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

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

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

J Bone Joint Surg Am. 2025 May 21;107(10):e56. doi: 10.2106/JBJS.24.01515. Epub 2025 May 21.

NO ABSTRACT

PMID:40397006 | DOI:10.2106/JBJS.24.01515

J Bone Joint Surg Am. 2025 May 21;107(10):e55. doi: 10.2106/JBJS.25.00087. Epub 2025 May 21.

NO ABSTRACT

PMID:40397005 | DOI:10.2106/JBJS.25.00087

J Bone Joint Surg Am. 2025 May 21;107(10):e54. doi: 10.2106/JBJS.24.01542. Epub 2025 May 21.

NO ABSTRACT

PMID:40397004 | DOI:10.2106/JBJS.24.01542

J Bone Joint Surg Am. 2025 May 21;107(10):e53. doi: 10.2106/JBJS.25.00014. Epub 2025 May 21.

NO ABSTRACT

PMID:40397003 | DOI:10.2106/JBJS.25.00014

J Bone Joint Surg Am. 2025 May 21;107(10):1041-1042. doi: 10.2106/JBJS.25.00206. Epub 2025 May 21.

NO ABSTRACT

PMID:40397002 | DOI:10.2106/JBJS.25.00206

J Bone Joint Surg Am. 2025 May 16. doi: 10.2106/JBJS.24.01096. Online ahead of print.

ABSTRACT

BACKGROUND: The calcaneonavicular distance has yet to be definitively defined on the basis of morphological studies and thus remains a somewhat elusive value for orthopaedists. The purposes of the present study were to measure the calcaneonavicular distance with use of magnetic resonance imaging (MRI) in a control pediatric population and to assess whether sex and age affected this distance.

METHODS: We retrospectively reviewed 363 MRI scans of the feet of healthy controls and measured calcaneonavicular distances (i.e., the distance between the bone margins of the anterior process of the calcaneus and the navicular and the distance between the cartilaginous margins of the anterior process of the calcaneus and the navicular) in the axial and sagittal planes.

RESULTS: Interobserver and intraobserver agreements were better for the bone measurements than for the cartilaginous measurements. The mean calcaneonavicular distance was 5.6 mm for values based on bone margins and 4.5 mm for those based on cartilaginous margins. On the basis of current criteria, the distributions of these distances were such that 41% to 46% of participants presented with values that defined them as having a too-long anterior process of the calcaneus. Furthermore, age seemed to play a major role in males, with calcaneonavicular distances narrowing with bone maturation.

CONCLUSIONS: The mean physiological calcaneonavicular distances measured in healthy pediatric controls are much shorter than reported previously. In almost 50% of cases, the calcaneonavicular distance measurements between the bone margins presented values that defined them as having a too-long anterior process of the calcaneus. Age played a major role in the calcaneonavicular distances in males, and we hypothesize that the calcaneonavicular distance narrows with bone maturation. We believe that it is essential to establish normative calcaneonavicular distance values based on sex and age so that they can be used as guidelines when diagnosing and treating patients suspected of having a too-long anterior process of the calcaneus.

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

PMID:40378236 | DOI:10.2106/JBJS.24.01096

J Bone Joint Surg Am. 2025 May 13. doi: 10.2106/JBJS.25.00071. Online ahead of print.

NO ABSTRACT

PMID:40359264 | DOI:10.2106/JBJS.25.00071

J Bone Joint Surg Am. 2025 May 13. doi: 10.2106/JBJS.24.00871. Online ahead of print.

ABSTRACT

BACKGROUND: Osseointegration of a bone-anchored limb (BAL) establishes a direct skeletal interface for prosthesis attachment, simplifying the donning/doffing process. The Timed Up and Go (TUG) test reliably assesses mobility in individuals with lower-extremity amputation who use socket prostheses, but it does not account for the time required to don a prosthetic limb. The aim of this study was to develop and examine the reliability and validity of the Colorado Limb Donning-Timed Up and Go (COLD-TUG) test. This test combines the time required for donning a prosthesis with the time to complete the TUG test in lower-extremity amputees using a prosthesis.

METHODS: Participants with a unilateral lower-extremity amputation were enrolled in this study; participants were divided into 2 groups: socket prosthesis users (n = 15) and BAL users (n = 22). The COLD-TUG test measured the time (in seconds) required to don the prosthesis, get up from a standard chair, walk 3 m, turn around, walk back to the chair, and sit down again. Group differences as well as the intrarater reliability and concurrent validity of the test were analyzed.

RESULTS: There were no significant differences between the 2 groups in terms of baseline characteristics. The intrarater reliability of the COLD-TUG test was excellent (intraclass correlation coefficient [ICC] = 0.94; p = 0.001). The concurrent validity between the COLD-TUG test and the TUG test in BAL patients was good (r = 0.712; p = 0.006). Participants in the BAL group had a significantly shorter mean COLD-TUG time (16.6 ± 5.6 seconds) compared with participants in the socket-prosthesis group (85.3 ± 61.4 seconds) (p < 0.001).

CONCLUSIONS: The COLD-TUG test accurately measures prosthesis-donning burden in the context of functional mobility, thus providing valuable insights into functional abilities and quality of life. Use of a BAL was associated with a shorter donning time compared with use of a socket prosthesis.

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

PMID:40359258 | DOI:10.2106/JBJS.24.00871

J Bone Joint Surg Am. 2025 May 13. doi: 10.2106/JBJS.24.00744. Online ahead of print.

ABSTRACT

BACKGROUND: Conventional sonication is a recommended method in the diagnosis of periprosthetic joint infection (PJI), but the accuracy of diagnosis is still not ideal. We have applied the use of a handheld ultrasonic device and the intraoperative direct sonication of prostheses and soft tissues retrieved during surgery to improve the efficacy of the microbiological diagnosis of PJI and the incubation time of pathogens.

METHODS: This was a retrospective study of patients diagnosed with PJI or aseptic loosening who underwent revision, DAIR (debridement, antibiotics, and implant retention), or resection, and for whom either sonication method was used between July 2017 and June 2023. Starting in August 2021, the removed implants and adjacent soft tissue were directly sonicated in a small metal container, and then the sonication fluid was incubated in blood culture bottles in the operating room under laminar air flow. Conventional sonication was continued through July 2021, and included vortex mixing for 30 seconds, sonication for 5 minutes, and additional vortex mixing for 30 seconds, as described by Trampuz et al. in 2007. The sensitivity, specificity, and time to positivity (TTP) of pathogen cultures were compared between intraoperative direct sonication and conventional sonication.

RESULTS: Of the 415 included patients, 266 had PJI and 149 had aseptic loosening. Fluid from intraoperative direct sonication and conventional sonication showed sensitivities of 88% and 69% (p < 0.001) and specificities of 84% and 93% (p = 0.105), respectively. Higher sensitivity was obtained by intraoperative direct sonication of only soft tissue than by direct sonication of only the prosthesis (80% versus 75%). Culture results from intraoperative direct sonication of soft tissue and the prosthesis were inconsistent in 55 cases (soft tissue plus prosthesis: 28 cases, soft tissue only: 17 cases, and prosthesis only: 10 cases). Gram-positive organisms grew significantly faster following direct sonication (median TTP for soft-tissue, 2.12 days [interquartile range (IQR), 1.40 to 3.16 days], and median TTP for the prosthesis, 2.02 days [IQR, 1.08 to 3.04 days]) compared with conventional sonication (median TTP, 2.92 days [IQR, 1.83 to 3.96 days]) (p = 0.003 and p < 0.001, respectively).

CONCLUSIONS: Intraoperative direct sonication was more sensitive than conventional sonication for the microbiological diagnosis of PJI and slightly shortened the TTP of microorganisms.

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

PMID:40359254 | DOI:10.2106/JBJS.24.00744