J Bone Joint Surg Am. 2025 Jan 23. doi: 10.2106/JBJS.24.00689. Online ahead of print.

ABSTRACT

BACKGROUND: Periprosthetic joint infections (PJIs) are a major complication of total joint replacement surgeries. This study investigated the enhancement of mechanical properties and antibiotic release in ultra-high molecular weight polyethylene (UHMWPE) through the encapsulation of submicron gentamicin sulfate (GS) particles, addressing the critical need for improved implant materials in orthopaedic surgery, particularly in managing PJIs.

METHODS: The present study involved embedding submicron GS particles into UHMWPE flakes at concentrations of 2% to 10% by weight. These particles were prepared and blended with UHMWPE flakes using a dual asymmetric centrifugal mixer, and the blends were consolidated. The present study compared the mechanical properties and antibiotic release rate of UHMWPE containing submicron, medium (as-received), and large (resolidified) GS particles.

RESULTS: UHMWPE samples with submicron GS particles exhibited superior mechanical properties, including higher ultimate tensile and Izod impact strengths, compared with samples with larger particles. Additionally, the submicron GS UHMWPE blends demonstrated a markedly higher and more sustained antibiotic release rate.

CONCLUSIONS: This study highlights the potential of incorporating submicron GS particles into UHMWPE to drastically improve the feasibility of using these therapeutic and functional spacer implants in expanded indications.

CLINICAL RELEVANCE: By offering improved mechanical strength and effective, prolonged antibiotic release, this innovative material could be used as a spacer implant to reduce the considerably high morbidity and mortality associated with PJIs. This material has the potential to prevent PJIs not only in high-risk revision cases but also in primary total joint arthroplasty procedures.

PMID:39847614 | DOI:10.2106/JBJS.24.00689

J Bone Joint Surg Am. 2025 Jan 22. doi: 10.2106/JBJS.24.00261. Online ahead of print.

ABSTRACT

BACKGROUND: Limb-salvage surgery for malignant bone tumors can be associated with considerable perioperative blood loss. The aim of this randomized controlled trial was to assess the safety and efficacy of the intraoperative infusion of tranexamic acid (TXA) in children and adolescents undergoing limb-salvage surgery.

METHODS: All participants were <18 years of age at the time of surgery and diagnosed with a malignant bone tumor of the femur that was treated with resection and reconstruction with a megaprosthesis. Exclusion criteria included anatomic locations other than the femur, reconstruction with a vascularized fibular graft, and a previous history of deep venous thrombosis, coagulopathy, or renal dysfunction. Participants were randomly allocated to either the TXA group (a preoperative loading dose infusion of 10 mg/kg of TXA followed by a continuous infusion of 5 mg/kg/hr until the end of surgery) or the placebo group (the same dosage but with TXA substituted with an infusion of normal saline solution). Intraoperative and perioperative blood loss were calculated with use of the hemoglobin balance method. Perioperative blood loss at postoperative day 1 and at discharge from the hospital were calculated. The total volumes of blood transfused intraoperatively and postoperatively were recorded. A statistical comparison between the groups was performed for blood loss and blood transfusion as well as for possible independent variables other than TXA, including age, body mass index, histopathologic diagnosis, tumor volume, preoperative hemoglobin level, type of resection, and the duration of surgery.

RESULTS: A total of 48 participants, with a mean age of 12.5 ± 3.44 years (range, 5 to 18 years) and a male-to-female ratio of 1.18, were included. All participants were Egyptians by race and ethnicity. There were no minor or major drug-related adverse events. There was no significant difference between the groups with respect to intraoperative blood loss (p = 0.0616) or transfusion requirements (p = 0.812), but there was a significant difference in perioperative blood loss at postoperative day 1 (p = 0.0144) and at discharge from the hospital (p = 0.0106) and in perioperative blood transfusion (p = 0.023).

CONCLUSIONS: TXA can be safely infused intraoperatively in children and adolescents undergoing limb-salvage surgery, and it contributes significantly to the reduction of perioperative blood loss and transfusion requirements.

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

PMID:39841811 | DOI:10.2106/JBJS.24.00261

J Bone Joint Surg Am. 2025 Jan 22. doi: 10.2106/JBJS.22.01273. Online ahead of print.

ABSTRACT

BACKGROUND: Comorbidity indices are used to help to estimate patients' length of hospital stay, care costs, outcomes, and mortality. Increasingly, they are considered in reimbursement models. The applicability of comorbidity indices to patients undergoing orthopaedic oncology surgery has not been studied. The purpose of this study was to determine the predominant comorbidities in patients undergoing orthopaedic oncology surgery and to evaluate the predictive value of these indices.

METHODS: Patient demographic characteristics, diagnoses, and preoperative comorbidities were collected retrospectively on 300 patients undergoing orthopaedic oncology surgery between January 2014 and March 2023. In this study, 3 subsets of 100 patients each with malignant primary bone tumors, malignant primary soft-tissue tumors, or osseous metastatic disease were randomly selected. Comorbidities were tabulated and weighted according to the guidelines of the Charlson Comorbidity Index (CCI), the National Institute on Aging/National Cancer Institute (NIA/NCI) index, the van Walraven Index, and the Agency for Healthcare Research and Quality (AHRQ) Index. Two-tailed bivariate Pearson correlations were performed to assess the relationship between the indices and between each index and patient outcomes. Comorbidities in our patient population were compared with those published in other studies.

RESULTS: The predominant comorbidities in patients undergoing orthopaedic oncology surgery were hypertension, deficiency anemias, metastatic disease, recent unintended weight loss or being underweight, and fluid or electrolyte disorders. The percentage of patients with certain comorbidities exceeded those reported in other cancer, orthopaedic, and inpatient populations. The 4 comorbidity indices had variable correlation when assessing our patient population. The number of comorbidities and the weighted scores from all indices demonstrated little to no correlation with length of stay and survival in our patient sample.

CONCLUSIONS: The prevalence of many comorbidities in patients undergoing orthopaedic oncology surgery is greater than those reported in other patient populations. Commonly utilized indices demonstrate variable correlation with one another. With these tools, there was little to no correlation between comorbidities and patient outcomes in our patient population. The comorbidities deemed protective in these tools may underestimate the true assessment of the comorbidities in patients undergoing orthopaedic oncology surgery. This highlights the importance of developing tools to properly assess the comorbidities in defined patient populations, especially as these models are used to set benchmarks for measuring patient outcomes; assessing quality, efficiency, and safety; and determining reimbursement criteria.

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

PMID:39841810 | DOI:10.2106/JBJS.22.01273

J Bone Joint Surg Am. 2025 Jan 22. doi: 10.2106/JBJS.24.01427. Online ahead of print.

NO ABSTRACT

PMID:39841804 | DOI:10.2106/JBJS.24.01427

J Bone Joint Surg Am. 2025 Jan 21. doi: 10.2106/JBJS.23.01397. Online ahead of print.

ABSTRACT

BACKGROUND: The aim of this study was to develop an accurate and clinically relevant prediction model for 30-day mortality following hip fracture surgery.

METHODS: A previous study protocol was utilized as a guideline for data collection and as the standard for the hip fracture treatment. Two prospective, detailed hip fracture databases of 2 different hospitals (hospital A, training cohort; hospital B, testing cohort) were utilized to obtain data. On the basis of the literature, the results of a univariable analysis, and expert opinion, 26 candidate predictors of 30-day mortality were selected. Subsequently, the training of the model, including variable selection, was performed on the training cohort (hospital A) with use of adaptive least absolute shrinkage and selection operator (LASSO) logistic regression. External validation was performed on the testing cohort (hospital B).

RESULTS: A total of 3,523 patients were analyzed, of whom 302 (8.6%) died within 30 days after surgery. After the LASSO analysis, 7 of the 26 variables were included in the prediction model: age, gender, an American Society of Anesthesiologists score of 4, dementia, albumin level, Katz Index of Independence in Activities of Daily Living total score, and residence in a nursing home. The area under the receiver operating characteristic curve of the prediction model was 0.789 in the training cohort and 0.775 in the testing cohort. The calibration curve showed good consistency between observed and predicted 30-day mortality.

CONCLUSIONS: The Rotterdam Hip Fracture Mortality Prediction-30 Days (RHMP-30) was developed and externally validated, and showed adequate performance in predicting 30-day mortality following hip fracture surgery. The RHMP-30 will be helpful for shared decision-making with patients regarding hip fracture treatment.

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

PMID:39836737 | DOI:10.2106/JBJS.23.01397

J Bone Joint Surg Am. 2025 Jan 21. doi: 10.2106/JBJS.24.00946. Online ahead of print.

ABSTRACT

BACKGROUND: Joint arthroplasty effectively treats osteoarthritis, providing pain relief and improving function, but postoperative venous thromboembolism (VTE) remains a common complication. This study therefore assessed the effectiveness and safety of aspirin compared with oral anticoagulants (OACs) for VTE prophylaxis after joint arthroplasty.

METHODS: A systematic review and meta-analysis was performed by searching PubMed, Embase, the Web of Science, and the Cochrane Library for randomized controlled trials (RCTs) up to May 14, 2024, that compared the effect of aspirin versus OACs on VTE prophylaxis in adults undergoing joint arthroplasty. Data extraction followed the PRISMA guidelines. Two independent researchers conducted the literature searches and data extraction. A random-effects model was used to estimate effects. The primary outcome was the incidence of VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE); secondary outcomes included bleeding, wound complications, and mortality.

RESULTS: The meta-analysis included 11 RCTs with a total of 4,717 participants (55.1% female) from several continents. The relative risk (RR) of VTE following joint arthroplasty was 1.11 (95% confidence interval [CI], 0.93 to 1.32) for aspirin compared with OACs. Similar results were observed for DVT (RR, 1.12; 95% CI, 0.90 to 1.40) and PE (RR, 1.18; 95% CI, 0.51 to 2.71). There were no significant differences in the risks of bleeding, wound complications, or mortality between patients receiving aspirin and those receiving OACs. Subgroup analyses considering factors such as study region, type of joint surgery, type of VTE detection, year of publication, use of mechanical VTE prophylaxis, aspirin dose, type of OAC comparator, study quality, and funding also found no significant differences in VTE incidence between aspirin and OACs. The overall quality of evidence for VTE and DVT outcomes was high.

CONCLUSIONS: Based on high-quality evidence from RCTs, aspirin is as effective and safe as OACs in preventing VTE, including DVT and PE, after joint arthroplasty, without increasing complications.

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

PMID:39836735 | DOI:10.2106/JBJS.24.00946

J Bone Joint Surg Am. 2025 Jan 21. doi: 10.2106/JBJS.24.00593. Online ahead of print.

ABSTRACT

The Centers for Medicare & Medicaid Services (CMS) recently introduced mandatory reporting of patient-reported outcomes (PROs) following primary, elective total joint arthroplasty (TJA) procedures. This article explores the implications and implementation challenges of this policy shift in the field of orthopaedic surgery. With a review of the existing literature, we analyze the potential benefits and limitations of PROs, discuss the role of CMS in health-care quality improvement initiatives, explain the predicted difficulties in the successful implementation of this new mandate, and provide recommendations for the successful integration of the reporting of PROs in clinical practice.

PMID:39836727 | DOI:10.2106/JBJS.24.00593

J Bone Joint Surg Am. 2025 Jan 17. doi: 10.2106/JBJS.24.00486. Online ahead of print.

ABSTRACT

BACKGROUND: Reoperation is a major adverse event following surgical treatment but has yet to be used as a primary outcome measure in population studies to assess current treatments for developmental dysplasia of the hip (DDH). The purpose of the present study was to explore the risk factors associated with reoperations following procedures under anesthesia ("operations") for DDH in patients between the ages of 1 and 3.00 years, with the goal of deriving treatment recommendations.

METHODS: This retrospective birth cohort study included children who had undergone closed reduction, open reduction, or osteotomy for the treatment of unilateral DDH between the ages of 1 and 3.00 years, identified using the Taiwan National Health Insurance Research Database. The children were followed until 10 years of age for reoperations, excluding implant removal and sequential closed reduction within 3 months postoperatively. A comparison between patients with and without reoperations was conducted, and binary logistic regression was used to identify factors associated with reoperation. Patients were further stratified by age and procedure for developing treatment recommendations.

RESULTS: Among 2,261,455 live births from 2000 to 2009, 701 patients underwent operations for unilateral DDH between 1 and 3.00 years of age (an incidence of 31.0 per 1,000 live births). The initial operations included closed reduction (n = 86; mean age, 1.34 years), open reduction (n = 73; mean age, 1.53 years), pelvic osteotomy (n = 405; mean age, 1.59 years), femoral osteotomy (n = 93; mean age, 1.76 years), and pelvic osteotomy plus femoral osteotomy (n = 44; mean age, 1.84 years). Reoperations were performed in 91 patients (13%) at a mean age of 3.80 years. Comparison between patients with and without reoperations revealed the operative procedure as a significant factor. Logistic regression revealed that closed reduction was associated with a 1.8 to 9.0 times higher reoperation risk than open reduction, depending on age, whereas pelvic osteotomy was associated with 0.34 times the risk of reoperation than open reduction in patients 1.5 to 2.0 years of age.

CONCLUSIONS: Reoperations may not be directly linked to radiographic and functional outcomes but are important from the patient's perspective and in terms of cost-effectiveness. To reduce the risk of reoperation, the findings of the present study support open reduction to properly reduce the hip joint at walking age and additional pelvic osteotomy for patients beyond 1.5 years of age.

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

PMID:39823351 | DOI:10.2106/JBJS.24.00486

J Bone Joint Surg Am. 2025 Jan 17. doi: 10.2106/JBJS.24.00911. Online ahead of print.

ABSTRACT

BACKGROUND: The relative advantages and disadvantages of 2-stage versus 1-stage management of infection following total hip arthroplasty (THA) are the current subject of intense debate. To understand the merits of each approach, detailed information on the short and, importantly, longer-term outcomes of each must be known. The purpose of the present study was to assess the long-term results of 2-stage exchange arthroplasty following THA in one of the largest series to date.

METHODS: We identified 331 periprosthetic joint infections (PJIs) that had been treated with a 2-stage exchange arthroplasty between 1993 and 2021 at a single institution. Patients were excluded if they had had prior treatment for infection. The mean age at the time of reimplantation was 66 years, 38% of the patients were female, and the mean body mass index (BMI) was 30 kg/m2. The diagnosis of PJI was based on the 2011 Musculoskeletal Infection Society criteria. A competing-risk model accounting for death was utilized. The mean duration of follow-up was 8 years.

RESULTS: The cumulative incidence of reinfection was 7% at 1 year and 11% at 5 and 10 years. Factors predictive of reinfection included BMI ≥30 kg/m2 (hazard ratio [HR] = 2; p = 0.049) and the need for a spacer exchange (HR = 3.2; p = 0.006). The cumulative incidence of any revision was 13% at 5 and 10 years. The cumulative incidence of aseptic revision was 3% at 1 year, 7% at 5 years, and 8% at 10 years. Dislocation occurred in 33 hips (11% at 10 years); 15 (45%) required revision. Factors predictive of dislocation were female sex (HR = 2; p = 0.047) and BMI <30 kg/m2 (HR = 3; p = 0.02). The mean Harris hip score (HHS) improved from 54 to 75 at 10 years.

CONCLUSIONS: In this series of 331 two-stage exchange arthroplasties that were performed for the treatment of infection, we found a low rate of aseptic revision (8%) and a low rate of reinfection (11%) at 10 years. These long-term mechanical and infection data must be kept in mind when considering a paradigm shift to 1-stage exchanges.

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

PMID:39823350 | DOI:10.2106/JBJS.24.00911

J Bone Joint Surg Am. 2025 Jan 15. doi: 10.2106/JBJS.24.00749. Online ahead of print.

ABSTRACT

➢ Jehovah's Witnesses refuse allogeneic blood products based on religious beliefs that create clinical, ethical, and legal challenges in orthopaedic surgery, requiring detailed perioperative planning and specific graft selection.➢ Detailed perioperative planning is particularly important for procedures with high intraoperative blood loss.➢ Graft selection must align with Jehovah's Witnesses patients' religious beliefs, with options including autografts, allografts, and synthetic materials; this requires shared decision-making between the patient and surgeon.➢ A multidisciplinary approach, integrating medical, ethical, and religious considerations, ensures optimal care, with innovative techniques and open dialogue being key to successful outcomes.

PMID:39813667 | DOI:10.2106/JBJS.24.00749

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.24.00386. Online ahead of print.

ABSTRACT

BACKGROUND: An accurate knowledge of a patient's risk of cord-level intraoperative neuromonitoring (IONM) data loss is important for an informed decision-making process prior to deformity correction, but no prediction tool currently exists.

METHODS: A total of 1,106 patients with spinal deformity and 205 perioperative variables were included. A stepwise machine-learning (ML) approach using random forest (RF) analysis and multivariable logistic regression was performed. Patients were randomly allocated to training (75% of patients) and testing (25% of patients) groups. Feature score weights were derived by rounding up the regression coefficients from the multivariable logistic regression model. Variables in the final scoring calculator were automatically selected through the ML process to optimize predictive performance.

RESULTS: Eight features were included in the scoring system: sagittal deformity angular ratio (sDAR) of ≥15 (score = 2), type-3 spinal cord shape (score = 2), conus level below L2 (score = 2), cervical upper instrumented vertebra (score = 2), preoperative upright largest thoracic Cobb angle of ≥75° (score = 2), preoperative lower-extremity motor deficit (score = 2), preoperative upright largest thoracic kyphosis of ≥80° (score = 1), and total deformity angular ratio (tDAR) of ≥25 (score = 1). Higher cumulative scores were associated with increased rates of cord-level IONM data loss: patients with a cumulative score of ≤2 had a cord-level IONM data loss rate of 0.9%, whereas those with a score of ≥7 had a loss rate of 86%. When evaluated in the testing group, the scoring system achieved an accuracy of 93%, a sensitivity of 75%, a specificity of 94%, and an AUC (area under the receiver operating characteristic curve) of 0.898.

CONCLUSIONS: This is the first study to provide an ML-derived preoperative scoring system that predicts cord-level IONM data loss during pediatric and adult spinal deformity surgery with >90% accuracy.

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

PMID:39813599 | DOI:10.2106/JBJS.24.00386

J Bone Joint Surg Am. 2024 Nov 19. doi: 10.2106/JBJS.24.00706. Online ahead of print.

ABSTRACT

BACKGROUND: Fractures of the thoracic and lumbar spine are increasingly common. Although it is known that such fractures may elevate the risk of near-term morbidity, the natural history of patients who sustain such injuries remains poorly described. We sought to characterize the natural history of patients treated for thoracolumbar fractures and to understand clinical and sociodemographic factors associated with survival.

METHODS: Patients treated for acute thoracic or lumbar spine fractures within a large academic health-care network between 2015 and 2021 were identified. Clinical, radiographic, and mortality data were obtained from medical records and administrative charts. Survival was assessed using Kaplan-Meier curves. We used multivariable logistic regression to evaluate factors associated with survival, while adjusting for confounders. Results were expressed as odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS: The study included 717 patients (median age, 66 years; 59.8% male; 69% non-Hispanic White). The mortality rate was 7.0% (n = 50), 16.2% (n = 116), and 20.4% (n = 146) at 3, 12, and 24 months following injury, respectively. In adjusted analysis, patients who died within the first year following injury were more likely to be older (OR = 1.03; 95% CI = 1.01 to 1.05) and male (OR = 1.67; 95% CI = 1.05 to 2.69). A higher Injury Severity Score, lower Glasgow Coma Scale score, and higher Charlson Comorbidity Index at presentation were also influential factors. The final model explained 81% (95% CI = 81% to 83%) of the variation in survival.

CONCLUSIONS: We identified a previously underappreciated fact: thoracolumbar fractures are associated with a mortality risk comparable with that of hip fractures. The risk of mortality is greatest in elderly patients and those with multiple comorbidities. The results of our model can be used in patient and family counseling, informed decision-making, and resource allocation to mitigate the potential risk of near-term mortality in high-risk individuals.

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

PMID:39813477 | DOI:10.2106/JBJS.24.00706

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.24.00347. Online ahead of print.

ABSTRACT

Published in 2003 by the Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care placed an unprecedented spotlight on disparities in the U.S. health-care system. In the 2 decades since the publication of that landmark report, disparities continue to be prevalent and remain an important significant national concern. This article synthesizes the evolution, current state, and future of racial and ethnic disparities in the use of elective total joint replacement surgeries. We contextualize our impressions with respect to the recommendations of the Unequal Treatment Report.

PMID:39813469 | DOI:10.2106/JBJS.24.00347

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.23.01351. Online ahead of print.

ABSTRACT

BACKGROUND: Rotator cuff repair (RCR) is a frequently performed outpatient orthopaedic surgery, with substantial financial implications for health-care systems. Time-driven activity-based costing (TDABC) is a method for nuanced cost analysis and is a valuable tool for strategic health-care decision-making. The aim of this study was to apply the TDABC methodology to RCR procedures to identify specific avenues to optimize cost-efficiency within the health-care system in 2 critical areas: (1) the reduction of variability in the episode duration, and (2) the standardization of suture anchor acquisition costs.

METHODS: Using a multicenter, retrospective design, this study incorporates data from all patients who underwent an RCR surgical procedure at 1 of 4 academic tertiary health systems across the United States. Data were extracted from Avant-Garde Health's Care Measurement platform and were analyzed utilizing TDABC methodology. Cost analysis was performed using 2 primary metrics: the opportunity costs arising from a possible reduction in episode duration variability, and the potential monetary savings achievable through the standardization of suture anchor costs.

RESULTS: In this study, 921 RCR cases performed at 4 institutions had a mean episode duration cost of $4,094 ± $1,850. There was a significant threefold cost variability between the 10th percentile ($2,282) and the 90th percentile ($6,833) (p < 0.01). The mean episode duration was registered at 7.1 hours. The largest variability in the episode duration was time spent in the post-acute care unit and the ward after the surgical procedure. By reducing the episode duration variability, it was estimated that up to 640 care-hours could be saved annually at a single hospital. Likewise, standardizing suture anchor acquisition costs could generate direct savings totaling $217,440 across the hospitals.

CONCLUSIONS: This multicenter study offers valuable insights into RCR cost as a function of care pathways and suture anchor cost. It outlines avenues for achieving cost-savings and operational efficiency. These findings can serve as a foundational basis for developing health-economics models.

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

PMID:39813412 | DOI:10.2106/JBJS.23.01351

J Bone Joint Surg Am. 2024 Nov 20. doi: 10.2106/JBJS.23.01480. Online ahead of print.

ABSTRACT

BACKGROUND: Oblique lumbar interbody fusion (OLIF) results in less tissue damage than in other surgeries, but immediate postoperative pain occurs. Notably, facet joint widening occurs in the vertebral body after OLIF. We hypothesized that the application of a facet joint block to the area of widening would relieve facet joint pain. The purpose of this study was to evaluate the analgesic effects of such injections on postoperative pain.

METHODS: This double-blinded, placebo-controlled study randomized patients into 2 groups. Patients assigned to the active group received an intra-articular injection of a compound mixture of bupivacaine and triamcinolone, whereas patients in the placebo group received an equivalent volume of normal saline solution injection. Back and dominant leg pain were evaluated with use of a visual analog scale (VAS) at 12, 24, 48, and 72 hours postoperatively. Clinical outcomes were evaluated preoperatively and at 6 months postoperatively with use of the Oswestry Disability Index (ODI) and VAS for back and dominant leg pain.

RESULTS: Of the 61 patients who were included, 31 were randomized to the placebo group and 30 were randomized to the active group. Postoperative fentanyl consumption from patient-controlled analgesia was higher in the placebo group than in the active group at up to 36 hours postoperatively (p < 0.001) and decreased gradually in both groups. VAS back pain scores were significantly higher in the placebo group than in the active group at up to 48 hours postoperatively. On average, patients in the active group had a higher satisfaction score (p = 0.038) and were discharged 1.3 days earlier than those in the placebo group.

CONCLUSIONS: The use of an intraoperative facet joint block decreased pain perception during OLIF, thereby reducing opioid consumption and the severity of postoperative pain. This effect was also associated with a reduction in the length of the stay.

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

PMID:39813409 | DOI:10.2106/JBJS.23.01480

J Bone Joint Surg Am. 2024 Nov 21. doi: 10.2106/JBJS.24.00012. Online ahead of print.

ABSTRACT

BACKGROUND: Risk factors for gluteal tears include age-related deterioration, female sex, and increased body mass index. As the literature that supports the sagittal relationship between the lumbar spine and the hip is increasing, there may be a parallel relationship between the perturbations in spinopelvic alignment caused by lumbar spine disease and gluteal muscle tears. Because no prior studies other than single-institution series have reported on this phenomenon, we investigated spine-abductor syndrome at the population level.

METHODS: This study utilized TriNetX, a federated research network that continuously aggregates deidentified electronic health record data from >92 million patients across the United States. The relative risks of gluteal tear encounter diagnoses and procedures were calculated for patients with and without the following characteristics: age ≥45 years, female sex, obesity, lumbar spine diagnoses, lumbar spine injections, and lumbar spine surgery. Utilizing the Cox proportional hazard model, we also analyzed gluteal tear-free survival over a period of ≥10 years in subgroups of patients who had been diagnosed with lumbar pathology, had been administered a lumbar injection, or had received lumbar surgery.

RESULTS: Of the 8,475,800 patients who had received lumbar spine diagnoses, undergone lumbar injections, and/or undergone lumbar surgeries, 458,311 patients (5.4%) had gluteal tears, representing a relative risk of 13.6 (95% confidence interval [CI]:13.6 to 13.6). After controlling for age, sex, and obesity, survival analysis showed markedly increased hazard ratios (HRs) for patients having a gluteal tear encounter diagnosis in the intervening 13 years (2010 to 2023) if they had had a previous lumbar spine pathology encounter diagnosis (HR: 4.8, 95% CI: 4.5 to 5.1), had undergone lumbar spine injections (HR: 7.7, 95% CI: 6.2 to 9.5), or had undergone lumbar spine surgery (HR: 6.6, 95% CI: 5.3 to 8.1) in 2010.

CONCLUSIONS: These findings suggest a strong association between lumbar spine pathology and abductor tears. Further biomechanical and neuroanatomic studies may elucidate the effects of lumbar spine disease in relation to gluteal tears. Additionally, there may be a need to optimize diagnostic protocols for lateral hip pain in patients with a history of lumbar spine disease.

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

PMID:39813406 | DOI:10.2106/JBJS.24.00012

J Bone Joint Surg Am. 2025 Jan 15;107(2):e6. doi: 10.2106/JBJS.24.01077. Epub 2025 Jan 15.

NO ABSTRACT

PMID:39812729 | DOI:10.2106/JBJS.24.01077

J Bone Joint Surg Am. 2025 Jan 15;107(2):e5. doi: 10.2106/JBJS.24.01004. Epub 2025 Jan 15.

NO ABSTRACT

PMID:39812728 | DOI:10.2106/JBJS.24.01004

J Bone Joint Surg Am. 2025 Jan 15;107(2):209-216. doi: 10.2106/JBJS.24.00357. Epub 2024 Nov 21.

ABSTRACT

➢ Advanced care planning most commonly refers to the act of planning and preparing for decisions with regard to end-of-life care and/or serious illness based on a patient's personal values, life goals, and preferences.➢ Over time, advanced care planning and its formalization through advanced directives have demonstrated substantial benefits to patients, their families and caregivers, and the larger health-care system.➢ Despite these benefits, advanced care planning and advanced directives remain underutilized.➢ Orthopaedic surgeons interact with patients during sentinel events, such as fragility hip fractures, that indicate a decline in the overall health trajectory.➢ Orthopaedic surgeons must familiarize themselves with the concepts and medicolegal aspects of advanced care planning so that care can be optimized for patients during sentinel health events.

PMID:39812727 | DOI:10.2106/JBJS.24.00357

J Bone Joint Surg Am. 2025 Jan 15;107(2):196-207. doi: 10.2106/JBJS.23.01289. Epub 2024 Nov 21.

ABSTRACT

BACKGROUND: No studies have evaluated the impact of the cement distribution as classified on the basis of the fracture bone marrow edema area (FBMEA) in magnetic resonance imaging (MRI) on the efficacy of percutaneous vertebral augmentation (PVA) for acute osteoporotic vertebral fractures.

METHODS: The clinical data of patients with acute, painful, single-level thoracolumbar osteoporotic fractures were retrospectively analyzed. The bone cement distribution on the postoperative radiograph was divided into 4 types according to the distribution of the FBMEA on the preoperative MRI. The primary outcomes were the postoperative visual analog scale (VAS) for pain and Oswestry Disability Index (ODI) scores. Cement leakage, adjacent vertebral fractures (an important concern in complications after vertebroplasty and a subset of new fractures), and recollapse of the treated vertebra were also evaluated.

RESULTS: A total of 128 patients, 80.5% of whom were female, were included and had follow-up for 24 months. The mean patient age (and standard deviation) was 74.2 ± 8.6 years. The cement distribution was classified as Type I in 18 patients, Type II in 26, Type III in 46, and Type IV in 38. At the primary time point (6 months), there was a significant difference in the ODI score favoring the Type-III and Type-IV groups compared with the Type-I and Type-II groups (adjusted 95% confidence interval [CI]: Type I versus Type II, -2.40 to 4.50; Type I versus Type III, 1.35 to 7.63; Type I versus Type IV, 1.27 to 7.92; Type II versus Type III, 0.67 to 6.21; Type II versus Type IV, 0.63 to 6.46; adjusted p < 0.0083), whereas no significant differences were found between the 4 groups in the VAS pain score. The Type-II and Type-IV groups had a higher incidence of cement leakage, and the Type-III and Type-IV groups had a lower incidence of vertebral recollapse.

CONCLUSIONS: An adequate distribution of bone cement is advantageous for functional improvement, short-term pain relief, and a lower rate of vertebral recollapse. The FBMEA appears to be a feasible reference marker for evaluating the performance of the PVA procedure.

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

PMID:39812726 | DOI:10.2106/JBJS.23.01289