JBJS

Drivers of Labor and Supply Cost Variation in Anterior Cruciate Ligament Reconstruction: A Multicenter Time-Driven Activity-Based Costing Analysis

J Bone Joint Surg Am. 2026 Apr 23. doi: 10.2106/JBJS.25.00667. Online ahead of print.

ABSTRACT

BACKGROUND: Understanding drivers of supply and labor cost variation in orthopaedic surgery is crucial to provide value-based care. Time-driven activity-based costing (TDABC) is a more accurate methodology for capturing costs of care than traditional methods. Anterior cruciate ligament reconstruction (ACLR) is one of the most performed outpatient procedures within orthopaedic surgery. The purpose of this study was to characterize the cost composition of ACLR and identify factors that drive cost variation.

METHODS: Cost data for supplies and time-based personnel usage were extracted from electronic health records and were used to calculate costs using TDABC. TDABC methodology was applied to calculate the cost of personnel usage by multiplying the duration and associated cost per minute. Descriptive statistics and mixed-effects modeling were used to determine cost drivers.

RESULTS: This study included 861 patients who underwent ACLR at 8 hospitals. The mean patient age (and standard deviation) was 31.1 ± 11.6 years. Of the 861 patients, 350 were male and 511 were female; 85.6% of patients were White, 8.1% were Asian, and 3.4% were Black. There was 3.2-fold variation in supply costs ($2,950) and 1.6-fold variation in labor costs ($940) between the 10th and 90th percentiles. Overall, supply costs accounted for 58.2% of total costs, whereas labor costs comprised the remaining 41.8%. The intraoperative phase was the greatest generator of total cost (89.7%). After adjusting for surgeon and hospital variability, variation in total cost was most effectively explained by graft type, primary surgery status, and meniscal repair (conditional R2 = 0.84; marginal R2 = 0.27). On subanalysis, patients undergoing allograft ACLR had significantly higher total costs, implant costs, and age compared with those undergoing ACLR with any autograft type (all p < 0.01).

CONCLUSIONS: The most notable drivers of labor and supply cost variation were graft type, surgeon, surgery center, primary surgery status, and concomitant meniscal repair. Understanding modifiable cost drivers may aid health systems in designing value-based pathways, implant formularies, and surgeon education programs. Future studies may integrate cost with outcome measures for a more holistic view of value.

LEVEL OF EVIDENCE: Economic and Decision Analysis Level III. See Instructions for Authors for a complete description of levels of evidence.

PMID:42024715 | DOI:10.2106/JBJS.25.00667

Development of a Radiographic Scoring System to Estimate Acetabular Protrusion Risk in Patients with Osteolytic Periacetabular Metastases

J Bone Joint Surg Am. 2026 Apr 22. doi: 10.2106/JBJS.25.01219. Online ahead of print.

ABSTRACT

BACKGROUND: For patients with periacetabular metastases, protrusio acetabuli is a severely painful and mobility-impairing complication that requires subsequent open joint surgery. We aimed to identify specific structural changes that are associated with progression to protrusio acetabuli and to create a scoring system to guide risk stratification.

METHODS: In this single-institution cohort study, we identified all patients who underwent primary surgical stabilization for periacetabular metastases with osteolytic or mixed osteolytic-osteoblastic characteristics from October 2017 through January 2025. Cases of protrusio acetabuli prior to surgical intervention were identified. Pain and ambulatory functional scores and treatment history were recorded. Locations of bone destruction were evaluated using coronal-cut computed tomography (CT) scans obtained within 3 months before clinical presentation (and earlier, as available). Trabecular and subchondral cortical bone mass of the periacetabular weight-bearing portions were indirectly assessed via Hounsfield unit ratio comparisons across scans. Univariable analysis of each feature was performed. The highest-scoring features were used to create a scoring system and analyzed using a receiver operating characteristic (ROC) curve. Finite element analysis was performed for biomechanical validation.

RESULTS: Eighty-seven patients (67 non-protrusio [mean age of 65.5 ± 13.0 years; 37 female]; 20 protrusio [mean age of 72.9 ± 10.1 years; 11 female]) were included. Locationally, bone defects, thinning, or linear fractures in the middle-third (apex) alongside contiguous involvement of either the medial- or lateral-third of the weight-bearing dome were highly predictive of protrusio. A >50% cortical bone-mass decrease of the acetabular weight-bearing dome was associated with protrusio (p < 0.05). A radiographic risk scoring system was then constructed using a grading system from low- to high-risk features. ROC analysis showed a score of ≥3.0 as 95.0% sensitive and 91.0% specific for progression to protrusio. Finite element analysis further showed that cortical bone loss of the middle-third (apex) of the weight-bearing dome was critical.

CONCLUSIONS: We propose the use of clinical and radiographic risk predictors to stratify patients with periacetabular metastases on the basis of the risk of protrusio. Anatomically, surgical stabilization of the middle-third (apex) of the weight-bearing dome is critical to preventing or delaying progression to protrusio.

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

PMID:42018647 | DOI:10.2106/JBJS.25.01219

The Persistent Challenges of Diagnosing Orthopaedic Implant-Related Infections

J Bone Joint Surg Am. 2026 Apr 22. doi: 10.2106/JBJS.25.01516. Online ahead of print.

ABSTRACT

Infection remains one of the most catastrophic complications following orthopaedic surgery. Despite substantial advances in molecular diagnostics, biomarker assays, and consensus definitions, accurately diagnosing orthopaedic infection continues to challenge even the most experienced clinicians. There are differences in the diagnosis and treatment of infections that are related to different anatomic regions. The difficulty arises from the inherent biological diversity of infecting organisms and surgical locations, variable host responses, and the absence of a true diagnostic "gold standard." This article summarizes the current diagnostic challenges and emerging solutions, drawing on recent high-impact evidence and consensus frameworks.

PMID:42018608 | DOI:10.2106/JBJS.25.01516

High-Grade 3-Column Osteotomies Are Not Interchangeable: Schwab-Grade-III PSO Versus Schwab-Grade-V VCR in Treating Severe Kyphoscoliosis with an Average 9-Year Follow-up

J Bone Joint Surg Am. 2026 Apr 21. doi: 10.2106/JBJS.25.01393. Online ahead of print.

ABSTRACT

BACKGROUND: Pedicle subtraction osteotomy (PSO) and vertebral column resection (VCR) are powerful techniques for correcting severe spinal deformities. Although PSO has been proposed as a viable alternative to VCR, their comparative efficacies and safety profiles require further elucidation.

METHODS: This single-center retrospective study analyzed 169 patients (mean age, 22 years; 84 male; 169 ethnic Chinese) with severe kyphoscoliosis who underwent primary corrective surgery via PSO (n = 85) or VCR (n = 84). Radiographic parameters, surgical data, intraoperative neuromonitoring (IOM) changes, Scoliosis Research Society (SRS)-22 scores, and complications were compared between groups.

RESULTS: Both techniques significantly improved all radiographic parameters and SRS-22 scores (p < 0.001). The VCR group demonstrated superior correction of the major curve (65.5% versus 56.9%, p = 0.003), segmental kyphosis (68.1% versus 61.5%, p = 0.03), and apical vertebral rotation (48.5% versus 34.4%, p = 0.001). At the critical osteotomy stage, 105 (62.1%) of 169 patients experienced IOM signal decline. The neurological complications rate was significantly higher in the VCR group (13 of 84 versus 7 of 85, p = 0.038), as was the overall complication rate (43 of 84 versus 29 of 85, p = 0.008). Each 1° increase in correction achieved with VCR was associated with a 1.6% higher risk of complications (OR = 1.016, p = 0.045).

CONCLUSIONS: Although both PSO and VCR were highly effective for major deformity correction, VCR provided a greater magnitude of correction in the coronal, sagittal, and axial planes. However, this advantage was counterbalanced by a significantly higher risk of complications, including neurological deficits. Despite the frequent reversibility of IOM signal declines, VCR retained a higher risk profile due to its higher overall complication rate.

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

PMID:42013198 | DOI:10.2106/JBJS.25.01393

Evaluation and Management of Meniscal Tears

J Bone Joint Surg Am. 2026 Apr 21. doi: 10.2106/JBJS.26.00230. Online ahead of print.

ABSTRACT

➢ Meniscal preservation has become the central management principle of meniscal tears. Biomechanical evidence has demonstrated that meniscal resection increases joint contact stress, accelerates osteoarthritis progression, and worsens long-term outcomes compared with repair and nonoperative management.➢ Treatment decisions should be individualized based on tear morphology, tissue quality, and patient-specific factors.➢ Repair technique selection (all-inside, inside-out, or outside-in) should be dictated by the tear location and pattern.➢ Adjunct treatment strategies, such as biologic augmentation, may be used selectively to increase the potential for meniscal healing, although these strategies have inconsistent outcomes.

PMID:42013196 | DOI:10.2106/JBJS.26.00230

Effectiveness of Intraosseous Morphine for Pain Control in Total Knee Arthroplasty: A Double-Blinded, Randomized Trial

J Bone Joint Surg Am. 2026 Apr 21. doi: 10.2106/JBJS.25.01037. Online ahead of print.

ABSTRACT

BACKGROUND: Effective pain management following total knee arthroplasty (TKA) is crucial to optimizing patient outcomes and experiences. Multimodal pain management protocols vary between institutions, with some recently proposing the addition of an intraosseous (IO) injection of morphine intraoperatively. The purpose of this study was to investigate whether the addition of an intraoperative, IO injection of morphine during elective primary TKA would lead to improved pain control and decreased narcotic consumption during the postoperative period.

METHODS: In this double-blinded, randomized controlled trial, 100 patients undergoing elective primary TKA were prospectively enrolled. All patients received spinal anesthesia and intravenous sedation combined with an intraoperative, surgeon-administered adductor canal block. The experimental group received an intraoperative, IO injection containing 10 mg of morphine and 500 mg of vancomycin in 110 mL of normal saline solution. The control group received the same injection but without morphine. All patients received 6 daily text-message surveys (3 in the morning and 3 in the evening) for 14 days postoperatively to collect pain scores, morphine milligram equivalent (MME) consumption, and nausea and vomiting events. Data on demographics, operative factors, post-anesthesia care unit (PACU) pain scores, PACU MME consumption, and patient-reported outcomes were also collected. Linear mixed-effects (LME) models were utilized.

RESULTS: A total of 88 patients (52.3% [n = 46] female; mean age, 69.1 ± 9.0 years [range, 46 to 89 years]; 89.8% [n = 79] White) were included in the analysis. The LME model demonstrated no differences between the groups with respect to daily pain scores at any time point within 14 days postoperatively (p = 0.969). There were no differences between the groups with respect to daily MME consumption at any time point within 14 days postoperatively (p = 0.377). There were also no differences in total MME consumption or weekly MME consumption postoperatively (p ≥ 0.878).

CONCLUSIONS: IO morphine did not significantly improve postoperative pain control or decrease narcotic consumption up to 2 weeks postoperatively among patients undergoing elective primary TKA.

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

PMID:42013190 | DOI:10.2106/JBJS.25.01037

Technology Assistance Mitigates the Volume-Dependent Risk of Hip Dislocation Following Total Hip Arthroplasty

J Bone Joint Surg Am. 2026 Apr 20. doi: 10.2106/JBJS.25.01237. Online ahead of print.

ABSTRACT

BACKGROUND: Lower surgeon case-volume has been associated with a greater risk of postoperative complications such as dislocation following total hip arthroplasty (THA). However, robotic assistance and computer navigation may mitigate the volume-dependent risk of instability. This study sought to compare dislocation rates between lower-volume surgeons performing technology-assisted (TA) THAs and higher-volume surgeons utilizing conventional instrumentation (CI).

METHODS: The Premier Healthcare Database was queried to identify adult patients who underwent primary elective THA from 2016 to 2023. Surgeons with <10% technology use formed the CI group, and surgeons with ≥90% technology use formed the TA group. These groups were further subdivided into higher-volume (HV) and lower-volume (LV) on the basis of surgeon annual case-volume, using a previously validated threshold of 109 cases/year. Mixed-effects modeling was used to compare the 90-day risk of dislocation between patients treated by low-volume surgeons using TA (LV-TA group) and high-volume surgeons using CI (HV-CI group).

RESULTS: A total of 669,098 patients undergoing THA were identified. Of these, 5,447 patients were treated by LV-TA surgeons and 190,550, by HV-CI surgeons. Notably, LV-TA surgeons achieved a similar rate of dislocation compared with HV-CI surgeons (0.48% versus 0.42%, p = 0.510). After controlling for confounding factors, the risk of dislocation remained comparable between LV-TA and HV-CI surgeons (adjusted odds ratio: 1.062, 95% confidence interval: 0.677 to 1.668, p = 0.793).

CONCLUSIONS: Surgeons with a lower case-volume who used technology assistance achieved a rate of dislocation similar to that of surgeons with a higher case-volume who used conventional instrumentation. These findings demonstrate that technology assistance, including computer navigation and robotic assistance, may attenuate the association between surgeon case-volume and dislocation risk following primary THA.

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

PMID:42008602 | DOI:10.2106/JBJS.25.01237

Knee Injectables in Young Athletes: Evidence, Recommendations, and Clinical Application

J Bone Joint Surg Am. 2026 Apr 16. doi: 10.2106/JBJS.26.00267. Online ahead of print.

ABSTRACT

Knee pain resulting from acute trauma and overuse injury is common among athletes and represents a major cause of reduced performance, time loss from sport, and long-term sequelae including osteoarthritis. Injectable therapies are frequently used as a nonoperative treatment modality to alleviate symptoms and facilitate early return to sport. This review evaluates the current evidence on commonly used knee injectables in the younger athletic population with pre-arthritic knee pain, including corticosteroids, hyaluronic acid, platelet-rich plasma (PRP), and other biologics. Relevant literature was identified without restriction on study design and with a focus on athlete-specific outcomes and clinical applicability. Overall, the available evidence on knee injectables for athletes remains limited, heterogeneous, and largely extrapolated from older, nonathletic cohorts. In the absence of available athlete-specific guidelines, most injectables carry weak and/or conditional recommendations, highlighting the need for individualized treatment and shared decision-making. High-quality, sport-specific clinical trials are required to establish clear guidelines and optimize outcomes in this population.

PMID:41990135 | DOI:10.2106/JBJS.26.00267

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