The latest medical research on Orthopaedic Surgery

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Does metabolic syndrome increase the risk of fracture? A systematic review and meta-analysis.

Archives of Osteoporosis

Metabolic syndrome is of increasing concern globally. The aspects of this disease and its interaction with other morbidities should be discussed in detail. By investigating the effects of metabolic syndrome on the bone fracture rate, we have shown a protective role for metabolic syndrome in the male population.

There is controversy on the effects of metabolic syndrome on bone health and fracture risk. This systematic review and meta-analysis reappraises the literature on the subject and quantitatively evaluates the fracture risk in individuals with metabolic syndrome.

PubMed, Embase, Web of Science, and Scopus were searched for all relevant articles. Studies were selected if they included the rate of any type of fracture in individuals with metabolic syndrome. Non-English studies, review articles, case reports, and editorials were excluded. The titles and abstracts were screened to identify relevant studies and the data was extracted from these. The data were analyzed to determine the estimated effect at a 95% confidence interval. Publication bias was assessed using the Egger's test, and funnel plots were drawn. The heterogeneity of the results was determined according to I2 statistics.

Of the 3141 articles from the initial search, 20 studies were selected for review and included 13 cross-sectional and seven cohort studies. A meta-analysis of all studies showed no association between metabolic syndrome and fractures across the entire population (HR = 0.954; p = 0.410). However, separate analysis of the cohort studies showed a decreased risk over the entire population (HR = 0.793; p = 0.000) and in males (HR = 0.671; p = 0.000), but not in females (HR = 1.029; p = 0.743).

This systematic review and meta-analysis showed that the current literature suggests that metabolic syndrome is a protective factor for bone fractures in males but has no net effect on fractures among females.

Real-world effectiveness of osteoporosis treatments in Germany.

Archives of Osteoporosis

This observational study assessed the impact on the fracture incidence of osteoporosis medications in postmenopausal women in Germany. Continued treatment with osteoporosis medications was associated with reductions of fracture rates in a real-world setting.

The efficacy of osteoporosis medications has been demonstrated in clinical trials, but a lack of evidence exists of their real-world effectiveness. This real-world study assessed the treatment patterns and impact on the fracture incidence of osteoporosis medications in postmenopausal women in Germany.

This cohort study used data from the WIG2 benchmark database, a German anonymised healthcare claims database. All women ≥ 50 years of age with ≥ 1 prescription for osteoporosis medication between 1 January 2013 and 31 December 2017 were included. The primary outcome was treatment effectiveness, evaluated as the change in fracture incidence after initiating treatment. Fracture types included all fractures, clinical vertebral, hip and wrist/forearm. Fracture incidence was assessed during the early-treatment period (0-3 months) and the on-treatment period (4-12, 13-24, 25-36 and 37-48 months).

Baseline covariates and treatment patterns were determined for 41,861 patients. The median duration of therapy was longer with denosumab (587 days) than with intravenous ibandronate (451 days), intravenous zoledronate (389 days) or oral bisphosphonates (258 days). The baseline incidence rate of all fractures was higher in patients receiving denosumab than in those receiving other treatments (87.6, 78.2, 56.6 and 66.0 per 1000 person-years for denosumab, oral bisphosphonates, intravenous ibandronate and intravenous zoledronate, respectively). Rates of all fractures declined with continued denosumab (by 38%, 50%, 56% and 67% at 12, 24, 36 and 48 months, respectively) and oral bisphosphonates (by 39%, 44%, 49% and 42%, respectively) treatment.

Continued treatment with osteoporosis medications was associated with reductions of fracture rates in a real-world setting.

Association of Craniocervical Sagittal Alignment With the Outcomes of Cervical Disc Replacement.

Global Spine Journal

Patients who underwent 1-level and 2-level CDR were retrospectively analyzed. Clinical outcomes were evaluated using scores on the Japanese Orthopaedic Association (JOA), Visual Analogue Scale (VAS), and Neck Disability Index (NDI). The craniocervical sagittal alignment parameters, including the C0-C2 Cobb angle, C2-C7 Cobb angle, C2 slope, T1 slope, C2-C7 sagittal vertical axis (SVA), C1-C7 SVA, the center of gravity of the head (CGH)-C7 SVA, and range of motion (ROM) at the surgical segments were measured.

To explore the association between craniocervical sagittal balance and clinical and radiological outcomes of cervical disc replacement (CDR).

A total of 169 patients were involved. Significantly lower pre- and postoperative C2 slope and CGH-C7 SVA were found in arthroplasty levels with better ROMs. Patients with a higher preoperative C2 slope and CGH-C7 SVA had lower cervical lordosis and ROM after surgery. There were no significant differences in the clinical outcomes between patients with different sagittal balance statuses. C2-C7 SVA and CGH-C7 SVA were significantly associated with radiographic adjacent segment pathology (rASP).

Craniocervical sagittal balance is associated with cervical lordosis and ROM at the index level after CDR. A higher preoperative SVA is related to the presence and progression of rASP. A relationship between sagittal alignment and clinical outcomes was not observed.

Knowledge and understanding risk factors and preventive measures for osteoporosis in women: results of a survey in 502 women with and without a migration background.

BMC Musculoskeletal Disorders

Osteoporosis is a disease of the skeletal system associated with loss of bone mass and an increased risk of fractures affecting women more often than men. Identification of the knowledge about osteoporosis and its preventive methods is the backbone of any awareness program. This study investigates the knowledge with a special focus on women with and without a migration background.

Data from systematic patient interviews based on a questionnaire were collected at three different sites in Berlin between February and June 2021. The survey included questions assessing migrant background, demographic characteristics, lifestyle habits including physical exercise and smoking, prevention by vitamin D intake and bone densitometry, and information on personal and family medical history. According to the responses, a scale was created to assess the level of knowledge of preventive osteoporosis measures. The ethic committee of the Charité, Medical faculty has approved this study. SPSS (version 24.0) was used for the statistical analyses.

The survey of 502 female patients revealed that 25% had low and 34% no previous knowledge of osteoporosis. Older age and a better education level correlate with a higher knowledge. Patients with gynecologic cancer are less well informed. There is a significant difference in vitamin D intake between migrant and non-migrant women (57% vs. 49%). There were no significant differences regarding the use of bone densitometry.

Knowledge of osteoporosis and the possibility of a bone densitometry as well as the implementation of preventive measures is low among women. Therefore, informing patients better should be a priority, with particular attention on the risks and needs of women with a migration background. Specific programs for women with and without migration background should be developed to increase the awareness of osteoporosis.

Comparison of Ma-Griffith combined with a minimally invasive small incision to a modified suture technique for the treatment of acute achilles tendon ruptures.

BMC Musculoskeletal Disorders

The Achilles tendon is the strongest tendon in the human body, although it is also prone to injury and rupture. Currently, the best treatment method for acute Achilles tendon rupture remains controversial. The aim of this study was to compare the efficacy of the Ma-Griffith method combined with a minimally invasive small incision (M-G/MISI) with the modified suture technique (MST).

We conducted a retrospective review of the medical records of all patients who underwent treatment for acute Achilles tendon rupture between January 2012 and January 2020 at our hospital. Demographic characteristics, operative details, and postoperative complications were recorded, and data were statistically analyzed to compare the treatment efficacy of the two operative methods.

A total of 67 patients were enrolled in the study, 34 of whom underwent M-G/MISI treatment, and 33 of whom underwent MST treatment. The intraoperative blood loss in the M-G/MISI group (16.47 ± 13.23 ml) was significantly lower than that in the MST group (34.55 ± 13.01 ml), and the difference was statistically significant (P ˂0.001). The incision in the M-G/MISI group (3.79 ± 1.81 cm) was significantly shorter than that in the MST group (5.79 ± 1.00 cm), and the difference was statistically significant (P˂0.001). The Achilles tendon rupture score and the American Orthopedic Foot and Ankle Society (AOFAS) score were higher than those of the MST group at the sixth month after the operation (P˂0.001). Postoperatively, there was 1 case of traumatic Achilles tendon rupture in the M-G/MISI group and 1 case each of infection and deep vein thrombosis in the modified suture group.

Compared with the MST group, the M-G/MISI group had better Achilles tendon and ankle function scores at 6 months postoperatively, and less bleeding and shorter incisions. M-G/MISI is less invasive than MST.

The effect of pre-operative carbohydrate loading in femur fracture: a randomized controlled trial.

BMC Musculoskeletal Disorders

NCT04838366, first registered on 09/042021 ( ).

This study was single-center, hospital-based, open-label, parallel-group randomized controlled trial conducted between August 2020 and November 2021. A total of 66 participants, aged 50 years and above having femur fractures planned for surgery were included in this study and assigned to the control (n = 33) and study (n = 33) groups through computer-generated random numbers. The control group was kept fasting from midnight to the next morning as in existence while the study group was intervened with carbohydrate loading according to the Enhanced Recovery After Surgery (ERAS) protocol. The pre-operative nutritional status was identified and the postoperative outcomes were measured using the Visual Analogue Score (VAS), Cumulative Ambulatory Score (CAS), and Modified Barthel Index (MBI) scoring systems. Statistical analyses were performed using the Chi-square test and the Student's two-sample t-test to compare the outcomes between the two groups.

All the participants completed the study. There was a significant reduction in the average postoperative pain in the carbohydrate loading group (VAS: 4.8 (SD ± 1.8), 95% CI: 4.7-5.4) as compared to the control group (VAS: 6.1 (SD ± 2.1), 95% CI: 5.3-6.8). The average CAS showed a significant improvement in regaining the mobility function of participants in the study group (CAS: 8.1 (SD ± 2.8), 95% CI: 7.1-9.1) than that of the control group (CAS: 6.8 (SD ± 2.8), 95% CI: 5.8-7.8). The mean MBI score of the participants at the time of discharge from the hospital was higher in the study group (MBI:13.1 (SD ± 2.3), 95% CI: 12.2-13.9) compared to the control group (MBI: 11.8 (SD ± 3.1), 95% CI:10.6-12.9). Similarly, the length of hospital stay after surgery had decreased in the study group than in the control group.

The uptake of carbohydrate loading showed reduced post-operative pain, enhanced functional mobility, and decreased length of hospital stay. This study warrants larger trials to show the effect of pre-operative carbohydrate loading in a clinical setting.

Fixation stability comparison of bone screws based on thread design: buttress thread, triangle thread, and square thread.

BMC Musculoskeletal Disorders

The influence of thread profile on the fixation stability of bone screws remains unclear. This study aimed to compare the fixation stability of screws with different thread profiles under several loading conditions.

Bone screws that differed in thread profile (buttress, triangle, and square thread) only were made of stainless steel. Their fixation stabilities were evaluated individually by the axial pullout test and lateral migration test, besides, they were also evaluated in pairs together with a dynamic compression plate and a locking plate in polyurethane foam blocks under cyclic craniocaudal and torsional loadings.

The triangle-threaded and square-threaded screws had the highest pullout forces and lateral migration resistance. When being applied to a dynamic compression plate, higher forces and more cycles were required for both triangle- and square-threaded screws to reach the same displacement under cyclic craniocaudal loading. On the other hand, the triangle-threaded screws required a higher torque and more cycles to reach the same angular displacement under cyclic torsional loading. When being applied to a locking plate, the square-threaded screws needed higher load, torque, and more cycles to reach the same displacement under both cyclic craniocaudal and torsion loadings.

The triangle-threaded screws had superior pullout strength, while square-threaded screws demonstrated the highest lateral migration resistance. Moreover, dynamic compression plate fixation with triangle- and square-threaded screws achieved more favorable fixation stability under craniocaudal loading, while triangle-threaded screws demonstrated superior fixation stability under torsional loading. Locking plate fixation with a square-threaded screw achieved better fixation stability under both loading types.

Effects of walking speeds and durations on the plantar pressure gradient and pressure gradient angle.

BMC Musculoskeletal Disorders

Walking exercise has been demonstrated to improve health in people with diabetes. However, it is largely unknown the influences of various walking intensities such as walking speeds and durations on dynamic plantar pressure distributions in non-diabetics and diabetics. Traditional methods ignoring time-series changes of plantar pressure patterns may not fully capture the effect of walking intensities on plantar tissues. The purpose of this study was to investigate the effect of various walking intensities on the dynamic plantar pressure distributions. In this study, we introduced the peak pressure gradient (PPG) and its dynamic patterns defined as the pressure gradient angle (PGA) to quantify dynamic changes of plantar pressure distributions during walking at various intensities.

Twelve healthy participants (5 males and 7 females) were recruited in this study. The demographic data were: age, 27.1 ± 5.8 years; height, 1.7 ± 0.1 m; and weight, 63.5 ± 13.5 kg (mean ± standard deviation). An insole plantar pressure measurement system was used to measure plantar pressures during walking at three walking speeds (slow walking 1.8 mph, brisk walking 3.6 mph, and slow running 5.4 mph) for two durations (10 and 20 min). The gradient at a location is defined as the unique vector field in the two-dimensional Cartesian coordinate system with a Euclidean metric. PGA was calculated by quantifying the directional variation of the instantaneous peak gradient vector during stance phase of walking. PPG and PGA were calculated in the plantar regions of the first toe, first metatarsal head, second metatarsal head, and heel at higher risk for foot ulcers. Two-way ANOVA with Fisher's post-hoc analysis was used to examine the speed and duration factors on PPG and PGA.

The results showed that the walking speeds significantly affect PPG (P < 0.05) and PGA (P < 0.05), and the walking durations does not. No interaction between the walking duration and speed was observed. PPG in the first toe region after 5.4 mph for either 10 or 20 min was significantly higher than 1.8 mph. Meanwhile, after 3.6 mph for 20 min, PPG in the heel region was significantly higher than 1.8 mph. Results also indicate that PGA in the forefoot region after 3.6 mph for 20 min was significantly narrower than 1.8 mph.

Our findings indicate that people may walk at a slow speed at 1.8 mph for reducing PPG and preventing PGA concentrated over a small area compared to brisk walking at 3.6 mph and slow running at 5.4 mph.

Correlation between carpal rotational alignment and postoperative wrist range of motion following total wrist arthroplasty.

BMC Musculoskeletal Disorders

Although total wrist arthroplasty (TWA) has become a common treatment option for wrists with damage due to rheumatoid arthritis (RA), the optimal implant axial alignment for TWA has been inadequately studied. This study was performed to investigate the relationships between implant alignment and carpal rotational alignment and the wrist range of motion (ROM) following TWA.

This study included 18 patients who underwent TWA using a DARTS® Total Wrist System (Teijin Nakashima Medical, Okayama, Japan) for wrist RA. Pre- and 6-month postoperative computed tomography scans were performed, including the radial volar line (Rv), capitohamate axis (CH), and Rv-CH angle in axial scans. The wrist ROM was also measured. The relationship between the Rv-CH angle and ROM was examined.

The mean Rv-CH angle showed significant wrist pronation from 73.0° to 83.4° postoperatively. We observed a significant positive correlation (0.58) between the postoperative Rv-CH angle and extension and a significant negative correlation (- 0.56) between the postoperative Rv-CH angle and flexion.

Implantation of the DARTS® TWA prosthesis resulted in pronation of the carpal axial alignment, which was correlated with postoperative wrist extension. The volar cortex of the distal radius can be a novel reference axis for adequate implant placement.

Biallelic variants in CHST3 cause Spondyloepiphyseal dysplasia with joint dislocations in three Pakistani kindreds.

BMC Musculoskeletal Disorders

Skeletal dysplasia is a heterogeneous group of disorders. Spondyloepiphyseal dysplasias comprise one subgroup. Deficiency of carbohydrate sulfotransferase 3 has been reported in a small number of patients with recessively inherited spondyloepiphyseal dysplasia with joint dislocation, short stature and scoliosis. We report here molecular and clinical findings of affected individuals in three consanguineous Pakistani families. Affected individuals in all three families had a uniform phenotype including severe short stature, multiple dislocated joints, progressive scoliosis and facial dysmorphism.

Clinical evaluation was done for three unrelated families. Radiological survey of bones was completed for patients from two of the families. Whole exome sequencing index patients from each family was performed followed by Sanger sequencing for validation of segregation of identified variants in respective families. In-silico analysis for determining pathogenicity of identified variants and conservation was done.

Whole-exome sequencing revealed biallelic variants c.590 T > C;p.(Leu197Pro), c.603C > A;p.(Tyr201Ter) and c.661C > T;p.(Arg221Cys) in CHST3 (NM_004273.5) in the three families with eight, five and two affected individuals, respectively. Contrary to previous reports, affected individuals in none of the families exhibited a hearing loss.

We describe genotypic and phenotypic findings of three unrelated families with spondyloepiphyseal dysplasia. Our study confirms phenotypic variability and adds to the genotypic spectrum of spondyloepiphyseal dysplasia.

Early manipulation under anaesthesia for stiffness following total knee arthroplasty is associated with a greater gain in knee flexion.

Knee Surg Sports Traumatol Arthrosc

This study aimed to identify the risk factors for manipulation under anaesthesia (MUA) following total knee arthroplasty (TKA) and whether performing an 'early' MUA within 3 months leads to a greater improvement in range of motion.


A total of 7386 primary TKAs were analysed in which 131 underwent an MUA (1.8%). Patients aged < 65 years were two times more likely to undergo MUA compared to patients aged ≥ 65 years (2.5 versus 1.3%, p < 0.001; adjusted HR = 2.1, p < 0.001). There was no difference in the final flexion angle post-MUA between early and late MUA (104.7° versus 104.1°, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3° versus 79.6°, p = 0.012), and subsequently had a greater overall gain in flexion compared to those who underwent late MUA (mean gain 33.1° versus 24.3°, p < 0.001).

Younger age was the only patient risk factor for MUA. Patients who underwent early MUA had similar post-MUA flexion, but had poorer pre-MUA flexion compared to those who underwent late MUA. Subsequently, a greater overall gain in flexion was achieved in those who underwent early MUA.

Strontium-89 plus zoledronic acid versus zoledronic acid for patients with painful bone metastatic breast cancer.

Journal of Bone and Mineral Metabolism

β-ray strontium-89 (Sr-89) intra-irradiation therapy has been approved and clinically used to reduce bone metastasis pain not alleviated by bone-modifying agents, external radiation, and analgesic agents. We examined the efficacy of zoledronic acid (ZOL) and Sr-89 combination therapy compared with ZOL alone in breast cancer patients with bone metastases.

A randomized controlled trial was conducted on breast cancer patients with bone metastasis to compare the efficacy between ZOL monotherapy and ZOL plus Sr-89 combination therapy. The primary endpoints were changes in urinary NTX levels at 13 weeks and brief pain inventory scores. The secondary endpoints were analgesic drug usages, response rates, changes in bone metabolism markers, quality of life, and adverse event rates.

Thirty of the planned 60 cases were randomly assigned to ZOL alone or ZOL + Sr-89. There were no significant differences in the changes in urinary NTX levels between the 2 groups (P = 0.365). There was no consistent difference in the pain score changes between the 2 groups. Sr-89 addition to ZOL slightly reduced the white blood cell and platelet counts. However, all adverse events were Grade 1. Safety and analgesic drug dose reduction were more evident in ZOL + Sr-89.

This trial showed the lack of benefits from Sr-89 addition to ZOL for breast cancer patients with painful bone metastases. However, safety and analgesic drug dose reduction were more evident in ZOL + Sr-89, indicating its potential for pain control. Sr-89 therapy is safe, thus more effective radiopharmaceuticals are anticipated.