Int Orthop. 2025 May 26. doi: 10.1007/s00264-025-06564-7. Online ahead of print.

ABSTRACT

INTRODUCTION: Since the introduction of videogames and augmented reality technology, injuries associated with e sports have garnered increased attention from researchers and healthcare professionals. This review articles examines the spectrum of injuries associated with videogames and augmented reality and describes the nuances of the diagnoses associated with gaming injuries.

MATERIALS AND METHODS: An online-based questionnaire of 25 items was distributed to all the members of the Italian Society of Orthopedic Surgery and Traumatology (SIOT) regarding their indications, usual practices, and complications encountered with hardware removal in upper and lower limbs. The survey was open from July 2024 to October 2024. Exclusion and inclusion criteria were applied.

RESULTS: Five hundred answers were received. While implant removal is primarily achieved in symptomatic patients, in the case of asymptomatic patients, it is not routinely performed, with a slightly higher tendency of removal in those aged 16-40 years old. These tendencies were registered both for the upper and lower limbs, with more reticence in hardware removal in the upper limbs. 96% of respondents declared the lack of hospital guidelines regarding this kind of surgery. The most feared intraoperative complications during the removal concerned screw stripping and implant breakage, with only 0.6% of respondents reporting no intraoperative difficulties. While patient discomfort and avoidance of future complications were the main indications for removal, postoperative complications occurred as wound scarring concerns, persistence of symptoms and bleeding. Despite not being considered a "procedure for the resident", when residents were specifically questioned, in 76% of cases they felt self-confident ≥ 7 on a scale from 1 to 10. Lastly, according to 62% of the respondents, titanium implants are more difficult to remove than stainless steel ones.

CONCLUSION: This survey describes a general tendency to not routinely remove implants, even in younger patients in the lower and especially upper limbs, unless in case of symptoms. Hardware removal could evolve from a simple procedure into a more complex surgery due to intraoperative technical difficulties. A lack of universal policy and guidelines exists throughout the Italian territory.

PMID:40415005 | DOI:10.1007/s00264-025-06564-7

Injury. 2025 May 14:112437. doi: 10.1016/j.injury.2025.112437. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma-related preventable death is considered death as a consequence of moderate to severe injury under (sub)optimal trauma care conditions and is used as a criterion to evaluate the management and quality of trauma care worldwide. A validated definition of trauma-related preventable death is still lacking due to differences in classification. To reach consensus on a definition and assess the necessity of an additional trauma prediction algorithm, a Delphi procedure was performed.

METHODS: A digital three-round Delphi procedure was performed. Trauma surgeons, neurosurgeons, forensic medicine physicians, anesthesiologists, and emergency care physicians working at a Level 1 or affiliated trauma center in the Netherlands were invited to participate. An electronic questionnaire was administered to assess the most suitable category of trauma-related preventable death (clinical definition, trauma prediction algorithm, clinical definition and trauma prediction algorithm or other) and the additional benefit of a trauma prediction algorithm.

RESULTS: Fifty-four panelists completed the study: 23 trauma surgeons, 13 emergency care physicians, 10 anesthesiologists, 4 neurosurgeons and 4 forensic medicine physicians. In the first round, a clinical definition and a clinical definition and trauma prediction algorithm (Trauma Score and Injury Severity Score and a combination of algorithms) were favored. The results were fed back to the panelists. In the final round, there was a tendency towards group consensus in favor of a clinical definition and trauma prediction algorithm (63 %). Consensus was reached on the most suitable algorithm: the Trauma Score and Injury Severity Score combined with the Probability of survival.

CONCLUSION: The identification of trauma-related preventable death is essential in the evaluation of trauma care. This study elucidates the difficulty of multidisciplinary consensus. However, a propensity towards consensus on a clinical definition, and consensus on the additional benefit of the PS, based on the TRISS, seems to be present.

PMID:40413123 | DOI:10.1016/j.injury.2025.112437

Injury. 2025 May 14;56(8):112427. doi: 10.1016/j.injury.2025.112427. Online ahead of print.

ABSTRACT

INTRODUCTION: Trauma video review (TVR), whereby resuscitations in the trauma bay are audio-visually recorded, has not been investigated within the orthopaedic context. The purpose of this study was to evaluate the utility of TVR as a practical method to evaluate the delivery of orthopaedic care and resident competency in the trauma bay.

MATERIALS AND METHODS: This was a retrospective study of 15 trauma resuscitations performed at an academic, level I trauma center between May - June 2024. TVR was used to evaluate the quality of orthopaedic care delivered in the trauma bay and to assess resident competency using Accreditation Council for Graduate Medical Education (ACGME) milestones and American Board of Orthopaedic Surgery (ABOS) Knowledge, Skills and Behavior criteria.

RESULTS: TVR allowed for quantification of multiple orthopaedic time-based metrics. TVR identified themes to prompt institutional quality improvement initiatives in the future. Importantly, TVR provided a unique opportunity to evaluate the resident interacting as part of an impromptu multidisciplinary team in a high stress environment. TVR effectively provided a method to assess competency using ACGME and ABOS criteria.

CONCLUSIONS: TVR is a practical tool to evaluate and improve the quality of orthopaedic care provided in the trauma bay. It offers a unique opportunity to assess resident competency by ACGME and ABOS criteria.

PMID:40412348 | DOI:10.1016/j.injury.2025.112427

Injury. 2025 May 15;56(8):112441. doi: 10.1016/j.injury.2025.112441. Online ahead of print.

ABSTRACT

OBJECTIVES: To address the conflicting evidence in the literature regarding time to surgery and its impact on outcomes for distal femoral fractures.

METHODS: This is a retrospective review of the American College of Surgeon's (ACS) National Surgical Quality Improvement Project (NSQIP®) database, that collects data from 680 hospitals across the United States. The database was queried from 2010-2021. Case selection was done by use of ICD-9 & ICD-10 codes for native distal femoral fractures and periprosthetic distal femur fractures, along with CPT codes for surgical fixation of distal femur, total knee arthroplasty and revision knee arthroplasty. Pre-operative, operative and post-operative factors were compared for patients undergoing surgery on hospital day 0 or 1 (HD ≤ 1) to patients undergoing surgery after hospital day 1(HD > 1). Primary outcome measure was 30-day mortality. Chi-square and logistic regression were used for univariable and multivariable analyses, respectively.

RESULTS: A total of 6857 cases were identified (mean age of 71.5 years). 84.5 % underwent surgery on HD ≤ 1, and 15.5 % on HD > 1. Rate of mortality was 1.37 % and 3.26 %, respectively. Patients who underwent surgical fixation of distal femoral fracture on HD ≤ 1 had a 40 % decrease in odds of mortality compared to fixation on HD > 1 (OR 0.587; p = 0.031). A multi variable analysis revealed that presence of dyspnea (OR 4.338, p = 0.005), preoperative blood transfusion (HR 2.32, p = 0.001) and bleeding disorder (OR 1.727, p = 0.03) were associated with increased mortality at 30-days on multivariable analysis, while younger age (OR 0.216; p = 0.001) had a protective effect.

CONCLUSIONS: Delayed surgical fixation is associated with increased odds of 30-day mortality for patients with distal femoral fractures. Further studies will help determine if the increased mortality is caused by the delay itself or by other confounding variables not identified in this study that may be associated with the reason for the delay.

LEVEL OF EVIDENCE: Level III.

PMID:40412347 | DOI:10.1016/j.injury.2025.112441

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01327. Online ahead of print.

ABSTRACT

BACKGROUND: An intraoperative midsubstance injury to the medial collateral ligament (MCL) is a devastating complication of total knee arthroplasty (TKA). No single treatment method has been shown to yield optimal stability. This cadaveric study compared primary MCL repair, increasing prosthetic constraint, and a combination of both techniques on tibiofemoral compartment gapping after an iatrogenic MCL injury.

METHODS: We performed 16 cadaveric, robotic-assisted TKAs (CORI; Smith+Nephew) and recorded tibiofemoral gap measurements at 10°, 30°, 60°, and 90° of flexion with a posterior-stabilized (PS) prosthesis as the control group. The experimental groups had no MCL repair and a PS component, no MCL repair and a varus-valgus constrained (VVC) component, MCL repair with a PS component, and MCL repair with a VVC component. The MCL was repaired with 2 figure-8 nonabsorbable sutures. Gap measurements were manually tensioned by the same surgeon for all specimens. The mean medial tibiofemoral gap with the 3 different methods of interest (the no MCL repair with VVC component group, the MCL repair with PS component group, and the MCL repair with VVC component group) was compared with the control group for the rate of deficit (RD) and was compared with the no MCL repair and PS component group for the rate of improvement (RI). Simple statistics were used to calculate the mean medial balance for the groups, and analysis of variance (ANOVA) modeling was used to determine the mean changes in RD and RI, with significance set at p < 0.05.

RESULTS: The mean RD was highest for the no MCL repair with PS component group at 621.13%, demonstrating an approximately 6-fold increase in medial tibiofemoral gapping compared with the control group. This was followed by the no MCL repair with VVC component group at 93.02%, the MCL repair with PS component group at 65.66%, and the MCL repair with VVC component group at 20.01% (p < 0.001). The mean RI for the MCL repair with VVC component group was highest at 83.08%, meaning that the combination of VVC component and MCL repair resulted in an 83% improvement in medial tibiofemoral gapping from no MCL repair with PS component. This was followed by the MCL repair with PS component group at 76.62% and the no MCL repair with VVC component group at 72.95% (p < 0.001).

CONCLUSIONS: This cadaveric study demonstrates that primary MCL repair with VVC component was the best for minimizing the deficit after an MCL injury and provided the highest RI. MCL repair with PS component and no MCL repair with VVC component were less effective reconstructive choices. This study supports the combination of a simple MCL repair with VVC component as the most stable reconstructive option following an intraoperative MCL injury.

PMID:40408512 | DOI:10.2106/JBJS.24.01327

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01353. Online ahead of print.

ABSTRACT

BACKGROUND: Patients with apical spinal cord deformity have been shown to be at a greater risk for intraoperative neuromonitoring (IONM) alerts when undergoing posterior spinal instrumented fusion (PSF) for adolescent idiopathic scoliosis (AIS). The use of intraoperative traction during deformity correction has also been associated with an increased risk of IONM alerts. With use of the Spinal Cord Shape Classification System (SCSCS), we investigated the interaction between spinal cord type and the use of intraoperative traction and their impact on IONM alerts during the surgical correction of AIS.

METHODS: A total of 441 consecutive patients who underwent PSF or combined PSF plus anterior spinal fusion (ASF) for AIS between 2003 and 2022 were retrospectively reviewed. Those with major thoracic curves of ≥70° and available preoperative magnetic resonance images (MRIs) were included. Charts were reviewed for IONM alerts and the use of intraoperative traction. Spinal cord morphology was determined using the SCSCS. A multivariable regression model was used to assess the risk factors for an IONM alert.

RESULTS: Preoperative MRIs were available for 102 patients. Type-3 cords were present in 15 (14.7%) of the 102 patients. Intraoperative traction was used in 15 (14.7%) of the 102 patients, including 5 with type-3 cords. Patients with type-3 cords were more likely to have an IONM alert than those with type-1 or 2 cords (40.0% [type 3] versus 12.6% [type 1 or 2]; odds ratio [OR], 4.60; 95% confidence interval [CI], 1.34 to 15.53). No such difference was observed between patients with type-1 cords and those with type-2 cords (12.5% and 12.7%, respectively; p > 0.9999). All patients with type-3 cords placed in intraoperative traction experienced IONM alerts, whereas only 10% of patients with type-3 cords not placed in traction experienced such alerts (p = 0.002). Multivariable regression modeling revealed intraoperative traction to be the only independent risk factor for an IONM alert (OR, 9.37; 95% CI, 2.47 to 38.24).

CONCLUSIONS: This study demonstrated that 14.7% of patients with AIS and curves of ≥70° had a type-3 cord. Intraoperative traction carried a ninefold increased risk of an IONM alert. When intraoperative traction is used for type-3 cords, surgeons should expect IONM alerts to occur. The SCSCS can be condensed into 2 groups for a pediatric population.

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40408508 | DOI:10.2106/JBJS.24.01353

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.00965. Online ahead of print.

ABSTRACT

BACKGROUND: There has been weak consensus and a paucity of robust literature with regard to the best postoperative weight-bearing and immobilization regime for operatively treated ankle fractures. This trial compared immediate protected weight-bearing (IWB) with non-weight-bearing (NWB) with cast immobilization following ankle fracture fixation (open reduction and internal fixation [ORIF]), with a particular focus on functional outcomes, complication rates, and cost utility.

METHODS: This INWN (Is postoperative Non-Weight-bearing Necessary?) study was a prospective, pragmatic, randomized controlled trial (RCT), with participants allocated in a 1:1 ratio to 1 of 2 parallel groups. IWB from postoperative day 1 in a walking boot was compared with NWB and immobilization in a cast for 6 weeks, following ORIF of all standard types of unstable ankle fractures. Skeletally immature patients and patients with tibial plafond fractures were excluded. The type of surgical fixation was at the surgeon's discretion. Patients were randomized postoperatively by an operating room nurse using computerized block randomization (20 patients per block). Surgeons were blinded until after the operation. The study was multicenter and included 2 major orthopaedic centers in Ireland. Analysis was performed on an intention-to-treat basis. The primary outcome was the functional outcome assessed by the Olerud-Molander Ankle Score (OMAS) at 6 weeks. A cost-utility analysis via decision tree modeling was performed to derive an incremental cost-effectiveness ratio (ICER).

RESULTS: We recruited 160 patients between January 1, 2019, and June 30, 2020, with 80 patients per arm, who were 15 to 94 years of age (mean age, 45.5 years), and 54% of patients were female. The IWB group demonstrated a higher mean OMAS at 6 weeks (43 ± 24 for the IWB group and 35 ± 20 for the NWB group, with a mean difference of 10.4; p = 0.005). The complication rates were similar in both groups, including surgical site infection, wound dehiscence, implant removal, and further operations. Over a 1-year horizon, IWB was associated with a lower expected cost (€1,027.68) than NWB (€1,825.70) as well as a higher health benefit (0.741 quality-adjusted life-year [QALY]) than NWB (0.704 QALY). IWB dominated NWB, yielding cost savings of €798.02 and a QALY gain of 0.04.

CONCLUSIONS: IWB in a walking boot following ankle fracture fixation demonstrated superior functional outcomes, greater cost savings, earlier return to work, and similar complication rates compared with NWB in a cast for 6 weeks. These findings support the implementation of IWB as the routine mobilization protocol following ankle fracture fixation.

LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

PMID:40408465 | DOI:10.2106/JBJS.24.00965

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01434. Online ahead of print.

ABSTRACT

BACKGROUND: Previous studies have not compared airway resistance and morphological parameters before and after the treatment of severe scoliosis. In the present study, 3-dimensional (3D) computed tomographic (CT) reconstruction and impulse oscillometry (IOS) were used to evaluate the changes in airway dilation and airway resistance caused by posterior spinal fusion for the treatment of severe kyphoscoliosis.

METHODS: Thirty-four patients with severe scoliosis (Cobb angle, >100°) underwent posterior spinal fusion. Preoperative and postoperative evaluations included CT scans, radiographic assessment, and IOS. Changes in bronchial dilation were evaluated with use of 3D CT reconstruction, and changes in airway resistance were evaluated with use of IOS. Differences were assessed with use of 2-tailed paired Student t tests, and correlations were evaluated with use of the Spearman rank test.

RESULTS: Nearly all spinal radiographic measurements improved after posterior spinal fusion. The mean Cobb angle was 133.21° ± 22.15° preoperatively and 50.92° ± 13.37° postoperatively (p < 0.001). The mean thoracic kyphosis angle was 121.42° ± 32.42° preoperatively and 50.67° ± 5.21° postoperatively (p < 0.001). The IOS measurements improved, with the reactance at 20 Hz (R20) decreasing from 0.4029 ± 0.0747 to 0.3100 ± 0.0837 kPa/(L/s) (p = 0.0004). Following posterior spinal fusion, the trachea, left main bronchus, and right main bronchus expanded. Moreover, the diameter and lumen area of the trachea were moderately correlated with R20 (r = -0.5071, p = 0.0114; r = -0.5537, p = 0.0050) and the diameter and lumen area of the right main bronchus were correlated with R20 (r = -0.5583, p = 0.0056; r = -0.6389, p = 0.0008). R20 and the lumen area of the trachea were correlated with the thoracic kyphosis angle (r = 0.6394, p = 0.0004; r = -0.6160, p = 0.0023).

CONCLUSIONS: Posterior spinal fusion can safely and effectively improve the curve and relieve airway obstruction in patients with severe scoliosis. Impulse oscillometry analysis suggested that R20 substantially increased after posterior spinal fusion, primarily because of altered central airway enlargement as measured with CT reconstruction.

LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

PMID:40408454 | DOI:10.2106/JBJS.24.01434

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01060. Online ahead of print.

ABSTRACT

BACKGROUND: The obesity epidemic has given rise to an orthopaedic patient subgroup with a body mass index (BMI) of ≥50 kg/m2. Without sound evidential guidance, arthroplasty surgeons and anesthesiologists do not know whether they can push the limits of the surgical feasibility of total knee arthroplasty (TKA) without risks of harm.

METHODS: In a retrospective cohort study of patients who had undergone primary TKA for degenerative arthritis at our academic center (n = 10,389; 6,821 women, 4,070 men, and 38 unknown), we compared the outcomes between patients with a BMI of ≥50 kg/m2 (n = 627) and patients in other weight classes. The average patient follow-up was 8.6 years. We used Cox proportional hazards models to estimate the association between BMI and revision risk, using overweight patients (BMI = 25 to 29.99 kg/m2) as the reference group while adjusting for patient age and sex. Patient satisfaction, pain scores on a visual analogue scale (VAS), and the Oxford Knee Score (OKS) were compared among groups preoperatively and at 1, 5, and 10 years postoperatively.

RESULTS: In the first year after surgery, the adjusted hazard ratio (HR) for revision TKA for patients with a BMI of ≥50 kg/m2 was 3.7 (95% confidence interval [CI] = 1.9 to 7.2), with overweight patients as the reference. There was virtually no difference between patients with a BMI of 35 to 39.99 kg/m2 and those with a BMI of 40 to 49.99 kg/m2. After the first year, the HR was 1.2 (95% CI = 0.7 to 2.4) for revision TKA for patients with a BMI of ≥50 kg/m2. Those patients reported worse preoperative function of the knee, with a median OKS of 15 versus 23 for overweight patients. For obese patients, each additional unit of BMI corresponded with an additional OKS improvement of 0.07 point (95% CI = 0.04 to 0.10) at 1 year.

CONCLUSIONS: Our study confirms the increased risk of failure of TKA in patients with a BMI of ≥50 kg/m2 in the first year after surgery, but we found no evidence of worse outcomes in the 40 to 49.99 kg/m2 group compared with the 35 to 39.99 kg/m2 group. The increase in the revision risk in the ≥50 kg/m2 group was found only in the first postoperative year and plateaued afterwards. Despite worse function and higher failure rates, patients with a BMI of ≥50 kg/m2 reported benefits and high satisfaction with TKA.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40408452 | DOI:10.2106/JBJS.24.01060

J Bone Joint Surg Am. 2025 May 23. doi: 10.2106/JBJS.24.01407. Online ahead of print.

ABSTRACT

BACKGROUND: Periprosthetic tibial fractures around a total knee replacement (TKR) remain challenging to manage, with little published information for guidance. The purpose of this study was to review the types, management techniques, and outcomes of periprosthetic tibial fractures in the largest series to date.

METHODS: We identified 300 periprosthetic tibial fractures (285 patients) around a TKR (43% in primary TKRs and 57% in revision TKRs) sustained between 1996 and 2020. Fractures were classified according to Felix et al. as Type I (tibial plateau), Type II (adjacent to stem), Type III (distal to stem), or Type IV (tibial tubercle), with subtypes A (well-fixed component), B (loose component), and C (intraoperative fracture). Of the fractures in this study, 53% were Type I, 24% were Type II, 16% were Type III, and 8% were Type IV. A total of 46% of fractures occurred intraoperatively, and 54% of fractures occurred postoperatively (61% subtype A, 39% subtype B). The mean patient age at fracture was 67 years, and 64% of patients were female. The mean follow-up was 6 years.

RESULTS: The intraoperative fracture incidence was 1.40% in revision TKRs and 0.10% in primary TKRs. Among intraoperative fractures, the 2-year survivorship free from tibial component revision was highest in Type I (100%) and lowest in Type IV (67%) (p < 0.001). For postoperative fractures, the 2-year survivorship free from any reoperation was 29% and the 2-year survivorship free from tibial component revision was 51%. Type-I postoperative fractures had the lowest 2-year survivorship free from tibial component revision (10%), whereas Type-III fractures had the highest survivorship (88%) (p < 0.001).

CONCLUSIONS: Intraoperative periprosthetic fracture of the tibia was fourteenfold more likely in revision TKRs compared with primary TKRs. Among all intraoperative fractures, Type-I fractures were well-tolerated, with 100% survivorship free from tibial component revision at 2 years. Conversely, Type-I postoperative fractures had only 10% survivorship at 2 years.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40408445 | DOI:10.2106/JBJS.24.01407

Int Orthop. 2025 May 23. doi: 10.1007/s00264-025-06561-w. Online ahead of print.

ABSTRACT

PURPOSE: This study aimed to evaluate the early outcomes and safety of allograft medial patellofemoral complex reconstruction (MPFC-R) in children and adolescents with patellofemoral instability (PFI).

METHODS: A retrospective analysis of prospectively collected data was conducted, including patients aged ≤ 18 years who underwent MPFC-R with allograft from January 2018 to December 2021. Preoperative assessment included evaluating patellar tracking and radiographic features, such as trochlear dysplasia, patellar height, and tibial tubercle-trochlear groove distance. Data on patient demographics, PFI type, complications, and patient-reported outcomes (Pedi-IKDC, Kujala Anterior Knee Pain Scale, Lysholm Knee Scoring Scale) were collected. Failure was defined by postoperative patellar dislocation or surgical revision for recurrent patellar instability.

RESULTS: A total of 24 allograft MPFC-R (21 patients) were analyzed with a mean follow-up of 28.8 months (range, 12-60 months). The mean age at surgery was 13.4 years (range, 3-18 years), and 71% were female. The mean Pedi-IKDC, Kujala, and Lysholm scores were 91.2 (± 7.2), 92.8 (± 7.5), and 94.3 (± 6.3) points, respectively. Two patients (8.3%) experienced a single episode of patellofemoral instability without needing surgical revision. No other complications were reported.

CONCLUSION: Allograft MPFC reconstruction appears to be a safe and effective surgical option for managing recurrent patellar instability in children and adolescents at a mean follow-up of two years. Further research is needed to confirm its long-term efficacy and safety.

LEVEL OF EVIDENCE: IV (Case series).

PMID:40407901 | DOI:10.1007/s00264-025-06561-w

SICOT J. 2025;11:31. doi: 10.1051/sicotj/2025023. Epub 2025 May 22.

ABSTRACT

INTRODUCTION: This study analyzed complication rates in two-stage bilateral Total Hip Arthroplasty (THA) across three distinct inter-stage intervals to determine the optimal timing for minimizing risk.

METHODS: This was a retrospective, multicentre, analytic study. The three intervals evaluated were <2 weeks (Group A), 2-12 weeks (Group B), and >12 weeks (Group C). The primary outcomes were blood transfusions, thromboembolic events (TVE), and coronary events, and the secondary outcomes were hospital stay, respiratory complications, reintervention, and mortality. The associations between demographic characteristics and complications and the risk hazard of complications were determined.

RESULTS: A total of 331 patients were included: 86 in Group A, 47 in Group B, and 198 in Group C. Blood transfusions after the second THA were performed in 29.1%, 14.9%, and 7.6% of the time interval groups respectively (p = 0.000). One TVE (1.1%) was recorded in group A and 4 (2%) in group C (p = 0.613).

CONCLUSIONS: Two-stage bilateral THA with a time interval between both surgeries of <2 weeks presented a significantly higher rate of blood transfusions than longer time intervals between surgeries, with an HR of 2.4 (CI: 95% 1.7-3.3, p = 0.000). The incidences of thromboembolic and coronary events were similar between the different timeintervals, demonstrating that two-stage bilateral THA is safe when performed with an interval of at least 2 weeks between both surgeries.

PMID:40403169 | PMC:PMC12097731 | DOI:10.1051/sicotj/2025023

J Bone Joint Surg Am. 2025 May 22. doi: 10.2106/JBJS.24.01261. Online ahead of print.

ABSTRACT

BACKGROUND: Long-bone fractures in children can lead to premature physeal bar formation and growth disturbance. Bar excision has been studied, but data on prophylactic tissue interposition into physeal fractures are limited. This study used an established animal model to evaluate acute placement of fat autograft. The number of animals was selected to give 80% power on the basis of pilot data on induction of radiographic bars in physeal fractures.

METHODS: Proximal tibial fractures were created in 30 rabbits by placing pins in the epiphysis and levering the distal tibia, propagating the fracture through the physis. Twenty fracture sites had interposed fat autograft (fat group), and 10 did not (fracture group). The 30 untreated contralateral limbs were the control group. Radiographs were assessed preoperatively and immediately, 10 days, and 6 weeks following fracture. Radiographic measurements were compared using repeated-measures analysis of variance. Micro-computed tomography (microCT) 3D reconstructions and histologic analysis further characterized the healing and control tibial physes.

RESULTS: Fat and fracture groups were similar (age, weight, body length, surgical duration, and weight and body length increases over 6 weeks). No difference was observed in the probability of radiographic bar formation between the fat (12 of 20) and fracture (7 of 10) groups (p = 0.702). On the basis of the medial-lateral side difference, fat (0.66 ± 1.64 mm) and fracture (0.53 ± 1.36 mm) groups demonstrated increased valgus growth compared with controls (-0.74 ± 1.16 mm) (p = 0.002 and p = 0.04). Six weeks following fracture, tibial length was less in the fat group compared with the control group (fat: 101.4 ± 3.1 mm, control: 103.7 ± 2.6 mm, p = 0.02). MicroCT 3D reconstructions demonstrated no difference in bone bridging between fat and fracture groups, and the fat group having more bone bridging than controls (83 ± 102 versus 11 ± 49, p = 0.004). Histologic analysis showed disorganized tissue without evidence of physeal cartilage preservation for most limbs in both treatment groups.

CONCLUSIONS: Fat autograft interposition did not reliably prevent radiographic bar formation or angular deformity when placed during physeal fracture reduction. 3D reconstructions and histology indicated that the fat was converted to bone just as readily as if a disrupted physis had no interposition, yet with a reduction in the surface area of bone bar formation that did not reach significance.

CLINICAL RELEVANCE: Given these findings, we do not necessarily advocate for acute prophylactic fat interposition into physeal fractures for bar prevention in pediatric fractures.

PMID:40403121 | DOI:10.2106/JBJS.24.01261

J Bone Joint Surg Am. 2025 May 22. doi: 10.2106/JBJS.24.01137. Online ahead of print.

ABSTRACT

➢ Medical ethics education is a required component of orthopaedic surgery resident training per the Accreditation Council for Graduate Medical Education (ACGME) guidelines, although no standardized curriculum currently exists.➢ Beyond the 4 principles of bioethics (autonomy, beneficence, nonmaleficence, justice), additional ethical concepts relevant to orthopaedic care include utilitarianism, deontology, virtue ethics, moral intuitionism, microethics, and narrative ethics.➢ Ethical themes identified in the literature relevant to orthopaedic surgery include the ethics involved in medical decision-making, use of new technologies, caring for vulnerable patients, performing high-stakes procedures, the impacts of trainee status on patient care, and patient attitude regarding conflict of interest.➢ Ethical themes that we sought to identify in the literature but found lacking include the ethics of providing orthopaedic care in low-resource settings, orthopaedics entrepreneurship, disability ethics, trainee mistreatment by their supervisors, and the ethics involved in the recognition and reporting of child and elder abuse.

PMID:40403094 | DOI:10.2106/JBJS.24.01137

J Bone Joint Surg Am. 2025 May 22. doi: 10.2106/JBJS.24.01213. Online ahead of print.

ABSTRACT

BACKGROUND: Acute compartment syndrome (ACS) is a medical emergency and a cause of medical litigation across multiple specialties. We sought to compare the characteristics and outcomes of ACS-related litigation levied against surgeons in orthopaedics compared with other specialties.

METHODS: The Westlaw database was queried for ACS-related cases filed within the United States between 1980 and 2023 using the search term "compartment syndrome." Inclusion criteria were defined as all jury verdicts or settlements tied to alleged medical malpractice concerning ACS of the spine and extremities. ACS cases of the abdomen were excluded.

RESULTS: Of 755 cases, 358 cases met inclusion criteria, 150 (42%) of which listed an orthopaedic surgeon as a defendant. A defendant verdict was reached in 203 cases (57%), a plaintiff verdict was reached in 88 cases (25%), and 67 cases (19%) were settled. The mean payout in orthopaedic cases was $3,219,519. Compared with non-orthopaedic practitioners, orthopaedic surgeons were significantly more likely to be named in cases in which ACS was due to surgery or fracture (both, p < 0.001) and in which the basis of litigation was alleged improper cast or splint application (p < 0.001). Orthopaedic surgeons were significantly less likely to be named in ACS cases when the basis of litigation was alleged negligent medication administration (p < 0.001). Only 3 cases (0.8%) mentioned documentation of compartment checks and intracompartmental pressures, and no cases were levied because of unnecessary fasciotomy. Two cases described the use of postoperative regional anesthesia for pain control.

CONCLUSIONS: ACS-related litigation is associated with a considerable financial burden in the wake of substantial morbidity and mortality. Lawsuits against orthopaedic surgeons more commonly involve fractures and cast or splint application, whereas those against non-orthopaedists more commonly involve medication or fluid infiltration. Documentation of close monitoring for symptoms specifically related to ACS and intracompartmental pressure measures may be a valid method to mitigate associated medicolegal risk. Prophylactic fasciotomies have not historically been a source of litigation.

LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40403083 | DOI:10.2106/JBJS.24.01213

J Bone Joint Surg Am. 2025 May 22. doi: 10.2106/JBJS.24.01349. Online ahead of print.

ABSTRACT

BACKGROUND: Brachial plexus injury (BPI) leads to a variety of life-altering changes, both physically and mentally. While tremendous effort has been dedicated to improving patients' upper-extremity function through surgical and rehabilitation advances, patients' life experiences after BPI are largely understudied and poorly understood. Our study aims were to qualitatively assess the patient experience after BPI through the use of a photojournalism method known as photovoice, a community-based participatory research methodology centered on participant photograph-taking, and to trial the use of photovoice as a novel qualitative method within the field of orthopaedics.

METHODS: We utilized both photovoice and qualitative methods to highlight the experiences of 7 participants living with a traumatic BPI (5 male and 1 female, 4 White and 2 Black, plus 1 not stated). The study was conducted in 6 phases with a mix of 1-on-1 and focus group discussions. Over the course of 10 weeks, the group met to generate photography prompts, analyze photographs (in 1-on-1 meetings with researchers), and discuss the meaning of photographs as a group. The research team analyzed transcripts from all 1-on-1 and group discussions to create 2 editions of e-magazines, which included quotes from transcribed data layered with photographs from each participant, to serve as patient-facing support materials for future patients with BPI. In the final phase, the research team shared the e-magazines with the participants in a group discussion.

RESULTS: The participant-selected topics highlighted in the e-magazines ranged from pain after injury to tips and tricks for living with BPI. Photovoice was effective in building community among patients with BPI and creating meaningful patient-facing support materials. Our findings demonstrate the utility of using participant-generated photography as a tool to encourage meaningful conversation and develop community among participants.

CONCLUSIONS: Participant-led methodologies, such as photovoice, provide opportunities for patients to convey their life experiences to their community and to their health-care providers in a unique way. Our study also demonstrates the potential for photovoice to improve the patient experience by generating a sense of community, allowing patients to express themselves, and inspiring others.

PMID:40403081 | DOI:10.2106/JBJS.24.01349

Int Orthop. 2025 May 22. doi: 10.1007/s00264-025-06563-8. Online ahead of print.

ABSTRACT

PURPOSE: Managing knee arthritis with an associated extra-articular deformity (EAD) by total knee arthroplasty (TKA) is technically demanding. Intra-articular correction of EAD often requires extensive soft tissue release, which can be challenging. This study evaluates whether imageless robotic assisted TKA facilitates intra-articular correction using functional alignment and desired under-correction of severe EAD. Additionally, we assess the short-term functional and radiological outcomes in these patients.

PATIENTS AND METHODS: We prospectively reviewed 14 consecutive patients with knee osteoarthritis and angular EAD of the femur or tibia due to malunited fractures who underwent robotic-assisted TKA between November 2022 and April 2024. Ten patients had tibial EAD, and four had femoral EAD. Twelve had varus deformity and rest two had valgus deformity. Functional outcomes were assessed using the Oxford Knee Score (OKS), Knee Society Score (KSS), and Knee Society Functional Score (KSS-F). Radiological parameters included the Hip-Knee-Ankle (HKA) axis, mechanical axis deviation (MAD), the centre of rotation of angulation (CORA), medial proximal tibial angle (MPTA), and lateral distal femoral angle (LDFA).

RESULTS: The mean follow-up period was 16 months (range: 8 to 25 months). The mean EAD measured 13.8° (range: 5.1°-21.1°) in the coronal plane and 8.2° (range: 1.2°-22.8°) in the sagittal plane. The mean HKA angle improved from 163.9° ± 7.8° preoperatively to 176.4° ± 1.4° postoperatively (p < 0.05) for varus knees and from 189.5 ± 9.2° to 183.8 ± 2.6° for valgus knees (p = 0.002). No patients required grade IV soft tissue release or constrained prosthesis. The mean arc of motion improved from 94.6° ± 19.3° to 109.6° ± 9.8° (p = 0.001). The KSS, KSS-F, and OKS significantly improved from 25.1 ± 10.8, 36.4 ± 14.5, and 17.2 ± 5.7 preoperatively to 86.8 ± 4.4, 88.6 ± 5.3, and 41.4 ± 4.8 postoperatively (p < 0.001). No radiolucent lines were observed at the bone-cement interface during follow-up. Additionally, no complications such as infection, aseptic loosening, or ligament instability occurred.

CONCLUSION: Robotic-assisted TKA allows for effective intra-articular correction of severe EAD while minimizing the need for extensive soft tissue release. Robotic-assisted TKA helps in executing functional alignment, desired under-correction of the deformity and optimal soft tissue balance, resulting in satisfactory functional and radiological outcomes.

PMID:40402236 | DOI:10.1007/s00264-025-06563-8

Injury. 2025 May 16;56(8):112439. doi: 10.1016/j.injury.2025.112439. Online ahead of print.

ABSTRACT

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with acute spinal cord injury (SCI). This study aimed to evaluate VTE incidence in patients with acute SCI and explore injury and management characteristics that may identify high-risk patients.

METHODS: Retrospective review of consecutive patients with acute SCI ≥18 years admitted to the National Spinal Injuries Unit (NSIU) between January 2016 and December 2020 was conducted. Data were extracted from the NSIU database, internal picture archiving and communication system and hospital records. Primary outcome was VTE incidence. Latent Class Analysis (LCA) was used to identify subgroups of patients based on injury level, neurological impairment and operative management. Subgroups were linked to VTE outcomes using BCH-Adjusted Proportional Assignment correction and multiple logistic regression.

RESULTS: 1369 patients were included in the analysis. Mean age was 54 years (SD-20) with a male predominance (831/1369; 61 %). VTE incidence was 2.34 %(CI: 1.60 - 3.28)(32/1369). LCA identified three distinct subgroups: undifferentiated injury, multilevel injury, and thoracic-spine predominant injury. Significant differences in VTE rates were observed across the subgroups, with thoracic spine injury associated with the highest VTE risk. After adjustment, individuals with thoracic-spine injuries and severe neurological impairment had an almost 4-fold increase in the odds of developing VTE compared to those with other injury/management profiles.

CONCLUSION: This study highlights the importance of tailored VTE prevention strategies for patients with acute SCI based on injury and management characteristics. An individualized approached to VTE risk stratification and prevention is required in this group.

PMID:40398331 | DOI:10.1016/j.injury.2025.112439

Injury. 2025 Apr 12;56(7):112288. doi: 10.1016/j.injury.2025.112288. Online ahead of print.

ABSTRACT

Spinal cord injury (SCI) is one of the most devastating neurological disorders associated with severe locomotor disability and a high rate of morbidity. Over the last 20-30 years, animal SCI models have proven to be extremely useful in better understanding the underlying molecular mechanism(s) involved in human traumatic SCI and in assessing the efficacy of available therapeutic agents. Thus, the current review article aims to provide readers with an overview of the methods used to induce traumatic SCI and highlight the recent advances in assessment of the functional recovery in rodent models. SCI models are classified into contusion, compression, transection, and Hypoxia-ischemia based on the mechanism of injury caused. Transection injury models are useful for studying the anatomic regeneration and neural circuitries in locomotion, whereas, compression/contusion injury models are used for studying complex biomechanism and neuropathology of human SCI. The ultimate goal of pre-clinical experimental work on traumatic SCI model is to develop effective repair/regenerative strategies for the clinical purpose. Here, we have summarized recent functional recovery assessment tool including quantification of myelin loss and motor neuron counts, axonal regeneration through behavioural and molecular studies.

PMID:40398195 | DOI:10.1016/j.injury.2025.112288

J Bone Joint Surg Am. 2025 May 21. doi: 10.2106/JBJS.24.01054. Online ahead of print.

ABSTRACT

BACKGROUND: Depression and anxiety are recognized as adverse prognostic factors in various orthopaedic surgical interventions. The aim of this study is to report the intermediate-term outcomes of hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and labral tears in patients with depression and/or anxiety.

METHODS: Data were retrospectively analyzed for patients with a self-reported history of depression and/or anxiety who had undergone primary hip arthroscopy for the treatment of FAI and labral tears from 2008 to 2018. Included patients had at least 1 of the following patient-reported outcome (PRO) scores: the modified Harris hip score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), patient satisfaction, Short Form 12-Mental (SF-M), Veterans RAND 12 Item-Mental (VR-M), and visual analog scale (VAS) for pain, or a revision procedure during the study period. Patients were propensity-matched with a benchmark control group of patients without depression and/or anxiety, in a 1:1 ratio, to control for confounding variables. Clinically relevant thresholds, revision procedures, and survivorship rates were also included in the analysis.

RESULTS: One hundred and twenty-five hips in patients with depression and/or anxiety were included in the study and were successfully matched to 125 control hips in patients without depression and/or anxiety. The depression/anxiety cohort demonstrated significant improvement in all functional outcome scores, with a magnitude of improvement that was comparable with that in the control group. However, the depression/anxiety group started with significantly lower preoperative scores for the HOS-SSS, SF-M, and VR-M; ended with lower intermediate-term scores for the mHHS, NAHS, HOS-SSS, SF-M, and VR-M; and had lower rates of achievement of patient-acceptable symptom state (PASS) thresholds for the mHHS and HOS-SSS. There was no significant difference between the 2 groups with regard to secondary procedures and complications.

CONCLUSIONS: Hip arthroscopy for the treatment of FAI and labral tears in patients with depression and/or anxiety resulted in significant intermediate-term improvements in functional and health-related quality-of-life scales. However, compared with a benchmark control group, the functional scores in this patient population started lower and ended lower. In addition, the patients in the depression/anxiety cohort had a lower rate of achieving PASS thresholds than those in the control group.

LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:40397758 | DOI:10.2106/JBJS.24.01054