior femoral head necrosis and collapse based on MRI-defined key necrotic layer sets

BACKGROUND

Current clinical studies on femoral head necrotic lesions primarily focus on the medial and lateral regions, while detailed MRI-based methods to evaluate the relationship between anterior or posterior necrosis and collapse remain lacking.

OBJECTIVE

By defining the anterior and posterior positions of the femoral head in MRI, a method was proposed for rapid clinical prognosis assessment of femoral head necrosis based on necrotic location.

METOHD

A retrospective analysis was conducted on TSE sequence T1W1 coronal plane images from 200 cases of femoral head necrosis. The frequency of necrotic lesions appearing on each MRI layer was statistically analyzed to construct a high-frequency necrotic layer set. Among these cases, 100 hips were randomly selected, and the relationship between femoral head collapse at one-year follow-up and different high-frequency necrotic layer sets was analyzed to identify the key necrotic layer set. Based on this, the anterior and posterior regions of the femoral head were defined on MRI. The remaining 100 hips were used as a validation set to assess the impact of anterior or posterior necrosis of the femoral head, as defined by this method, on collapse.

RESULTS

In this study, a total of eight high-frequency necrotic lesion layer sets (S1-S8) were constructed based on MRI data. Among them, S3 (L1 + L2 + L0 + L3) showed the strongest correlation with femoral head collapse, with an AUC of 0.662. Therefore, S3 was defined as the anterior side of the femoral head. Analysis of the validation set revealed that, using this method, the probability of femoral head collapse was 11.4 times higher when necrotic lesions appeared on the anterior side compared to the absence of necrosis on the anterior side.

CONCLUSION

In MRI, the anterior side of the femoral head corresponds to the S3 region, where necrosis increases the risk of collapse by 11.4 times.

No cost difference between single or dual implants for distal femur fractures in the perioperative period

PURPOSE

This study uses a value-driven outcome model to assess the cost-effectiveness of single versus dual implants used in the fixation of distal femur fractures (DFF).

METHODS

A retrospective review identified all DFF treated at a level I trauma center between 2013 and 2023. Patients with open fractures, bilateral fractures, multiple injuries, and less than six months of cost-data or follow-up were excluded. DFF were divided into fixation by an intramedullary nail (IMN), lateral plate (LP), or dual construct (DC) including IMN and plate or dual plating. Cost data included all costs, including implant, facility, and operative costs associated with initial surgery and subsequent admissions associated with the injury. Actual cost data were analyzed via an inverse Gaussian regression model.

RESULTS

Of 293 cases, 123 were treated by IMN, 133 by LP, and 37 by DC. There was no demographic, BMI, Charlson Comorbidity Index (CCI), or Injury Severity score (ISS) differences between groups. DC DFF tended to be AO Type C (27%) or periprosthetic fractures (35%) (p < 0.001). DC was 47% more expensive than IMN and 43% more expensive than LP at initial surgery (p < 0.001) and 46% more expensive than IMN and 40% more costly than LP downstream (p < 0.001). However, when controlling for age, BMI, fracture classification, and ISS, there was no difference in total cost across fixation types.

CONCLUSION

The total cost for dual construct fixation of distal femur fractures was similar to intramedullary nailing or lateral plating despite higher initial costs and use in more complex fracture patterns.

Effects of previous arthroscopic knee surgery on the outcomes of primary total knee arthroplasty: a systematic review and PRISMA-compliant meta-analysis

OBJECTIVE

The aim of this study was to evaluate the potential adverse effects of prior arthroscopic knee surgery on the prognosis of primary total knee arthroplasty (TKA).

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed in the PubMed, Embase, Cochrane Library, and other relevant databases up to October 2024. Cohort studies comparing the outcomes of patients with and without previous arthroscopic knee surgery were retrieved. Meta-analysis was performed to assess the differences in postoperative function, complications, and revision rates between the arthroscopy and primary TKA groups.

RESULTS

The analysis included 11 cohort studies comprising a total of 194,367 patients; 13,086 of these patients had a history of knee arthroscopy. The meta-analysis results revealed no significant differences in postoperative range of motion, functional improvement, stiffness, periprosthetic fracture, venous thromboembolism (VTE), and other complications between the groups. However, the arthroscopic group showed a higher risk of postoperative prosthetic joint infection (PJI) and manipulation under anaesthesia (MUA). The revision rate was also higher in the arthroscopic group (Relative Risk (RR) 1.423, 95% Confidence Interval (CI) 1.280 to 1.583). Subgroup analysis revealed an increased PJI risk within one year of arthroscopic TKA (RR 1.314, 95% CI 1.156 to 1.493). Sensitivity analysis confirmed the stability of the results, and Egger's test showed no publication bias.

CONCLUSION

Prior arthroscopic surgery was not found to have significant impacts on the functional outcomes of TKA but was found to increase the risks of postoperative infection and revision.

Reverse guide wire technique for percutaneous anterior column screw of the acetabulum: A second look at the technique and a step-by-step guide. A surgical technique

INTRODUCTION

Pelvis and acetabulum fractures are serious injuries, especially in polytrauma patients. Traditionally, open reduction with internal fixation is the way to go; fortunately, percutaneous fixation has evolved with the advancement of understanding pelvis anatomy and fixation pathways. Nonetheless, the debate regarding indications, safety, radiation exposure, and other complications emerged. Our paper presented a reverse guide wire technique for percutaneous anterior column/superior pubic rami intramedullary screw fixation.

PRESENTATION OF CASE

A 24-year-old male presented after a road traffic accident. The patient sustained a left anterior column acetabular fracture associated with a medial wall blowout and a right posterior column fracture. Computed tomography imaging was analyzed to determine the possibility of percutaneous fixation of the anterior column fixation.

DISCUSSION

This study applied a modified PF technique, initially described by Tosounidis and Giannoudis, for pelvic fracture fixation. The approach shows promising effects in minimizing cortical breaches, particularly in osteoporotic patients, while avoiding major complications. However, limitations include presenting a single case and the inability to conduct a cohort study due to follow-up challenges. Further research is needed to assess the broader applicability of this technique.

CONCLUSION

The modified PF technique shows promising results for pelvic fracture fixation, but further studies with larger sample sizes and proper follow-up are necessary to evaluate its long-term effectiveness and safety. Future research will help clarify its role in pelvic fracture management and compare it to other techniques in terms of outcomes and complications.

Orthobiologic therapies delay the need for hip arthroplasty in patients with avascular necrosis of the femoral head: A systematic review and survival analysis

PURPOSE

The aim of this systematic review and survival analysis was to quantify the benefits of orthobiologic augmentation therapies for the treatment of avascular necrosis (AVN) of the femoral head and identify the most effective approach to delay the need for total hip arthroplasty (THA).

METHODS

A systematic review of the literature was performed on PubMed, Scopus, and Cochrane on clinical studies on orthobiologic therapies used alone or as an augmentation to core decompression or other procedures to address hip AVN. A qualitative analysis of the different biological therapies applied was performed. Afterward, the results of these procedures were quantitatively analysed to document their survivorship from THA compared to treatment groups without orthobiologics. Kaplan-Meier analysis was performed for all studies and then by categorising orthobiologics into treatment subgroups.

RESULTS

A total of 106 studies were included (4505 patients). Different orthobiologic approaches have been evaluated: cell-based therapies including bone marrow aspirate concentrate (BMAC) and bone marrow mesenchymal stromal cells (BM-MSCs), platelet-rich plasma (PRP), or other bioactive molecules applied in the osteonecrotic area or as intra-arterial injections. The survival analysis at 120 months documented a higher (p < 0.0005) cumulative survivorship with orthobiologics (69.4%) compared to controls (48.5%). The superiority was shown specifically for BMAC (p < 0.0005), BM-MSCs (p < 0.0005), intra-arterial (p < 0.0005) and PRP (p = 0.011) approaches, but the direct comparison of these approaches with their controls confirmed benefits only for BMAC (p < 0.0005).

CONCLUSION

This systematic review and survival analysis demonstrated that orthobiologics have the potential to improve survivorship in patients affected by hip AVN. In particular, the specific analysis of different orthobiologic products supported relevant benefits for BMAC augmentation in terms of survival from the need for THA, while no clear benefits were confirmed for other orthobiologics.

LEVEL OF EVIDENCE

Level III.

Economic Evaluation of Total Knee Replacement Compared with Non-Surgical Management for Knee Osteoarthritis in India

OBJECTIVE

This study is an economic evaluation of total knee replacement (TKR) in comparison with non-surgical management in India.

METHODS

Cost-utility analysis and budget impact analysis (BIA) were conducted on individuals aged ≥ 50 years with osteoarthritis of the knee (OA knee) Kellgren-Lawrence grades 2 and 3 using a provider's perspective. Three scenarios were considered, varying the age at which TKR is administered while assuming a 20-year lifespan for the implant. A Markov model was used to determine incremental cost-effectiveness ratios (ICERs). Sensitivity analysis was conducted incorporating implant costs and other input parameters.

RESULTS

Net quality-adjusted life-years (QALYs) gained per OA knee treated with TKR were superior when performed at the age of 50, regardless of OA severity and across all scenarios. The lowest ICER was 36,107 Indian National Rupees (INR) (USD 482.9)/QALY gained, observed at 50 years, while the highest was INR 61,363 (USD 820.72)/QALY gained at 70 years for grade-2 severity. Sensitivity analysis revealed that the ICER was most sensitive to the cost of non-surgical management, health utility values gained in an improved state, and the cost of TKR across scenarios. For the BIA in Scenario 1, with 40% coverage for TKR, costs reach INR 5013 crores (cr) (USD 670,477,060) in 2023 and INR 8444 cr (USD 1,024,628,736) in 2028 (1% of government budgets). In Scenario 2 (full coverage), costs are INR 12,532 cr (USD 1,520,683,008) (2.7%) in 2023, declining to 2.4% in 2028. In Scenario 3, covering 40% under the National Health Mission (NHM), costs vary from 17% in 2023 to 25% in 2028.

CONCLUSION

This study concludes that TKR is a cost-effective treatment option compared with non-surgical management for OA knee in India, irrespective of age, implant types, and severity.

Most Orthopaedic Platelet-Rich Plasma Investigations Don't Report Protocols and Composition: An Updated Systematic Review

PURPOSE

To systematically review the literature to assess the heterogeneity of platelet-rich plasma (PRP) preparation and composition reporting for the treatment of musculoskeletal/orthopaedic pathologies.

METHODS

A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify Level I and Level II studies from 2016 to 2022 that evaluated the use of PRP therapy for musculoskeletal pathologies. The search phrase used was "platelet-rich plasma clinical studies." Studies were assessed based on their reporting of the PRP preparation methods and reporting of PRP composition.

RESULTS

One hundred twenty-four studies (in 120 articles) met inclusion criteria for analysis. Of these studies, 15 (12.1%) provided comprehensive reporting, including a clear, well-described, and reproducible preparation protocol that future investigators can follow. Thirty-three studies (26.6%) quantitatively reported the final PRP product composition.

CONCLUSIONS

Among the studies using PRP for the treatment of musculoskeletal/orthopaedic pathologies, less than 20% provided a clear, well-described, and reproducible PRP preparation protocol, and only one-fourth of studies reported on the final PRP product composition.

CLINICAL RELEVANCE

A diverse current reporting of PRP composition between studies provides a high heterogeneity of the term "PRP," which becomes a limitation for a comparison of studies using PRP.

"Association of vitamin D blood deficiency and the rs731236 polymorphism vitamin D receptor with primary knee osteoarthritis in subjects from Mexico"

Vitamin D deficiency is a public health problem worldwide. Some studies have associated serum vitamin D deficiency with knee osteoarthritis. Additionally, some vitamin D receptor polymorphisms have been linked to knee osteoarthritis. This study analyzed the associations among the rs731236 polymorphism of the vitamin D receptor, blood levels of vitamin D and primary knee osteoarthritis in a population from northern Mexico. A case‒control study was conducted from November 2023 to June 2024 with 449 unrelated participants. The vitamin D concentration in the blood was measured semiquantitatively. The presence of vitamin D receptor gene polymorphism genotypes (rs731236) was determined via the rhAmpTM SNP Assay methodology. We used the chi-square test to compare the groups and odds ratios with confidence intervals to calculate risk. In the presence of vitamin D deficiency, subjects showed a 1.5-fold increased risk of primary knee osteoarthritis (59.5%; p = 0.001). Notably, this association remained significant for subjects carrying the AA and AG genotypes and in a dominant model (60.0%, p = 0.023; 61.1%, p = 0.008 and 59.0%, p = 0.042, respectively), after including a multivariate association model. Our study identified a high prevalence of Vitamin D deficiency among individuals with primary knee osteoarthritis. This study suggests a potential association between deficient levels of vitamin D and primary KOA in carriers of the AA and AG rs731236 genotypes. Key Points • We observed a significant 1.5-fold increased risk of primary knee osteoarthritis in the presence of vitamin D deficiency. • Vitamin D deficiency is significantly associated with primary knee osteoarthritis in carriers of AA and AG genotypes of rs73123.

Long Term Outcomes After Flexor Tendon Tenotomy of the Diabetic Foot

Background

Hammertoes is one if not the most common deformity that afflicts the diabetic foot and leads to increased risk of diabetic foot ulcers. Flexor tendon tenotomy treatment of the diabetic hammertoe has gained increased interest and is now recommended in international guidelines as a treatment of hammertoes to prevent diabetic foot ulcers. There is however no published data on the long term outcomes following tenotomy treatment.

Introduction

The objectives of this study was to describe the demographics and long-term outcomes following tenotomy treatment of individuals with diabetes who had flexor tendon tenotomies of hammertoes performed between 2006 and 2009.

Methods

This was an observational study of a cohort from a prior study. The study was performed at Steno Diabetes Center Copenhagen between 1st of January 2020 and 31st of June 2020. Participants from the prior study were invited to join the study, consisting of one visit where foot examination was performed by orthopedic surgeon. Information on medical history was obtained from medical records.

Results

Of the original 38 operated participants, 21 (55.3%) had died during the follow-up period, one (2.6%) had moved away, and one (2.6%) had incorrect procedure performed originally. At follow-up (mean 149.7 months (±17)), age of the remaining 15 participants (86.7% male) was 66.6 years (±11.4), diabetes duration was 32.2 years (±13.3), all had neuropathy and 14 (93.3%) had palpable foot pulses. The 15 Included participants had 22 toes tenotomized in the original study, of which five toes (22.7%) in four participants (26.7%) had recurrent hammertoe deformities. Of the 15 participants, 14 (93.3%) had incurred at least one ulcer during the observation period, and eight (53.3%) had incurred an amputation.

Conclusion

This study reports an undescribed risk of recurrence of deformities after tenotomies and supports that this population is at high risk of new ulcers, amputations, and have a high mortality rate.

Optimizing Outcomes in Mangled Lower Extremity Reconstruction: Insights from a Retrospective Study of 93 Patients and Their Functional Scores

Background/Objectives: Over the past 25 years, reconstructive techniques and patient management advancements have significantly improved outcomes in mangled lower extremity injuries. Functional results of limb salvage have been demonstrated to surpass those of primary amputations. Developments such as local fasciocutaneous flaps, vacuum-assisted closure, and hyperbaric oxygen therapy have enhanced the reconstructive ladder. Despite progress, the utility of the Mangled Extremity Severity Score (MESS) and Gustilo-Anderson classification remains debated, particularly in their prognostic value for limb salvage decisions. In the study, we aimed to evaluate the outcomes of optimizing mangled lower extremity reconstruction in 93 patients, focusing on their functional scores retrospectively. Methods: This retrospective study analyzed 93 patients treated for mangled lower extremities between January 2015 and October 2022. Patients were assessed for age, gender, injury location, MESSs, Gustilo-Anderson classifications, surgical methods, and functional outcomes using the Lower Extremity Functional Scale (LEFS). Surgical interventions included internal and external fixation, skin grafts, local flaps, muscle flaps, and free tissue transfer. LEFS scores were categorized into disability levels for functional evaluation. Correlations were drawn between LEFS and variables such as MESS, Gustilo-Anderson types, and nerve injuries. Results: Among the 93 patients, 16 had MESSs ≥ 7, and 77 had MESSs < 7. Reconstruction methods included local fasciocutaneous and muscle flaps (37 patients), free tissue transfer (29 patients), and skin grafting with vacuum-assisted closure (27 patients). Smoking was associated with delayed union and increased infection rates. LEFS scores were significantly lower in patients with MESSs ≥ 7, Gustilo grade 3C fractures, and tibial nerve injuries. Flap failures and a higher number of surgeries (>3) also correlated with poorer functional outcomes. The average soft tissue healing time was 18 days, and bone union time was 17 weeks. Conclusions: Lower extremity reconstruction demands precise surgical planning and execution, prioritizing functional restoration. MESSs and Gustilo-Anderson classifications provide practical frameworks but have limitations in predicting long-term functionality. Factors such as joint involvement, nerve injuries, and flap selection significantly influence outcomes. Smoking and delayed healing remain critical challenges. While free flaps are essential for complex defects, more straightforward methods yield better outcomes in suitable cases. LEFS emerged as a reliable tool.

Early Intra-articular Hyaluronic Acid Injection After Anterior Cruciate Ligament Reconstruction Provides Short-Term Pain Relief and Improves Early Postoperative Function With No Clinical Benefits at 6 and 12 Months: A Randomized Controlled Trial

PURPOSE

To assess the safety and effectiveness of intra-articular hyaluronic acid (HA) when administered at various time points after arthroscopic anterior cruciate ligament reconstruction (ACLR) surgery.

METHODS

Ninety patients with anterior cruciate ligament tears undergoing arthroscopic ACLR were divided into 1 of 3 groups: The early HA group received HA on day 2 and saline solution at 2 months, the late HA group received saline solution on day 2 and HA at 2 months, and the placebo group received saline solution at both times. Clinical variables (range of motion [ROM], knee circumference, Lysholm score, International Knee Documentation Committee [IKDC] score, visual analog scale [VAS] score, EQ-5D-5L [EuroQol 5-dimension 5-level questionnaire] score, and Tegner score) and blood parameters (erythrocyte sedimentation rate and C-reactive protein level) were assessed at baseline, monthly up to 6 months, and at 12 months. The synovial tumor necrosis factor α level was measured at baseline, on day 2, and at 3 months.

RESULTS

The early HA group showed significantly better ROM than the placebo group (P = .041) and late HA group (P = .029) at 1 and 2 months after surgery. Pain was significantly lower in the early HA group at 1 month compared with the placebo group (P = .033). The early HA group achieved a faster median recovery time to a Lysholm score greater than 83 (P = .01) and had superior Lysholm scores at 2 months. In addition, EQ-5D-5L and IKDC scores were significantly better at 1 and 2 months in the early HA group. There were no differences in erythrocyte sedimentation rate and C-reactive protein level between the groups at any follow-up. However, both HA groups showed a significant decrease in tumor necrosis factor α level from baseline (P < .05). No adverse events were reported. The minimal clinically important difference (MCID) for the VAS score at 1 month was achieved by 93.3%, 60.7%, and 65.5% of participants in the early HA group, late HA group, and placebo group, respectively (P < .01). However, no significant differences were observed between the groups in the percentage of patients achieving the MCID for the VAS score at 1 year or the MCIDs for the IKDC and Lysholm scores at 1 month, 2 months, and 1 year.

CONCLUSIONS

Early intra-articular HA injection after ACLR effectively reduced pain and improved ROM during the early postoperative period, leading to enhanced functional outcomes and quality of life. However, these benefits were not sustained beyond 2 months, and no clinical benefits were noted at 6- and 12-month follow-up. The treatment was found to be safe and well tolerated for postoperative use. Notably, there was no significant difference in the number of patients achieving the MCIDs for functional scores, except for pain at 1 month.

LEVEL OF EVIDENCE

Level I, double-blind randomized controlled study.

Arthroscopic treatment of scaphoid nonunion, a new algorithm after six years practice

INTRODUCTION

Scaphoid nonunion is still a challenging problem in hand surgery. Till now most of the patients have been treated with open revision, bone grafting and internal stabilization. Arthroscopy plays an increasing role in hand surgery since the last decade. In this retrospective study, we want to present our results and current treatment protocol, adapted after midterm analysis.

MATERIAL AND METHODS

In 2017, arthroscopic treatment of scaphoid nonunion was started at our department. Debridement is done arthroscopically as well as insertion of radius cancellous bone graft. Fixation has been accomplished with K-wires and/or head compression screws percutaneously, by help of fluoroscopy. Till 2020, 24 patients were treated, observing three delayed unions, treated successfully by extra corporal shockwave therapy and modifying the fixation. A subsequent analysis of the results yielded the modification of our fixation methods, and consequently, all patients received shockwave therapy as well.

RESULTS

Comparing the success rate with the 28 operated after 2020, the adaption of our algorithm showed an improvement of the healing rate from 87 to 96%. There we found only one ongoing nonunion in the proximal 1/3. The median time to bony healing was comparable in the two groups, operation time showed no significant difference. After a median follow-up of 30 months, an excellent range of motion could be found, as well as a significant reduction in pain and grip strength matchable with the unaffected hand in all 52 patients. DASH and Mayo Wrist Score showed satisfactory results, and 45 patients came back to their earlier occupation and sports.

CONCLUSION

Arthroscopy has a fix place in the algorithm for scaphoid nonunion in our institution. It is hypothesized that the implementation of an adequate and stable fixation on the section of the nonunion is indispensable. The distal radius is a sufficient donor-site for cancellous bone grafting. Extra corporal shockwave therapy is from now on used routinely in arthroscopic treatment of scaphoid nonunion.

LEVEL OF EVIDENCE

IV.

Leg Length Discrepancy in Total Hip Arthroplasty: Not All Discrepancies Are Created Equal

The original review article, published in 2006, describing leg length discrepancy after total hip arthroplasty commented that "equal leg length should not be guaranteed." There has been considerable advancement in surgical technique and technology over the past decade, allowing surgeons to "hit the target" much more consistently. In this interval paper, we review leg length discrepancy and introduce some technologies designed to mitigate this complication. In addition, we present challenging clinical scenarios in which perceived leg length may differ from true leg length and how these can be addressed with proper workup and surgical execution.

Post-fasciotomy complications in lower extremity acute compartment syndrome: a systematic review and proportional meta-analysis

PURPOSE

This meta-analysis aims to update the evidence on post-fasciotomy outcomes in lower limb acute compartment syndrome (ACS) by quantifying pooled prevalence rates for amputation and mortality and evaluating the impact of key risk factors.

METHODS

PRISMA-compliant search of Medline, Embase, CINAHL, and Web of Science was conducted from inception through July 2024. Risk of bias was assessed using the Joanna Briggs Institute and National Institutes of Health tools, with evidence certainty evaluated via the GRADE approach. Prevalence rates with 95% confidence intervals (CI) were calculated using the Freeman-Tukey double arcsine transformation, accounting for between- and within-study variance. Logistic regression models estimated odds ratios (OR) using a random-effects model, with sensitivity analyses excluding low-sample-size studies.

RESULTS

Eleven studies encompassing 2504 patients were included. The pooled prevalence of post-fasciotomy mortality was 7.7% (95% CI, 4.6-11.5%) across eight studies, while amputation prevalence was 10.5% (95% CI, 7.8-13.5%) across 10 studies. Vascular compromise increased amputation odds (OR 1.88, 95% CI 1.03-3.43) but showed no statistically significant association with mortality (OR 2.67, 95% CI 0.77-9.24). Early fasciotomy (< 6 h) reduced amputation odds (OR 0.31, 95% CI 0.13-0.75) and showed a modest trend towards lower mortality. Intracompartmental pressure monitoring (ICPM) was associated with reduced amputation odds (OR 0.23, 95% CI 0.10-0.54), although its effect on mortality was inconclusive.

CONCLUSION

This meta-analysis demonstrates that early fasciotomy, particularly within six hours, and ICPM may mitigate amputation risk in lower limb ACS. While vascular compromise significantly increases the risk of amputation, its link to mortality remains uncertain. These findings emphasise the importance of timely surgical intervention and suggest potential benefits of ICPM for risk stratification. However, the reliance on observational studies, aggregate data, and retrospective research limits causal inferences. Further high-quality research is needed to validate these associations and inform clinical decision-making.

The use of external fixation for the correction of recurrent clubfoot: a systematic review and meta-analysis

BACKGROUND

Recurrent clubfoot (CF) remains a challenging orthopedic condition, often requiring surgical intervention due to deformity rigidity and scarring from previous treatments. External fixation, particularly the Ilizarov technique, has emerged as a promising approach to correct recurrent and complex CF deformities. However, there is considerable variability in reported results regarding success and recurrence rates.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the efficacy and safety of external fixation with a focus on success rates, recurrence rates, and complication profiles in patients treated for recurrent CF.

METHODS

A systematic search of five databases (PubMed, Embase, Web of Science, ScienceDirect, Cochrane Library) was performed according to PRISMA guidelines. Studies evaluating external fixation for recurrent clubfoot and reporting quantitative data on success and recurrence rates were included. A total of 438 records were screened and 21 studies met the inclusion criteria. Data extraction was performed on demographic characteristics, treatment details, and outcomes. Meta-analysis was performed using a random effects model to pool success and recurrence rates.

RESULTS

The review analyzed 21 studies involving 489 treated feet in 406 patients. The pooled overall success rate was 81.4% (95% CI: 74.5-88.4%), while the pooled recurrence rate was 17.7% (95% CI: 11.3-24.1%). The studies showed minimal heterogeneity (I² = 0%) in both success and recurrence rates. Complications were common, with pin tract infection being the most common (29.3%), followed by toe contractures and digital ischemia.

CONCLUSIONS

External fixation is an effective approach for recurrent CF, with satisfactory success rates. However, the risk of complications underscores the need for vigilant postoperative care. The results support the use of external fixation for complex CF recurrences, but further studies are needed.

Inflammaging contributes to osteoarthritis development and human microbiota variations and vice versa: A systematic review

OBJECTIVE

To report evidence on microbiota and its relationship with inflammaging, the innate immune system and osteoarthritis (OA) in human patients.

DESIGN

A systematic review was performed in accordance with PRISMA and following the PICO model. Web of Science, Scopus, Cochrane Library for clinical trials and PubMed were searched. The analysis was focused on human OA patients, and the outcome was mainly microbiota identification, improvement or deterioration of OA pain, stiffness or inflammation.

RESULTS

After screening, 24 studies fulfilled the inclusion criteria. There is not a standardised procedure yet, as microbiota analysis in OA is relatively new. The 16S rRNA gene is the most used in bacterial phylogeny and taxonomy studies as it is highly conserved. Selected articles hypothesise about the correlation between the altered composition of the gut microbiota and OA severity, which seems to affect the immune composition by disrupting gut permeability and releasing pro-inflammatory factors. Five preliminary clinical trials used pro-prebiotics to treat OA patients, and although their results are not conclusive and the methodology needs to be improved, it might indicate a favourable approach for further studies in the prevention of OA.

CONCLUSIONS

Several hypotheses have been made on the associations between microbiota changes and inflammation. They mainly advocate that those changes in the gastrointestinal tract affect gut permeability, which alters the immune system, leading to OA progression. Research advances, along with the continual growth and improvement of technology, mark this 'microbiota-inflammaging-OA' axis as a promising line of investigation.