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

ABSTRACT

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

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

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

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

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

PMID:40627681 | DOI:10.2106/JBJS.24.01030

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

ABSTRACT

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

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

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

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

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

PMID:40627679 | DOI:10.2106/JBJS.24.01169

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

NO ABSTRACT

PMID:40600896 | DOI:10.2106/JBJS.25.00400

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

NO ABSTRACT

PMID:40591698 | DOI:10.2106/JBJS.25.00471

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

NO ABSTRACT

PMID:40591353 | DOI:10.2106/JBJS.25.00113

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

NO ABSTRACT

PMID:40591263 | DOI:10.2106/JBJS.25.00088

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

NO ABSTRACT

PMID:40591261 | DOI:10.2106/JBJS.25.00154

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

NO ABSTRACT

PMID:40591255 | DOI:10.2106/JBJS.25.00170

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

NO ABSTRACT

PMID:40587605 | DOI:10.2106/JBJS.25.00152

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

NO ABSTRACT

PMID:40577440 | DOI:10.2106/JBJS.25.00008

J Bone Joint Surg Am. 2025 Jun 26. doi: 10.2106/JBJS.24.01081. Online ahead of print.

ABSTRACT

BACKGROUND: AAOS Clinical Practice Guidelines recommend spica casting for the treatment of most femoral fractures in children 6 months to 5 years of age. The purpose of the present study was to compare the outcomes of treatment with prefabricated braces with those of spica casting.

METHODS: We performed a randomized prospective study of patients 6 months to 5 years of age who were managed with functional bracing or spica casting for the treatment of diaphyseal femoral fractures at 2 pediatric trauma centers. Patients with polytrauma, medical comorbidities impacting fracture-healing, or <6 weeks of follow-up were excluded. Spica casts were placed in the operating room with the patient under anesthesia. Functional braces were placed at bedside.

RESULTS: Eighty patients (40 in the spica casting group and 40 in the functional bracing group) met the inclusion criteria and were analyzed. The mean age was 2.0 years in the casting group and 2.3 years in the bracing group (p = 0.15). Radiographs demonstrated similar shortening (9.0 ± 7.6 mm in the casting group and 6.8 ± 8.2 mm in the bracing group; p = 0.21), varus angulation (9.0º ± 11.9º in the casting group and 5.6º ± 9.4º in the bracing group; p = 0.19), and procurvatum (9.4º ± 12.9º in the casting group and 6.7º ± 8.4º in the bracing group; p = 0.31). At 6 weeks, there were no differences in shortening (13.1 ± 9.4 mm in the casting group and 11.0 ± 10.0 mm in the bracing group; p = 0.35), varus angulation (2.4º ± 7.3º in the casting group and 5.3º ± 6.3º in the bracing group, p = 0.06), or procurvatum (12.3º ± 9.8º in the casting group and 9.1º ± 8.1º in the bracing group; p = 0.11). Fifty-one patients (24 in the casting group and 27 in the bracing group) had 1 year of follow-up. There were no differences between the groups in terms of shortening (4.9 ± 5.4 mm in the casting group and 3.0 ± 6.9 mm in the bracing group; p = 0.23) or varus angulation (1.8º ± 3.5º in the casting group and 1.2º ± 4.1º in the bracing group; p = 0.56), but there was a slight difference in procurvatum (11.7º ± 8.3º in the casting group and 5.1º ± 5.8º in the bracing group; p < 0.01). More superficial skin issues were observed in the bracing group than in the casting group (9 compared with 1; p = 0.02), but all skin issues resolved with local wound care. Patients in the casting group had more difficulty moving independently (median score, 8 of 10 in the casting group and 5 of 10 in the bracing group; p = 0.05). Patients in the bracing group were more likely to fit into their car seat (40% in the casting group versus 86% in the bracing group; p < 0.01).

CONCLUSIONS: In this prospective randomized trial, patients who were treated with functional bracing had equivalent outcomes to those who were treated with spica casting. Prefabricated functional braces provided a viable alternative, avoiding the cost and anesthesia associated with cast placement.

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

PMID:40570075 | DOI:10.2106/JBJS.24.01081

J Bone Joint Surg Am. 2025 Jun 26. doi: 10.2106/JBJS.24.01554. Online ahead of print.

ABSTRACT

Leadership selection in the field of orthopaedic surgery takes place in many settings, including national, regional, and local associations; academic departments; and private practice groups. In general, there is neither a consistent method of competency-based leadership selection nor a codified set of criteria by which to identify a successful leader in national organizations. This can potentially lead to leadership based on personality rather than process. Polling results among the orthopaedic leaders who were present at the 2024 American Orthopaedic Association (AOA) Annual Meeting Symposium revealed that 80% think that the selection process for board leadership for national orthopaedic organizations needs to improve, and 75% think that the selection process for academic department chairs also needs to improve. This summary of the 2024 AOA Symposium provides a strategy for consistent, competency-based leadership selection in orthopaedic organizations, identifies potential key selection criteria that are necessary to identify talent, and enumerates steps that can be used by nominating or search committees. Although the focus of this work is directed toward the process that is used to identify leaders for national orthopaedic organizations, features of academic medical leadership and corporate talent selection will be highlighted for consideration and translation to the orthopaedic community.

PMID:40570068 | DOI:10.2106/JBJS.24.01554

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.01489. Online ahead of print.

ABSTRACT

BACKGROUND: The Roussouly classification is a popular system for the categorization of spinal alignment, although the categorization of continuous measures may compromise efforts toward a precision-medicine approach to sagittal alignment in spine surgery. Vertebral-pelvic angles provide continuous measures of sagittal alignment without the risk of misclassification.

METHODS: We performed a cross-sectional study of asymptomatic adult volunteers with normal spines (no evidence of disc degeneration or scoliosis). Full-spine radiographs were obtained, and radiographic parameters were collected, including pelvic incidence (PI), sacral slope, lumbar lordosis, the apex of lordosis, the L1-pelvic angle (L1PA), and the T4-pelvic angle (T4PA). All spines were classified as Roussouly Type 1, 2, 3, or 4 on the basis of sacral slope and the apex of lumbar lordosis. Associations between the L1PA and PI, the L1PA and T4PA, and the T4-L1PA mismatch and PI were assessed for the whole cohort and when stratified by Roussouly type. A multinomial logistic regression model was fit to estimate Roussouly type based on PI, the L1PA, and the T4PA. Agreement (weighted κ), accuracy, and area under the receiver operating characteristic curve (1 type versus the rest) were computed. A subanalysis assessed potential variations in the relationships when Roussouly Type-3 spines were further classified as Type 3A (anteverted) versus Type 3.

RESULTS: The 320 included volunteers had a median age of 37 years (interquartile range [IQR], 27 to 47 years), and 193 (60%) were female. By self-reported race or ethnicity, the highest percentage of patients were Caucasian (White, 38%) or East Asian (36%), followed by Arabo-Bèrbère (16%). Spines were classified as Roussouly Type 1 in 18 (6%) of the volunteers, as Type 2 in 63 (20%), as Type 3 in 161 (50%), and as Type 4 in 78 (24%). The L1PA was strongly associated with PI across Roussouly types (weakest in Roussouly Type-1 spines). A multinomial logistic regression model estimating Roussouly type by PI, the L1PA, and the T4PA showed strong agreement (weighted κ, 0.84), excellent discrimination, and overall accuracy of 0.82.

CONCLUSIONS: The T4-L1-Hip axis is conceptually aligned with the description of spinal shapes in the Roussouly classification but with the advantage of utilizing continuous measures of spinal alignment. Goals of surgical realignment incorporating the T4-L1-Hip axis will be comparable with alignment planning using the Roussouly classification but with improved accuracy and precision.

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

PMID:40560977 | DOI:10.2106/JBJS.24.01489

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.00009. Online ahead of print.

ABSTRACT

BACKGROUND: The diagnosis of acute compartment syndrome (ACS) using a single-point pressure measurement device has demonstrated low specificity. Recently, sensors that allow for continuous monitoring of compartment pressure have been introduced, with improved specificity and sensitivity compared with single-point measurement. In this article, we present an economic model used to evaluate the cost-benefits of continuous pressure measurement in patients at risk for ACS.

METHODS: The model used a decision-tree structure to estimate the treatment costs of ACS at 60 days and 1 year after admission and over the patient's lifetime. It assumed systematic use of the diagnostic devices for all tibial shaft and tibial plateau fractures and estimated the cost-effectiveness of continuous pressure measurement compared with noncontinuous pressure measurement by comparing costs, quality-adjusted life-years (QALYs), and length of stay (LOS).

RESULTS: The improved specificity of continuous pressure measurement reduced unnecessary fasciotomies by 94%. The inflation-adjusted cost of an uncomplicated tibial fracture averaged $57,144; the performance of an unnecessary fasciotomy increased that cost by $27,790. The gain in QALYs was 0.004 per patient, with a net health benefit of 0.06 QALYs. Over a 60-day time horizon, the model showed an estimated decrease in LOS of 2.73 days, on average, per patient. The net monetary benefit was $2,789 (range, -$1,246 to $6,151) in favor of the continuous measurement, increasing to $4,085 (range, -$745 to $8,103) over the lifetime of the patient following the most conservative scenario of equal ACS grade distribution.

CONCLUSIONS: Most of the ACS economic burden lies in the lack of specificity of the current diagnostic methods. The low incidence of ACS and the high risk associated with prophylactic treatment indicate that improvement in health and economic outcomes should focus on reducing the rate of unnecessary fasciotomies.

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

PMID:40560966 | DOI:10.2106/JBJS.24.00009

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.01419. Online ahead of print.

ABSTRACT

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS) has undergone numerous changes to promote care for patients at high social risk. However, the effect of these changes on surgeon MIPS performance and caseload selection remains unclear. Thus, the purpose of this study was to evaluate how orthopaedic surgeon MIPS scores, demographics, practice characteristics, and patient populations varied on the basis of patient social risk in 2017 compared with 2021.

METHODS: CMS data were utilized to examine U.S. orthopaedic surgeons. Surgeons were placed into social-risk quintiles on the basis of the proportion of their patients who were dually eligible for Medicare and Medicaid, with the highest quintile representing the highest social risk. Demographics, practice location characteristics, patient data, and MIPS performance were assessed for the years 2017 and 2021. Differences between social-risk quintiles were assessed utilizing chi-square, Student t, and Wilcoxon signed-rank tests and multivariable logistic regression.

RESULTS: In 2017, surgeons with caseloads at the highest, compared with the lowest, social risk had lower MIPS performance scores (mean [and standard deviation], 66.0 ± 37.6 versus 70.1 ± 33.5; p < 0.001). However, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk had significantly higher MIPS performance scores (mean, 88.7 ± 16.9 versus 81.5 ± 18.3; p < 0.001). In terms of demographics, in 2021, orthopaedic surgeons with caseloads at the highest, compared with the lowest, social risk were more often women (9.2% versus 3.6%; p < 0.001), more often had a DO degree (11.2% versus 6.6%; p < 0.001), more recently graduated from medical school (mean, 23.0 ± 12.9 versus 25.7 ± 10.9 years; p < 0.001), and worked in areas with higher Distressed Communities Index (DCI) distress scores (mean, 56.9 ± 27.3 versus 35.1 ± 25.2; p < 0.001). Similar findings were present in 2017.

CONCLUSIONS: The addition of the Complex Patient Bonus to the MIPS in 2020 may have reduced performance inequities in MIPS scoring for surgeons with caseloads at high social risk. However, the demographics and practice patterns of the orthopaedic surgeons caring for populations at the highest social risk remained consistent between years.

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

PMID:40560965 | DOI:10.2106/JBJS.24.01419

J Bone Joint Surg Am. 2025 Jun 25. doi: 10.2106/JBJS.24.01126. Online ahead of print.

ABSTRACT

BACKGROUND: Glenoid component loosening remains a challenge in anatomic total shoulder arthroplasty (aTSA). The aims of this study were to evaluate complications, implant survival, and revision rates in patients with primary and secondary osteoarthritis (OA) undergoing stemless aTSA using the Arthrex Eclipse humeral implant with a cemented pegged all-polyethylene glenoid component and to identify risk factors leading to revision.

METHODS: Of 211 patients who underwent primary stemless aTSA (using the Eclipse humeral component with a cemented pegged all-polyethylene glenoid) with prospectively documented data in a local registry, 197 were evaluated, grouped by OA pathology (primary OA, 153 patients; secondary OA, 44 patients). Demographic and functional data (e.g., age, sex, shoulder function) and the cause of OA were documented preoperatively in both groups. Comparative analyses were conducted to assess complications and implant revisions between the study groups. In addition, various radiographic parameters (e.g., glenoid morphology, critical shoulder angle, lateral acromion index, implant sizing [humeral component overhang], radial matching of the humeral and glenoid components, glenohumeral distance, and medial glenoid cement penetration) were evaluated to explore their potential association with revision. A subset of these parameters was subsequently included in the multivariable Cox model on the basis of clinical relevance.

RESULTS: After a median postoperative period of 72 months, the overall revision rate was 51%. The reasons for revision were glenoid component loosening (85%), periprosthetic humeral fracture (9%), early rotator cuff failure (3%), and low-grade infection (3%). The median implant survival in patients with primary OA (95 months; 95% confidence interval [CI]: 84 to 108) was significantly longer than that in patients with secondary OA (71 months; 95% CI: 60 to 88; p = 0.027). Female patients had a significantly shorter time to revision than male patients (p = 0.016). There were no significant differences in complications or revision rates by OA pathology. Secondary OA, the presence of medial glenoid cement penetration, and an anterior overhang of the humeral component were associated with an increased risk of revision.

CONCLUSIONS: Our findings indicate a high rate of glenoid component loosening as the primary cause of revision in patients with primary and secondary OA undergoing stemless aTSA with the Eclipse and a cemented pegged all-polyethylene glenoid component. This outcome emphasizes the need for careful consideration of implant design, patient selection criteria, and implant positioning and cementation in order to optimize implant survival.

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

PMID:40560961 | DOI:10.2106/JBJS.24.01126

J Bone Joint Surg Am. 2025 Jun 24. doi: 10.2106/JBJS.24.01373. Online ahead of print.

ABSTRACT

Medical slang is commonly used in the orthopaedic community to improve communication, enhance team cohesion, and provide humor in intense work environments. However, when used carelessly, inappropriate terminology can alienate certain groups of physicians. When encountered in clinical settings, these terms can create uncomfortable environments, reduce trust, and discourage trainees from pursuing orthopaedics. To create more inclusive and effective clinical teams, it is important to regularly reassess medical slang and develop alternative terms that are respectful, practical, and consistent. This contemporary article highlights 8 examples of inappropriate terminology that are used in the orthopaedic community, explores their history of use, and suggests more appropriate alternatives.

PMID:40554618 | DOI:10.2106/JBJS.24.01373

J Bone Joint Surg Am. 2025 Jun 24. doi: 10.2106/JBJS.24.01538. Online ahead of print.

ABSTRACT

BACKGROUND: The usage of medial unicompartmental knee arthroplasty (mUKA) is increasing, but concerns remain regarding the risk of early periprosthetic tibial fracture (PPTF), particularly following cementless mUKA. The aims of this study were to compare the risk of PPTF between cemented and cementless mUKAs and to analyze risk factors for early PPTF.

METHODS: Using data from the Danish Knee Arthroplasty Register and the Danish National Patient Registry, all mUKAs from 1997 to 2022 were identified and stratified as cemented or cementless mUKAs. Subsequent fractures were identified through the reason for revision, diagnosis codes, and fracture-specific procedure codes.

RESULTS: This study included 9,700 cemented mUKAs (mean follow-up of 9 years) and 12,380 cementless mUKAs (mean follow-up of 3 years). The 4-month cumulative proportions of PPTF were 0.2% (95% confidence interval [CI], 0.2% to 0.4%) after cemented mUKA and 0.7% (95% CI, 0.6% to 0.9%) after cementless mUKA. Risk factors for early PPTF (≤4 months) were cementless mUKA (hazard ratio [HR], 2.9; 95% CI, 1.6 to 5.5), female sex (HR, 2.6; 95% CI, 1.6 to 4.2), an age of ≥70 years (HR, 4.0; 2.5 to 6.4), body mass index (BMI) of ≥40 kg/m2 (HR, 2.4; 95% CI, 1.0 to 5.8), and a height of <160 cm (HR, 2.2; 95% CI, 1.3 to 3.6). Female patients ≥70 years of age with a BMI of ≥40 kg/m2 and/or a height of <160 cm represented 3% of all mUKAs. In this group, patients with cementless mUKA had a 4-month cumulative proportion of PPTF of 4.5% (95% CI, 2.9% to 6.9%).

CONCLUSIONS: The risk of early, surgery-related PPTF was higher after cementless mUKA compared with cemented mUKA. Risk factors for early PPTF include cementless mUKA, female sex, an age of ≥70 years, a BMI of ≥40 kg/m2, and a height of <160 cm. Our data highlight the need for careful, bone-conserving tibial preparation and consideration of cemented tibial fixation for female patients ≥70 years of age with a height of <160 cm and/or a BMI of ≥40 kg/m2.

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

PMID:40554616 | DOI:10.2106/JBJS.24.01538

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01225. Online ahead of print.

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:40536949 | DOI:10.2106/JBJS.24.01225

J Bone Joint Surg Am. 2025 Jun 19. doi: 10.2106/JBJS.24.01485. Online ahead of print.

ABSTRACT

BACKGROUND: Patient-level value analysis (PLVA) has been applied to several orthopaedic procedures but has not yet been utilized to assess the value of total knee arthroplasty (TKA). The purpose of this study was to evaluate the 1-year episode of care for TKA with use of PLVA to identify characteristics that influence value at both the patient and surgeon level.

METHODS: The institutional patient-reported outcome (PRO) database was queried for all patients who underwent TKA from 2020 to 2022. Patients were excluded on the basis of an index revision procedure, a pathology other than primary osteoarthritis, unicompartmental knee arthroplasty, robotic-assisted TKA, incomplete baseline or 1-year PROs, concomitant procedures (i.e., bilateral TKA or hardware removal), complications requiring readmission or reoperation, TKA without patellar resurfacing, the use of constrained implants, incomplete cost information, or other hip or knee arthroplasty procedure during the 1-year episode of care. PROs of interest included preoperative and 1-year postoperative Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR) scores. Episode-of-care costs were calculated using time-driven activity-based costing. The 1-year value quotient (VKOOS) was calculated for each patient as the ratio of the 1-year change in KOOS-JR score to the total episode-of-care cost.

RESULTS: A total of 684 patients (62% female; mean age, 68 ± 8 years) met the inclusion criteria. The mean KOOS-JR score significantly increased from baseline (53 ± 11) to 1 year (79 ± 14; p < 0.001), with a mean improvement of 26 ± 16. The mean total episode-of-care cost was $9,563 ± $2,370. There was no significant correlation between episode-of-care costs and the change in KOOS-JR score (r = 0.02; p = 0.581). Surgery performed at an ambulatory surgery center (p < 0.001) and as an outpatient procedure (p = 0.036) were predictive of lower costs. Patient-specific instrumentation (p < 0.001) and a tibial stem extension (p < 0.001) were predictive of higher costs. Older age (p = 0.023) and male sex (p = 0.007) were predictive of less improvement in KOOS-JR scores from baseline to 1 year.

CONCLUSIONS: Our study identified patient and surgical characteristics that drive costs and PROs in TKA. PLVA can be used to identify "bright spots" in orthopaedic procedures to optimize care delivery.

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

PMID:40536933 | DOI:10.2106/JBJS.24.01485