J Bone Joint Surg Am. 2025 Jul 11. doi: 10.2106/JBJS.24.01461. Online ahead of print.

ABSTRACT

BACKGROUND: We conducted a randomized controlled trial to compare the outcomes of tension band wiring and precontoured plate fixation for the treatment of 2-part and multifragmented isolated, displaced olecranon fractures.

METHODS: We recruited 200 patients, 18 to 75 years of age, who had isolated, displaced olecranon fractures and randomly allocated them to tension band wiring (n = 100) or plate fixation (n = 100). The patients were followed at 6 weeks, 12 weeks, 12 months, and 24 months. The study was designed as a noninferiority trial. The primary outcome measure was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at 12 months.

RESULTS: More patients in the tension band wiring group were classified as ASA (American Society of Anesthesiologists) grade I; otherwise, the randomization groups were similar. Two patients in the tension band wiring group and 3 in the plate fixation group did not receive the allocated treatment. The duration of the surgical procedure was 64 and 88 minutes in the tension band wiring and plate fixation groups, respectively (p < 0.01). After 12 months, the median QuickDASH score was 5 for both groups, and the median of the differences was 0 (95% 1-sided confidence interval [CI], 2.3). There were no clinically relevant differences between the groups at any time point. In addition, there were no differences in outcomes in subgroup analyses of 2-part and multifragmented olecranon fractures. Complications and secondary surgical procedures were analyzed on the basis of the treatment received (tension band wiring = 101 patients, plate fixation = 99 patients). Sixty-four complications were recorded in 52 patients (tension band wiring, 30 patients; plate fixation, 22 patients; relative risk [RR], 1.20 [95% CI, 0.88 to 1.58]; p = 0.23). In the tension band wiring and plate fixation groups, 49 and 34 patients (RR, 1.33 [95% CI, 1.01 to 1.74]; p = 0.04) required at least 1 additional surgical procedure, respectively. Hardware-related irritation was the most reported indication of secondary surgery.

CONCLUSIONS: When treating isolated, displaced 2-part and multifragmented olecranon fractures, tension band wiring was noninferior compared with plate fixation. The surgical procedure was quicker for tension band wiring, but the frequency of secondary surgical procedures was higher. The majority of secondary surgical procedures were removal of symptomatic hardware.

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

PMID:40644505 | DOI:10.2106/JBJS.24.01461

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01106. Online ahead of print.

ABSTRACT

BACKGROUND: Hypermobile Ehlers-Danlos syndrome (hEDS) is a collagen disorder affecting multiple organ systems, including the musculoskeletal system. We sought to determine the type and severity of orthopaedic manifestations experienced by these patients. The purpose of this study was to identify the most common orthopaedic manifestations in patients with hEDS and to examine the patient-reported helpfulness of treatments. Of note, collagen disorders such as hEDS may affect the success rates of orthopaedic interventions. The success or failure of treatment is not currently fully understood for this patient population.

METHODS: A total of 1,999 patients who were enrolled in an international EDS registry were contacted to complete a 260-question survey regarding their experience with nonoperative and operative treatments for musculoskeletal instability and/or pain. Participants reported their demographic characteristics, hEDS diagnosis characteristics, symptomatic joints, nonoperative and operative treatments, and satisfaction with each treatment.

RESULTS: Over a 30-day period, 1,075 responses were received. Participants were predominately female (95.3%) and had a median age of 40.0 years (interquartile range width, 17.0 years). The majority (60.8%) of respondents reported a mental health burden every day, with the remainder reporting a mental health burden weekly (24.4%), monthly (11.0%), or never (3.80%). Compared with those who underwent standard physical therapy (n = 378), individuals who underwent physical therapy tailored to EDS (n = 602) more frequently reported improved posture (78.6% versus 43.1%; p < 0.001), greater helpfulness (p < 0.001), and a longer duration of attending therapy (p < 0.001). A total of 1,120 primary and 261 revision operations for joint or spine instability and/or pain were reported. The reported complication rates were 35.7% and 42.9% for joint and spine surgeries, respectively. Physical therapy was the only nonoperative treatment for which the median reported helpfulness sometimes equaled or exceeded that of a joint or spine surgery.

CONCLUSIONS: This study offers insights into the demographics and management of hEDS. The high rate of surgical complications reported by patients indicates the need for a better understanding of surgical indications and treatment options. These findings should guide physicians in managing hEDS and highlight the importance of incorporating this knowledge into clinical practice to improve the management of orthopaedic manifestations in patients with hEDS.

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

PMID:40638721 | DOI:10.2106/JBJS.24.01106

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01304. Online ahead of print.

ABSTRACT

BACKGROUND: Researchers employ murine fracture models to study bone healing, but the temporal relationship between mouse and human fracture healing is poorly understood. The hypothesis of this study was that it was possible to quantify specific post-fracture time frames corresponding to the stages of endochondral ossification in both mice and humans.

METHODS: Radiographs of mice and human femoral fractures treated with intramedullary stabilization were reviewed. The study included 330 human femoral fractures (OTA/AO 32A, B, or C injuries) that ultimately healed without complications in patients aged 18 to 55 years and 309 surgically created midshaft femoral fractures in 3-month-old C57BL6/J mice. Multiple orthopaedic surgeons assessed the radiographs using the Modified Radiographic Union Score for Tibia (mRUST). A 4-parameter log-logistic curve was fit to describe fracture healing over time, with 3 parameters allowed to vary: Y∞ (mRUST score at time = ∞), k (healing rate in [1/log(time)]), and X0.5 (time to half-healing).

RESULTS: The values (and 95% confidence interval) for the mice were Y∞ = 14.70 (14.54 to 14.87), k = 4.54/log(days) (4.30 to 4.77), and X0.5 = 11.77 days (11.56 to 11.98). For the humans, the values were Y∞ = 16.78 (16.21 to 17.36), k = 1.37/log(days) (1.28 to 1.45), and X0.5 = 91 days (83 to 99). All parameters differed significantly between the mice and humans (p < 0.05).

CONCLUSIONS: Using mRUST scoring and mathematical modeling, we were able to quantify and compare the temporal progression of fracture healing in mice and humans.

CLINICAL RELEVANCE: These data are relevant for designing and/or interpreting fracture healing studies of mice and humans to promote rational translation of fracture research between species.

PMID:40638717 | DOI:10.2106/JBJS.24.01304

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01293. Online ahead of print.

ABSTRACT

BACKGROUND: Orthopaedic surgeons routinely delay surgical management of femoral neck fractures in patients taking direct oral anticoagulants (DOACs) to decrease perioperative bleeding and associated complications. However, this practice contradicts the principles of hip fracture management, as early surgery is associated with morbidity and mortality benefits. The purpose of this study was to quantify the association of DOAC use and perioperative outcomes in patients who underwent hemiarthroplasty (HA) or total hip arthroplasty (THA) for femoral neck fractures. We hypothesized that early surgical intervention on a patient taking a DOAC medication would not lead to worse perioperative outcomes.

METHODS: A retrospective cohort study was conducted on 2,833 patients who underwent primary THA or HA for femoral neck fractures between December 31, 2017, and January 29, 2024, across our hospital system. The patients taking a DOAC were divided into 3 groups based on the time since the last DOAC intake: 1 day, 2 days, and ≥3 days. Propensity matching was performed 1:1, accounting for age, sex, Elixhauser Comorbidity Index, preoperative chronic kidney disease stage, preoperative hemoglobin, body mass index, and hospital type. Subanalyses utilizing linear and conditional logistic regression models were performed to assess differences in outcomes between the groups that had a DOAC withheld and the control groups.

RESULTS: The mean age of all patients was 81 ± 10 years, 1,805 patients (64%) were women, and 207 patients (7%) were taking a DOAC prior to surgery. Despite comparable preoperative and postoperative hemoglobin levels between the groups that had a DOAC withheld and the control groups (all p > 0.05), the patients who had a DOAC withheld for 1 day were more likely to receive a postoperative blood transfusion (23.1% compared with 0%; p = 0.002). This difference in transfusion rate was not observed in other cohorts. There were no differences in medical complications, reoperation, discharge disposition, or mortality between the groups that had a DOAC withheld and the matched controls at any time point.

CONCLUSIONS: Delaying surgical management due to DOAC medications may be unnecessary in patients undergoing arthroplasty for femoral neck fractures. Consideration should be given to adjusting transfusion triggers to reduce unwarranted blood transfusions in patients taking a DOAC.

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

PMID:40638713 | DOI:10.2106/JBJS.24.01293

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01287. Online ahead of print.

ABSTRACT

➢ Glucagon-like peptide-1 (GLP-1) receptor agonists are a promising tool for preoperative weight loss in the patient who is undergoing orthopaedic surgery and has concomitant obesity and type-2 diabetes mellitus.➢ With regard to the perioperative management of GLP-1 receptor agonists for the orthopaedic surgeon, the American Society of Anesthesiologists (ASA) recommends withholding daily-dose GLP-1 therapy on the day of the elective surgical procedure and withholding weekly-dose therapy for the week prior to the procedure.➢ The ASA recommends postponing surgery or proceeding with "full stomach precautions" if the patient undergoing an orthopaedic procedure and taking GLP-1 therapy exhibits gastrointestinal symptoms on the day of the elective procedure.➢ In the trauma setting, patients taking GLP-1 therapy should proceed with the surgical procedure at the discretion of the surgeon with full stomach precautions or a preoperative point-of-care gastric ultrasound.➢ GLP-1 receptor agonists show the potential for disease modification in osteoarthritis and osteoporosis.

PMID:40638702 | DOI:10.2106/JBJS.24.01287

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.00098. Online ahead of print.

ABSTRACT

BACKGROUND: The diagnostic accuracy of neurological examination findings for identifying degenerative cervical myelopathy (DCM) is not apparent, given the paucity of studies with appropriate control groups. In order to address this knowledge gap, we conducted a community cervical spine screening project and examined subjects without DCM or evidence of myelopathy on cervical magnetic resonance imaging (MRI).

METHODS: This study included a total of 229 patients diagnosed with DCM, based on MRI evidence of spinal cord compression and improvement after surgery, and 807 controls without DCM (40 to 79 years of age) enrolled in the screening project. Neurological examination was performed on each subject, including the assessment of deep tendon reflexes at the biceps, triceps, patella, and Achilles tendon and the Hoffmann reflex, Babinski sign, sensory disturbance, and 10-second grip-and-release test. Multiple logistic regression analysis was performed to build a diagnostic model for DCM based on the neurological examination findings.

RESULTS: Using a stepwise multiple logistic regression analysis method, an almost perfect diagnostic model was designed that comprised sex, age, 10-second grip-and-release test, patellar tendon reflex, Hoffmann reflex, Babinski sign, and sensory disturbance (area under the curve [AUC] in the receiver operating characteristic curve analysis, 0.994). However, given that the last 2 parameters are less commonly evaluated in routine practice, an alternative reduced model was developed for practical use and consisted of sex, age, Hoffmann reflex, patellar tendon reflex, and 10-second grip-and-release test. The reduced model yielded a nearly equivalent AUC of 0.956.

CONCLUSIONS: Both diagnostic prediction models demonstrated excellent accuracy in distinguishing patients with DCM from subjects without DCM, highlighting the importance of combining specific neurological signs and performance measures when evaluating patients with suspected DCM.

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

PMID:40638695 | DOI:10.2106/JBJS.24.00098

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01219. Online ahead of print.

ABSTRACT

BACKGROUND: Psychological distress is increasing in adolescents and young adults, but comprehensive screening programs are not commonly incorporated into orthopaedic clinical practice. We implemented a screening program for depression symptoms and psychological distress in adolescents and young adults with hip pain. The aims of this study were to report the prevalence and risk factors and determine the relationship with patient-reported pain and dysfunction.

METHODS: Patients 10 to 24 years of age presenting for hip pain at an initial clinic visit completed the Patient Health Questionnaire-9 (PHQ-9), the 17-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag (OSPRO-YF) tool, and the International Hip Outcome Tool-12 (iHOT). Two outcome levels for depression symptoms using the PHQ-9 were compared (mild or less versus moderate or greater), and 3 outcome levels for psychological distress using the OSPRO-YF were compared (none or mild versus moderate versus severe). Age, sex, body mass index, previous surgery, and the hip diagnosis were entered into logistic regression models to predict outcomes for the levels of depression symptoms and psychological distress. iHOT scores were compared between groups using the Wilcoxon rank-sum test and the Kruskal-Wallis test followed by pairwise Wilcoxon rank-sum tests.

RESULTS: Among 500 patients who completed screening, 10.6% had moderate or greater depression symptoms and 26.9% had severe psychological distress. Multivariable logistic regression revealed that young adults (age, 20 to 24 years) had higher odds of moderate or greater depression symptoms compared with adolescents (age, 10 to 19 years) (odds ratio, 2.09; p = 0.016). Female patients (risk ratio [RR], 1.86; p = 0.026), patients who had undergone a prior surgery (RR, 2.29; p = 0.025), and overweight patients (RR, 2.10; p = 0.008) had a higher risk of severe psychological distress. Both moderate or greater depression symptoms and increasing levels of psychological distress were significantly associated with lower iHOT scores (all p < 0.001).

CONCLUSIONS: Psychological distress was common in adolescents and young adults with hip pain and was associated with greater patient-reported hip pain and dysfunction. Young adults had a greater risk of depression symptoms. Severe psychological distress was more common in female patients, overweight patients, and those who had undergone failed prior hip surgery.

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

PMID:40638688 | DOI:10.2106/JBJS.24.01219

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01420. Online ahead of print.

ABSTRACT

➢ Strategic action following the measurement of outcomes in the context of cost allows for the reallocation of resources to value-adding interventions, while eliminating non-value-adding services.➢ Providers and administrators should leverage institutional alignment to advance best-practice principles through integration and utilization of patient-reported outcomes and cost-containment initiatives and engagement in institution-wide value-based care dialogue.➢ Health-care policy and reimbursement structures in the United States are shifting from a fee-for-service model to a value-based care model with policy changes such as the Hospital Price Transparency Regulation by the U.S. Centers for Medicare & Medicaid Services, Comprehensive Care for Joint Replacement, the risk-standardized performance measure for elective total hip arthroplasty and total knee arthroplasty based on patient-reported outcomes, and the Transforming Episode Accountability Model.➢ The incorporation of machine learning technologies presents major potential for refining our understanding of high-value events and identifying exemplary surgeons within the orthopaedic field. The successful incorporation of artificial intelligence models into practice requires investment from and alignment of several partners: health-care administrators, information technology, legal teams, providers, and patients.

PMID:40638684 | DOI:10.2106/JBJS.24.01420

J Bone Joint Surg Am. 2025 Jul 10. doi: 10.2106/JBJS.24.01565. Online ahead of print.

ABSTRACT

BACKGROUND: Race and ethnicity and insurance status have been identified as major contributors to disparities in health care. Several studies have analyzed racial and ethnic disparities in patients with private and government insurances, but very little is known about disparities in managed care models. Kaiser Permanente (KP) is a health-care organization (health maintenance organization, HMO) within the managed health-care system. It provides integrated care through its network of facilities and doctors, with equal access to all of its beneficiaries. Hence, the objective of this study was to determine whether there are health-care disparities in spinal fusion outcomes among patients enrolled in a managed health-care system such as Kaiser Permanente.

METHODS: Using data from the KP Spine Registry, we performed a retrospective cohort study of adults ≥18 years of age who underwent spinal fusion. The predictor was race/ethnicity (White [reference], Black, Hispanic, Asian). The primary outcome was reoperations, and the secondary outcomes were 90-day emergency department (ED) visits, 90-day readmissions, and 90-day and 1-year mortality. Multivariable Cox regression and logistic regression models were used to adjust for confounders.

RESULTS: We included 40,258 patients with spinal fusions. A lower reoperation risk was observed for Black (hazard ratio [HR] = 0.90; 95% confidence interval [CI] = 0.82 to 0.99; p = 0.038), Hispanic (HR = 0.78; 95% CI = 0.71 to 0.85; p < 0.001), and Asian (HR = 0.62; 95% CI = 0.55 to 0.71; p < 0.001) patients. Black (odds ratio [OR] = 1.25; 95% CI = 1.14 to 1.36; p < 0.001) and Hispanic (OR = 1.15; 95% CI = 1.07 to 1.25; p < 0.001) patients had a higher likelihood of an ED visit within 90 days. A higher likelihood of readmission within 90 days was also observed for Black patients (OR = 1.18; 95% CI = 1.05 to 1.32; p = 0.005). No significant differences in 90-day and 1-year mortality were observed.

CONCLUSIONS: Despite equal access to spine surgery in a managed health-care system such as Kaiser Permanente, our study showed that some disparities exist among Black and Hispanic patients. We believe that managed care networks can reduce disparities relative to other health-care delivery systems, although more work needs to be done to ensure equitable outcomes in all domains. These findings underscore the urgent need to address these disparities with further research.

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

PMID:40638682 | DOI:10.2106/JBJS.24.01565

J Bone Joint Surg Am. 2025 Jul 8. doi: 10.2106/JBJS.24.01429. Online ahead of print.

ABSTRACT

BACKGROUND: Privacy-preserving large language models (PP-LLMs) hold potential for assisting clinicians with documentation. We evaluated a PP-LLM to improve the clinical information on radiology request forms for musculoskeletal magnetic resonance imaging (MRI) and to automate protocoling, which ensures that the most appropriate imaging is performed.

METHODS: The present retrospective study included musculoskeletal MRI radiology request forms that had been randomly collected from June to December 2023. Studies without electronic medical record (EMR) entries were excluded. An institutional PP-LLM (Claude Sonnet 3.5) augmented the original radiology request forms by mining EMRs, and, in combination with rule-based processing of the LLM outputs, suggested appropriate protocols using institutional guidelines. Clinical information on the original and PP-LLM radiology request forms were compared with use of the RI-RADS (Reason for exam Imaging Reporting and Data System) grading by 2 musculoskeletal (MSK) radiologists independently (MSK1, with 13 years of experience, and MSK2, with 11 years of experience). These radiologists established a consensus reference standard for protocoling, against which the PP-LLM and of 2 second-year board-certified radiologists (RAD1 and RAD2) were compared. Inter-rater reliability was assessed with use of the Gwet AC1, and the percentage agreement with the reference standard was calculated.

RESULTS: Overall, 500 musculoskeletal MRI radiology request forms were analyzed for 407 patients (202 women and 205 men with a mean age [and standard deviation] of 50.3 ± 19.5 years) across a range of anatomical regions, including the spine/pelvis (143 MRI scans; 28.6%), upper extremity (169 scans; 33.8%) and lower extremity (188 scans; 37.6%). Two hundred and twenty-two (44.4%) of the 500 MRI scans required contrast. The clinical information provided in the PP-LLM-augmented radiology request forms was rated as superior to that in the original requests. Only 0.4% to 0.6% of PP-LLM radiology request forms were rated as limited/deficient, compared with 12.4% to 22.6% of the original requests (p < 0.001). Almost-perfect inter-rater reliability was observed for LLM-enhanced requests (AC1 = 0.99; 95% confidence interval [CI], 0.99 to 1.0), compared with substantial agreement for the original forms (AC1 = 0.62; 95% CI, 0.56 to 0.67). For protocoling, MSK1 and MSK2 showed almost-perfect agreement on the region/coverage (AC1 = 0.96; 95% CI, 0.95 to 0.98) and contrast requirement (AC1 = 0.98; 95% CI, 0.97 to 0.99). Compared with the consensus reference standard, protocoling accuracy for the PP-LLM was 95.8% (95% CI, 94.0% to 97.6%), which was significantly higher than that for both RAD1 (88.6%; 95% CI, 85.8% to 91.4%) and RAD2 (88.2%; 95% CI, 85.4% to 91.0%) (p < 0.001 for both).

CONCLUSIONS: Musculoskeletal MRI request form augmentation with an institutional LLM provided superior clinical information and improved protocoling accuracy compared with clinician requests and non-MSK-trained radiologists. Institutional adoption of such LLMs could enhance the appropriateness of MRI utilization and patient care.

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

PMID:40627696 | DOI:10.2106/JBJS.24.01429

J Bone Joint Surg Am. 2025 Jul 8. doi: 10.2106/JBJS.24.01030. Online ahead of print.

ABSTRACT

BACKGROUND: Postoperative urinary retention (POUR), a common complication after spine surgery, can contribute to longer hospital stays, urinary tract infection, pain, and morbidity. This study aimed to determine the incidence of POUR in patients who underwent lumbar decompression and to construct a predictive model for preoperatively identifying high-risk patients.

METHODS: This was a retrospective review of patients undergoing primary lumbar decompression from 2017 to 2023. Demographic characteristics, comorbidities, and perioperative data were collected. Factors associated with POUR were assessed, and multivariable logistic regressions were performed to identify independent predictors of the development of POUR. A nomogram to predict the development of POUR was developed within a training subset, based on a multivariable logistic regression model of preoperative variables, followed by the internal validation of the model in a validation subset and assessment of its performance.

RESULTS: Of the 1,938 patients included in this study, 133 (6.9%) developed POUR. Following multivariable analysis, the following risk factors for POUR were identified: a history of urinary retention (odds ratio [OR], 4.956 [95% confidence interval (CI), 2.157 to 11.383]; p < 0.001), insurance that was not commercial (private) (OR, 2.256 [95% CI, 1.298 to 3.922]; p = 0.004), intraoperative Foley catheter use (OR, 5.967 [95% CI, 3.506 to 10.156]; p < 0.001), inpatient opioid consumption of >93 morphine milligram equivalents (OR, 1.898 [95% CI, 1.220 to 2.952]; p = 0.004), and anticholinergic medication use during hospitalization (OR, 3.450 [95% CI, 2.313 to 5.148]; p < 0.001). The nomogram, which included the preoperative variables of male sex, age of >65 years, history of urinary retention, history of benign prostatic hyperplasia, not having commercial insurance, and American Society of Anesthesiologists (ASA) classification of >2, demonstrated good discrimination in the training subset (area under the curve [AUC], 0.725 [95% CI, 0.673 to 0.776]) and the validation subset (AUC, 0.709 [95% CI, 0.599 to 0.819]). The Hosmer-Lemeshow goodness-of-fit test demonstrated that the model fit the data well (chi-square test = 9.063; p = 0.170).

CONCLUSIONS: The incidence of POUR after lumbar decompression surgery was found to be 6.9%. A history of urinary retention, not having commercial (private) insurance, intraoperative Foley catheter usage, inpatient opioid consumption of >93 morphine milligram equivalents, and the administration of anticholinergic medication during hospitalization increased the risk of developing POUR. Furthermore, we constructed a preoperative predictive model with good performance metrics to help clinicians to identify patients at elevated risk for developing POUR.

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

PMID:40627681 | DOI:10.2106/JBJS.24.01030

J Bone Joint Surg Am. 2025 Jul 8. doi: 10.2106/JBJS.24.01169. Online ahead of print.

ABSTRACT

BACKGROUND: Whether the fixation of pertrochanteric and intertrochanteric fragility fractures impacts the risk of subsequent peri-implant fracture remains unclear. We hypothesized that peri-implant fracture after an index pertrochanteric or intertrochanteric fragility fracture is associated with fixation that does not reach the distal metaphysis (non-spanning fixation).

METHODS: Retrospective chart review was performed of patients treated for index pertrochanteric and intertrochanteric femoral fragility fractures at 2 health-care systems between January 1, 2005, and January 1, 2018. Cases were categorized by whether or not fixation reached the distal metaphysis (spanning compared with non-spanning). Kaplan-Meier survival analyses estimated cumulative incidences of peri-implant fracture stratified by patient, injury, and treatment characteristics, with hazard ratios (HRs) reported when significant. We also assessed whether spanning or non-spanning fixation was associated with a contralateral femoral fracture (a proxy for patient-related fracture risk). Significance was set at p < 0.05.

RESULTS: In this study, 913 patients with a median age of 80 years had a median follow-up of 5 months (interquartile range [IQR], 3 weeks to 2.7 years). The OTA/AO classification included 388 type 31-A1 fractures, 324 type 31-A2 fractures, and 201 type 31-A3 fractures. There were 18 subsequent peri-implant fractures (1.9%) and 40 subsequent contralateral femoral fractures (4.4%). The cumulative incidence of peri-implant fracture was lower over time (p < 0.01) with spanning fixation (0% prior to 1 year) compared with non-spanning (3.3% prior to 1 year). The HR of spanning fixation for the entire time period was 0.14 (95% confidence interval, 0.03 to 0.62; p < 0.01). Peri-implant fracture risk was greater with non-spanning plates (p < 0.01) and non-spanning nails (p < 0.01) than spanning fixation, with cumulative 1-year incidences of 3.5% for non-spanning plates, 2.6% for non-spanning nails, and 0% for spanning fixation. Peri-implant fracture was not associated with other variables (p > 0.05). Contralateral fracture was not associated with the fixation group (p = 0.77), tempering concern regarding potential bias.

CONCLUSIONS: Spanning fixation following pertrochanteric and intertrochanteric femoral fragility fractures mitigates the risk of a peri-implant fracture. However, the choice of fixation for a given patient requires that this risk be considered within the greater context of surgical decision-making.

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

PMID:40627679 | DOI:10.2106/JBJS.24.01169

J Bone Joint Surg Am. 2025 Jul 2;107(13):e74. doi: 10.2106/JBJS.25.00400.

NO ABSTRACT

PMID:40600896 | DOI:10.2106/JBJS.25.00400

J Bone Joint Surg Am. 2025 Jul 1. doi: 10.2106/JBJS.25.00471. Online ahead of print.

NO ABSTRACT

PMID:40591698 | DOI:10.2106/JBJS.25.00471

J Bone Joint Surg Am. 2025 Jul 2;107(13):e72. doi: 10.2106/JBJS.25.00113.

NO ABSTRACT

PMID:40591353 | DOI:10.2106/JBJS.25.00113

J Bone Joint Surg Am. 2025 Jul 2;107(13):e70. doi: 10.2106/JBJS.25.00088.

NO ABSTRACT

PMID:40591263 | DOI:10.2106/JBJS.25.00088

J Bone Joint Surg Am. 2025 Jul 2;107(13):e73. doi: 10.2106/JBJS.25.00154.

NO ABSTRACT

PMID:40591261 | DOI:10.2106/JBJS.25.00154

J Bone Joint Surg Am. 2025 Jul 2;107(13):e71. doi: 10.2106/JBJS.25.00170.

NO ABSTRACT

PMID:40591255 | DOI:10.2106/JBJS.25.00170

J Bone Joint Surg Am. 2025 Jun 30. doi: 10.2106/JBJS.25.00152. Online ahead of print.

NO ABSTRACT

PMID:40587605 | DOI:10.2106/JBJS.25.00152

J Bone Joint Surg Am. 2025 Jun 27. doi: 10.2106/JBJS.25.00008. Online ahead of print.

NO ABSTRACT

PMID:40577440 | DOI:10.2106/JBJS.25.00008