J Bone Joint Surg Am. 2025 Sep 4. doi: 10.2106/JBJS.25.00036. Online ahead of print.

ABSTRACT

The U.S. orthopaedic surgery residency match is among the most competitive in medicine; in 2024, 40% of applicants were unmatched. This drives applicants to differentiate themselves, while residency programs aim to evaluate candidates holistically. In order to understand the process that is used to select and educate the best surgeons, we examined medical student advising, the role of national organizations, and programmatic practices for resident selection. Effective career advising is essential for attracting and supporting highly qualified applicants. Exposure through preclinical courses, clerkships, and accessible mentorship enhances interest in orthopaedics among applicants with an array of experiences, skills, and backgrounds. National initiatives (e.g., the Orthopaedic Residency Information Network [ORIN]) provide centralized resources to address disparities in information access, although further standardization and consolidation are needed. Collaboration among national stakeholders is necessary to ensure fairness in the match process and to attract the best applicants. Initiatives like preference signaling have shown promise, increasing interview rates at preferred programs and better aligning applicants with residency opportunities. However, barriers such as limited access to research, costly away rotations, and expensive applications disproportionately affect underrepresented groups, highlighting the need for systemic changes. Resident selection practices must evolve to counter the inefficiencies and biases. Holistic review processes, structured interviews, and mission-driven scoring can improve alignment with program values. Programs must consider their setting and their population and also consider applicants who demonstrate an understanding of, and have an interest in caring for, that community. Improving orthopaedic residency selection requires collaborative efforts across organizations, advisors, and programs to refine processes and ensure the selection and training of those who will advance clinical orthopaedics and the science of orthopaedic surgery and also meet the needs of all patient populations.

PMID:40906795 | DOI:10.2106/JBJS.25.00036

J Bone Joint Surg Am. 2025 Sep 4. doi: 10.2106/JBJS.25.00781. Online ahead of print.

ABSTRACT

Kyle J. Jeray, MD, presented this Presidential Address, "Out of Left Field: Leadership Lessons I Didn't See Coming," at the Annual Meeting of the American Orthopaedic Association in Minneapolis, Minnesota, in June 2025. During his installation, he focused on the importance of 4 personal leadership lessons: (1) personal connections matter, (2) building a team culture, (3) kindness and humility in leadership, and (4) innovation, precision, and adaptability with resilience.

PMID:40906776 | DOI:10.2106/JBJS.25.00781

J Bone Joint Surg Am. 2025 Sep 3. doi: 10.2106/JBJS.24.01463. Online ahead of print.

ABSTRACT

BACKGROUND: Low- and middle-income countries (LMICs) are disproportionately affected by trauma, resulting in >5 million deaths annually. An essential treatment for musculoskeletal trauma is external fixation. However, in LMICs, current external fixator assemblies are unaffordable, costing patients upward of $5,000 (USD), leaving LMICs to rely on donations that fail to meet the needs of the patient population.

METHODS: New, affordable external fixator (AEFIX) clamps (SONA Global), designed for use in LMIC settings, were compared with Hoffmann 3 (Stryker Medical) clamps to examine their mechanical efficacy compared with commercially available, industry-standard clamps in the U.S. market. In axial and torsional loading scenarios, mechanical testing was performed at the component level and construct level (uniplanar external fixation of a tibial diaphyseal fracture).

RESULTS: The AEFIX constructs showed no differences in axial or torsional stiffness compared with Stryker constructs. AEFIX constructs yielded at 434.5 N compared with Stryker constructs at 533.6 N (p = 0.04); however, the pins failed before clamp failure could occur in all AEFIX and Stryker constructs. Under cyclic loading at 100 and 300 N, no differences were observed in construct stiffness or interfragmentary gap change. At 500 N of cyclic loading, the AEFIX and Stryker constructs resulted in median gap changes of -4.3 and -1.1 mm, respectively (p < 0.001), with no difference in % change in construct stiffness (p = 0.281).

CONCLUSIONS: AEFIX clamps were comparable to industry-standard Stryker Hoffman 3 clamps in terms of mechanical properties and effectiveness, suggesting that the AEFIX clamps may provide safe external fracture fixation in the non-weight-bearing patient.

CLINICAL RELEVANCE: As a safe and affordable solution, AEFIX clamps provide a foundation for enhancing essential trauma surgery capacity in resource-constrained settings around the globe.

PMID:40901974 | DOI:10.2106/JBJS.24.01463

J Bone Joint Surg Am. 2025 Sep 3. doi: 10.2106/JBJS.24.01390. Online ahead of print.

ABSTRACT

BACKGROUND: The purpose of this study was to develop a frailty index for pediatric patients undergoing posterior spinal fusion for deformity correction.

METHODS: The National Surgical Quality Improvement Program (NSQIP) Pediatric database was used. Patients <18 years of age who had undergone posterior spinal fusion for the treatment of spinal deformity were included. The outcomes of interest included any adverse events, Clavien-Dindo grade-IV adverse events, mortality, and extended length of stay. Significant variables from the multivariable regression analysis were used to create a frailty index. The frailty index was assessed with use of receiver operating characteristic (ROC) curve analysis of each outcome of interest. The frailty index was externally validated with use of a validation cohort. The rates of the outcomes of interest were expressed as proportions and were stratified by the frailty index score.

RESULTS: The present study included 34,478 patients (28,377 in the derivation cohort and 6,101 in the validation cohort). The frailty index included severe respiratory disease, gastrointestinal disease, neuromuscular disease, cognitive/developmental delay, seizure disorder, and asthma. In the derivation cohort, the area under the curve (AUC) for any adverse event, a Clavien-Dindo grade-IV adverse event, mortality, and extended length of stay were 0.77, 0.85, 0.91, and 0.79, respectively. On external validation, the AUC for any adverse event, a Clavien-Dindo grade-IV adverse event, mortality, and extended length of stay were 0.72, 0.88, 0.90, 0.78, respectively. An increasing frailty index score was associated with increasing rates of all morbidity and mortality outcomes.

CONCLUSIONS: The frailty index had good to excellent discrimination for morbidity and mortality. This frailty index allows for better risk stratification and informed decision-making.

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

PMID:40901929 | DOI:10.2106/JBJS.24.01390

J Bone Joint Surg Am. 2025 Sep 3;107(17):e86. doi: 10.2106/JBJS.25.00669.

NO ABSTRACT

PMID:40900119 | DOI:10.2106/JBJS.25.00669

J Bone Joint Surg Am. 2025 Sep 3;107(17):e87. doi: 10.2106/JBJS.25.00559.

NO ABSTRACT

PMID:40900099 | DOI:10.2106/JBJS.25.00559

J Bone Joint Surg Am. 2025 Sep 2. doi: 10.2106/JBJS.24.01588. Online ahead of print.

ABSTRACT

BACKGROUND: We sought to evaluate the incidence of cardiovascular and cerebrovascular diseases in patients undergoing total knee arthroplasty (TKA) and the impact of perioperative physical activity levels on these risks.

METHODS: This nationwide cohort study used data from the National Health Insurance Service of the Republic of Korea. Patients who underwent a pair of health examinations at 2-year or 4-year intervals and did not have a diagnosis of cardiovascular or cerebrovascular disease at the first examination were included. The study population was divided into those who underwent TKA and those who did not between the 2 examinations. Physical activity was defined on the basis of the frequency of moderate-to-high-intensity activities and was categorized into inactive or active 1 to 2, 3 to 4, and ≥5 times weekly. Cox proportional hazards models were used to evaluate the association between physical activity changes and disease incidence over a 5-year follow-up.

RESULTS: Compared with controls who did not undergo TKA, patients who underwent TKA exhibited higher incidences of cardiovascular diseases (19.3% compared with 17.1%) and cerebrovascular diseases (25.7% compared with 23.9%). These incidences were associated with perioperative physical activity levels. Higher physical activity levels after TKA were associated with lower risks of both diseases. Specifically, engaging in physical activity ≥5 times per week was linked to lower cardiovascular risk (hazard ratio [HR], 0.918; p < 0.001) and cerebrovascular risk (HR, 0.890; p < 0.001). Previously inactive patients who began activity showed a reduction in the risks of both diseases, whereas previously active patients who became inactive had a significantly increased cerebrovascular risk.

CONCLUSIONS: Patients who underwent TKA demonstrated higher incidences of cardiovascular and cerebrovascular diseases compared with controls over a 5-year follow-up. Our findings underscore the importance of initiating regular physical activity after surgery, particularly among previously inactive patients. Conversely, the increased cerebrovascular events among patients who ceased activity emphasize the critical need to maintain activity levels after surgery. Therefore, maintaining or initiating physical activity may be a core component of optimizing long-term outcomes after TKA.

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

PMID:40892877 | DOI:10.2106/JBJS.24.01588

J Bone Joint Surg Am. 2025 Aug 29. doi: 10.2106/JBJS.24.01630. Online ahead of print.

ABSTRACT

BACKGROUND: Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) is a serious complication associated with notable loss of function, impaired quality of life, and excess short-term mortality. In this study, we aimed to report the impact of PJI on long-term mortality and its associated risk factors.

METHODS: Using data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR), we used Kaplan-Meier estimates of survivorship and standardized mortality ratios (SMRs) based on Australian period life tables to describe mortality rates following revision for PJI, aseptic revisions (excluding those for fracture), and unrevised primary TKA. Additionally, hazard ratios (HRs) were calculated with multivariable proportional hazard models to assess the impact of the risk factors of age, gender, comorbidities, and minor versus major revisions.

RESULTS: Among 867,113 TKA procedures overall, there were 8,642 first revisions for PJI and 25,328 aseptic first revisions. At 5, 10, and 15 years, 16.1%, 34.4%, and 53.4% of patients with revision for PJI had died. When compared with a matched population, the SMR for revision for PJI was 1.33 (95% confidence interval [CI]: 1.28 to 1.39); for aseptic revision, 0.84 (95% CI: 0.82 to 0.87); and for unrevised primary TKA, 0.79 (95% CI: 0.78 to 0.79). Increasing age and higher American Society of Anesthesiologists (ASA) scores were significant mortality risk factors. Major revisions for PJI were not associated with a greater mortality risk compared with minor revisions for PJI.

CONCLUSIONS: Patients with revision for PJI had a 33% greater-than-expected mortality. There was a high mortality in the early postoperative period, and the excess mortality risk persisted beyond 15 years. Increasing age and higher ASA scores were associated with increased mortality.

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

PMID:40880507 | DOI:10.2106/JBJS.24.01630

J Bone Joint Surg Am. 2025 Aug 29. doi: 10.2106/JBJS.24.01466. Online ahead of print.

ABSTRACT

BACKGROUND: There is no foundational classification that 3-dimensionally characterizes arthritic anatomy to preoperatively plan and postoperatively evaluate total knee arthroplasty (TKA). With the advent of computed tomography (CT) as a preoperative planning tool, the purpose of this study was to morphologically classify pre-TKA anatomy across coronal, axial, and sagittal planes to identify outlier phenotypes and establish a foundation for future philosophical, technical, and technological strategies.

METHODS: A cross-sectional analysis was conducted using 1,352 pre-TKA lower-extremity CT scans collected from a database at a single multicenter referral center. A validated deep learning and computer vision program acquired 27 lower-extremity measurements for each CT scan. An unsupervised spectral clustering algorithm morphometrically classified the cohort. The optimal number of clusters was determined through elbow-plot and eigen-gap analyses. Visualization was conducted through t-stochastic neighbor embedding, and each cluster was characterized. The analysis was repeated to assess how it was affected by severe deformity by removing impacted parameters and reassessing cluster separation.

RESULTS: Spectral clustering revealed 4 distinct pre-TKA anatomic morphologies (18.5% Type 1, 39.6% Type 2, 7.5% Type 3, 34.5% Type 4). Types 1 and 3 embodied clear outliers. Key parameters distinguishing the 4 morphologies were hip rotation, medial posterior tibial slope, hip-knee-ankle angle, tibiofemoral angle, medial proximal tibial angle, and lateral distal femoral angle. After removing variables impacted by severe deformity, the secondary analysis again demonstrated 4 distinct clusters with the same distinguishing variables.

CONCLUSIONS: CT-based phenotyping established a 3D classification of arthritic knee anatomy into 4 foundational morphologies, of which Types 1 and 3 represent outliers present in 26% of knees undergoing TKA. Unlike prior classifications emphasizing native coronal plane anatomy, 3D phenotyping of knees undergoing TKA enables recognition of outlier cases and a foundation for longitudinal evaluation in a morphologically diverse and growing surgical population. Longitudinal studies that control for implant selection, alignment technique, and applied technology are required to evaluate the impact of this classification in enabling rapid recovery and mitigating dissatisfaction after TKA.

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

PMID:40880455 | DOI:10.2106/JBJS.24.01466

J Bone Joint Surg Am. 2025 Aug 28. doi: 10.2106/JBJS.24.00733. Online ahead of print.

ABSTRACT

➢ The use of multirod constructs (≥3 rods) in complex spine surgery has increased as its utility has been recognized over the past decade.➢ There are multiple different rod configurations that may be utilized on the basis of the desired supplemental rod function, with each type having its own advantages and clinical indications.➢ Literature has continued to demonstrate a reduced incidence of pseudarthrosis, rod fracture, and reoperation when comparing multirod constructs with traditional dual-rod constructs.➢ The use of consistent nomenclature when describing multirod constructs will allow for more productive clinical and biomechanical research.

PMID:40875787 | DOI:10.2106/JBJS.24.00733

J Bone Joint Surg Am. 2025 Aug 26. doi: 10.2106/JBJS.24.01333. Online ahead of print.

ABSTRACT

➢ With any study, readers should be cautious and critical when the conclusion is that "these treatments are the same."➢ If only superiority testing was performed, failing to find a difference does not mean that the treatments are the same, even when the study was adequately powered.➢ Noninferiority analysis is the correct method to compare treatments that researchers and clinicians think may be "the same" for the primary outcome.➢ The most important aspect of a noninferiority analysis is the selection of the noninferiority margin, which is the minimum difference between groups that would be considered meaningful.➢ To perform noninferiority testing, the difference in an outcome measure of interest between experimental and control groups must be examined with respect to the noninferiority margin of the same outcome measure. Assuming that a greater value indicates improvement in an outcome measure, if the lower bound of a 95% confidence interval of a difference in means based on a 1-sided test is greater than the noninferiority margin, then the experimental treatment can be considered noninferior to the control.

PMID:40857355 | DOI:10.2106/JBJS.24.01333

J Bone Joint Surg Am. 2025 Aug 25. doi: 10.2106/JBJS.24.01326. Online ahead of print.

ABSTRACT

BACKGROUND: Fourth-generation percutaneous, or minimally invasive, hallux valgus surgery utilizes a transverse osteotomy to achieve deformity correction. There are only a small number of studies reporting the clinical and radiographic outcomes of transverse osteotomies, many of which have methodological limitations such as small sample size, limited radiographic follow-up, or use of non-validated outcome measures. The aim of this study was to provide a methodologically robust investigation of percutaneous transverse osteotomies for hallux valgus deformity.

METHODS: We studied a prospective series of consecutive patients undergoing fourth-generation metatarsal extracapsular transverse osteotomy performed by a single surgeon (P.L.) between November 2017 and January 2023. The primary outcome was clinical foot function assessed using the Manchester-Oxford Foot Questionnaire (MOXFQ), a validated patient-reported outcome measure. Secondary outcomes included the radiographic deformity (the hallux valgus angle [HVA], 1-2 intermetatarsal angle [IMA], and sesamoid position) assessed according to American Orthopaedic Foot & Ankle Society (AOFAS) guidelines as well as a visual analog scale for pain and radiographic evidence of deformity recurrence (defined as an HVA of >20° at final radiographic follow-up). P values of <0.05 were considered significant.

RESULTS: Seven hundred and twenty-nine feet (483 patients; 456 female and 27 male; mean age, 57.9 ± 11.9 years) underwent fourth-generation metatarsal extracapsular transverse osteotomy. Radiographic data were available at a vminimum of 12 months postoperatively for 99.7% of the feet, which were followed for a mean of 2.6 ± 1.3 years (range, 1.0 to 5.7 years). There was a significant improvement (p < 0.05) in both the HVA (from 29.5° ± 8.5° preoperatively to 7.3° ± 6.7° at final follow-up) and the IMA (from 12.9° ± 3.3° to 4.6° ± 2.5°). All MOXFQ domains showed significant improvement (p < 0.05), with the MOXFQ Index improving from 36.9 ± 18.9 to 13.4 ± 15.8, Pain improving from 40.5 ± 22.0 to 17.2 ± 18.3, Walking/Standing improving from 32.3 ± 23.1 to 12.0 ± 18.2, and Social Interaction improving from 40.4 ± 20.4 to 11.0 ± 15.2. The recurrence rate was 4.5% (n = 33). The complication rate was 6.1%, which included a screw removal rate of 2.9%.

CONCLUSIONS: This study, which was the largest consecutive series of any percutaneous osteotomy technique used to correct hallux valgus deformity, demonstrated significant improvement in clinical and radiographic outcomes with a low rate of recurrence.

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

PMID:40854004 | DOI:10.2106/JBJS.24.01326

J Bone Joint Surg Am. 2025 Aug 22. doi: 10.2106/JBJS.24.01236. Online ahead of print.

ABSTRACT

BACKGROUND: Tranexamic acid (TXA) and absorbable hemostat (AH) are widely used to reduce perioperative blood loss in total knee arthroplasty (TKA). However, the efficacy of single-method hemostatic strategies is increasingly insufficient for meeting clinical demands. This study tested the efficacy and safety of TXA combined with AH for perioperative blood management in TKA.

METHODS: Hemostatic efficacy was preliminarily evaluated through in vitro dynamic coagulation assays, lactate dehydrogenase activity measurements, and scanning electron microscopy, as well as in vivo using a rabbit liver bleeding model. The in vivo biocompatibility was also measured. Subsequently, the efficacy and safety of TXA combined with AH were further evaluated in a prospective, blinded study involving 149 individuals who were randomized to receive TXA, AH, or TXA+AH during TKA. The primary outcomes were perioperative blood loss, blood transfusion, hemoglobin and hematocrit levels, maximum hemoglobin change, anemia, and postoperative complications. Secondary outcomes included perioperative inflammation, coagulation function, and knee joint function.

RESULTS: Coagulation assays and the liver hemostasis model demonstrated that TXA combined with AH effectively promoted coagulation, with satisfactory biocompatibility. The clinical results of 114 Han Chinese (East Asian) patients indicated that the combination significantly reduced perioperative blood loss in TKA (564.51 ± 136.26 mL in the TXA+AH group, 879.35 ± 85.62 mL in the TXA group, and 692.70 ± 96.06 mL in the AH group; p < 0.001) without an increase in thromboembolic events or wound-related complications. Additionally, the combination accelerated early postoperative knee function recovery without significantly affecting pain scores or inflammatory markers.

CONCLUSIONS: The combination of TXA and AH effectively reduced perioperative blood loss in TKA, accelerated early patient recovery, and did not increase the rate of complications.

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

PMID:40845176 | DOI:10.2106/JBJS.24.01236

J Bone Joint Surg Am. 2025 Aug 22. doi: 10.2106/JBJS.25.00090. Online ahead of print.

ABSTRACT

BACKGROUND: Glycation stress has been implicated in frozen shoulder, potentially inducing oxidative stress through advanced glycation end products (AGEs) and their receptor (RAGE). As the role of oxidative stress in frozen shoulder remains undetermined, this study examined the expression of related genes: NOX, SOD, and PRDX.

METHODS: Thirty-eight participants 35 to 70 years old (23 men and 15 women; all ethnic Japanese) were included; 16 had frozen shoulder, and 22 had a rotator cuff tear without range-of-motion limitations. Tissue samples were collected from the rotator interval capsule and the middle glenohumeral ligament during surgical procedures. Oxidative stress was evaluated by quantifying dihydroethidium (DHE) fluorescence intensity and protein carbonyl levels. Expression levels of genes associated with oxidative stress (SOD1, SOD2, SOD3, PRDX5, NOX1, NOX4), matrix turnover and remodeling (COL1, COL3, MMP1, MMP3, MMP13), and glycation stress (RAGE, RELA) were measured using real-time polymerase chain reaction. Superoxide dismutase (SOD) activity was also evaluated.

RESULTS: In the frozen shoulder group, oxidative stress was indicated by elevated DHE fluorescence and protein carbonyl levels in tissue samples from both the rotator interval capsule and the middle glenohumeral ligament. NOX4, RELA, and MMP13 were significantly upregulated, while SOD1 was significantly downregulated, in the rotator interval capsule and middle glenohumeral ligament in the frozen shoulder group compared with the rotator cuff tear controls. PRDX5, RAGE, and COL1 were significantly upregulated and SOD2 was significantly downregulated in the rotator interval capsule in the frozen shoulder group. SOD activity was significantly downregulated in the rotator interval capsule and middle glenohumeral ligament in the frozen shoulder group.

CONCLUSIONS: The frozen shoulder group showed increased expression of glycation stress genes and NOX along with decreased SOD expression and activity, indicative of oxidative stress. Oxidative stress, in addition to glycation stress, could be involved in the pathogenesis of frozen shoulder.

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

PMID:40845125 | DOI:10.2106/JBJS.25.00090

J Bone Joint Surg Am. 2025 Aug 21. doi: 10.2106/JBJS.24.00821. Online ahead of print.

ABSTRACT

BACKGROUND: Predicting anterior cruciate ligament reconstruction (ACLR) revision risk using machine learning (ML) regression analyses of large-scale registry data offers an evidence-based approach for clinical decision-making and management at a patient-specific level. We examined the performance of an enhanced ML-Cox regression analysis of the Danish Knee Ligament Reconstruction Registry (DKRR) for predicting ACLR revision risk.

METHODS: We analyzed surgical and patient-reported outcome measure data from 18,753 patients in the DKRR who underwent primary ACLR between 2005 and 2023. Enhanced ML-Cox regression analyses, using the least absolute shrinkage and selection operator (LASSO) and stable iterative variable selection (SIVS) approaches, were applied to predict the risk of ACLR revision (i.e., the risk of repeat surgery to reconstruct the ACL). The SIVS procedure identified key variables, including age at the time of primary ACLR and several Knee injury and Osteoarthritis Outcome Score (KOOS) items from 12-month follow-up surveys, as inputs for the best-performing regression models for predicting ACLR revision risk. The resultant Cox regression models for the prediction of ACLR revision risk, therefore, did not involve an analysis of patients with incomplete 12-month follow-up survey data, including patients with graft ruptures within 12 months after the primary surgery.

RESULTS: The best-performing Cox regression model for predicting ACLR revision risk incorporated age at the time of primary ACLR and 3 KOOS items (Pain P1 and Quality of Life Q2 and Q3) from the 12-month postoperative follow-up assessment. This model demonstrated good prediction accuracy 1, 2, and 5 years after the 12-month follow-up assessment (C-index [and standard error], 0.73 [0.03], 0.73 [0.02], and 0.74 [0.02], respectively). This 4-variable Cox regression model was well-calibrated across these time points. An online clinical point-of-care tool, the Danish KOOS3 Risk Monitoring Tool (DK3), was developed for predicting ACLR revision risk.

CONCLUSIONS: Enhanced ML-Cox regression, incorporating patient age and 3 KOOS items obtained 12 months postoperatively, provided good prediction accuracy for ACLR revision risk from 1 to 5 years after the 12-month follow-up assessment, a period that has been associated with the vast majority of ACLR revisions. The newly developed DK3 point-of-care tool offers a direct-input method to predict and monitor the risk of ACLR revision.

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

PMID:40839712 | DOI:10.2106/JBJS.24.00821

J Bone Joint Surg Am. 2025 Jun 19;107(16):1818-1824. doi: 10.2106/JBJS.24.01225.

ABSTRACT

BACKGROUND: Implant-associated infections (IAIs) require aggressive debridement to eliminate microbial bioburden. The use of irrigants may improve microbial killing during debridement. This study compared the efficacy of surgical irrigants in vitro against Staphylococcus aureus alone and in combination with Candida albicans, in both planktonic and biofilm states.

METHODS: Full-strength Dakin's solution, 0.35% povidone-iodine (PI), 10% PI, 3% hydrogen peroxide (HP), a 1:1 combination of 10% PI and 3% HP (PI + HP), Irrisept, XPERIENCE, Bactisure, and normal saline solution were tested. For planktonic testing, 1 × 106 colony-forming units (CFUs) of S. aureus and C. albicans were utilized, and biofilms were grown in these conditions on 0.8 × 10-mm titanium alloy Kirschner wires for 48 hours. Killing assays were performed using 5-minute dwell times. Success was defined by complete eradication of planktonic or biofilm CFUs.

RESULTS: PI + HP and Bactisure were the only irrigants to eradicate S. aureus in both planktonic and biofilm states. PI + HP was the only irrigant to eradicate polymicrobial S. aureus + C. albicans bioburden in both states.

CONCLUSIONS: PI + HP and Bactisure were superior irrigants against S. aureus, eliminating it in planktonic and biofilm states. PI + HP was the only irrigant to eradicate polymicrobial S. aureus + C. albicans bioburden in both states. In vivo studies are needed to evaluate the clinical effectiveness.

CLINICAL RELEVANCE: Surgical irrigants have variable efficacy in eradicating microbes depending on their state of existence (planktonic versus biofilm). In this study, the most effective eradication of polymicrobial S. aureus + C. albicans bioburden was a 1:1 combination of 10% PI and 3% HP, which is of nominal cost.

PMID:40833422 | PMC:PMC12356552 | DOI:10.2106/JBJS.24.01225

J Bone Joint Surg Am. 2025 Jul 10;107(16):1879-1886. doi: 10.2106/JBJS.24.01287.

ABSTRACT

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

PMID:40833394 | PMC:PMC12356572 | DOI:10.2106/JBJS.24.01287

J Bone Joint Surg Am. 2025 Aug 20. doi: 10.2106/JBJS.24.01411. Online ahead of print.

ABSTRACT

BACKGROUND: The effect of home call on the sleep of orthopaedic residents and attending surgeons remains unquantified, despite known negative impacts of poor sleep on cognition, fine motor skills, and decision-making. We prospectively measured the impact of home call on orthopaedic surgery residents' and attending surgeons' sleep patterns (total sleep, slow-wave sleep [SWS], and rapid eye movement [REM] sleep), as well as on heart rate variability (HRV). We hypothesized that orthopaedic home call would negatively impact all phases of sleep and suppress post-call HRV.

METHODS: Sixteen orthopaedic attending surgeons and 14 orthopaedic surgery residents taking home call at multiple Level-I trauma centers in a single program wore WHOOP 3.0 Straps. The WHOOP Strap objectively measures and quantifies total sleep, SWS, and REM sleep. Over a 13-month period, home call nights were prospectively recorded and matched with physiological data to compare on-call, post-call night 1 (PCN 1), and PCN 2 metrics. Fixed-effects regression models were used for statistical analysis.

RESULTS: Over 13 months, we observed 4,574 recorded nights of residents' sleep and 3,573 recorded nights of attending surgeons' sleep. The mean baseline (non-call night) sleep parameters were highly varied among individuals. Overall, the mean sleep time was significantly shorter (p < 0.001) for attending surgeons (6.0 hours) than for residents (6.7 hours). When on home call, residents' total sleep decreased by 20% from baseline (p < 0.001), REM sleep decreased by 12% (p < 0.001), and SWS decreased by 12% (p < 0.001). For attending surgeons, total sleep on call decreased by 10% from baseline (p < 0.001), REM sleep decreased by 7% (p < 0.001), and SWS decreased by 4% (p < 0.01).

CONCLUSIONS: Orthopaedic surgery residents and attending surgeons exhibited low baseline sleep, and taking home call reduced this further. This suggests that there is a previously unmeasured toll of home call on orthopaedic surgeons, upon which further research is required to ensure excellent patient care, maximize educational environments, and develop strategies for resilience.

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

PMID:40834105 | DOI:10.2106/JBJS.24.01411

J Bone Joint Surg Am. 2025 Aug 20;107(16):e81. doi: 10.2106/JBJS.24.01633.

NO ABSTRACT

PMID:40833424 | DOI:10.2106/JBJS.24.01633

J Bone Joint Surg Am. 2025 Aug 20;107(16):e80. doi: 10.2106/JBJS.25.00526.

NO ABSTRACT

PMID:40833398 | DOI:10.2106/JBJS.25.00526