J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.00048. Online ahead of print.

ABSTRACT

BACKGROUND: For patients with rheumatoid arthritis (RA) undergoing total ankle arthroplasty (TAA), conflicting data have been reported regarding complications and patient-reported outcome (PRO) improvement when compared with patients with osteoarthritis (OA). The purpose of this study was to compare complication rates and PROs among patients with RA, primary OA, or posttraumatic arthritis.

METHODS: This was a retrospective study of 1,071 primary TAAs performed at a single institution between March 2000 and October 2020. Minimum follow-up was 2 years. Patients were stratified by indication for TAA (OA, n = 372; posttraumatic arthritis, n = 642; RA, n = 57). Patient demographics, intraoperative variables, postoperative complications, and PRO measures were compared among the groups using univariable statistics. Cox regression was performed to assess the risk of implant failure. The overall cohort had a mean age of 63.4 years, 51.3% were male, and 94.8% were White. The mean duration of follow-up (and standard deviation) was 5.7 ± 3.1 years.

RESULTS: Compared with the OA and posttraumatic arthritis groups, the RA cohort had the lowest mean age (p < 0.001), lowest percentage of males (p < 0.001), and highest American Society of Anesthesiologists (ASA) score (p < 0.001). Univariable analysis showed no significant difference in the infection rate among the groups (p = 1.0). The RA cohort had the highest rate of heterotopic ossification postoperatively (2 of 57, 3.5%; p < 0.040). Cox regression analysis showed no increased risk of implant failure for the RA cohort (p = 0.08 versus the OA cohort, 0.14 versus the posttraumatic arthritis cohort). For the Short Musculoskeletal Function Assessment (SMFA), Short Form (SF)-36, Foot and Ankle Outcome Score (FAOS)-symptoms subscale, and FAOS-activities of daily living subscale, the RA group reported significantly worse scores in the postoperative period (p < 0.001). However, the RA cohort demonstrated improvements in all PROs.

CONCLUSIONS: In the largest single-institution study to date, patients with RA reported poorer PRO scores compared with the OA and posttraumatic arthritis groups but experienced functional outcome improvement from the preoperative baseline.

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

PMID:40279451 | DOI:10.2106/JBJS.24.00048

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.01111. Online ahead of print.

ABSTRACT

BACKGROUND: Tillaux-Chaput fractures (TCFs) occur in the anterolateral rim of the distal tibia. TCFs are often overlooked on radiographic review, increasing the risk of chronic pain, instability, and ankle osteoarthritis. This study evaluated the effect of the computed tomography (CT) scan on preoperative planning for TCFs in adults.

METHODS: A retrospective review of ankle fractures evaluated from 2013 to 2023 at a university hospital was conducted. The inclusion criteria were patients ≥18 years of age who underwent radiographic and CT evaluation and had a TCF that was confirmed by CT. The exclusion criteria included pilon and distal tibial fractures and prior ankle surgery. Three orthopaedic surgeons assessed radiographs, classified TCFs using the Rammelt classification, formulated a treatment plan (conservative versus surgical), and, if a surgical treatment was indicated, determined the patient positioning, fixation type, and approach for the TCF. After evaluating CT images, changes in treatment strategy were recorded. Forward stepwise regression was utilized to analyze variables associated with modifications in preoperative planning.

RESULTS: A total of 481 fractures had ankle radiographs and CT scans; of these, 83 (17.3%) had a TCF. After the CT evaluation, the Rammelt classification and the surgical decision changed by 69.1% and 12.5%, respectively. Changes in patient positioning, the type of fixation, and the surgical approach for a TCF (when surgery was indicated) occurred in 32.1%, 43.8%, and 35.3% of all cases, respectively. Multivariable analysis showed that the detection of a TCF on CT predicted changes in the surgical decision and fixation type, while changes in the TCF classification predicted modifications in the fixation type and surgical approach. Posterior malleolar fractures were the unique predictor of changes in the patient positioning.

CONCLUSIONS: CT evaluation modified the surgical decision, type of fixation, and surgical approach for a TCF in 12.5%, 43.8%, and 35.3% of cases, respectively. Moreover, the detection of a TCF and a change in the classification after CT evaluation were predictors of a change in treatment strategy. These findings underscore the importance of the CT scan in the preoperative planning for TCFs in adults. Therefore, we strongly recommend conducting a CT scan when a TCF is suspected in adult patients.

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

PMID:40279443 | DOI:10.2106/JBJS.24.01111

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.01322. Online ahead of print.

ABSTRACT

BACKGROUND: Rotator cuff tears (RCTs) commonly lead to muscle atrophy, fatty infiltration, and fibrosis, resulting in pain, weakness, and impaired shoulder mobility. These pathological changes are often irreversible and pose substantial treatment challenges. The aim of this study was to evaluate the therapeutic potential of muscle-derived mitochondria (Mito) in mitigating muscle degeneration and fibrosis following RCTs.

METHODS: Sprague Dawley rats were assigned to 3 groups: sham surgery, RCTs treated with Mito, or RCTs treated with phosphate-buffered saline solution (PBS). Following RCTs, in vivo Mito or PBS treatments were administered to the supraspinatus muscles (SSPs) of the rats immediately and then biweekly for 12 weeks. Data were collected on muscle morphology, fibrosis, fatty infiltration, oxidative stress, mitochondrial function, macrophage phenotypes, and serum inflammatory cytokines. In vitro experiments included mitochondria tracking in bone marrow-derived macrophages (BMDMs), characterization of macrophage polarization, and inflammatory cytokine profiling.

RESULTS: Isolated mitochondria preserved their morphology and function. Mito treatment improved muscle wet weight (p < 0.0001) and fiber cross-sectional area (p < 0.0001) while reducing fibrosis (p < 0.0001) and fatty infiltration (p < 0.0001). It upregulated mitochondrial markers cytochrome c oxidase (COX IV) and translocase of outer mitochondrial membrane 20 (TOMM20) (p < 0.0001) and enhanced antioxidative activity, as shown by increased superoxide dismutase (SOD) activity (p < 0.0001), elevated glutathione peroxidase (GSH-PX) levels (p = 0.038), and decreased malondialdehyde (MDA) levels (p = 0.0002). Mitochondrial density and morphology were restored in SSPs after Mito treatment. Additionally, Mito treatment induced an anti-inflammatory macrophage phenotype and reduced pro-inflammatory cytokines in vivo and in vitro.

CONCLUSIONS: Mito treatment mitigated muscle degeneration, improved mitochondrial function, and fostered an anti-inflammatory environment through macrophage modulation, demonstrating its potential as a cell-free therapeutic strategy for RCT-related muscle pathologies.

CLINICAL RELEVANCE: Although this is a preclinical study, its approach offers a novel avenue for improving RCT treatment outcomes. However, further validation in large animal models is needed to address the translational applicability of these findings, given the inherent regenerative capacity of rodent muscles.

PMID:40279441 | DOI:10.2106/JBJS.24.01322

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.01094. Online ahead of print.

ABSTRACT

➢ Bone defect management is challenging, but essential, in revision total knee arthroplasty.➢ Appropriate metaphyseal fixation is crucial for stability and implant support.➢ Allografts have been traditionally used to address large defects, but the advent of highly porous metaphyseal cones and sleeves has attracted attention during the past years.➢ Metaphyseal implants are now available in a variety of shapes and sizes to meet various clinical needs.➢ These devices can successfully fill large defects, can better support revision implants, and can achieve long-term biologic fixation.➢ Very good intermediate-term outcomes have been reported with the available metaphyseal implants, using fully cemented or press-fit stems.➢ More research is warranted to further assess surgical indications and the strengths and weaknesses of the various implants used for metaphyseal fixation.

PMID:40279440 | DOI:10.2106/JBJS.24.01094

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.01057. Online ahead of print.

ABSTRACT

BACKGROUND: The literature on the subjective experience of patients undergoing treatment for periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) is scarce, and treatment success is defined without consideration of patient values. The primary objective of this study was to characterize the experience of patients undergoing PJI management. The secondary and tertiary aims were to identify factors that patients associate with successful treatment and to assess alignment with a 2019 outcome-reporting tool (ORT) by the Musculoskeletal Infection Society (MSIS).

METHODS: Patients treated for PJI at 2 international tertiary arthroplasty centers and for whom no less than 1 year and no more than 5 years had elapsed since their most recent revision surgery were included. From August 2023 to April 2024, patients participated in semistructured interviews with a phenomenological approach-an approach that aims to provide detailed examinations of personal lived experiences and to identify themes regarding how a particular phenomenon is experienced. Interview topics included experiences with primary TJA, PJI diagnosis and management, and patient perceptions of the success of their PJI management. Interviews were transcribed, and a thematic analysis was performed. The concordance between patient-defined and MSIS ORT-defined treatment success was calculated.

RESULTS: Of 27 total patients, 21 (78%) reported considerable mental health impacts during the period from PJI onset to treatment conclusion. In defining successful PJI management, patients consistently emphasized the importance of function, pain relief, mobility, and independence. Nine (33%) of the patients (p < 0.001) did not agree with their MSIS ORT classification of success versus failure.

CONCLUSIONS: PJI is a devastating complication following TJA, and success as defined by patients does not align with success as defined by clinicians. As a result, there is insufficient support offered to patients throughout the PJI management process. Future avenues for research include the exploration of the feasibility and impact of implementing patient-centered care models that feature psychological support.

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

PMID:40279409 | DOI:10.2106/JBJS.24.01057

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.00331. Online ahead of print.

ABSTRACT

BACKGROUND: A lumbosacral hemivertebra poses a unique problem, as it leads to a long compensatory curve above it and an obvious main curve. One-stage posterior hemivertebra resection with short segmental fusion is a standard surgery for patients with congenital scoliosis, but curve progression often occurs after surgery. The objective of this study was to investigate the risk factors for curve progression in patients who underwent 1-stage posterior hemivertebra resection with short segmental fusion.

METHODS: This study included 58 Han Chinese patients with congenital scoliosis who underwent 1-stage posterior hemivertebra resection with short segmental fusion. Baseline information, radiographic parameters, and the Scoliosis Research Society-22r questionnaire were collected preoperatively, 3 months postoperatively, and at the last follow-up. Risk factors for curve progression were evaluated using logistic regression analysis and receiver operating characteristic (ROC) curve analysis.

RESULTS: The mean age at surgery was 7.3 years, and the mean follow-up was 7.5 years. Nine patients (15.5%) were diagnosed with curve progression at the final follow-up. Compared with their preoperative condition, patients exhibited a significant reduction in the main curve (95% confidence interval [CI], 25.2° to 28.9° preoperatively versus 6.8° to 9.4° at 3 months; p < 0.001), compensatory curve (95% CI, 15.0° to 19.8° versus 5.5° to 8.1°; p < 0.001), and coronal balance (95% CI, 12.4 to 16.9 mm versus 7.0 to 10.5 mm; p < 0.001) at 3 months postoperatively. The progression group had larger preoperative pelvic obliquity values than the non-progression group (95% CI, 3.19° to 6.55° versus 2.01° to 2.63°; p = 0.008). The logistic regression analysis revealed that preoperative pelvic obliquity was a significant independent risk factor for curve progression (odds ratio, 1.653; 95% CI, 1.096 to 2.495; p = 0.017). The ROC analysis revealed that preoperative pelvic obliquity had good discriminatory capability (area under the ROC curve, 0.876; 95% CI, 0.677 to 1.000; p < 0.001).

CONCLUSIONS: In summary, preoperative pelvic obliquity was an independent risk factor for curve progression, which means that preoperative measures should be taken to ensure minimal pelvic obliquity in patients in order to effectively prevent curve progression. The presence of pelvic obliquity should alert the surgeon and patients to the high risk of deformity progression and to the need for scheduling more frequent follow-ups as appropriate.

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

PMID:40279408 | DOI:10.2106/JBJS.24.00331

J Bone Joint Surg Am. 2025 Apr 25. doi: 10.2106/JBJS.24.00993. Online ahead of print.

ABSTRACT

BACKGROUND: Traditional Medicare (TM) claims data are widely used by researchers and registries to report survivorship following total knee arthroplasty (TKA). The purpose of the present study was to investigate whether the mass exodus of patients from TM to Medicare Advantage (MA) has compromised the fidelity of TM data.

METHODS: We identified 11,717 Medicare-eligible patients (15,282 knees) who had undergone primary TKA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 84% of TKAs were covered by TM. The rates of survivorship free from revision or reoperation were calculated for patients with TM coverage. The same survivorship end points were recalculated after censoring of patients who transitioned to MA after primary TKA, thereby modeling the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean duration of follow-up was 10 years.

RESULTS: From 2000 to 2020, there was a decrease in TM insurance (from 94% to 68%) and a corresponding increase in MA insurance (from 0% to 19%) among patients undergoing TKA. Following TKA, 25% of patients with TM coverage switched to MA. For patients with TM at the time of surgery, the 15-year rates of survivorship free from any reoperation or revision were 90% and 96%, respectively. When patients were censored upon transition from TM to MA, the 15-year rates of survivorship free from any reoperation (92% versus 90%; hazard ratio [HR] = 1.2; p = 0.001) or any revision (97% versus 96%; HR = 1.3; p = 0.002) were significantly higher.

CONCLUSIONS: One in 4 patients left TM for MA after primary TKA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM resulted in falsely elevated estimates of survivorship free from reoperation and from revision, with increasing divergence in survivorship over time, when MA data were excluded. As MA continues to grow, efforts to incorporate these data will become increasingly important.

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

PMID:40279407 | DOI:10.2106/JBJS.24.00993

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.00670. Online ahead of print.

ABSTRACT

BACKGROUND: Musculoskeletal abnormalities have been reported among female professional ballet performers due, in part, to intrinsic predispositions related to joint and/or connective tissue laxity and extrinsic effectors such as reduced energy availability, low body mass, and high training volumes that may increase the risk of developing idiopathic scoliosis (IS). The purpose of this investigation was to characterize IS prevalence in this population. We hypothesized that there would be elevated prevalence in female performers and that those with IS would exhibit reduced bone mineral density (BMD), body mass, fat mass, and lean mass.

METHODS: A retrospective analysis of whole-body anteroposterior radiographs was performed on 98 professional ballet dancers (49 male performers [mean age, 25 ± 6 years] and 49 female performers [mean age, 27 ± 5 years]) from a single company. Body composition and BMD were assessed via dual x-ray absorptiometry. The criterion for IS was defined as a Cobb angle of >10°. The frequency of IS was plotted against general-population norms. A t test was used to compare demographic characteristics, anthropometrics, and BMD between performers with and without IS and to compare the Cobb angles between sexes. A Fisher exact test was used to compare the IS prevalence between sexes. The Type-I error was set at α = 0.05.

RESULTS: Compared with male performers, female performers had greater spinal asymmetry (mean Cobb angle, 7.98° [95% confidence interval (CI) width, 1.76°] for men and 4.02° [95% CI width, 1.00°] for women; p = 0.027). The prevalence of IS among male performers (3 [6.12%] of 49) was comparable with the general-population norms (0.31% to 5.60%). Women had an elevated prevalence of IS compared with men (10 [20.41%] of 49; p = 0.037) and with general-population norms (0.65% to 8.90%). Among women, performers with IS were observed to have a reduced percentage of body fat (p = 0.021) and reduced fat mass (p = 0.040) compared with performers without IS.

CONCLUSIONS: Female professional ballet performers demonstrate a heightened prevalence of IS that, in addition to intrinsic predisposition, is associated with modifiable factors such as reduced fat mass commonly associated with reduced energy availability known to impact musculoskeletal health in athletes. Future investigations should seek to determine the prevalence of IS in other young female athlete populations commonly exposed to high degrees of activity and reduced energy availability.

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

PMID:40273227 | DOI:10.2106/JBJS.24.00670

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.00857. Online ahead of print.

ABSTRACT

BACKGROUND: At our institution, surgeons were observing cases of failed total knee arthroplasties (TKAs) with surface delamination of the tibial insert fabricated by direct compression molding. The increase in unexpected failure led us to investigate the prevalence of delamination and its causes through the use of retrieval analysis and reviews of clinical, demographic, and radiographic data.

METHODS: Between 2000 and 2019, a total of 519 Exactech Optetrak posterior-stabilized direct-compression-molded polyethylene inserts had been retrieved. To determine prevalence, we utilized institutional usage data, manufacturer sales to our institution, and hospital records to determine the delamination rate. Eighty-six retrieved specimens (16 with delamination) were assessed for oxidation with use of infrared spectroscopy.

RESULTS: Sixty-four (12%) of the 519 inserts had delamination. The delamination rate was 0.36% across the 20-year period. Osteolysis was the reason for revision in 25% of delaminated cases, compared with 4% of non-delaminated cases. The mean oxidation index of the delaminated inserts was 2.67 ± 1.4 (range, 1.2 to 6.6). Delamination was not associated with surgical factors (cement viscosity and tibial insert thickness) or processes associated with manufacturing and implantation of the inserts into the patients (implantation year, shelf life, and packaging and sterilization dates).

CONCLUSIONS: The lack of causative factors for the increase in delamination was perplexing. In 2021, following the completion of our study, the manufacturer determined that since 2004, polyethylene inserts were packaged in "non-conforming" vacuum bags that were missing a secondary barrier layer intended to markedly lessen oxygen permeation. The use of non-conforming bags apparently increased the risk of premature oxidation, delamination, and associated osteolysis.

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

PMID:40273225 | DOI:10.2106/JBJS.24.00857

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.01118. Online ahead of print.

ABSTRACT

BACKGROUND: Sarcopenia increases postoperative complication and mortality rates in elderly patients. Although measurement of the psoas muscle area on computed tomography (CT) scans is traditionally used to diagnose sarcopenia, CT is not routine in orthopaedic practice and causes unnecessary radiation exposure. EOS, a low-dose full-body imaging modality, captures musculoskeletal structures in an upright position, offering an alternative for sarcopenia diagnosis.

METHODS: Patients ≥18 years of age were included in this retrospective study if they had undergone non-contrast CT spine and EOS imaging between May 2022 and May 2024. Psoas muscle measurements at L3 and L4 were made using non-contrast CT scans, while thigh muscle measurements were obtained with EOS imaging. Inter- and intra-rater reliabilities were assessed using intraclass correlation coefficients (ICCs). Predicted probabilities for L4-psoas sarcopenia were determined through logistic regression, controlling for demographic covariates and validated with an 80% to 20% train-validate split. Sarcopenia cutoffs for anteroposterior (AP) thigh thickness and lateral (LAT) quadriceps thickness were determined with use of the Youden index.

RESULTS: Sarcopenia was identified in 23.1% of 134 patients (85 female and 49 male; 121 White, 7 Black, and 6 Hispanic) on the basis of L4-psoas muscle index thresholds. EOS and CT measurements showed excellent ICCs (≥0.90). Multivariable regressions identified AP thigh thickness and LAT quadriceps thickness as significant predictors of psoas area and L4-psoas sarcopenia. The area under the receiver operating characteristic curve for identifying L4-psoas sarcopenia was 0.85 for AP thigh thickness and 0.77 for LAT quadriceps thickness. Cutoffs were 12.47 cm (males) and 10.68 cm (females) for AP thigh thickness, and 3.23 cm (males) and 2.20 cm (females) for LAT quadriceps thickness. In the validation cohort of 27 patients, the AP thigh thickness model showed 0.94 sensitivity and 0.89 specificity, while the LAT quadriceps thickness model showed 0.70 sensitivity and 1.00 specificity. Applying these cutoffs to the entire data set showed that 66.7% of males and 75.0% of females with measurements below both cutoffs had sarcopenia.

CONCLUSIONS: EOS is a reliable alternative to CT for muscle mass assessment and sarcopenia diagnosis. EOS may be a valuable tool for assessing sarcopenia without a CT scan, as thigh muscle measurements via EOS correlate well with CT-derived psoas measurements. This imaging modality aids in early sarcopenia diagnosis, potentially enhancing preoperative planning and reducing radiation exposure, unnecessary costs, and resource utilization.

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

PMID:40273215 | DOI:10.2106/JBJS.24.01118

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.01212. Online ahead of print.

ABSTRACT

BACKGROUND: Although it is well established that the type of organism can be a risk factor for failure in patients with periprosthetic joint infection (PJI), no study to date has examined the impact of the number of positive cultures on treatment outcomes in patients undergoing 2-stage exchange. The purpose of this multicenter study was to determine the prognostic utility of multiple positive cultures at resection as a predictor of failure following reimplantation.

METHODS: This retrospective multicenter study identified 437 patients with chronic knee PJI who had undergone 2-stage exchange arthroplasty with a minimum of 1 year of follow-up following reimplantation. PJI was defined with use of the 2013 Musculoskeletal Infection Society (MSIS) criteria. Patients with culture-negative PJI were excluded (n = 138). Treatment failure was defined as either any reoperation for infection or PJI-related mortality. Multivariable regression controlling for risk factors for failure after a 2-stage arthroplasty was performed to determine whether ≥2 positive intraoperative cultures at resection can predict outcomes following reimplantation when compared with a single positive culture.

RESULTS: Two hundred and ninety-nine patients were included. At a mean follow-up of 6.2 ± 2.6 years, 48 patients (16.1%) experienced failure. Patients who had a failure were more likely to have had a longer interstage interval (p = 0.038) and were also more likely to have had ≥2 positive cultures at the time of resection arthroplasty (95.8% versus 75.3%; p = 0.001). On regression analysis, ≥2 positive cultures at resection was the only variable that was identified as a risk factor for failure following reimplantation in both the univariate (odds ratio [OR], 7.55 [95% CI, 2.24 to 47.0]; p = 0.006) and multivariable models (OR, 8.12 [95% CI, 2.31 to 51.9]; p = 0.005).

CONCLUSIONS: This is the first study to examine the impact of the number of positive cultures on outcomes in patients with PJI. We found that the presence of ≥2 positive cultures at resection was an indicator of a poor prognosis and resulted in a greater than eightfold increase in the risk of treatment failure in patients undergoing a 2-stage exchange.

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

PMID:40273213 | DOI:10.2106/JBJS.24.01212

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.23.01391. Online ahead of print.

ABSTRACT

BACKGROUND: The aim of this study was to determine the risk factors associated with deep vein thrombosis (DVT) or pulmonary embolism (PE) within 30 days after multilevel adult spinal deformity (ASD) surgery and to develop risk prediction models.

METHODS: A retrospective observational study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database from 2010 to 2019. Current Procedural Terminology (CPT) codes 22843 and 22844 were used to query the database and to identify patients who underwent surgical correction of ASD with ≥7 levels of posterior instrumentation. The primary outcomes were the incidences of, and risk factors for, postoperative DVT and PE. Multiple logistic regression was utilized to identify variables associated with an elevated risk of DVT or PE within 30 days after surgery and to develop prediction models for assessing risk.

RESULTS: A total of 7,445 patients (56% female; 73% Caucasian; mean age, 61 years) met the inclusion criteria. Postoperatively, the rate of any venous thromboembolism (VTE; i.e., DVT or PE) was 3.4% (254 patients), the rate of DVT was 2.0% (151 patients), and the rate of PE was 1.7% (127 patients). The following independent predictors of any VTE were identified: weight (odds ratio [OR], 1.054; 95% confidence interval [CI]: 1.027 to 1.081), age per decade of life (OR, 1.106; 95% CI: 1.012 to 1.209), body mass index (BMI; OR, 1.032; 95% CI: 1.015 to 1.049), medicated hypertension (OR, 1.523; 95% CI: 1.168 to 1.987), chronic corticosteroid use (OR, 2.654; 95% CI: 1.848 to 3.812), American Society of Anesthesiologists (ASA) class (OR, 1.768; 95% CI: 1.426 to 2.192), and total operative time (OR, 1.002; 95% CI: 1.002 to 1.003) (p < 0.05 for all). When incorporated into a single model, total operative time, BMI, ASA class, and chronic corticosteroid use were associated with VTE risk.

CONCLUSIONS: Four major risk factors were identified as being associated with postoperative VTE risk in patients undergoing surgery for ASD. Corticosteroid use for a chronic medical condition was the strongest predictor of VTE risk, followed by ASA class, BMI, and operative time. Knowledge of these risk factors can aid in preoperative risk assessment, informed consent, and medical decision-making, such as in determining the clinical thresholds for VTE testing and chemoprophylaxis.

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

PMID:40273208 | DOI:10.2106/JBJS.23.01391

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.24.01265. Online ahead of print.

ABSTRACT

BACKGROUND: Osseous reconstructive surgery for hip displacement in children with cerebral palsy (CP) consists of proximal femoral reorientation by varus derotational osteotomy (VDRO) combined with pelvic osteotomy when indicated. The rate of recurrent hip instability after the index surgery can be as high as 77%. We evaluated the association between femoral diaphyseal medialization at the VDRO site and recurrent instability. We hypothesized that medialization may modify the hip joint reaction force (HJRF), reducing the femoral remodeling that leads to recurrent coxa valga and instability.

METHODS: A retrospective evaluation of the clinical and radiographic records of 140 patients (280 hips) with CP, Gross Motor Function Classification System (GMFCS) Level IV or V, who had been treated with bilateral VDRO as the index surgery for hip displacement between 1998 and 2012 (mean follow-up, 11.3 years) was conducted. Radiographic measurement of medialization was performed using the medialization index (MeI) preoperatively, at 6 weeks and 12 months postoperatively, and at skeletal maturity. Recurrent instability was defined as the need for revision surgery before skeletal maturity or a final migration percentage (MP) of >40%.The influence of the MeI was determined by Poisson regression with multiple variances. The inter- and intra-observer reliability of the MeI, measured by 4 different observers, was assessed using the Cohen d test.

RESULTS: Groups with and without relapse were comparable preoperatively regarding femoral and acetabular parameters. The baseline MP was higher in the relapse group (p < 0.001). The MeI at 6 weeks postoperatively was significantly lower in the relapse group (p = 0.004, relative risk [RR] = 0.07, 95% confidence interval [CI] = 0.01 to 0.42) than in the no-relapse group in multivariable analysis. The MeI showed good inter- and intra-observer reliability, with a Cohen d of <0.5.

CONCLUSIONS: Patients with greater medialization had lower rates of recurrent hip instability at long-term follow-up. The MeI proved to be reliable as a radiographic measurement, and medialization did not increase mechanical instability.

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

PMID:40273207 | DOI:10.2106/JBJS.24.01265

J Bone Joint Surg Am. 2025 Apr 24. doi: 10.2106/JBJS.25.00101. Online ahead of print.

NO ABSTRACT

PMID:40273198 | DOI:10.2106/JBJS.25.00101

J Bone Joint Surg Am. 2025 Apr 22. doi: 10.2106/JBJS.24.00248. Online ahead of print.

ABSTRACT

BACKGROUND: We previously established a small animal model of femoral head-neck cam-type hip deformity by inducing physeal injury in immature rabbits. We investigated whether this induced deformity led to hip osteoarthritis (OA) within 4 months.

METHODS: Six-week-old immature New Zealand White rabbits underwent surgery to induce physeal injury in the right femoral head, causing growth arrest and secondary head-neck deformity. Animals were divided into early-pre-OA (4 weeks) and late-OA (16 weeks) groups. Left hips served as (nonsurgical) controls. Radiographs were made to visualize deformities and OA progression. The Beck classification was used to assess macroscopic cartilage damage and OA on the acetabulum and femoral head. Micro-computed tomography (CT), histological scoring, and gene expression were used to evaluate OA progression. The Wilcoxon signed-rank test was used for group comparisons. Significance was set at p < 0.05.

RESULTS: At 16 weeks, the injured hips showed radiographic evidence of joint space narrowing and a higher OA grade than the control hips (p = 0.0002). Micro-CT confirmed degenerative OA changes and a higher femoral head bone volume fraction (BV/TV) and trabecular thickness (Tb.Th) in the injured hips than in the control hips (BV/TV: p = 0.0001, Tb.Th: p = 0.0007). Macroscopically, the injured hips exhibited a greater prevalence and severity of chondral lesions at 4 weeks (83.3%, p = 0.015) and 16 weeks (100.0%, p = 0.002) post-injury compared with the control hips (0%), with worsening over time (4 versus 16 weeks: p = 0.016). The Osteoarthritis Research Society International (OARSI) score and synovitis score increased from 4 to 16 weeks post-injury. Compared with the control hips, the injured hips showed decreased Col2 expression and increased Col10 and MMP13 expression at 16 weeks post-injury (p = 0.062, p = 0.016, p = 0.041, respectively), confirming catabolism and OA progression.

CONCLUSIONS: To our knowledge, we have created the first small animal model of hip OA secondary to experimentally induced head-neck deformity. In this model, the deformity resulted in hip OA at 16 weeks post-injury.

CLINICAL RELEVANCE: This model can be used to test future interventional therapies and study mechanisms of femoroacetabular impingement-mediated hip OA.

PMID:40261969 | DOI:10.2106/JBJS.24.00248

J Bone Joint Surg Am. 2025 Apr 18. doi: 10.2106/JBJS.24.00542. Online ahead of print.

ABSTRACT

BACKGROUND: Accelerated recovery from bone injuries is a paramount health-care goal with substantial impacts on physical status and overall well-being. The aim of this study was to evaluate the impact of colostrum supplementation on bone healing in patients with a traumatic extracapsular hip fracture (ECF).

METHODS: Patients with an ECF undergoing internal fixation were randomly assigned to receive either bovine colostrum or whey protein. Bone healing was assessed using the Radiographic Union Score for Hip (RUSH). Physical rehabilitation was evaluated using the Harris hip score (HHS) and the Short Musculoskeletal Functional Assessment (SMFA) within 3 months postoperatively. A generalized estimating equation (GEE) was used to assess the time-by-group interactions of these longitudinal variables. Patients were monitored for postoperative complications for 12 months, with the risk difference (RD) and risk ratio (RR) calculated.

RESULTS: A total of 116 patients with an ECF were included in the final analysis (colostrum group, n = 59; whey group, n = 57). Baseline characteristics, including age, gender, ethnicity, and body mass index, were similar between the groups (p > 0.05 for all). The colostrum group had a significantly greater increase in the RUSH score (β = 0.88; p = 0.001) and HHS (β = 1.2; p = 0.001) over time compared with the whey group. SMFA dysfunction and bother indices demonstrated significantly greater decreases over time in the colostrum group compared with the whey group (β = -1.2 and -2.4, respectively; p < 0.001 for both).

CONCLUSIONS: The present study provides preliminary evidence suggesting that colostrum may accelerate bone healing and enhance short-term physical rehabilitation outcomes more effectively than whey protein.

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

PMID:40249794 | DOI:10.2106/JBJS.24.00542

J Bone Joint Surg Am. 2025 Apr 17. doi: 10.2106/JBJS.24.00810. Online ahead of print.

ABSTRACT

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a substantial cause of morbidity and mortality among hospitalized patients. Although rare in the general pediatric population, VTE remains a potential concern in hospitalized children, particularly those with lower-extremity (LE) fractures. With this study, we aimed to determine the risk of VTE in pediatric patients with surgically treated LE fractures through a retrospective, propensity-matched, cohort analysis.

METHODS: The TriNetX Research Network, encompassing data from >80 health-care organizations and >120 million patient records, was utilized for this retrospective cohort study comparing 3 age-based cohorts (children [age of <14 years], adolescents [age of 14 to 17 years], and adults [age of ≥18 years]) who underwent surgical treatment of LE fractures between January 1, 2003, and January 1, 2023.

RESULTS: A total of 634,880 patients with surgically treated LE fractures were included; 13.3% were children, 5.6% were adolescents, and 81.1% were adults. Propensity-score matching was used to compare VTE incidence across cohorts, resulting in 3 independent matched comparisons. Overall, the incidence of VTE (either DVT or PE) was 0.2% in children, 1.0% in adolescents, and 4.1% in adults. Adults had a significantly higher risk of developing DVT (risk ratio [RR]: 17.0; 95% confidence interval [CI]: 14.5 to 20.0) and PE (RR: 21.8; 95% CI: 17.0 to 28.1) compared with children. Similarly, adolescents had a higher risk of DVT (RR: 3.5; 95% CI: 2.7 to 4.4) and PE (RR: 3.1; 95% CI: 2.2 to 4.4) compared with children. The incidence of VTE varied by fracture location, with femoral and knee joint (incidence: 0.5% in children, 2.5% in adolescents) and pelvic and hip joint (incidence: 1.2% in children, 2.8% in adolescents) fractures presenting the highest risk across all age groups.

CONCLUSIONS: The incidence of VTE in a large cohort of pediatric patients undergoing surgical treatment of LE fractures was higher in adolescents than in children. These findings may warrant prophylactic VTE measures in adolescents undergoing surgical treatment of femoral or pelvic fractures.

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

PMID:40245162 | DOI:10.2106/JBJS.24.00810

J Bone Joint Surg Am. 2025 Apr 17. doi: 10.2106/JBJS.23.01088. Online ahead of print.

ABSTRACT

BACKGROUND: The treatment of ankle fractures involving the posterior malleolus (PM) has changed in favor of open reduction and internal fixation (ORIF), and the need for additional syndesmotic stabilization has decreased; however, there are still doubts regarding the diagnosis and treatment of residual syndesmotic instability. The aim of the present study was to evaluate the effect of fixation of the PM and to assess the need for additional stabilization methods. We hypothesized that ORIF of the PM would not sufficiently stabilize the syndesmosis and that additional syndesmotic reconstruction would restore kinematics.

METHODS: Eight unpaired, fresh-frozen, cadaveric lower legs were tested in a 6-degrees-of-freedom robotic arm with constant loading (200 N) in the neutral position and at 10° dorsiflexion, 15° plantar flexion, and 30° plantar flexion. The specimens were evaluated in the following order: intact state; osteotomy of the PM; transection of the anterior inferior tibiofibular ligament (AITFL) and interosseous ligament (IOL); ORIF of the PM; additional syndesmotic screw; combination of syndesmotic screw and AITFL augmentation; and AITFL augmentation.

RESULTS: A complete simulated rupture of the syndesmosis (PM osteotomy with AITFL and IOL transection) caused translational (6.9 mm posterior and 1.8 mm medial displacement) and rotational instability (5.5° external rotation) of the distal fibula. ORIF of the PM could eliminate this instability in the neutral ankle position, whereas sagittal and rotational instability remained in dorsiflexion and plantar flexion. The remaining instability could be eliminated with an additional procedure, without notable differences between screw and AITFL augmentation.

CONCLUSIONS: In our model, isolated PM osteotomy and isolated AITFL and IOL rupture (after PM refixation) only partially increased fibular motion in dorsiflexion and plantar flexion, whereas the combination of PM osteotomy and AITFL and IOL rupture resulted in an unstable syndesmosis in all planes.

CLINICAL RELEVANCE: In complex ankle fractures, ORIF of the PM is essential to restore syndesmotic stability; however, residual syndesmotic instability can be detected by a specific posterior shift of the fibula on stress testing. In these cases, anatomical AITFL augmentation is biomechanically equivalent to the use of a syndesmotic screw.

PMID:40245116 | DOI:10.2106/JBJS.23.01088

J Bone Joint Surg Am. 2025 Apr 17. doi: 10.2106/JBJS.24.01493. Online ahead of print.

ABSTRACT

Orthopaedic surgeons are called upon to lead in numerous clinical settings, but the importance of physician leadership is also relevant to administrative roles. As the complexity of health care has increased, the challenges confronting the orthopaedic physician leader have increased as well. During the past century, there has been a substantial increase in the number of non-physician CEO leaders, and this is particularly critical in the academic health system, for which investment in the research and education missions is heavily dependent upon the clinical enterprise. Therefore, physician leadership becomes even more important, with heightened influence. Being an orthopaedic surgeon, or any type of physician, is not synonymous with excellence in leadership. Rather, growth as a leader requires hard work dedicated to the acquisition and nurturing of the knowledge, behaviors, and competencies that result in excellence. We readily acknowledge that physicians must work with a multidisciplinary administrative team of content experts but believe that true expert leaders also possess the inherent knowledge and expertise in the core business for which the organization exists. We encourage our physician colleagues to work to become stronger leaders regardless of their ultimate career aspirations.

PMID:40245106 | DOI:10.2106/JBJS.24.01493

J Bone Joint Surg Am. 2025 Apr 16;107(8):e38. doi: 10.2106/JBJS.24.01481. Epub 2025 Apr 16.

NO ABSTRACT

PMID:40237720 | DOI:10.2106/JBJS.24.01481