Air arthrography: a safe technique for intra-articular hip injections

INTRODUCTION

Diagnosing the specific causes of young adult hip pain remains challenging due to non-specific symptoms. Fluoroscopy-guided injections are useful for confirming intra-articular hip pain and differentiating it from extra-articular pathology. When performing injections, accurate needle placement into the hip joint is critical. Traditionally, a contrast agent is used to confirm intra-articular positioning. Air arthrograms are an alternative technique that avoids adverse reactions to contrast, which may compromise interpretation of results, as well as being more cost-effective. This study presents the air arthrography technique for intra-articular hip injections, and assesses outcomes and complications in a consecutive patient cohort.

METHODS

A retrospective review was performed on patients who underwent an air arthrography guided intra-articular hip injection at a single institution between April 2019 and September 2022. We identified 352 hips in 294 patients. Patient records were evaluated for complications from the injection or any subsequent hip surgery.

RESULTS

Mean age at time of injection was 38 years (±14.7 SD) for 216 females and 78 males. Mean follow-up time post injection was 138 days (IQR = 46-186). Results showed a 2.56% complication rate, primarily attributed to steroid flares, all of which resolved without further intervention. 102 patients proceeded to subsequent hip surgery; the mean time from injection to procedure was 341 days (IQR = 194-456) and the mean follow-up post subsequent procedure was 346 days (IQR = 87-531). There were no infective complications following the injections or any subsequent procedures.

CONCLUSIONS

This is the first study that evaluates longer-term patient outcomes following air arthrography guided injections with or without subsequent surgery. Our results demonstrate that the use of air arthrograms is a reliable, safe, and cost-effective method for intra-articular hip injections, without the additional risks posed by contrast media.

Global consensus on optimal exercise recommendations for enhancing healthy longevity in older adults (ICFSR)

Aging, a universal and inevitable process, is characterized by a progressive accumulation of physiological alterations and functional decline over time, leading to increased vulnerability to diseases and ultimately mortality as age advances. Lifestyle factors, notably physical activity (PA) and exercise, significantly modulate aging phenotypes. Physical activity and exercise can prevent or ameliorate lifestyle-related diseases, extend health span, enhance physical function, and reduce the burden of non-communicable chronic diseases including cardiometabolic disease, cancer, musculoskeletal and neurological conditions, and chronic respiratory diseases as well as premature mortality. Physical activity influences the cellular and molecular drivers of biological aging, slowing aging rates-a foundational aspect of geroscience. Thus, PA serves both as preventive medicine and therapeutic agent in pathological states. Sub-optimal PA levels correlate with increased disease prevalence in aging populations. Structured exercise prescriptions should therefore be customized and monitored like any other medical treatment, considering the dose-response relationships and specific adaptations necessary for intended outcomes. Current guidelines recommend a multifaceted exercise regimen that includes aerobic, resistance, balance, and flexibility training through structured and incidental (integrated lifestyle) activities. Tailored exercise programs have proven effective in helping older adults maintain their functional capacities, extending their health span, and enhancing their quality of life. Particularly important are anabolic exercises, such as Progressive resistance training (PRT), which are indispensable for maintaining or improving functional capacity in older adults, particularly those with frailty, sarcopenia or osteoporosis, or those hospitalized or in residential aged care. Multicomponent exercise interventions that include cognitive tasks significantly enhance the hallmarks of frailty (low body mass, strength, mobility, PA level, and energy) and cognitive function, thus preventing falls and optimizing functional capacity during aging. Importantly, PA/exercise displays dose-response characteristics and varies between individuals, necessitating personalized modalities tailored to specific medical conditions. Precision in exercise prescriptions remains a significant area of further research, given the global impact of aging and broad effects of PA. Economic analyses underscore the cost benefits of exercise programs, justifying broader integration into health care for older adults. However, despite these benefits, exercise is far from fully integrated into medical practice for older people. Many healthcare professionals, including geriatricians, need more training to incorporate exercise directly into patient care, whether in settings including hospitals, outpatient clinics, or residential care. Education about the use of exercise as isolated or adjunctive treatment for geriatric syndromes and chronic diseases would do much to ease the problems of polypharmacy and widespread prescription of potentially inappropriate medications. This intersection of prescriptive practices and PA/exercise offers a promising approach to enhance the well-being of older adults. An integrated strategy that combines exercise prescriptions with pharmacotherapy would optimize the vitality and functional independence of older people whilst minimizing adverse drug reactions. This consensus provides the rationale for the integration of PA into health promotion, disease prevention, and management strategies for older adults. Guidelines are included for specific modalities and dosages of exercise with proven efficacy in randomized controlled trials. Descriptions of the beneficial physiological changes, attenuation of aging phenotypes, and role of exercise in chronic disease and disability management in older adults are provided. The use of exercise in cardiometabolic disease, cancer, musculoskeletal conditions, frailty, sarcopenia, and neuropsychological health is emphasized. Recommendations to bridge existing knowledge and implementation gaps and fully integrate PA into the mainstream of geriatric care are provided. Particular attention is paid to the need for personalized medicine as it applies to exercise and geroscience, given the inter-individual variability in adaptation to exercise demonstrated in older adult cohorts. Overall, this consensus provides a foundation for applying and extending the current knowledge base of exercise as medicine for an aging population to optimize health span and quality of life.

Associations of overweight status with spinal curve correction and complications in patients undergoing vertebral body tethering: a multicenter retrospective review

PURPOSE

Our purpose was to determine associations between body mass index (BMI) category and outcomes of vertebral body tethering (VBT), a non-fusion treatment for adolescent idiopathic scoliosis (AIS) and juvenile idiopathic scoliosis (JIS).

METHODS

Using a multicenter database, we identified patients with AIS or JIS who underwent VBT from 2012 to 2018 and had minimum 2-year follow-up (median, 3.0 [interquartile range 2.2, 3.8]). BMI percentiles were used to classify patients as overweight (≥ 85th percentile) or non-overweight (< 85th percentile). Univariate and multivariate regressions assessed associations between complication rates and curve correction between groups, controlling for sex, triradiate cartilage closure, and preoperative curve magnitude.

RESULTS

Of 271 patients, 48 (18%) were overweight. Complication rates did not differ between groups. Factors associated with less correction from preoperative to first postoperative-erect imaging were overweight (β = - 10, p < 0.001), male sex (β = - 8.8 p < 0.01), closed triradiate cartilage (β = 6.0, p = 0.01), and smaller preoperative curve (β = 0.3, p < 0.01). Factors associated with a larger curve at latest follow-up were overweight (β = 4.0, p = 0.02) and larger preoperative curve (β = 0.5, p < 0.001), but tether breakage did not differ between groups (p = 0.31).

CONCLUSION

In patients who were overweight, VBT was associated with less curve correction at first erect imaging and larger final curve. However, complications and curve correction during the modulation phase were not different from those of non-overweight patients. These findings suggest that surgeons should expect less correction with VBT in patients who are overweight but similar correction over time.

LEVEL OF EVIDENCE

Prognostic, Level III.

Curve progression following selective and nonselective spinal fusion for adolescent idiopathic scoliosis: are selective fusions stable?

PURPOSE

The purpose of this study is to compare postoperative outcomes between selective and non-selective fusions longitudinally over the first five postoperative years.

METHODS

Patient parameters were retrieved from a multicenter, prospective, database. Patients with Lenke 1-6, B and C deformities were included. Patients were stratified into 2 groups: selective fusion (SF), if the last instrumented vertebra (LIV) was at or cranial to the lumbar apex, or non-selective fusion (NSF). Differences in coronal and sagittal radiographic outcomes were assessed with generalized linear models (GLMs) at 1-, 2- and 5- year postoperative outcomes. Five-year postoperative categorical radiographic outcomes, flexibility, scoliosis research society scores (SRS), and reoperation rates were compared between groups. Matched cohorts were created for subgroup analysis.

RESULTS

416 (SF:261, NF:155) patients, including 353 females were included in this study. The mean preoperative thoracic and lumbar Cobb angles were 57.3 ± 8.9 and 45.3 ± 8.0, respectively. GLMs demonstrated greater postoperative coronal deformity in the SF group (p < 0.01); however, the difference between groups did not change overtime (p > 0.05) indicating a relatively stable postoperative deformity correction. The SF group had a greater incidence of lumbar Cobb ≥ 26 degrees (p < 0.01). The NSF group demonstrated worse forward and lateral flexibility at 5-year postoperative outcome (p < 0.05). There was no difference in postoperative SRS scores between the SF and NSF groups. Reoperation rates were similar between groups.

CONCLUSION

Selective fusion results in greater coronal plane deformity; however, this deformity does not progress significantly over time compared to non-selective fusion. Selective spinal fusion may be a beneficial option for a larger subset of patients than previously identified.

LEVEL OF EVIDENCE

III.

Preoperative Spinal Sagittal Alignment Affects Improvement of Locomotive Syndrome by Four Years After Total Hip Arthroplasty

Introduction Most patients with hip osteoarthritis requiring total hip arthroplasty suffer from locomotive syndrome stage 3, which indicates difficulty with mobility and social participation. Although total hip arthroplasty improves their locomotive syndrome stage, some patients remain at locomotive syndrome stage 3 after total hip arthroplasty, despite hip function improvement. Patients with severe hip osteoarthritis may have an abnormal spinal sagittal alignment. This study investigated the influence of preoperative spinopelvic parameters for locomotive syndrome improvement at four years after total hip arthroplasty. Methods This retrospective cohort study of a prospectively maintained database included 65 patients who had undergone total hip arthroplasty. Patients were divided into two groups based on whether they showed improvement from Locomotive Syndrome stage 3 at four years postoperatively: improved group (n = 51) and unchanged group (n = 14). Preoperative spinopelvic parameters were compared between the two groups and examined using logistic analysis to determine locomotive syndrome improvement. The cut-off values for preoperative key factors of locomotive syndrome improvement obtained using logistic analysis were determined using receiver operating characteristics analysis. Results Preoperative sagittal vertical axis was significantly larger and sacral slope was significantly smaller in the unchanged group than in the improved group. In the logistic regression analysis, preoperative sacral slope and the 25-question Geriatric Locomotive Function Scale (GLFS-25) were identified as factors associated with locomotive syndrome improvement. The receiver operating characteristic analysis showed that the cut-off values of preoperative sacral slope and GLFS-25 for locomotive syndrome improvement were 32.5° and 44.5, respectively. Conclusions Among hip osteoarthritis (OA) patients with locomotive syndrome stage 3, those who have small preoperative sacral slope and large preoperative GLFS-25 score may have difficulty improving their postoperative mobility. Therefore, it may be useful to suggest preoperatively that such patients should be prepared to use social services and other services after surgery to support their postoperative mobility.

Computed Tomography Evaluation of Alumina Ceramic-on-Ceramic Total Hip Arthroplasty With More Than 20 years of Follow-Up: Is a Follow-Up Computed Tomography Scan Necessary?

BACKGROUND

Ceramic-on-ceramic (CoC) bearings have been increasingly used in total hip arthroplasty (THA) because of their superior wear resistance and biocompatibility. However, there is a scarcity of reports on the computed tomography (CT) evaluation of CoC bearings with more than 10 years. The aim of this study was to evaluate the long-term CT results of THA using CoC bearings for more than 20 years of follow-up. We hypothesized that there would be no wear, osteolysis, or ceramic fracture.

METHODS

Between November 1997 and June 2003, 956 hips underwent THA using alumina-on-alumina bearings at a tertiary referral hospital. Among them, 107 hips were assessed, all of which underwent a CT examination more than 20 years after the index surgery. The mean age at the time of surgery was 41 years, and a CT scan was performed at an average of 22.0 years postoperatively (range, 20.0 to 25.1). The CT scans were thoroughly assessed for osteolysis, stem notching, and ceramic component fracture.

RESULTS

No loosening was observed in the acetabular cup or femoral stem. Stem notching was observed in 3 hips (2.8%). In the CT scan taken after a minimum of 20 years of follow-up, 1 case (0.9%) of osteolysis around the cup and 2 cases (1.9%) of osteolysis around the femoral stem were noted. Suspected chip fractures of the ceramic insert were discovered in 4 cases (3.7%). Despite these findings, the patients remained asymptomatic, and no subsequent surgical intervention was needed after close follow-up.

CONCLUSIONS

Routine CT examinations for patients who underwent THA using CoC bearings over 20 years ago revealed unexpected findings, such as osteolysis and suspected chip fractures of the ceramic liner. However, routine CT scans may not be universally necessary. The CT evaluation in this cohort should be selectively performed for patients who have relevant clinical symptoms.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Osteoarthritis Year in Review 2024: Molecular biomarkers of osteoarthritis

OBJECTIVE

To provide a comprehensive and insightful summary of studies on molecular biomarkers at the gene, protein, and metabolite levels across different sample types and joints affected by osteoarthritis (OA).

METHODS

A literature search using the PubMed database for publications on OA biomarkers published between April 1, 2023 and April 30, 2024 was performed. Publications were then screened, examined at length, and summarized in a narrative review.

RESULTS

Out of the 364 papers initially identified, 44 publications met inclusion criteria, were relevant to OA, and were further examined for data extraction and discussion. These studies included 1 genomic analysis, 22 on protein markers, 6 on metabolite markers, 9 on inflammatory mediators, and 6 integrating multiple molecular levels.

CONCLUSIONS

Significant advancements have been made in identifying molecular biomarkers for OA, encompassing various joints, sample types, and molecular levels. Despite this progress, gaps remain, particularly in the need for validation, larger sample sizes, the integration of more clinical data, and consideration of covariates. For early detection and improved treatment of OA, continued efforts in biomarker identification are needed. This effort should seek to identify effective biomarkers that advance early detection, support prevention, evaluate interventions, and improve patient outcomes.

Patient-Reported Outcomes of Bicruciate Multiligament Versus Single Cruciate Multiligament Knee Injuries

BACKGROUND

Multiligament knee injuries (MLKIs) are heterogeneous, and bicruciate knee ligament injuries are considered a serious form of this injury. The current literature tends not to distinguish between single and bicruciate MLKI when reporting outcomes.

PURPOSE

To investigate patient-reported outcomes after surgical treatment of MLKI comparing single cruciate MLKI with bicruciate MLKI. The secondary aim was to investigate the influence of different factors on patient-reported outcomes after surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This study was designed as a cross-sectional cohort study. Patients who underwent surgical treatment for MLKI at a single level 1 trauma center between January 2013 and December 2020 were included in this study. Patient-reported outcomes included the Tegner score, Lysholm score, International Knee Documentation Committee (IKDC) subjective knee form, Knee injury and Osteoarthritis Outcome Survey (KOOS), and a visual analog scale for pain.

RESULTS

Of the 191 patients meeting the inclusion criteria, 124 (65%) agreed to participate and had a complete data set with a follow-up time at a mean 74 ± 27 months. Patients with single cruciate MLKI (type I) had significantly higher scores for IKDC (P = .007), Lysholm (P = .012), KOOS Pain (P = .04), KOOS Activities of Daily Living (P = .01), KOOS Sport and Recreation (P = .005), KOOS Quality of Life (P = .04), KOOS4 (which considers the subscales of Pain, Symptoms, Sport and Recreation, and Quality of Life) (P = .01), Tegner (P = .04), and visual analog scale for pain during activity (P = .004) when compared with patients with bicruciate MLKI (type II-type IV). Furthermore, age was significantly associated with a lower IKDC (P = .001), and an increased severity of injury was significantly associated with IKDC (P = .015), KOOS4 (P = .022), and Lysholm (P = .029) scores.

CONCLUSION

MLKIs involving a single cruciate ligament had significantly higher patient-reported postoperative outcome measures compared with bicruciate MLKIs. Age and type of injury were important predictors for outcomes. Patients presenting with dislocated knees had lower patient-reported outcomes; however, there was no significant difference in outcomes between bicruciate MLKIs and patients presenting with dislocated knees.

Evaluating the impact of robotic-assisted total knee arthroplasty on quality of care through patient-reported outcome measures in a third-level hospital in Italy: A prospective cohort study

BACKGROUND

With the shift towards personalized medicine, understanding the impact of robotic-assisted total knee arthroplasty (TKA) on patient-reported outcome measures (PROMs) is essential for evaluating its effectiveness and patient satisfaction. The QUAROB (Quality-assessment-of-ROBotic-orthopedic-surgery) study aims at assessing the impact of robotic surgery on quality of care and joint functionality at 6 months post-surgery among patients undergoing robotic-assisted TKA.

METHODS

This observational, prospective cohort study included patients from Ravenna Hospital, Italy, who underwent elective robotic TKA (2022-2023), and a historical cohort who underwent traditional TKA (2019). PROMs questionnaires (EuropeanQualityofLife-Visual AnalogScale, EQ-VAS, EuropeanQualityofLife-5Dimensions-3Likert, EQ-5D-3L, and KneeinjuryOsteoarthritisOutcomeScore-PatientSatisfaction, KOOS-PS) were administered within 30 days before surgery and 6 months post-surgery. Statistical analysis involved comparing baseline and follow-up PROMs, focusing on patients achieving at least a 10% improvement (Minimal Clinically Important Difference, MCID).

RESULTS

The study enrolled 214 robotic surgery patients, with 208 completing baseline and 103 completing 6-month follow-up questionnaires. Patients undergoing robotic-assisted TKA demonstrated significant improvements in EQ-VAS, EQ-5D-3L, and KOOS-PS scores at 6 months. A significant proportion of patients achieved improvements exceeding the MCID threshold (68.9% for EQ-VAS, 58.3% for EQ-5D-3L, and 68.9% for KOOS-PS). Robotic TKA patients experienced shorter hospital stays (7 vs. 9 days, p < 0.001) and higher engagement in rehabilitation compared to traditional TKA patients.

CONCLUSIONS

The QUAROB study provides evidence of the impact and benefits of robotic-assisted TKA, highlighting significant enhancements in PROMs, reduced hospital stays, and increased rehabilitation engagement. These outcomes reinforce the role of robotic technology in improving surgical precision and patient satisfaction in orthopedic surgery.

Stress Analysis in Conversion Total Hip Arthroplasty: A Finite Element Analysis on Stem Length and Distal Screw Hole

Background/Objectives: Proximal femoral fractures are particularly common in older adults, and cases requiring conversion to total hip arthroplasty may arise because of treatment failure or osteoarthritis. Fractures around the distal screw removal holes can be problematic. This study aimed to analyze the relationship between stem length and femoral stress distribution to determine the optimal stem length. Methods: A finite element analysis simulation was conducted using pre-existing femoral computed tomography data, an intramedullary nail, and three types of stems of varying lengths. Loads simulating normal walking and stair climbing were applied, and the average and maximum equivalent stresses were measured on both the medial and lateral sides of the distal screw removal hole for each stem length. Statistical analysis was then performed to evaluate the stress distributions. Results: The average stress around the distal screw removal hole tended to decrease as stem length increased. The maximum stress was significantly lower with the 160-mm stem, which provides a 40-mm bridging length, compared to the 120-mm and 130-mm stems, where the stem tip aligned with or only slightly extended past the distal screw removal hole (bridging lengths of 0 mm and 10 mm, respectively). Conclusions: In conversion hip total arthroplasty following proximal femoral fractures, using a sufficiently long stem can help avoid stress concentration around the distal screw removal hole, thereby potentially reducing the risk of periprosthetic fractures.

Anterior Cruciate Ligament Reconstruction with LARS Synthetic Ligament: Outcomes and Failures

Background: Anterior cruciate ligament (ACL) injuries are common in athletes, but their prevalence has also increased among adults. ACL reconstruction (ACLR) is a key treatment option, with graft choice playing a critical role in recovery. The study evaluates the clinical and functional outcomes of ACLR using the Ligament Augmentation and Reconstruction System (LARS) in patients over 35 years old. It assesses implant survival, failure rate, and revision rate, and measures quality of life and subjective outcomes. Methods: Fifty-three patients were finally included in this retrospective two-center study. The study assessed quality of life (QoL) and subjective outcomes using IKDC and Lysholm scores, evaluated implant survival and revision rates, and assessed the difference in activity levels between the two years before ACL injury and at follow-up. Results: The study found high Lysholm (90.61) and IKDC (80.25) scores, indicating positive clinical results. However, about 40% of patients did not return to their pre-injury activity levels. The graft failure rate was low at 3.8%, with no cases of infection or implant rejection. Conclusions: The study concluded that LARS ACLR is an effective option for middle-aged patients, offering faster recovery and fewer complications. However, it may not be suitable for younger, professional athletes due to its mechanical limitations. Further research with larger sample sizes and longer follow-up is recommended.

iTRAQ proteomic analysis of exosomes derived from synovial fluid reveals disease patterns and potential biomarkers of Osteoarthritis

Exosomes extracted from synovial fluid (SF-exo) reflect the status of their originating cells. The proteomic profiles of SF-exo are important for the diagnosis of osteoarthritis (OA). To delineate the proteomic differences between SF-exo from OA patients and healthy individuals, a quantitative proteomic study based on iTRAQ technology was performed. In this study, a total of 439 proteins were identified, with 20 proteins exhibiting increased expression in the OA patient group, while 5 showed decreased expression levels. Bioinformatic analysis showed these differentially expressed proteins (DEPs) were involved in a variety of immune-related processes, including complement activation and antigen binding. For further screening, we downloaded a publicly available dataset of synovial fluid (PXD023708) and compared it with our dataset. The comparative Results identified that 5 DEPs overlapped in two datasets, and protein-protein interaction revealed that C3, C4B and APOM were key members of a tightly interactive network. Through receiver operating characteristic (ROC) curve analysis and enzyme-linked immunosorbent assay (ELISA), we confirmed 5 DEPs (C3, C4B, APOM, MMP3, DPYSL2) as potential diagnostic biomarkers for OA. And Pearson correlation analysis confirmed that most of these biomarkers had no significant linear correlation with age. Overall, our study provides the first comprehensive description of the proteomic landscape of SF-exo in OA and identifies several potential biomarkers. These findings are expected to provide valuable insights into the diagnosis and treatment of OA.

Periprosthetic joint infections: state-of-the-art

In general, periprosthetic joint infection (PJI) is regarded as one of the most common complications of total joint arthroplasty (TJA) and may lead to surgical failure, revision surgery, amputation or death. Nowadays, PJI has become a global health concern, which brings a great burden to public healthcare. In addition, there are still obstacles to achieve high success rates in the prevention, diagnosis and treatment of PJI. However, promising studies are also available with the advancements in biotechnology. This article will present an overview of the current methods used in the prevention, diagnosis and management of PJI while underlining the new technologies utilized.

Difficulty of diagnostic accuracy of periprosthetic joint infection: a retrospective analysis of revision surgery of total hip arthroplasty and total knee arthroplasty in a tertiary hospital

BACKGROUND

Diagnostic accuracy of periprosthetic joint infection still remains controversial and an unsolved problem with respect to clinical signs and laboratory measures. Influencing factors of diagnosis like age, sex, abnormal physical findings and comorbidities are published with different results. The aim of our study was to find factors strengthening the diagnosis.

METHODS

We therefore retrospectively investigated all revision surgeries of total knee arthroplasty and total hip arthroplasty in the years 2019 and 2020 in a tertiary hospital with special regard to diagnostic accuracy of periprosthetic joint infection and switch in diagnosis to aseptic mechanical loosening or vice versa. All patients were divided into 4 non-hierarchical groups: suspected and discharge diagnosis periprosthetic joint infection (P1), suspected and discharge diagnosis mechanical loosening (P2), suspected diagnosis mechanical loosening and discharge diagnosis periprosthetic joint infection (P3), suspected diagnosis PJI and discharge diagnosis mechanical loosening (P4).

RESULTS

In the years 2019-2020, 106 patients underwent revision surgery of total knee arthoplasty and total hip arthroplasty. 33 patients showed periprosthetic joint infection (31.1%) according to Infectious Diseases Society (IDSA) criteria, 73 patients showed mechanical loosening (68.9%). Of the periprosthetic joint infection -patients, 15 were men (46%) and 18 were women (54%). The patients with mechanical loosening were 27 men (37%) and 46 women (63%). In group P1 (25 patients), 22 could be classified according to the histopathological classification Krenn and Morawietz grade 2 and grade 3, 2 patients to grade 4 and one patient could not be classified. In group P3 (8 patients) all could be classified according to the classification Krenn and Morawietz grade 2 and 3. Groups P1 - P4 were correlated with categorial basic data: All Groups P1 - P4 showed a statistical correlation towards American Society of Anesthesiologists (ASA) categorization 3-4 versus ASA 2 (p = 0.01). In the pairwise comparison in the exact Fisher´s exact test P1 and P2 showed a statistical correlation towards ASA categorization 3-4 versus ASA 2 (p = 0.01). Charlson Comorbidity Index (CCI) categories 5-7 versus 0,1-2 and 3-4 showed a statistical correlation towards groups P1-P4 (p = 0.007) and in the pairwise comparison in the exact Fisher´s exact test a discrimination of P1 and P2 (p = 0.001) and P1 and P3 (p = 0.007). The preoperative corticoid therapy showed a statistical correlation to groups P1-P4 (p = 0.05) and in the pairwise comparison in the exact Fisher test a discrimination of P1 and P4 (p = 0.02).

CONCLUSION

We therefore conclude that diagnosis of periprosthetic joint infection still remains difficult. Switches in diagnosis during hospital stay from periprosthetic joint infection to aseptic mechanical loosening and vice versa are not unusual and the role of different diagnostic tools needs further investigation. Patients categorized according to ASA and CCI as severely ill might be more likely to be diagnosed correctly with periprosthetic joint infection.

Current Status of Vertebral Body Tethering for Adolescent Idiopathic Scoliosis: An Umbrella Review

Background

Adolescent idiopathic scoliosis (AIS) is a prevalent spinal deformity among teenagers worldwide. Vertebral body tethering (VBT) is an innovative, minimally invasive technique developed to address spinal curvature by modulating vertebral growth. However, the existing body of evidence regarding the effectiveness and safety of VBT in treating AIS is fragmented and requires thorough consolidation and critical assessment.

Methods

Six databases were thoroughly examined, yielding 11 relevant systematic reviews and meta-analyses. The methodological quality of the included studies was evaluated using the Joanna Briggs Institute's critical appraisal checklist. The key findings were encapsulated using a narrative synthesis approach.

Results

The reviews indicated notable improvements in coronal plane radiographic parameters, transverse plane clinical outcomes, and health-related quality of life scores following VBT. Nevertheless, the complication rates associated warrant attention. Additionally, the variability in methodological quality across the included reviews underscores the necessity for more robust and systematic investigations in this domain.

Conclusion

This umbrella review revealed promising results for VBT as a treatment option for AIS. However, further research is needed to address knowledge gaps and limitations, focusing on long-term outcomes, patient selection, standardized techniques, and comparison with traditional treatments.

Quality appraisal of systematic reviews on high-intensity laser therapy for musculoskeletal pain management: an umbrella review

Musculoskeletal pain (MSP) remains one of the leading causes of disability worldwide. Recent approaches to treating this condition have prompted the development of several systematic reviews investigating the efficacy of high-intensity laser therapy (HILT), whose analgesic mechanisms are based on photobiomodulation neural inhibition, endorphin and serotonin release and anti-inflammatory effects. To assess the methodological quality, reliability, and validity of the systematic reviews (SRs) on HILT in MSP. This study is an overview of SRs (umbrella review) with an observational, retrospective, and secondary design. The search considered PubMed, Scopus, Web of Science, CINAHL, Embase, Cochrane Library, ScienceDirect, and Google Scholar databases (updated October 23, 2024). The primary focus was on the methodological quality of the reviews and their reporting of pain intensity results. The HILT effects on pain intensity were reported using mean differences (MD) or standardized mean differences (SMD). The quality assessment was conducted using the A Measurement Instrument to Assess Systematic Reviews 2 checklist (AMSTAR-2), and the findings were synthesized narratively. The MD and SMD obtained from all reviews were presented using forest plots. The Shapiro-Wilk normality test assessed MD and SMD distributions for pain intensity across meta-analyses. The average MD and SMD, along with their respective confidence intervals (CI), were estimated and presented based on the aggregate study outcomes. Twenty SRs were included, fourteen of which conducted meta-analyses covering diverse musculoskeletal disorders such as knee osteoarthritis, epicondylalgia, myofascial pain, frozen shoulder, plantar fasciitis, neck, and low back pain. The primary databases used were PubMed, Web of Science, and the Cochrane Library. The AMSTAR-2 average score was 12.9 points (± 1.8), indicating varying methodological quality with one or two criteria resulting in low or critically low. HILT's best analgesic effects are observed in frozen shoulder disorder (MD = -2.23 cm; 95% CI:-3.3,-1.2; p < 0.01), knee osteoarthritis (MD = -1.9 cm; 95% CI:-2.0,-1.8;p < 0.01), low back pain (MD = -1.9 cm; 95% CI = -2.9,-1.0; p < 0.01), and myofascial pain (MD = -1.9 cm; 95% CI:-2.6,-1.2; p < 0.01). Largest effect sizes are for neck pain (SMD = 2.1; 95% CI = 1.2,3.0, p < 0.05) and low back pain (SMD = 1.1 (95% CI = 1.4,0.8; p < 0.01). This review underscores the generally low to critically low methodological quality of SRs on HILT, as assessed by AMSTAR-2. Key areas for improvement for future SRs of RCTs include addressing publication bias, disclosing funding sources, and enhancing search strategies and discussions on heterogeneity. The scarcity of RCTs for conditions such as temporomandibular disorders, carpal tunnel syndrome, and myofascial pain highlights the need for further research. SRs on spinal disorders, frozen shoulder, and neck pain demonstrated the most favorable analgesic effects, providing valuable insights for clinical practice and future RCTs.

The Clinical and Radiological Outcomes and Complications of Bilboquet Implant for Proximal Humerus Fractures: A Systematic Review

Background/Objectives: There is no consensus in the literature regarding the optimal treatment for complex proximal humerus fractures (PHFs). The aim of this study is to evaluate the clinical, functional, and radiological outcomes, and complications, associated with the Bilboquet implant in the treatment of PHFs. Methods: The search was conducted from the first description of the Bilboquet device in 1994 to June 2024, across PubMed, Web of Science, and Google Scholar, using specific keywords such as ("Bilboquet" OR "Bilboquet prosthesis" OR "Bilboquet device") AND ("proximal humerus fracture" OR "shoulder fracture"), along with Boolean operators. The inclusion criteria comprised studies published in English or French that focused on the use of the Bilboquet implant for PHFs. Eligible study designs included case series, cohort studies, randomized controlled trials (RCTs), and non-RCTs evaluating clinical, functional, and radiological outcomes, and complications. Studies that do not contain relevant results to this systematic review, pediatric populations, or the use of alternative implants were excluded. Results: A total of eight studies (235 patients) published between 1996 and 2021 were included. The mean age was 68.6 years (56 to 76.8) in all the studies. The majority of patients, 76.2%, were females, with male patients accounting for only 23.8%. A total of 10 (4.3%) patients had 2-part fractures, 40% of patients had 3-part fractures, and 55.7% of patients had 4-part fractures. The mean follow-up was 36.4 months (25.8-88.7), with a mean constant score of 69.7 (62-78.6). Complications included non-union in 2.65% of cases, avascular necrosis in 19.7%, revision surgery in 5.1%, and protrusion of the staple in 4.3%. Conclusions: Despite limited knowledge of the Bilboquet implant, it shows promise in managing complex PHFs in both young and older adults, with favorable clinical and radiological outcomes. It offers advantages over traditional fixation methods and allows easy conversion to arthroplasty if osteonecrosis occurs. However, the long-term outcomes require further study. While early results are promising, larger randomized studies are needed to confirm its broader clinical utility.

Multiligament knee injury (MLKI): an expert consensus statement on nomenclature, diagnosis, treatment and rehabilitation

Multiligament knee injuries (MLKIs) represent a broad spectrum of pathology with potentially devastating consequences. Currently, disagreement in the terminology, diagnosis and treatment of these injuries limits clinical care and research. This study aimed to develop consensus on the nomenclature, diagnosis, treatment and rehabilitation strategies for patients with MLKI, while identifying important research priorities for further study. An international consensus process was conducted using validated Delphi methodology in line with British Journal of Sports Medicine guidelines. A multidisciplinary panel of 39 members from 14 countries, completed 3 rounds of online surveys exploring aspects of nomenclature, diagnosis, treatment, rehabilitation and future research priorities. Levels of agreement (LoA) with each statement were rated anonymously on a 5-point Likert scale, with experts encouraged to suggest modifications or additional statements. LoA for consensus in the final round were defined 'a priori' if >75% of respondents agreed and fewer than 10% disagreed, and dissenting viewpoints were recorded and discussed. After three Delphi rounds, 50 items (92.6%) reached consensus. Key statements that reached consensus within nomenclature included a clear definition for MLKI (LoA 97.4%) and the need for an updated MLKI classification system that classifies injury mechanism, extent of non-ligamentous structures injured and the presence or absence of dislocation. Within diagnosis, consensus was reached that there should be a low threshold for assessment with CT angiography for MLKI within a high-energy context and for certain injury patterns including bicruciate and PLC injuries (LoA 89.7%). The value of stress radiography or intraoperative fluoroscopy also reached consensus (LoA 89.7%). Within treatment, it was generally agreed that existing literature generally favours operative management of MLKI, particularly for young patients (LoA 100%), and that single-stage surgery should be performed whenever possible (LoA 92.3%). This consensus statement will facilitate clinical communication in MLKI, the care of these patients and future research within MLKI.

Effects of Direct and Indirect Suggestions for Analgesia: The Role of Hypnotizability and Expectation of Pain Relief

Among the methods for cognitive control of pain, the suggestions for analgesia-direct or indirect-have been widely and successfully used in experimental and clinical trials. The primary aim of this study was to contribute to the debate about the difference in the effectiveness of indirect and direct suggestions for the management of experimental pain in the ordinary state of consciousness. The secondary aim of the study was to ascertain the role of hypnotizability and expectation of pain relief in the suggestions' effect. A sample of 65 healthy participants with different levels of direct (Harvard Group Scale of Hypnotic Susceptibility: A score) and indirect suggestibility level (Alman-Wexler Indirect Hypnotic Susceptibility Scale score) and different levels of declared expectation of pain relief was submitted to direct and indirect suggestions for analgesia during cold pressure test. The results showed that both direct and indirect suggestions increase the threshold of experimental pain and that the expectation of pain relief is relevant only to the effect of direct suggestions. PERSPECTIVE: Although the reported findings cannot be extended to clinical pain, they suggest that indirect suggestions can be effective independently from the expectation of pain relief, thus evading the possible negative effects of traits such as catastrophism or reactance. Thus, indirect suggestions should be preferred in clinical contexts.

Preoperative corticosteroid injections are associated with a higher periprosthetic infection rate following primary total shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

Corticosteroid injections (CSIs) are commonly used for the treatment of shoulder pain in patients with osteoarthritis and rotator cuff arthropathy. These injections may increase the risk of infection following eventual shoulder arthroplasty. The purpose of this study was to perform a systematic review and meta-analysis of existing data to explore the relationship between preoperative CSI's and postoperative periprosthetic joint infection (PJI) following shoulder arthroplasty.

METHODS

A literature search was performed on PubMed, Embase, and Web of Science databases through September 29, 2023. Of the 4221 retrieved, 7 studies including 136,233 patients were included for qualitative analysis. Studies describing patients receiving CSI prior to shoulder arthroplasty and the effect on postoperative infection risk were included in the systematic review and subsequent meta-analysis. Assessment of risk of bias was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.

RESULTS

Receiving a CSI prior to shoulder arthroplasty was found to have a statistically significant association with increased risk for PJI (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06-1.19; P < .0001). The rate of PJI increased when injections were given closer to the time of surgery. Patients who received an injection at any time point before surgery had a 5.4% risk of PJI compared to 7.9% and 9.0% in patients receiving an injection within 3 months and 1 month of surgery, respectively. This time dependent association however did not reach statistical significance: 1 month OR 1.48; 95% Cl: 0.86-2.53; P = .16, 3 months OR 1.95; 95% Cl: 0.95-4.00; P = .07.

CONCLUSION

The results of this systematic review and meta-analysis demonstrate that patients receiving corticosteroid shoulder injections prior to shoulder arthroplasty may be at an increased risk for PJI postoperatively. While time dependent stratification did not reach statistical significance, our findings indicate a clear trend of increased risk for patients receiving injections closer to surgery.

Recent advances on polydeoxyribonucleotide extraction and its novel application in cosmeceuticals

Polydeoxyribonucleotide (PDRN) is a registered DNA-derived proprietary drug containing a mixture of DNA fragments of molecular weights of 50 and 1500 kDa extracted mainly from salmon with a highly pure active substance (>95 %). It has many valuable medicinal effects and multi-functions related to cosmeceuticals. In-vivo tests and even clinical trials have confirmed this substance as non-toxic. Its promising bioactivities and safety profile have prompted increasing research and discovery of this active ingredient. However, most previous review papers have only focused on the bioactivities of PDRN in medicine and mainly evaluated the efficiency of salmon-derived sources. Only one review has elucidated the capacity of PDRN as promising anti-aging without mentioning other effects in cosmeceuticals. Thus, an overview of novel sources for the extraction of PDRN and their functions in the cosmeceuticals field is lacking, and is the main topic of discussion in this review. Besides general information about PDRN, this review evaluated the advantages and disadvantages of different novel sources and procedures for PDRN extraction. The bioactivities of PDRN regarding cosmeceuticals are also elucidated comprehensively. This review aims to supply worthy scientific information for further studies on PDRN extraction and its bioactivity in cosmeceuticals.

Development of reduced volume endosseous cuspid tooth implant using topology optimization by SIMP technique for improved osseointegration

The article aims to design and develop a topology-optimized endosseous cuspid tooth implant of the maxilla region. The manuscript presents a numerical analysis of the resulting von Mises stresses and effective strain resulting in the topology-optimized implant with occlusal loading of 110 N. Solid Isotropic Material with Penalization (SIMP) method is employed for topology optimization and four different models, namely model-1, model-2, model-3, and model-4, are developed based on volume reduction rates of 8%, 16%, 24%, and 32%, respectively. FEA results highlight that the maximum stress and strain in the screw increases with volume reduction rates. The comparative analyses of the resulting stresses in the compact and cancellous bone along with the strain in the screw led to the conclusion that model-1, model-2, and model-3 resulted in moderate stresses on compact and cancellous bone compared to the original model of the implant. However, the screw and bones are subjected to maximum stress and strain in the model-4. The study concludes that model-2, with 16% reduced volume and 14.2% reduced mass as compared to the original implant, may be considered as the optimized design of the model. The resulting model offers a significant reduction in the weight and volume with a minor increase in effective stress and strain without negatively impacting the functionality and bio-mechanical performance of the implant. The optimized dental implant prototype is also fabricated as a proof of concept by the Fused Deposition Modelling process.

Accuracy and reliability of the AO/OTA classification for tibial shaft fractures

Background

Available literature lacks information regarding the accuracy and reliability of the AO/OTA classification for tibial shaft fractures. This study aimed to assess the inter- and intra-observer agreement and accuracy of the AO/OTA 42 classification (4-signs) for adult patients with tibial shaft fractures.

Materials and methods

The study design is an accuracy, inter- and intra-observer agreement study. Anterior posterior (AP) and lateral X-rays of the fracture were used in the examination. The raters comprised of two junior doctors and two orthopedic trauma consultants, who underwent patient scoring twice in a blinded and randomized set-up. A committee including two consultant orthopedic trauma surgeons, one consultant orthopedic radiologist, and one associate professor was established to represent the "gold standard." The 3- and 4-signs AO/OTA 42 classification was used for classification.

Results

A total of 101 patients were included. X-rays were available for all 101 patients. Based on the gold standard classification, AO/OTA 42-A1 (56 %) was the most common fracture type, followed by AO/OTA 42-A3 (14 %). The agreement at 4-signs, when comparing the four raters and the gold standard classification was between 75 % and 86 % (Choen's kappa 0.53 to 0.79). Choen's kappa coefficient at 4-sgns for intra-and inter-observer agreement was between 0.47 and 0.74 and 0.31 and 0.60, respectively.

Conclusion

This study showed substantial to moderate accuracy of the 4-signs AO/OTA 42- classification for tibial shaft fractures. Intra-observation agreements at 4-signs showed moderate to substantial agreement with and without available CT scans. Inter-observer agreements at 4-signs showed moderate to substantial agreement with only X-rays available. Inter-observer agreements for CT scan at 4-signs showed slight to moderate agreements.

Femoral shaft fracture with a third fragment treated with an intramedullary nail: Is the displacement of the third fragment predictive of nonunion?

PURPOSE

Femoral shaft fractures with third fragments are difficult to reduce anatomically, affecting bone healing chances. The goal of this study is to determine the impact of the third fragment's radiological characteristics assessed on post-operative radiographs, as well as other factors, on the healing of type 32B femur shaft fractures treated with intramedullary nail.

METHODS

We conducted a retrospective study of 93 patients treated for femoral shaft fractures type 32 B. On post-operative X-rays, two radiologic parameters were evaluated: the third fragment size and the mean third fragment displacement. Patients had radiologic follow-up at 2, 4, 6, 9, and 12-months and were separated into 3 groups based on their fracture healing time: within 6 months (group 1), between 6 and 12 months (group 2), or nonunion after 12 months (group 3).

RESULTS

Among the 93 patients, 72 (77.4%) showed fracture healing at 6 months, 13 (14%) at 12 months, and 8 (8.6%) demonstrated nonunion at 12 months. The mean third fragment displacement was notably different between groups (p < 0.001) and was considerably greater in group 3 than in groups 1 and 2. The influence of third fragment displacement on outcomes under 6 months was determined by ROC analysis, using a cut-off value of 14 mm. Displacement under 14 mm predicted healing within 6 months with a sensitivity of 90.3% and a specificity of 61.9%. The statistical analysis demonstrated that the odds of experiencing non-union or delayed healing were approximately 15 times higher for patients with a third fragment displacement of 14 mm or greater.

CONCLUSION

The third fragment displacement is the most important factor influencing healing within twelve months in femur shaft fractures type 32B managed with an intramedullary nail. Inversely, the third fragment size had no effect on the healing of the fractures in our series.

ERAS perioperative management measures in total hip replacement in HIV-positive patients with osteonecrosis of the femoral head

OBJECTIVE

This study aims to investigate the feasibility and effectiveness of enhanced recovery after surgery (ERAS) in HIV-positive patients diagnosed with osteonecrosis of the femoral head (ONFH) undergoing total hip replacement (THR).

METHODS

We retrospectively included 80 HIV-positive patients diagnosed with ONFH who underwent THR between 2011 and 2022. Forty patients treated before August 2019 constituted the control group, receiving standard antiviral regimens and traditional perioperative management pathways. The remaining 40 patients, treated after August 2019, formed the study group, which followed the ERAS protocol. This protocol emphasized the use of more effective antiviral medications, rapid viral load reduction, immune enhancement, improved nutritional status, control of co-infections, prophylactic antibiotics, and anti-osteoporosis measures. We recorded patients' general status and imaging examinations before surgery, as well as detailed perioperative management strategies, antiviral regimens, durations, and immunological indicators for both groups. Targeted and standardized treatment measures were applied to the ERAS group, allowing for a comparison of the efficacy of perioperative management between the two patient groups.

RESULTS

Preoperative nutritional and immune indicators were lower in the control group than in the study group, while inflammatory markers were higher. Postoperatively, immune, nutritional, and inflammatory indicators were significantly better in the ERAS group compared to the control group. Following antiviral treatment, the viral load was predominantly undetectable in the ERAS group (target not detected, TND). Comprehensive measures minimized complications in the ERAS group (P = 0.028, P < 0.05). The hospitalization duration for the ERAS group was significantly shorter than that of the control group, with both groups showing marked improvement compared to preoperative conditions and no incidents of loosening or dislocation.

CONCLUSION

Strengthening antiviral treatment, anti-infective strategies, incision care, and nutritional support effectively prevents and reduces complications such as delayed wound healing in HIV-positive patients. The implementation of ERAS measures requires careful attention to the patient's immune status, close monitoring of clinical changes, and timely adjustments to treatment and care plans.

LEVEL OF EVIDENCE

Treatment studies.

Impact of COVID-19 lock-down period on orthopedic and trauma surgical activity in a northern Italian hospital

Objectives

This study aims to describe the impact of COVID-19 on Orthopedic and Trauma surgical activity in a single level-I trauma center in Northern Italy during the lockdown period. We proposed comparing surgical procedures performed during the outbreak and in the same period the previous year.

Methods

In this single-center retrospective epidemiological cohort study, the "lockdown cohort" of patients who were treated from March 1st to May 24th, 2020, was compared to the "control cohort" who received treatment during the same period in 2019. The primary outcome was to evaluate the differences between the lockdown and control cohorts regarding surgical volumes. The secondary outcome was to evaluate any differences in the type of surgical procedures performed in the two cohorts in the elective and emergency setting.

Results

Orthopedic surgical activity has suffered a global reduction of 72.4% during the lockdown period (from 36 ± 6.1 to 10.7 ± 8.4 per week; p < 0.01), with the ratio of emergency to elective operations increasing from 0.7:1 in 2019 to 3.3:1 in 2020. Elective surgery has in fact been almost completely suspended and was affected with a reduction of 88.9% (from 20.8 ± 5.2 to 4.3 ± 2.8 cases per week; p < 0.01), while emergency trauma surgery suffered a 49.7% reduction (from 15.1 ± 3.2 to 8.2 ± 6.1 cases per week; p < 0.01).

Conclusion

The COVID-19 outbreak severely impacted Italy, particularly the Lombardy region, and affected the national health system. The 2020 COVID-19 lockdown has heavily conditioned our Orthopedic and Trauma department surgical activity.

Biomechanical Finite Element Analysis of Two Types of Short-Angled Implants Across Various Bone Classifications

The aim of this finite element analysis (FEA) was to investigate the distribution of von Mises stress within dental implant components, as well as trabecular and cortical bone. The study considered various bone qualities that influence cortical thickness in contact with the implant, specifically examining cortical thicknesses of 0.5, 1.5, and 3 mm, corresponding to Bergkvist's classifications IV, III, and II, respectively. A simplified 3D model of the bone was developed for the analysis. Two short implants were inserted into the model: one with a 30° inclined abutment (IA) and another positioned at a 30° angle featuring a straight abutment (II). A vertical force (120 N) was applied to the upper surface of the abutments. FEA software was employed to assess the stresses on the peri-implant tissues and the implants. The findings indicated that a reduction in cortical bone thickness results in an increase in stress within the cortical bone. For IA, the stresses recorded 32.56, 56.12, and 96.14 MPa for cortical thicknesses of 3, 1.5, and 0.5 mm, respectively. Conversely, II exhibited increased stresses across all bone qualities (52.32, 76.15, and 126.32 MPa for the same cortical thicknesses). It is advisable to avoid II in cases of poor bone quality and thin cortical due to the heightened risk of overload-induced bone resorption; however, it may be preferable to use IA in scenarios involving good bone quality and thicker cortical.

Lumbar Vertebral Body Tethering: Single Center Outcomes and Reoperations in a Consecutive Series of 106 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate the outcomes and reoperation rates in patients with adolescent idiopathic scoliosis undergoing lumbar anterior vertebral body tethering (AVBT).

BACKGROUND

AVBT is a viable option for growing children. The benefit of motion preservation must be balanced by a higher reoperation rate. A paucity of reports has addressed lumbar AVBT.

MATERIALS AND METHODS

A single-center retrospective study was conducted to identify all patients who underwent lumbar AVBT (lowest instrumented vertebra L3 or L4) with a minimum of 2 years of follow-up. Clinical and radiographic parameters, including complications and reoperations, were also collected. Statistical analysis was performed using the Student t test for qualitative variables.

RESULTS

From a data set of 551 patients, we identified 106 patients (89% female) who underwent a lumbar AVBT (33 lumbar only, 73 bilateral thoracic/lumbar) with a mean follow-up of 4.1 ± 1.6 years at which point 85% (90/106) had reached skeletal maturity. Preoperatively, these patients were skeletally immature (age: 12.8 ± 1.3 yr, Sanders: 3.3 ± 0.8, R = 0.6 ± 0.9) with a lumbar coronal curve angle of 49.6° ± 11.2° which corrected to 19.9° ± 11.2° ( P < 0.0001) at most recent follow-up. At the latest follow-up, 76.4% (81/106) of the patients harbored a coronal curve angle of <30°. Twenty patients (18.9%) underwent 23 reoperations, with overcorrection being the most common (10/23, 43%). Broken tethers led to reoperation in 3 instances (3/23, 13%). Six patients in the cohort needed a posterior spinal fusion (6/106, 5.4%).

CONCLUSIONS

Vertebral body tethering is a viable treatment option for skeletally immature patients with idiopathic scoliosis. This report is the largest to date for lumbar AVBT, highlighting that 84% of patients harbored a curve <35° at the latest follow-up but with an 18.9% reoperation rate.

LEVEL OF EVIDENCE

3.

ICF based comparison of musculoskeletal health in regions of Poland and Spain

The International Classification of Functioning, Disability and Health (ICF) is the framework for describing disability. The aim of the study was to compare differences in health status between the populations of the Podkarpackie region of Poland and the Castilla y León region of Spain, using the ICF core set for post-acute musculoskeletal conditions. A total of 840 people were included in the study. The brief version of ICF core set for post-acute musculoskeletal conditions was used in the study. Information obtained from semi-structured interviews and a physiotherapy assessment was recoded into ICF qualifiers to obtain comparable data. Significant differences in functioning were found between the two samples, with a higher prevalence in all the ICF entities for the Spanish sample. Similarities were found in the ICF components 'Body Functions' and 'Environmental Factors', with the most prevalent ICF entities being 'b280 Sensation of pain' and 'e225 Climate' respectively. For 'Activities and Participation', differences were observed, with 'd430 Lifting and carrying objects' being the most common for the Spanish sample and 'd450 Walking' for the Polish sample. Significant differences were found between the two samples, indicating better musculoskeletal health in the Polish sample. Future research using the ICF Core Sets in practice should be expanded and carried out in other countries to improve the ability to make comparisons between populations and to develop policies for territorial equity in health.Trial registration: NCT06283407.

Zero incidence of culture-positive septic arthritis and low infection rate following ACLR with all-soft tissue quadriceps tendon autograft: An analysis of 1053 cases

PURPOSE

To evaluate the infection rate following anterior cruciate ligament reconstruction (ACLR) using all-soft tissue quadriceps tendon (ASTQT) autograft.

METHODS

All primary ASTQT autograft ACLRs within a single surgeon's prospectively collected database from 2011 to 2021 were retrospectively reviewed. No topical antibiotics were administered and no graft-soaking with antibiotics was performed during the study period. Patients who underwent multiligament knee reconstruction or a cartilage restoration procedure were excluded. Patients who underwent a subsequent procedure, including irrigation and debridement (I&D) of the knee joint, were included. Case-specific data, including fluid culture analysis, antibiotics (type, route of administration and duration), time to debridement and method of debridement, were collected. Descriptive statistics were utilized to analyze demographics, incidence and possible association between the need for I&D and concomitant meniscus surgery.

RESULTS

Out of 1053 cases (mean age: 20.2 ± 6.3, 44.6% female), four patients (0.38%) (mean age: 18.5 ± 4.0, 25% female) underwent subsequent I&D (arthroscopic I&D only [n = 1], graft harvest site I&D only [n = 1], combined graft harvest site and arthroscopic I&D [n = 1] and tibia wound and arthroscopic I&D [n = 1]). There was no significant difference with regard to demographics. No joint fluid cultures returned positive; one wound culture returned positive for Methicillin-susceptible Staphylococcus aureus from their graft harvest site. The time to I&D ranged from 18 to 23 days. Concomitant meniscectomy or meniscal repair was not associated with requiring surgical I&D. All patients who underwent I&D were prescribed antibiotics for a minimum of 10 days and a maximum of 31 days (mean: 16.25 days). Three patients (75%) who underwent I&D ultimately returned to sport. One patient was lost to follow-up. ACL grafts were retained in all patients.

CONCLUSION

The incidence of culture-positive septic arthritis following ASTQT autograft ACLR is 0%, while the overall need for I&D of 0.38% is low and not related to concomitant meniscal procedures or patient-specific factors.

LEVEL OF EVIDENCE

Level IV.

Ipsilateral Femoral Neck and Shaft Fractures: Complex Injuries With High Rates of Femoral Shaft Nonunion

OBJECTIVE

To investigate nonunion rates and risk factors in patients with ipsilateral femoral neck and shaft fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Two Level I trauma centers.

PATIENT SELECTION CRITERIA

Two hundred seven patients treated for ipsilateral femoral neck (AO/OTA 31-B) and shaft (AO/OTA 32A-C) fractures from 2013 to 2022. Patients with less than 6 months of follow-up were excluded.

OUTCOME MEASURES AND COMPARISONS

The primary outcome of this study was femoral shaft nonunion. Risk factors for nonunion were evaluated, including smoking, open fracture, delay to full weight-bearing, blood transfusions, and AO/OTA classification.

RESULTS

Two hundred twenty-seven patients were initially identified, but only 154 patients had sufficient follow-up and were included in final analysis. The mean age was 38.9 years (SD = 15.3), and injury severity score was 19.5 (9.7). One hundred ten patients (71%) were male and 69 (45%) required intensive care unit care. Thirty-eight patients (25%) experienced an open fracture, and 44 fractures (29%) were AO/OTA Type C. Thirty patients (20%) underwent initial external fixation, and 88 patients (57%) received a perioperative transfusion. Thirty-four patients (22%) developed a femoral shaft nonunion, and 5 (3%) experienced a surgical site infection. Nonunion was associated with perioperative blood transfusion, AO/OTA Type C fracture, postoperative non-weight-bearing, and delay to full weight-bearing ≥12 weeks. Multivariable regression identified perioperative blood transfusion ≥3 (risk ratio [RR] = 1.91; CI, 1.12-2.72; P = 0.02) and AO/OTA Type C fracture (RR = 2.45; CI, 1.50-3.34; P = 0.001) as independent risk factors.

CONCLUSIONS

Ipsilateral femoral neck and shaft fractures remain difficult injuries to treat. Much attention is given to diagnosis and treatment of the femoral neck component. These results suggest that successful treatment of the femoral shaft component presents its own challenges with high nonunion rates.

LEVEL OF EVIDENCE

Prognostic Level III.

The Effect of Superficial Heat-Cold Application on the Sleep Quality of Patients With Restless Leg Syndrome: A Systematic Review and Meta-Analysis

AIM

The present study was conducted to determine the effect of the superficial heat-cold application on the sleep quality of patients with restless leg syndrome.

DESIGN

This study was a systematic review and meta-analysis.

METHODS

In the present study, the electronic databases Scopus, ProQuest, Web of Science, PubMed, SID and Google Scholar were searched from their inception to September 2023. The quality of included studies was evaluated through the Cochrane Collaboration's Risk of Bias Tool, and finally, a meta-analysis was conducted by calculating standardised mean differences (SMDs).

RESULTS

The meta-analysis results revealed that superficial heat-cold application improved sleep quality in patients with RLS (SMD = 0.685, 95% CI: 0.421-0.950). The meta-regression results showed that as the temperature increased, the intervention was more effective in improving sleep quality (β = 0.0182, 95% CI: 0.0096-0.0268, p < 0.05). Moreover, the effectiveness of the intervention in improving the sleep quality of patients with RLS reduced significantly as the duration of intervention in each session (β = -0.031, 95% CI: -0.059 to -0.001, p < 0.05) as well as participants' age increased (β = -0.013, 95% CI: -0.024 to -0.001, p = 0.0259).

PATIENT OR PUBLIC CONTRIBUTION

This research showed that superficial heat-cold application had the capability to improve the sleep quality of patients with restless leg syndrome. In addition, in this study, settings were suggested according to which the maximum effectiveness of the intervention could be achieved.

The clinical effect of Huoxue Huayu Recipe combined with ibuprofen in patients with postoperative pain after ankle fracture

The curative effect of Huoxue Huayu Recipe combined with ibuprofen in the postoperative pain in patients with ankle fractures was analyzed. 68 patients with ankle fractures were divided into study group (n = 34, Huoxue Huayu Decoction combined with ibuprofen) and control group (n = 34, ibuprofen). The levels of inflammatory factors, ankle joint function, VAS score and bone metabolism indexes were compared. Complications, isokinetic muscle strength and clinical related index levels were compared after treatment. High AOFAS score and low VAS score were identified in the study group compared with the control group at 1 week, 1 month and 2 months after operation. Compared to the control group, the incidence of postoperative complications was declined in the study group. After treatment, IL-6 and TNF-α levels in both groups were significantly decreased, and the study group had lower IL-6 and TNF-α levels. After treatment, the torque acceleration energy, relative peak torque value and endurance in the study group were obviously improved. The disappearance time of swelling and pain, fracture healing time, and complete weight-bearing time in the study group were reduced compared to the control group. After treatment, BGP and BALP levels in study group were higher than control group. Huoxue Huayu Recipe combined with ibuprofen can reduce inflammatory factors levels in patients with ankle fracture, improve isokinetic muscle strength and ankle function, and accelerate the recovery of patients.

Impact of COVID-19 public health restrictions on fall-related hip fracture hospitalizations: An interrupted time series analysis

PURPOSE

There is limited evidence regarding the impact of public health restrictions on hip fracture hospitalization by place of fracture occurrence. This study aimed to examine the impact of COVID-19 public health restrictions on fall-related hip fracture hospitalization rates by place of occurrence.

METHODS

This retrospective cohort study was conducted using hospitalization data in New South Wales, Australia, between January 2014 and June 2022. Older adults aged ≥65 years admitted to hospital following a fall-related hip fracture. An interrupted time-series analysis using autoregressive integrated moving average models evaluated the impact of public health restrictions on fall-related hip fracture hospitalization by place of fracture occurrence (home/residence, residential aged care facility (RACF), or away from usual residence).

RESULTS

The mean observed fall-related hip fracture hospitalization rate during COVID-19 public health restrictions (36.3 per 100,000 people per month) was 13.4 % lower than the forecasted rate (41.1 per 100,000 people per month). The mean observed hospitalization rates for fall-related hip fractures at home/residence, at a RACF, and away from the usual residence were 3.8 %, 18.5 %, and 40.1 % lower than the forecasted rates, respectively. Level changes in the fall-related hip fracture hospitalization rates at RACFs and away from usual residences were -0.9 per 100,000 people per month (95 % CI -1.6 to -0.2) and -1.7 per 100,000 people per month (95 % CI -2.5 to -0.9), respectively.

CONCLUSIONS

There was a decline in fall-related hip fracture hospitalization rates among older adults, where the fracture occurred at RACFs and away from a person's usual residence during COVID-19 public health restrictions.

Modern multiligament knee injury surgical reconstruction techniques can achieve excellent knee function and patient satisfaction, with low complication rates

PURPOSE

To report on the recovery of strength and functional capacity symmetry following multiligament knee surgical reconstruction (MLKR), as well as the capacity of athletes to return to sport.

METHODS

This prospective cohort study recruited 47 patients undergoing MLKR between February 2018 and July 2021. Forty patients had full outcome assessment postoperatively at 6, 12 and 24 months and were included in the analysis, 75% were knee dislocation one injuries and 60% were injured playing sport. Patient-reported outcome measures (PROMs) assessed included the International Knee Documentation Committee score, the Knee Outcome Survey, the Lysholm Knee Score and the Tegner Activity Scale (TAS). Patient satisfaction was also assessed. Objective assessment included assessment of active knee flexion and extension range of motion (ROM), the single (single horizontal hop for distance [SHD]) and triple (triple horizontal hop for distance [THD]) hop tests for distance and peak isokinetic knee flexor/extensor torque.

RESULTS

All PROMs significantly improved (p < 0.001) from presurgery to 24 months postsurgery. At 24 months, 70% of patients were satisfied with their sports participation. Active knee flexion (p < 0.0001) and extension (p < 0.0001) ROM significantly improved over time, as did the limb symmetry indices (LSIs) for the SHD (p < 0.0001), THD (p < 0.0001), peak knee extensor (p < 0.0001) and flexor (p = 0.012) torque. While LSIs for the SHD, THD and knee flexor strength tended to plateau by 12 months, knee extensor strength continued to improve from 12 to 24 months.

CONCLUSIONS

The majority of patients undergoing modern MLKR surgical techniques and rehabilitation can achieve excellent knee function, with low complication rates.

LEVEL OF EVIDENCE

Level IV.

Analysis of Serum and Synovial Inflammatory Markers in Periprosthetic Joint Infections: A Narrative Review

Periprosthetic joint infection (PJI) is considered a rare but devastating complication after total joint arthroplasty (TJA). The problem lies in the fact that there is a paucity of "gold standard" diagnostic tests that make the diagnosis of PJI extremely challenging. Recently, there have been increasing evidence-based guidelines that have been introduced to standardise the approach to a patient with a suspected PJI. Diagnosing a case of PJI traditionally involves initial screening for elevated serum inflammation markers C-reactive protein (CRP) (mg/dL) and erythrocyte sedimentation rate (ESR), and aspiration remains the sole confirmatory investigation. However, several factors would affect the values of the aforementioned markers, such as gender, age, and the presence of inflammatory circumstances. Serum D-dimer that detects fibrinolytic activities during infection has high sensitivity, but the specificity was not persuasive as it would elevate during other conditions, such as venous thromboembolism. Therefore, there is also a need for a simultaneous and secondary marker. There are also several synovial biomarkers, including ESR, CRP, alpha-defensin, and synovial fluid leukocyte count and differential for the detection of PJI. In this narrative review, we want to sum up the serum and inflammatory markers that have been introduced so far for detecting PJI.

Locally Delivered Antibiotics in Fracture-Related Infection

The prevention and treatment of fracture-related infections (FRIs) pose significant challenges in orthopaedic trauma care, with current practices predominantly relying on systemic antibiotic administration. However, locally delivered antibiotics achieve substantially higher tissue concentrations and minimise systemic side effects. Whilst extensively researched in periprosthetic joint infections (PJIs), the use of local delivery methods is increasingly prevalent in FRI prevention and treatment. Various local delivery methods such as powders, aqueous injections and carriers such as cement, bone graft, bioceramics, polymers and hydrogels have been explored. Biodegradable antibiotic carriers offer a promising alternative to non-absorbable carriers (i.e., cement), which necessitate surgical removal. There is good evidence for the use of local antibiotics in preventing and treating FRI, particularly in high-risk fractures or in treating more severe, resistant infections. Despite theoretical concerns, reports of adverse events in human studies are rare. To enhance our understanding of the safety and efficacy of these methods across various fracture patterns, further prospective randomised controlled trials are warranted. This article describes the current strategies and methodologies for FRI prevention and treatment and reviews the existing evidence base.

Comparison of Stress between Three Different Functionally Graded Hip Stem Implants Made of Different Titanium Alloys and Composite Materials

This study aims to evaluate the mechanical behavior, by ways of the FEM, of three femoral stems made of a Ti-6Al-4V titanium alloy with transverse holes in the proximal zone and a stem made of a β-type titanium alloy with a stiffness varying from 65 GPa in the proximal zone to 110 GPa in the distal zone and the CFRP composite material. The purpose of the study was to evaluate the effect of stress shielding on an intact femoral bone. A three-dimensional model of the intact femur was created, and the three prostheses were inserted with perfect stem bone fit. Applying constraint conditions such as fixation in all directions of the distal part of the femur and the application of a static load simulating standing still during a gait cycle allowed the stresses of both the implants and the bone to be compared. Evaluating the stress shielding for the three proposed materials was possible by identifying the seven Gruen zones. We can see from the results obtained that the metal alloys produced observable stress shielding in all the Gruen zones. There was a difference for the β-type alloy which, as a result of its stiffness variation from the proximal to the distal zone, did not show any level of stress shielding in Gruen zones 1 and 2. The CFRP composite, in contrast, showed no stress shielding in all of the Gruen zones and is an excellent material for the fabrication of total hip replacements. Further in vitro and in vivo validation studies are needed to make the modeling more accurate and understand the biological effects of the use of the three materials.

Numerical Optimization of Functionally Graded Ti-HAP Material for Tibial Bone Fixation System

Functionally graded materials (FGMs) are heterogeneous composites characterized by outstanding properties. They are built from two or more components with a gradient distribution of chemical composition along a given direction. A promising graded material for biomedical engineering as an implant could be a FGM made of titanium (Ti) and hydroxyapatite (HAP). It would allow us to counteract the difference between the stiffness modulus of pure titanium and bone tissue. Moreover, it can be a good solution to the problem of stress shielding for bone fixation plates made of conventional titanium or steel. The presented paper aims to perform micromechanical modeling and optimization of a functionally Ti-HAP graded plate, followed by numerical analysis of a fractured tibia stabilization system under specific boundary conditions. Finite element analysis was performed using ANSYS Workbench 2021 software. The models of the FGM plate and tibial fixation system were made using the Space Claim tool. The ANSYS software allowed the optimization of the model considered and the selection of the appropriate structural parameters of the FGM Ti-HAP material. In general, the results proved that the osteosynthesis plate built of graded Ti-HAP material resulted in lower bone stress compared to titanium and steel plates. The results obtained confirmed the validity of the design and the possibility to use functionally graded Ti-HAP bone fixation plates.

Expert opinion on heat therapy for teenagers' musculoskeletal pain management

Background

Among children and adolescents, up to 40% will experience musculoskeletal pain (MP), which can significantly impair functional ability, reduce quality of life, cause emotional distress, and lead to sleeping disorders for both patients and their families. The first-line treatment often involves pharmacological interventions, even though there is a lack of evidence supporting the efficacy or the safety of this approach in this specific age group. Recent guidelines recommend the implementation of preventative strategies and physical tools as the first option to minimize the use of medications. We aimed to provide an expert opinion on the use of heat therapy for MP management in young patients.

Methods

This paper is the result of a virtual advisory board held by the authors in order to discuss and provide an expert opinion about the use of heat therapy in MP in children and adolescents.

Results

MP is a significant burden affecting children and adolescents. While non-steroidal anti-inflammatory drugs are currently the first-choice treatment of acute and chronic MP in children and adolescents, avoiding or reducing them in such patients is advisable, to reduce side effects and to prevent the development of chronic pain and medication overuse headaches. Heat therapy can be an additional treatment option due to its ability to promote muscle relaxation, enhance blood circulation, and modulate nociceptors with a good safety profile.

Conclusions

MP in children and adolescents is a common condition that should be approached multidisciplinary, including information, therapeutic exercise and physical therapies like hot or cold therapies. Future studies should be conducted to evaluate the safety, efficacy and indications of each treatment in MP.

A Local Heating Profile to Manage Lower Back Pain in an Automotive Seat: A Pilot Study

Lower back pain (LBP) is one of the most prevalent health losses in adults worldwide. Historically, heat has been successfully used for treating pain and relieving tight muscles. Given the effective contact with the occupant's back and proximity to the heat source, coupled with increasing commute times, automotive seats offer an opportunity to intervene. Fifteen adults (nine female) who experienced acute, subacute, and chronic lower back pain were recruited to examine the effectiveness of heat delivered to the lower back in providing temporary pain relief. Participants sat in a car seat for 38 min on two days, which included a 5-min baseline followed by a 33-min intervention; control, or localized. For the control condition, participants sat for 33 min without any thermal devices on, while the localized condition heated and maintained the seat surface temperature of the lower seat back area to ~45 °C. Over the 33-min control condition, the back skin temperature increased by ~1-2 °C and did not impact the subjective LBP. Heating the lower back for 33 min to ~39 °C reduced the subjective LBP by 10%. We demonstrated that lower back pain can be alleviated from an automotive seat providing heat to the lower back within normal commute times in those with lower back pain.

Conversion hip arthroplasty for failed nailing of intertrochanteric fracture: Reflections on some important aspects

In this editorial, I present my comments on the article by Solarino et al. Conversion hip arthroplasty, which is an optional salvage procedure performed following unsuccessful fixation of intertrochanteric femur fractures in elderly patients, entails more complex processes and higher rates of operative complications than primary arthroplasty. Hence, it is important to consider the appropriateness of the primary treatment choice, as well as the adequacy of nailing fixation for intertrochanteric fractures. This article briefly analyzes the possible factors contributing to the nailing failure of intertrochanteric fractures and attempts to find corresponding countermeasures to prevent fixation failures. It also analyzes the choice of treatment between nailing fixation and primary arthroplasty for intertrochanteric fractures.

Long-term surgical outcomes of hemiarthroplasty for patients with femoral neck fracture with metal versus ceramic head in Taiwan

AIMS

Hip fractures are a significant health concern, especially in the elderly. Hemiarthroplasty has been the preferred treatment for displaced femoral neck fractures. The use of ceramic femoral heads has recently become popular due to their claimed durability. This study aimed to determine long-term outcomes associated with different implant choices in hemiarthroplasty.

METHODS

The study sample included patients aged 50 years and above, with an index femoral neck fracture admission and hip hemiarthroplasty identified from Taiwan's National Health Insurance (NHI) claims data (2009-2019). To compare two groups of users of different heads, we performed 1:2 matching of the ceramic group versus metal group according to age, gender, index year, and six major comorbidities. Cumulative incidence rates were assessed for revision, post-operative complications, and medical complications. Cause-Specific hazard Cox models were used to estimate the hazard ratios for the two different implants groups.

RESULTS

Among 47,158 patients, 2559 out of 2637 who received ceramic head hemiarthroplasty with co-payment, were successfully matched with 5118 receiving metal head prostheses fully covered by the NHI. Over a mean follow-up of 3.12 years, no significant differences were observed in revision rates between the ceramic and metal head groups. The ceramic head group demonstrated significantly lower risks of postoperative complications and medical complications within 90 days than the metal head group.

CONCLUSIONS

This study found ceramic implant had lower postoperative complications and medical complication rates than metal head implant in hip hemiarthroplasty, but there was no difference in the revision rates between the two heads.

The predictive value of stress-induced hyperglycemia parameters for delayed healing after tibial fracture post-surgery

PURPOSE

The objective of this retrospective cohort study was to investigate the predictive value of stress-induced hyperglycemia parameters for delayed healing after tibial fracture post-surgery.

METHODS

A cohort of 108 participants who underwent surgical intervention for tibial fractures caused by trauma was included in this retrospective study. Data collected from electronic medical records encompassed demographic characteristics, bone healing assessments, stress-induced hyperglycemia parameters, inflammatory markers, and stress-related hormones. Comparative analyses, correlation analyses, univariate logistic regression analyses, and receiver operating characteristic (ROC) curve analyses were conducted to assess the predictive value of the studied parameters.

RESULTS

The delayed healing group exhibited higher levels of fasting blood glucose, postprandial glucose, and HbA1c, as well as elevated levels of inflammatory markers and stress-related hormones compared to the normal healing group. Correlation analysis and logistic regression demonstrated positive associations between stress-induced hyperglycemia parameters, inflammatory markers, stress-related hormones, and delayed union of tibial fractures (R2: 0.183 ~ 0.403;OR: 1.091 ~ 16.332). ROC curve analysis revealed high area under the curve (AUC = 0.911) values for stress-induced hyperglycemia parameters, indicating their potential as predictive markers for delayed healing. Multivariate regression analysis further substantiated the predictive capability of stress-induced hyperglycemia parameters.

CONCLUSION

The study findings highlight the complex interplay between stress-induced hyperglycemia, inflammatory response, and bone healing outcomes in patients undergoing surgical intervention for tibial fractures. The identification of stress-induced hyperglycemia parameters as potential predictive markers for delayed healing after tibial fracture surgery offers insights for risk assessment and patient management, emphasizing the need for comprehensive understanding of these factors to optimize postoperative recovery in orthopedic patients.

Surgical Treatment of Periarticular Distal Radius Fracture in Elderly: A Systematic Review

Background/Objectives: The treatment of periarticular distal radius fractures remains challenging. Different surgical treatment options have been proposed as alternatives to conservative treatment. This systematic review aims to compare the functional outcomes, radiological outcomes, and complications among volar locking plates (VLPs), Kirschner-wire fixations, and external fixations (EFs) for distal radius fractures in patients aged 60 years and older. Methods: We conducted a comprehensive search of PubMed, Cochrane, and Science Direct databases assessing the effects of VLP, EF, and K-wire treatments for distal radius fractures in patients aged 60 years and over. The primary outcome was the evaluation of the range of motion (ROM) degrees after three surgical procedures, trying to assess the best treatment option. The secondary outcome included evaluation of the Disabilities of the Arm, Shoulder, and Hand (DASH) score, quick-DASH score, Patient-Rated Wrist Evaluation (PRWE) score, Visual Analog Scale (VAS) score, grip strength, radiographic assessment, and complications comparing VLPs, EFs and K-wires. Results: A total of 23 studies were included, comparing VLP, EF, and K-wire fixation. The overall population comprised 5618 patients, with 4690 females and 1015 males, of which 4468 patients were treated with VLP, 503 with EF, and 647 with K-wire. The most common complications among the VLP group were complex regional pain syndrome (7.5%) and carpal tunnel syndrome (6.8%); for the EF group, infections (9.8%) and carpal tunnel syndrome (6.8%); and for the K-wire group, carpal tunnel syndrome (7.5%) and infections (6.9%). Conclusions: VLP showed better clinical outcomes in the first few months after treatment. However, these differences decreased over time and became similar after one year. EF and K-wire fixations remain easier to manage during surgery.

Single-Taper Conical Tapered Stem in Total Hip Arthroplasty for Primary Osteoarthritis: A Comparative Long-Term Registry Evaluation

Background/Objectives: Single-taper conical tapered stems (STCTSs) are possible options for femoral reconstruction in THA performed for primary osteoarthritis, but outcomes are poorly ascertained. A specific STCTS in THA performed for primary osteoarthritis was investigated and compared to a control group including all the other cementless stems, aiming to assess the following: (1) the survival rates of the two cohorts and the hazard ratios for failure; (2) the survival rates and the hazard ratios for failures for stem failure, stem aseptic loosening, and periprosthetic fracture. Methods: A regional arthroplasty registry study evaluating a specific STCTS in THA performed for primary osteoarthritis was designed. A control group including all the other cementless stems was considered. Results: In total, 1773 STCTSs were compared to 37,944 cementless stems. The cumulative survivorship of the STCTS cohort was 95.6% at 10 years and 92.7% at 15 years, which was not different to the control group (p = 0.252). After age stratification, the hazard ratio for STCTS failure was not different to the control group. With stem revision as the endpoint, the STCTS cohort outperformed the control group (at 10 years, 98% versus 96.8%; p < 0.001). The STCTSs achieved better survival rates in females <65 years (p = 0.023). With stem aseptic loosening as the endpoint, the survival rates did not differ between the two cohorts (p = 0.085), as well as the adjusted hazard ratios (p = 0.264). With periprosthetic fracture as the endpoint, the survival rates were better for the STCTSs (p < 0.001). Conclusions: STCTSs in THA for primary osteoarthritis provided dependable long-term outcomes, not inferior to all the other cementless stems with various designs.

Mix and Match Use of Revision Universal Head-Neck Adapters in Hip Arthroplasty: A Complications and Survival Analysis of 306 Cases

BACKGROUND

Outcomes and safety of "mix and match" in total hip arthroplasty (THA) using universal head-neck adapters (UHNA) are a matter of ongoing discussion and concern due to legal affairs. This study aimed at analyzing the "mix and match" use of UHNA and evaluating complication and reoperation rates, possible risk factors, and the implant's survival.

METHODS

A total of 306 patients treated with THA (94.1% revisions) using a UHNA at our institution between 2006 and 2022 were identified and included. Diagnoses, comorbidities, implants, and UHNA specifications were retrospectively recorded. Outcomes, complications, and survival analyses were evaluated, taking into account various possible risk factors.

RESULTS

There were 19.9% of the 306 included cases (58.5% women; median age 74 years; median follow-up 57 months) that had at least 1 complication. There were 43 patients (14.1%) who had to receive ≥1 rerevision surgery. The most common complication was postoperative recurrent dislocation (n = 27, 8.8%). There was one case of a prosthetic stem-neck fracture that was registered. Statistically significant risk factors for postoperative recurrent dislocations and postoperative aseptic loosening were, respectively, dislocation as an indication for UHNA implantation (P < .001) and oversized neck lengths (≥2XL; P = .004). The overall revision-free survival was 92% after 1 year and 82% at ten years. Statistically significant better survival rates were registered in patients ≥60 years old, who had fewer comorbidities (<2), and normal neck lengths (S to XL).

CONCLUSIONS

The results of this study underline the overall safety of UHNA use in THA through "mix and match." Only one case of a stem-neck fracture was identified. The highlighted risk factors for failure must be kept in mind during the decision-making process with patients.

Rotator Cuff Repair by All-Arthroscopic Versus Mini-Open Technique: A Comparison of Clinical and Functional Outcome

BACKGROUND

Rotator cuff tears can lead to debilitating shoulder function and impairment. Rotator cuff repair aims to eliminate pain and improve function with increased shoulder strength and range of motion. This study evaluated the differences between all-arthroscopic (AA) and mini-open (MO) repair procedures for rotator cuff tendon tears regarding clinical and functional outcomes.

METHODS

This was a prospective study conducted at a tertiary care government Hospital in Kolkata, India, between March 2015 and September 2016 which evaluated 25 patients who had undergone all-arthroscopic surgery and 25 patients who underwent mini-open repair (total of 50 patients) for rotator cuff tear with a minimum one-year follow-up. The UCLA score was used to assess the functional outcome of these patients.

RESULTS

The mean age of all patients included in this study was 45.32 years. 86% of patients were male. The two groups had similar demographic characteristics, pre-operative baseline parameters, and intra-op findings. The average UCLA score showed significant improvement from 13.92 pre-operatively to 29.76 at the final follow-up. The patients in the all-arthroscopic surgery group experienced a notable decrease in pain within the first three months compared to the mini-open group. However, at the time of the final follow-up, no significant difference was noted between both groups when comparing the University of California at Los Angeles (UCLA) score, Visual Analogue Scale (VAS) score for pain, and active or passive glenohumeral motion.

CONCLUSION

The outcomes of all-arthroscopic and mini-open rotator cuff repair surgery are equivocal in terms of both clinical and functional results, with no significant difference in post-operative pain, shoulder joint strength range of motion, or patient satisfaction over the long term.

Men and women undergoing total hip arthroplasty have different clinical presentations before surgery and different outcomes at 1-year follow-up

PURPOSE

The purpose of this study was to investigate the influence of sex on patients undergoing total hip arthroplasty (THA) for hip osteoarthritis (HOA), aiming to assess the clinical and functional outcomes using patient-reported outcome measures (PROMs).

METHODS

A retrospective analysis of patients undergoing THA at Ospedale Galeazzi-Sant'Ambrogio between 2016 and 2022 was conducted. Inclusion criteria encompassed Kellgren-Lawrence grade III or IV HOA, with preoperative and 12-month postoperative PROMs. Enroled patients have been selected from a larger cohort without matching design for confounders. The analyses were performed using R software v4.0.3 (R Core Team) and data distributions were assessed using the Shapiro-Wilk normality test.

RESULTS

One hundred ninety patients (72 male and 118 female) who had both preoperative and postoperative PROMs have been analysed from our institutional prosthesis registry (Datareg). Baseline and 12-month post-THA PROMs showed significant improvements overall. VAS score dropped notably from baseline to 3 months postsurgery (7.1 ± 2.1 vs. 0.9 ± 1.7). Functional and mental PROMs, including Harris Hip Score-functional (HHS-F), Harris Hip Score-total (HHS-t), SF-12PS and SF-12MS, exhibited substantial improvements post-THA. Stratifying by sex, males had lower baseline VAS, higher HHS-F, SF-12MS and hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS). At 12 months, males displayed significantly better VAS, HHS-F, SF-12PS and HOOS-PS scores. Complication rates were minimal (1.5%), with stable rates across genders, mostly involving dislocation and periprosthetic fractures. Implant survival at 12 months reached an impressive 99%.

CONCLUSION

THA remains an effective treatment for severe HOA. However, females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males. This difference could be attributed to physiological and psychosocial factors associated with sex, including hormonal changes, muscle mass decline and perception of pain. Longer follow-ups and prospective studies are necessary to validate these findings and facilitate personalised approaches in HOA treatment, emphasising the need for careful consideration of sex-related variables in clinical decision-making for THA patients.

LEVEL OF EVIDENCE

Level III.