J Bone Joint Surg Am. 2025 Feb 6. doi: 10.2106/JBJS.24.00260. Online ahead of print.

ABSTRACT

BACKGROUND: A lumbosacral hemivertebra (LSHV) presents a complex challenge in treating congenital scoliosis. Previous studies have proven the effectiveness of posterior LSHV resection. However, they have primarily focused on coronal balance, neglecting the sagittal alignment, which is crucial for spinal function. The aim of this retrospective study was to assess preoperative sagittal imbalance in patients with an LSHV and to evaluate the evolution of sagittal alignment following posterior hemivertebra resection and short-segment fusion.

METHODS: A retrospective analysis was performed that included 58 patients with LSHV who underwent posterior LSHV resection between 2010 and 2020 and had a mean follow-up duration of 7.5 years. All patients were Han Chinese, and 30 of the 58 patients were female. The mean age was 7.3 years. Sagittal balance parameters were measured preoperatively and at multiple postoperative time points. Clinical outcomes were assessed with use of the Scoliosis Research Society (SRS)-22 questionnaire.

RESULTS: Preoperatively, 60.3% of patients presented with sagittal imbalance (defined as a sagittal vertical axis [SVA] of >20 mm). Postoperatively, the mean SVA significantly improved, decreasing to <20 mm at the 1-year follow-up (p = 0.016). The pelvic incidence-lumbar lordosis mismatch (PI-LL) also showed significant improvement at the immediate postoperative time point (p = 0.012) and at the last follow-up (p = 0.013). Patients who underwent anterior column reconstruction demonstrated better postoperative global sagittal balance than those who did not (SVA, p = 0.015; PI-LL, p < 0.001). SRS-22 total, self-image, and satisfaction scores significantly (p < 0.001) improved postoperatively.

CONCLUSIONS: This study highlighted the prevalence of preoperative sagittal imbalance in patients with an LSHV and emphasized the impact of LSHV resection (particularly when accompanied by anterior column reconstruction) in achieving postoperative sagittal balance and in enhancing patient quality of life during the long-term follow-up period.

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

PMID:39913624 | DOI:10.2106/JBJS.24.00260

J Bone Joint Surg Am. 2025 Feb 6. doi: 10.2106/JBJS.24.01192. Online ahead of print.

NO ABSTRACT

PMID:39913608 | DOI:10.2106/JBJS.24.01192

J Bone Joint Surg Am. 2025 Feb 6. doi: 10.2106/JBJS.24.01131. Online ahead of print.

ABSTRACT

The growing linguistic diversity in the United States presents substantial challenges to equitable health-care delivery. This article outlines strategies to promote health equity for orthopaedic surgery patients who speak a language other than English, including supporting the accessibility of professional interpreter services, enhancing language-specific patient educational resources, ensuring equity in the care tools that are used to improve access and engagement, strengthening the multilingual workforce in orthopaedic surgery, and standardizing the collection of language data elements for quality improvement and research. By adopting these strategies, health-care systems can better address the unique needs of non-English-speaking patients and reduce health disparities. Implementing these recommendations is crucial for advancing equity-focused value-based care in orthopaedics.

PMID:39913551 | DOI:10.2106/JBJS.24.01131

J Bone Joint Surg Am. 2025 Feb 5. doi: 10.2106/JBJS.24.00647. Online ahead of print.

ABSTRACT

➢ The administration of antibiotics, revascularization, effective initial debridement, stabilization, and dead-space management are important time-dependent, acute actions.➢ Following the adequate resuscitation of the patient and the local soft tissues, the first stage of the Masquelet technique is performed together with the definitive coverage of the soft-tissue defect.➢ The optimal time for the second stage (grafting of the bone defect) depends on the progress of the soft-tissue reconstruction and the overall state of the patient. It is usually at 6 to 14 weeks.➢ Bone graft involves cancellous autograft; depending on the volume of the defect, it can be acquired using different donor sites and methods and can be combined with cancellous allograft, bone substitutes, bone marrow aspirate, and inductive molecules.➢ Bone healing is independent of the size of the defect, assuming that revascularization of the graft material has not been disturbed.➢ The development of signs of a fracture-related infection in the clinical setting of a severe open fracture dictates surgical treatment and pathogen-specific antibiotics, debridement of the membrane and the surrounding soft tissues, and reinitiation of the staged process of limb salvage.➢ The results of staged management of severe open fractures with bone defects are reproducible and good.

PMID:39908357 | DOI:10.2106/JBJS.24.00647

J Bone Joint Surg Am. 2025 Feb 5. doi: 10.2106/JBJS.24.00926. Online ahead of print.

ABSTRACT

BACKGROUND: We previously reported the 5-year results of the Birmingham Hip Resurfacing (BHR) implant. This study evaluates BHR survivorship as well as radiographic and clinical outcomes at long-term follow-up.

METHODS: A total of 224 patients with contemporary indications, including 179 patients from the original study, were included in this analysis. Survivorship was calculated. Metal ion levels and radiographs were updated. Patient-reported outcomes (PROs) were compared with those for matched patients who had undergone total hip arthroplasty (THA). The mean follow-up was 14 years.

RESULTS: Survivorship free from any revision and from aseptic revision was 96.0% and 97.4% at 15 years, respectively. Two patients had undergone revision since the original study. The median serum cobalt and chromium levels were 1.4 and 1.5 ppb, respectively. The PROs were similar to those for the THA cohort. Equal proportions of patients remained active; however, the BHR group trended toward more remaining highly active (p = 0.12).

CONCLUSIONS: Although activity was similar to THA at long-term follow-up, the BHR implant remains an excellent option for the treatment of osteoarthritis in younger male patients.

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

PMID:39908356 | DOI:10.2106/JBJS.24.00926

J Bone Joint Surg Am. 2025 Feb 5. doi: 10.2106/JBJS.24.00620. Online ahead of print.

ABSTRACT

While female representation within surgical specialties is increasing, the field of orthopaedic surgery remains male-dominated. Residency, fellowship, and early career coincide with the childbearing years of female surgeons. Given the overlap between these critical career stages and years of childbearing, there has been a rise in articles characterizing the experiences and perceptions around childbearing and its impact on surgeons and their careers. Multiple studies have reported the alarmingly high rates of pregnancy complications, infertility, pregnancy loss, voluntary delay in childbearing, and postpartum depression in surgeons, including those in the field of orthopaedic surgery. However, perinatal complications are not the only barriers female orthopaedic surgeons may face should they decide to start a family alongside their career. Negative perceptions and lack of support from their colleagues and institutions have also been reported as commonplace. Limited but successful support programs, policies, and resources that are designed to support female surgeons and their partners have been created in North America. Successful support programs can be used to inspire institutional policies across North America to hopefully improve the pregnancy and childbirth experiences of orthopaedic surgeons.

PMID:39908353 | DOI:10.2106/JBJS.24.00620

J Bone Joint Surg Am. 2025 Feb 3. doi: 10.2106/JBJS.24.00703. Online ahead of print.

ABSTRACT

BACKGROUND: The objective of this study was to determine the relationship between surgical volume and patient outcome after arthroplasty of the patellofemoral joint, to improve patient outcomes and inform future resource planning.

METHODS: All patellofemoral arthroplasty (PFA) records in the National Joint Registry from January 2003 to December 2021 were linked to the Hospital Episode Statistics database for England. The main outcome measure was revision surgery. Secondary outcome measures were serious adverse effects, patient selection characteristics, and implant designs used. Associations of early and late revision with surgical volume were examined based on surgical volume, and reasons for revision were explored.

RESULTS: Of the knee arthroplasty surgeons in the database, 858 (26%) performed ≥1 PFA during the study period; 14,615 PFA cases were available for analysis. The modal caseload was 2 per year. High-volume surgeons were defined as surgeons performing >5 PFAs per year. The hazard ratio (HR) for a high-volume surgeon was 0.98 per additional PFA per year, and the patients treated by these surgeons had a lower risk of revision than than those treated by low-volume surgeons irrespective of the patient's age. High-volume surgeons were more likely to identify and treat patients with patellar disorders than low-volume surgeons (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.09 to 1.77; p < 0.05), and their patients were less likely to have serious adverse effects as these surgeons' experience increased (OR per additional PFA per year, 0.97; 95% CI, 0.95 to 0.99; p = 0.02). Inlay implants had a higher risk of revision than onlay implants irrespective of surgical experience: for low-volume surgeons, inlays had an HR of 1.68 (95% CI, 1.23 to 2.30; p = 0.01), and for high-volume surgeons, inlays had an HR of 2.38 (95% CI, 1.83 to 3.11; p = 0.01). The most common reason for revision was progressive osteoarthritis. High-volume surgeons' patients were less likely than low-volume surgeons' patients to have an early revision (<2 years postoperatively) (OR, 0.72; 95% CI, 0.55 to 0.93; p < 0.05).

CONCLUSIONS: An association was found between surgeons performing >5 PFAs per year and a lower revision rate. This study should inform surgical planning services to improve the outcomes of PFA.

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

PMID:39899649 | DOI:10.2106/JBJS.24.00703

J Bone Joint Surg Am. 2025 Feb 3. doi: 10.2106/JBJS.24.00453. Online ahead of print.

ABSTRACT

BACKGROUND: The effects of sclerotic bone on anti-tuberculosis (anti-TB) drug distribution in the blood and in spinal tuberculosis (STB) lesions were investigated.

METHODS: Fifty-six patients with STB were prospectively enrolled from January 2020 to March 2023 and were divided into 2 groups: a group with sclerotic bone and a group without sclerotic bone, as identified on preoperative computed tomography (CT) scans. Individuals in the sclerotic bone group were further divided into fragmentary and non-fragmentary sclerotic bone groups. The patients underwent surgery, and blood was collected along with normal vertebral and STB-lesion-containing bone tissue samples. Following treatment, the samples were processed by a pharmacological laboratory in order to detect the concentrations of anti-TB drugs, including pyrazinamide, rifampicin, isoniazid, and ethambutol.

RESULTS: Twenty-seven East Asian female and 29 East Asian male patients with STB were included in this study. The levels of anti-TB drugs showed a progressive decrease with increased circulatory distance, from blood to normal vertebral tissue to TB lesions, across all patient groups. Drug concentrations in TB lesions in the sclerotic bone group were significantly lower than those in the non-sclerotic bone group, as were concentrations in TB lesions in the non-fragmentary sclerotic bone group relative to those in the fragmentary sclerotic bone group. Drug levels in the blood and in normal vertebral bone tissue did not significantly differ between the sclerotic and non-sclerotic groups, nor between the fragmentary and non-fragmentary groups. Drug levels in the blood were linearly correlated with those in TB lesions in both the non-sclerotic bone group and the fragmentary sclerotic bone group.

CONCLUSIONS: These results indicate that sclerotic bone negatively affects the dissemination of anti-TB drugs, with non-fragmentary sclerotic bone posing a greater obstacle than fragmentary sclerotic bone. In patients with STB without sclerotic bone or with fragmentary sclerotic bone, anti-TB drug levels in the blood were linearly correlated with drug levels in STB lesions.

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

PMID:39899645 | DOI:10.2106/JBJS.24.00453

J Bone Joint Surg Am. 2025 Jan 31. doi: 10.2106/JBJS.24.00679. Online ahead of print.

ABSTRACT

BACKGROUND: Whether an adductor canal block (ACB) is more effective when administered before or after total knee arthroplasty (TKA) is unclear. This study compared pain, stress, and functional outcomes between patients who received the block before surgery and those who received the block after surgery.

METHODS: In this double-blinded trial, 100 patients at our hospital were randomized to receive an ACB at either 30 minutes before general anesthesia or postoperatively in the post-anesthesia care unit (PACU). All patients received periarticular local infiltration analgesia during surgery. The 2 groups were compared with respect to the primary outcome, the postoperative consumption of morphine as rescue analgesia, and in terms of the secondary outcomes, including the time from the end of surgery to the first rescue analgesia or discharge, intraoperative and postoperative stress, postoperative pain, functional recovery, the incidence of chronic pain, and complications.

RESULTS: All included patients were Asian (Chinese) in race/ethnicity. The 2 groups had similar demographic information. Compared with the postoperative ACB, the preoperative ACB was associated with significantly lower morphine consumption within the first 24 hours postoperatively and lower total morphine consumption. It was also associated with a longer time until the first rescue analgesia, lower intraoperative consumption of opioids and inhaled anesthetic, fewer episodes of hypertension during surgery, a lower rate of rescue analgesia in the PACU, lower levels of cortisol and adrenocorticotropic hormone in serum on the morning of postoperative day 1, lower pain on a visual analog scale while at rest or during motion within 12 hours postoperatively, better range of knee motion on postoperative day 1, and a lower incidence of chronic pain at 3 months postoperatively. The 2 groups did not differ significantly with respect to postoperative ambulation distance, time until discharge, or complication rates.

CONCLUSIONS: Administering an ACB before rather than after TKA may lead to lower opioid consumption during hospitalization, lower intraoperative and postoperative stress responses, better pain relief during hospitalization, and a lower incidence of chronic pain at 3 months postoperatively.

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

PMID:39888982 | DOI:10.2106/JBJS.24.00679

J Bone Joint Surg Am. 2025 Jan 31. doi: 10.2106/JBJS.24.00437. Online ahead of print.

ABSTRACT

BACKGROUND: The cause of hallux rigidus remains controversial. However, it is assumed that dysfunction of the windlass mechanism and metatarsus primus elevatus play a role in the pathology. Three-dimensional (3D) computed tomography (CT) imaging is ideal for analysis of movements of the foot, which involve 3D and rotational motion. The purpose of the present study was to compare the windlass mechanism in healthy normal feet with that in feet with hallux rigidus by 3D CT imaging.

METHODS: A total of 17 feet with hallux rigidus and 21 normal feet were selected. Hallux rigidus was classified as grade 1 or 2 with use of the Coughlin and Shurnas system. CT imaging was performed during weight-bearing and non-weight-bearing with the first metatarsophalangeal joint in a neutral position or in 30° of dorsiflexion. We measured the rotation of each joint and the height of the navicular during dorsiflexion and weight-bearing. We also compared changes in the tarsometatarsal joint and metatarsus primus elevatus in the neutral position between the non-weight-bearing and weight-bearing conditions.

RESULTS: During dorsiflexion, there were significant differences between the 2 groups in eversion and adduction at the talonavicular and talocalcaneal joints (p < 0.05), with less movement of bones in the hallux rigidus group. There was a significantly greater increase in height of the navicular in the control group than in the hallux rigidus group (1.2 ± 0.6 mm versus 0.7 ± 0.6 mm; p = 0.02). There was also a significant difference in metatarsus primus elevatus during the non-weight-bearing and weight-bearing conditions (p < 0.01).

CONCLUSIONS: Hallux rigidus restricts the movement of the Chopart joint and hindfoot associated with dorsiflexion of the first metatarsophalangeal joint, suggesting an association between hallux rigidus and windlass mechanism dysfunction.

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

PMID:39888978 | DOI:10.2106/JBJS.24.00437

J Bone Joint Surg Am. 2025 Jan 29. doi: 10.2106/JBJS.24.00561. Online ahead of print.

ABSTRACT

BACKGROUND: Magnetic resonance imaging (MRI) has not been routinely used for infants with brachial plexus birth injury (BPBI); instead, the decision to operate is based on the trajectory of clinical recovery by 6 months of age. The aim of this study was to develop an MRI protocol that can be performed without sedation or contrast in order to identify infants who would benefit from surgery at an earlier age than the age at which that decision could be made clinically.

METHODS: This prospective multicenter NAPTIME (Non-Anesthetized Plexus Technique for Infant MRI Evaluation) study included infants aged 28 to 120 days with BPBI from 3 tertiary care centers. Subjects had nonsedated non-contrast rapid volumetric proton density MRI on 3-T scanners. Neuroradiologists at each site calculated the NAPTIME nerve root injury score for subjects at their site. Interrater reliability was performed on a subset of subjects. All of the subjects were evaluated with routine clinical examinations up to 6 months of age, by which time the treating surgeon determined whether to offer nerve surgery. Surgeons were blinded to the MRI results. The ability of the NAPTIME score to discriminate surgeon indication for surgery was evaluated using the receiver operating characteristic (ROC) curve, by estimating the area under the curve (AUC) across the range of NAPTIME scores.

RESULTS: Sixty-five infants successfully completed the NAPTIME MRI; 18 (28%) ultimately met the clinical criteria for nerve surgery. The interrater reliability for the NAPTIME score was moderate at 0.703 (95% confidence interval [CI], 0.582 to 0.818). The median NAPTIME score for subjects who met the criteria for nerve surgery was 16.2 (interquartile range [IQR], 9.9 to 18.9), while the median score for those who did not was 7.0 (IQR, 5.0 to10.5). The NAPTIME score predicted meeting the criteria for surgery with an AUC of 0.812 (95% CI, 0.688 to 0.936). A score of >13 offered a specificity of 0.94 and a sensitivity of 0.61 for surgical indication.

CONCLUSIONS: Non-contrast MRI without sedation is a useful tool in determining the severity of injury in BPBI. The NAPTIME score might distinguish which infants will meet the criteria for reconstructive nerve surgery earlier than when the decision can be made clinically.

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

PMID:39879284 | DOI:10.2106/JBJS.24.00561

J Bone Joint Surg Am. 2025 Jan 29. doi: 10.2106/JBJS.24.001193. Online ahead of print.

NO ABSTRACT

PMID:39879283 | DOI:10.2106/JBJS.24.001193

J Bone Joint Surg Am. 2025 Jan 29. doi: 10.2106/JBJS.23.01451. Online ahead of print.

ABSTRACT

BACKGROUND: The accurate inclusion of patient comorbidities ensures appropriate risk adjustment in clinical or health services research and payment models. Orthopaedic studies often use only the comorbidities included at the index inpatient admission when quantifying patient risk. The goal of this study was to assess improvements in capture rates and in model fit and discriminatory power when using additional data and best practices for comorbidity capture.

METHODS: Hip fracture care was used as an exemplary case of an inpatient condition in a population typically having multiple comorbidities. Cohorts were built from 3 administrative resources: (1) Medicare, (2) all-payer, and (3) private-payer. Elixhauser comorbidities were calculated first using only the index admission and subsequently by adding inpatient and outpatient data from the previous year. Comorbidities identified on outpatient records required 2 instances occurring ≥30 days apart. Model fit and discriminatory power for in-hospital metrics (death, length of stay, and costs or charges) and post-discharge metrics (90-day readmission and surgical site infection, and 90-day and 1-year death) were compared among capture strategies.

RESULTS: The index admission missed 9.3% to 65.6% of individual Elixhauser comorbidities for the Medicare cohort, 2.9% to 39.0% for the all-payer cohort, and 14.1% to 57.9% for the private-payer cohort compared with data from the index admission plus the previous year. Using prior inpatient and outpatient data provided substantial improvements in model fit and explanatory power for post-discharge outcomes, whereas information from the index admission was sufficient for in-hospital death and length of stay. The utility of outpatient data was greatest when complete outpatient claims were captured compared with only ambulatory surgery claims.

CONCLUSIONS: The comorbidity capture strategies demonstrated in this study, namely including all available data for post-discharge outcomes, using a 1-year lookback period, and requiring outpatient codes to appear on 2 claims ≥30 days apart, are relevant for improved risk adjustment in orthopaedic clinical or health services research and quality improvement and payment models.

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

PMID:39879281 | DOI:10.2106/JBJS.23.01451

J Bone Joint Surg Am. 2025 Jan 28. doi: 10.2106/JBJS.24.00894. Online ahead of print.

ABSTRACT

BACKGROUND: In this study, we estimated the risk of surgically treated postoperative periprosthetic femoral fractures (POPFFs) associated with femoral implants frequently used for total hip arthroplasty (THA).

METHODS: In this cohort study of patients who underwent primary THA in England between January 1, 2004, and December 31, 2020, POPFFs were identified from prospectively collected revision records and national hospital records. POPFF incidence rates, adjusting for potential confounders, were estimated for common stems. Subgroup analyses were performed for patients >70 years of age, with non-osteoarthritic indications, and with femoral neck fracture.

RESULTS: POPFFs occurred in 0.6% (5,100) of 809,832 cases during a median follow-up of 6.5 years (interquartile range [IQR], 3.9 to 9.6 years). After cemented stem implantation, the majority of POPFFs were treated with fixation. Adjusted prosthesis time incidence rates (PTIRs) for POPFFs varied by stem design, regardless of cement fixation. Cemented composite beam (CB) stems demonstrated the lowest risk of POPFF. Collared cementless stems had an equivalent or lower rate of POPFF compared with the current gold standard of a polished taper slip cemented stem.

CONCLUSIONS: Cemented CB stems were associated with the lowest POPFF risk, and some cementless stem designs outperformed modern cemented stem designs. Stem design was strongly associated with POPFF risk, regardless of the presence of cement. Surgeons, policymakers, and patients should consider these findings when considering femoral implants in those most at risk for POPFF.

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

PMID:39874379 | DOI:10.2106/JBJS.24.00894

J Bone Joint Surg Am. 2025 Jan 28. doi: 10.2106/JBJS.24.00829. Online ahead of print.

ABSTRACT

BACKGROUND: Previous studies have reported normative data for sagittal spinal alignment in asymptomatic adults. The sagittal spinal alignment change in European children was recently reported. However, there is a lack of studies on the normative reference values of sagittal spinal and pelvic alignment and how these parameters change at different growth stages in Chinese children. The aims of this study were to establish the normative reference values of sagittal spinopelvic parameters in Chinese children, to investigate their variation during growth, and to compare these parameters between Chinese and European populations.

METHODS: The radiographic data of 1,916 healthy Chinese children (female:male sex ratio, 1.02:1; mean age, 11.9 ± 4.3 years) were analyzed in a retrospective, single-center study. Full-spine radiographs were utilized to measure several sagittal parameters, including pelvic parameters, T1-T12 thoracic kyphosis (TK), and L1-S1 lumbar lordosis (LL). TK was divided into proximal, middle, and distal parts, and LL was divided into proximal and distal parts. Patients were stratified into 5 groups according to skeletal maturity (based on age, Risser sign, and triradiate cartilage status).

RESULTS: During skeletal growth, pelvic incidence (PI) increased from 31.3° to 38.4° (p < 0.001), and pelvic tilt (PT) increased from 7.8° to 12.2° (p < 0.001). There were also increases in LL (from 45.0° to 46.3°; p = 0.020) and proximal LL (from 14.5° to 15.9°; p = 0.023). The peak of change in PI occurred between Groups 1 and 2 (from 31.3° to 35.8°; p = 0.011). The peak of change in LL was observed between Groups 1 and 3 (from 45.0° to 47.7°; p = 0.008). The peak of change in proximal LL (from 14.5° to 15.9°; p = 0.039) and distal TK (from 6.1° to 6.9°; p = 0.039) occurred between Groups 1 and 5. A subgroup comparison showed that age and TK were significantly higher in male patients than in female patients across the skeletal growth groups.

CONCLUSIONS: This was a comprehensive study of sagittal alignment in a large cohort of Chinese children. These findings can serve as age, sex, and ethnicity-specific reference values for spine surgeons when assessing and planning correction surgery for pediatric patients. The sagittal alignment variations during skeletal growth were different from those in European children, representing a unique cascade effect occurring during skeletal maturation in the Chinese population.

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

PMID:39874374 | DOI:10.2106/JBJS.24.00829

J Bone Joint Surg Am. 2025 Jan 24. doi: 10.2106/JBJS.24.00394. Online ahead of print.

ABSTRACT

BACKGROUND: To date, no studies have evaluated the longevity of calcaneal lengthening osteotomy (CLO) in patients with cerebral palsy (CP) and pes planovalgus. This study aimed to explore the changes in foot alignment following CLO in patients with CP, utilizing both radiographic evaluations and dynamic foot-pressure assessments.

METHODS: A retrospective study of 282 feet in 180 ambulatory patients was performed. The mean patient age at the surgical procedure was 8.9 ± 2.6 years. The mean follow-up period was 8.0 ± 4.3 years, and the mean age at the final follow-up 16.9 ± 4.4 years. Weight-bearing radiographs at 3 separate time points (before the surgical procedure, 6 months postoperatively, and at the final follow-up) were used. The feet were classified as corrected, undercorrected, or overcorrected on the basis of the radiographic parameters.

RESULTS: At the final follow-up, we classified 98 feet (34.8%) as corrected, 58 (20.6%) as undercorrected, and 126 (44.7%) as overcorrected. Foot-pressure analysis demonstrated that the undercorrected feet had higher relative vertical impulses in the medial forefoot and medial midfoot than in the other groups, whereas the overcorrected feet had higher impulse in the lateral midfoot. There were no significant differences in preoperative radiographic parameters between the 3 groups, except for the calcaneal pitch angle. At 6 months after the surgical procedure, we classified 181 feet (64.2%) as corrected, 58 (20.6%) as undercorrected, and 43 (15.2%) as overcorrected. However, 53.6% of initially corrected feet changed to being undercorrected or overcorrected during further follow-up, 43.1% of the undercorrected feet became corrected or overcorrected, and 16.3% of the overcorrected feet became corrected. A younger age at the surgical procedure and lower naviculocuboid overlap at 6 months after the surgical procedure were the risk factors for overcorrection.

CONCLUSIONS: Although CLO is an effective method for correcting planovalgus foot deformities and enhancing foot-pressure distribution, the extent of correction observed early after the surgical procedure was not necessarily sustained over the follow-up period in individuals with CP. Furthermore, our findings highlight a noticeable tendency toward the overcorrection of the deformity, as evidenced by increased pressure exerted on the lateral midfoot.

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

PMID:39854489 | DOI:10.2106/JBJS.24.00394

J Bone Joint Surg Am. 2025 Jan 24. doi: 10.2106/JBJS.24.00113. Online ahead of print.

ABSTRACT

BACKGROUND: Although delays in musculoskeletal care in low- and middle-income countries (LMICs) are well documented in the open fracture literature, the impact of surgical delays on closed fractures is not well understood. This study aimed to assess the impact of surgical delay on the risk of infection in closed long-bone fractures treated with intramedullary nailing in LMICs.

METHODS: Using the SIGN (Surgical Implant Generation Network) Surgical Database, patients ≥16 years of age who were treated with intramedullary nailing for closed diaphyseal femoral and tibial fractures from January 2018 to December 2021 were identified. Infection was diagnosed based on the assessment by the treating surgeon. A logistic regression model, adjusting for potential confounders, was used to analyze the association between delays to surgery (in weeks) and infection.

RESULTS: Of the 9,477 closed fractures that were included in this study, 58% were femoral fractures and 42% were tibial fractures. The mean age was 35 years, and 76.2% of the patients were men. The mean delay to surgery was 10.5 days, and the median delay to surgery was 6 days. The overall infection rate was 3.1%. The odds of developing an infection increased by 9.2% with each week of delayed surgical treatment (odds ratio,1.092; 95% confidence interval, 1.042 to 1.145). Increasing delays were also associated with longer surgery duration and higher rates of open reduction.

CONCLUSIONS: Surgical delays in LMICs were associated with an increased risk of infection in closed long-bone fractures. This study quantified the increased risk of infection due to delays in receiving care, highlighting the importance of timely surgery for closed fractures in LMICs.

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

PMID:39854435 | DOI:10.2106/JBJS.24.00113

J Bone Joint Surg Am. 2024 Oct 2;106(19):e43. doi: 10.2106/JBJS.24.00710. Epub 2024 Oct 2.

NO ABSTRACT

PMID:39853225 | DOI:10.2106/JBJS.24.00710

J Bone Joint Surg Am. 2024 Oct 2;106(19):e41. doi: 10.2106/JBJS.24.00586. Epub 2024 Oct 2.

NO ABSTRACT

PMID:39853224 | DOI:10.2106/JBJS.24.00586

J Bone Joint Surg Am. 2024 Oct 2;106(19):1739-1749. doi: 10.2106/JBJS.23.01390. Epub 2024 Aug 5.

ABSTRACT

BACKGROUND: Fixation of distal femoral fractures remains a challenge, and nonunions are common with standard constructs. Far cortical locking (FCL) constructs have been purported to lead to improved fracture-healing as compared with that achieved with traditional locking bridge plates. We sought to test this hypothesis in a comparative effectiveness clinical trial.

METHODS: This randomized trial was performed across 16 centers and included adult patients with an AO/OTA type 33A or 33C distal femoral fracture that was suitable for bridging fixation. We excluded patients with periprosthetic fractures. Participants were randomly assigned to either FCL fixation or standard locking plate fixation. The primary outcome was a hierarchical composite of radiographic and clinical fracture-healing at 3 months after fixation. We estimated between-group differences with use of the win ratio approach. Secondary outcomes included radiographic healing, clinical fracture-healing, complications, reoperations, and health-related quality of life (Short Form-36 Health Survey Version 2 [SF-36] Physical Component Summary and Mental Component Summary scores) at 3, 6, and 12 months after fixation.

RESULTS: We randomly assigned 193 patients to treatment with either FCL screws (96 patients) or standard screws (97 patients). The study population had a mean age of 63.4 years, consisted predominantly of women (68%), and was well-balanced between AO/OTA 33A and 33C fractures. Based on 4,355 pairwise comparisons, the calculated win ratio was 1.18 (95% confidence interval [CI], 0.77 to 1.79; p = 0.45), indicating that patients assigned to FCL screws had better outcomes in 51% of the comparisons. Radiographic healing did not differ significantly between the groups (odds ratio, 1.36; 95% CI, 0.69 to 2.72; p = 0.38), nor did Function IndeX for Trauma (FIX-IT) scores (p = 0.41). There were no significant differences between the groups in terms of SF-36 Physical Component Summary scores at 3 months or in the change in scores at 12 months after fixation.

CONCLUSIONS: In this multicenter randomized trial of adult patients with an AO/OTA type 33A or 33C distal femoral fracture, similar clinical and radiographic healing outcomes were observed in the FCL and standard fixation groups.

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

PMID:39853223 | DOI:10.2106/JBJS.23.01390