JBJS

Orthopaedic Research in Singapore: The Past, Present, and Future

J Bone Joint Surg Am. 2026 Jan 9. doi: 10.2106/JBJS.25.01276. Online ahead of print.

ABSTRACT

Orthopaedic surgeons are the custodians of the musculoskeletal system in Singapore, with >350 orthopaedic surgeons looking after the whole continuum of musculoskeletal disease in a population of 6 million. Orthopaedic research in Singapore currently has 4 focus areas: tissue engineering, biomechanics, clinical registries and cohorts, and population health and health services research. We have identified 4 key enablers of the continued development of orthopaedic research: talent development and academic clinical programs; shared data infrastructure, national cohorts, and artificial intelligence; innovation; and interdisciplinary, industry, and international collaboration. This is an exciting time for orthopaedic research in Singapore, where we find ourselves at the cusp of a new wave of talent, ideas, and resources. We stand ready and excited to partner with the world to advance musculoskeletal care globally.

PMID:41512087 | DOI:10.2106/JBJS.25.01276

Prevention of Postoperative Coronal Imbalance in Patients with Adolescent Idiopathic Scoliosis with a Major Lumbar Curve: The Intraoperative Crossbar Coronal-Balancing Technique

J Bone Joint Surg Am. 2026 Jan 7;108(1):60-67. doi: 10.2106/JBJS.25.00597. Epub 2025 Dec 2.

ABSTRACT

BACKGROUND: Patients who have undergone corrective surgery for adolescent idiopathic scoliosis (AIS), especially those with a major lumbar curve, may have persistent postoperative coronal imbalance (PCI) due to an insufficient ability to compensate for lumbar curve overcorrection. However, the optimal amount of curve correction required to prevent PCI remains uncertain. Therefore, this study aimed to evaluate the use of the intraoperative crossbar coronal-balancing technique as a strategy to minimize the risk of PCI in patients with AIS with a major lumbar curve (Lenke type-5 and 6 curves), and to confirm that the tilt angle of the lowest instrumented vertebra (LIV), intraoperatively and at the final follow-up, could be predicted from the preoperative supine right-side-bending (RSB) radiograph that was used to guide the correction.

METHODS: This study involved 39 patients with Lenke 5 or 6 AIS who underwent posterior spinal fusion and had a minimum 2-year follow-up. The median age was 14 years, 15% were male, and all were of Malaysian ethnicity: 84.6% Chinese, 12.8% Malay, and 2.6% Indian. The LIV tilt angle measured on the preoperative supine RSB radiograph, adjusted according to the pelvic obliquity (PO) measured on the erect radiograph (α angle), was used as a guide for the intraoperative LIV tilt angle (β angle). Following curve correction, the crossbar was centered over the sacrum intraoperatively. The position of the C7 vertebra was then assessed relative to the crossbar, and the amount of correction was adjusted to ensure that the proximal portion of the crossbar bisected the C7 vertebra under fluoroscopy. Outcomes included the coronal balance distance (CBD) and the LIV tilt angle at the final follow-up (δ angle).

RESULTS: Only 2 (5.1%) of the patients in the cohort had PCI at the final follow-up. At that time, the mean CBD was -6.6 ± 9.2 mm and the mean δ angle was -12.4° ± 4.8°. There were no significant differences between the α and β angles (p = 0.799) or between the α and δ angles (p = 0.705). The α angle correlated strongly with the β angle (ρ = 0.707) and the δ angle (ρ = 0.730, p < 0.001).

CONCLUSIONS: The intraoperative crossbar coronal-balancing technique was shown to be an effective method to minimize the risk of PCI in patients with AIS with a major lumbar curve. Guided by the α angle measured preoperatively, this approach may help facilitate the determination of the optimal intraoperative LIV tilt angle (β), which corresponds to the LIV tilt angle at the final folow-up (δ).

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

PMID:41498772 | DOI:10.2106/JBJS.25.00597

Trends and Impact of Pharmacological VTE Prophylaxis Timing for Traumatic Cervical Spinal Cord Injury Across North American Trauma Centers

J Bone Joint Surg Am. 2026 Jan 7;108(1):51-59. doi: 10.2106/JBJS.24.00563. Epub 2025 Dec 2.

ABSTRACT

BACKGROUND: The aims of this study were to evaluate the timing and trend of venous thromboembolism (VTE) prophylaxis initiation following surgical intervention, and the impact of VTE prophylaxis timing on the occurrence of VTE complications, across North American trauma centers in patients with complete traumatic cervical spinal cord injury (SCI).

METHODS: This retrospective, observational cohort study utilized data from the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) from 2013 to 2020. We identified surgically treated patients with complete traumatic cervical SCI. Patient variables included age, sex, race, insurance coverage, and comorbidity status. Outcomes of interest included time to VTE prophylaxis following surgery and the occurrence of VTE complications. Mixed-effect regression models were constructed to evaluate the adjusted estimate for each outcome accounting for patient-, injury-, and hospital-level covariates.

RESULTS: The study included 5,325 patients treated across 463 trauma centers. The mean age in the cohort was 46.7 ± 18.9 years, with male predominance (81.1%). Race was predominantly White (62.3%) and Black (23.0%). The mean time to VTE prophylaxis initiation was 90 ± 112 hours, and the median time was 65 hours (interquartile range, 39 to 105 hours). The annual trend of VTE prophylaxis initiation after surgery was a decrease by 5.2 hours per year over the 8-year study interval. This was associated with an annual reduction of 6.2% in the odds of VTE complication occurrence. Multivariable mixed-effect regression models demonstrated a significant reduction in time to VTE prophylaxis (mean difference, -3.7 hours per year [95% confidence interval [CI], -5.3 to -2.1 hours per year]; p < 0.001) and VTE complications (odds ratio, 0.93 per year [95% CI, 0.88 to 0.98 per year]; p = 0.01) over the study period, after adjustment.

CONCLUSIONS: This analysis provides insight into VTE prophylaxis practice patterns following surgery for complete cervical SCI across North American trauma centers from 2013 to 2020. The timing of VTE prophylaxis initiation consistently decreased, which appeared to be associated with a significant reduction found in VTE complications.

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

PMID:41498771 | DOI:10.2106/JBJS.24.00563

Decreased Robot-Related Complications Following the Development and Adoption of a Standardized Safety Protocol

J Bone Joint Surg Am. 2026 Jan 7;108(1):45-50. doi: 10.2106/JBJS.25.00406. Epub 2025 Nov 20.

ABSTRACT

BACKGROUND: Robot-assisted spine surgery (RASS) enables precise pedicle screw insertion via pre-planned trajectories, and yet complications remain a notable concern. Prior work suggests that osseous pedicle wall breaches from instrumentation and ensuing complications related to robotic surgery may be from shifting of the reference frame or improper methodology. In this study, we hypothesized that the introduction of standardized institutional guidelines for RASS would reduce complications associated with robotic screw placement.

METHODS: This retrospective cohort study included patients who underwent RASS using 2 robotic systems at a single institution. We analyzed the cases of 264 patients in a historical cohort before, and 290 patients after, the implementation of a standardized institutional protocol developed to ensure safety with robotic placement of pedicle screws. The protocol provided surgeons with detailed guidelines for reference-frame placement, intraoperative screw trajectory and alignment checks, depth of drill insertion, verification of screw positioning, neuromonitoring for thoracic instrumentation, and postoperative imaging. Patient demographics, preoperative diagnoses, surgical characteristics, and complications were collected for all patients.

RESULTS: There was no difference between the pre-protocol and post-protocol groups with respect to patient demographics. In the pre-protocol cohort, 6 (2.3%) of the patients experienced robot-related complications, including nerve injury, durotomy, and malpositioned screws, with half of these complications attributed to reference-frame errors. Following the implementation of the protocol, no patient (0%) experienced a robot-related complication among 290 cases involving 2,030 screws placed with robotic assistance, representing a significant reduction (p = 0.01). The number of patients with open surgery (versus minimally invasive surgery) did not differ significantly between the pre-protocol (132 patients, 50%) and post-protocol (143 patients, 49.3%) groups. The mean number of instrumented levels per patient post-protocol was 3.3 ± 2.1. Non-robot-related complication rates were similar post-protocol (19.7%) versus pre-protocol (26.1%) (p > 0.05). Notably, post-protocol, there were no instances of a pedicle breach with neurostimulation or on postoperative imaging.

CONCLUSIONS: Following the implementation of standardized robotic surgery guidelines, no robot-related screw complications occurred in a post-protocol cohort of 290 patients. This study underscores the importance of protocol standardization, alongside technological advancements, in optimizing patient safety and improving outcomes in RASS. Well-designed institutional protocols may notably reduce robotic surgery complications and can be a valuable model for other institutions.

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

PMID:41498770 | DOI:10.2106/JBJS.25.00406

Humeral Head Reconstruction in Anatomic Shoulder Arthroplasty: How to Assess It, How to Avoid Overstuffing, and Whether It Matters

J Bone Joint Surg Am. 2026 Jan 7;108(1):25-34. doi: 10.2106/JBJS.24.01583. Epub 2025 Dec 1.

ABSTRACT

➢ Humeral head anatomy affects the tension and mechanics of the glenohumeral joint. Thus, aiming for anatomic reconstruction can help to avoid negative consequences of component malpositioning (such as "overstuffing") on soft-tissue tension and impingement-free range of motion.➢ The most common method to assess humeral head reconstruction is comparing the prosthetic humeral articular surface with the "perfect circle" incorporating the lateral cortex of the greater tuberosity, the medial greater tuberosity, and the medial calcar at the anatomic neck. Although this method is quick and helpful in assessing multiple parameters, it is important to also compare the radius of curvature, assess traditional measurements of humeral head anatomy or glenohumeral thickness, and consider that non-anatomic sizing may be used to achieve tension goals.➢ There is no consistent evidence of superior humeral head reconstruction quality with stemless, short-stem, or standard-length humeral components, suggesting that surgical technique and familiarity with an implant system remain most important.➢ Although stemless and short-stem components offer versatility in recreating pre-arthritic anatomy, their use places emphasis on having a reproducible technique for humeral neck osteotomy depth and inclination. Some techniques include careful osteophyte resection to visualize the true anatomic neck, the use of an intramedullary guide, and intraoperative assessment with fluoroscopy.➢ Although small deviations from pre-arthritic anatomy do not appear to affect clinical outcome, center-of-rotation deviations of exceeding 3 to 4 mm from the perfect circle have been associated with an inferior clinical outcome.

PMID:41498769 | DOI:10.2106/JBJS.24.01583

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